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17A-157 FROM Eger kehi re Insurance Group (MOH) DEC 14 2008 12: 00 /ST. 11: 58 /Ho. 7527318638 P 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) Page 2 of 2 INS025 (01 . PROM Berkshire Insurance Group (MON)DEC 14 2008 11: 58/ST. 11:58 /No. 7527318838 P 1 • ACORD CERTIFICATE OF LIABILITY INSURANCE 12/ IMMIDDIYYYYy 9, PRODUCER (413)773 -9913 FAX: (413)774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MassOne Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE enc B Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 638 Greenfield MA 01302 -0638 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental Western Pella Products, Inc. INSURERS: ATTN: John Benjamin INSURER C: 155 Main Street INSURER D: Greenfield MA 01301 -3258 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YY) DATE (MM /DB/MY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ( DAMAGE TO E occ ED $ ' ° _,. ._3.0 U:,. . ,,}, A CLAIMS MADE I X I OCCUR CPA020470112 1/1/2009 1/1/2010 MED EXP (Any one person) 5 .15,ii".`i0. PERSONAL & ADV INJURY $ 1 . 00:Q"j O GENERAL AGGREGATE $ ? ! ,QO0 S 100 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 , O.O: , 000 POLICY JECT I i LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000, -000 A ALL OWNED AUTOS MAA020470212 1/1/2009 1/1/2010 BODILY INJURY - (Per person) $ X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY $ _ X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ . ANY AUTO OTHER THAN EA ACC $ „ -'_.. AUTO ONLY: AGG $ - EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ , i .�Cl OCCUR CLAIMS MADE AGGREGATE $ - .... • $ 'v I. DEDUCTIBLE $ `;frl t( -- $( RETENTION $ A WORKERS COMPENSATION AND X TORY LIMITS IMITS 0 ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 5,00., 004, OFFICER/MEMBEREXCLUDED? WCA020470512 1/1/2009 1/1/2010 E.L. DISEASE - EA EMPLOYEE $ 500 „ 000. If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000. OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Operations usual to the sales & installation of doors & windows. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE_: THE ' Eric Dostal EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO,,IWAIL,_ 61 Fox Farms Road 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF7,;eU7 Florence, MA 01067 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE, INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Robin Sargent /RMS u ACORD 25 (2001/08) © ACORD CORPORATION 9$ INS025 (0108).08a Pag,dgIOf 4 'ter ollaw T3 U'3 4,//3.1' The Commonwealth of Massachusetts _* : Department of Industrial Accidents I = *!l Office of Investigations tG . y 1= 600 Washington Street `: _ l:�_ Boston, MA 02111 '` ..�- www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /' e //a /'D c/ti- S � ,.GhG Address: / 376 ..7/rl 5 .ree 9" City /State /Zip: 4rC-C n 4/e" I el Miq Q 1.301 Phone #: / 7 / /:f - 77 07 " 'D J /5 Are you an employer? Check the appropriate box: Type of project (required): 1 . ®. I am a employer with 7/ 4. ❑ I am a general contractor and I 6. n New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I 7 ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' ��� / q ] comp. insurance required.] 13.Xt Othe d� /ICe , e(/ii, hcz),S *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C. 4 C / 0 �4 S a r .i n CC (24 sW7 c74 v Policy # or Self -ins. Lim #: (4/6. /3 Q.--o /7 /J /02 Expiration D / ate:_ - /J /. d G / v / rtc ,!.)u,..1.YZ4/ Job Site Address: 6 / ,C c r a ►^m 5 �0e7e✓ City/State /Z �7 rCncc' /' Q /D 7 i Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby t y nder the pains and penalties of perjury that the information provided above is true and correct. Signature: eit4.4 A61441 `�L,i7 tt/ Date: DEC 14 2009 Phone #: /3 ' 7 D/ 5 - 3 k 3 a,I Official use only. Do not write in this area, to be completed by city or town official. '" City or Town: Permit /License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SITE RESPONSIBILITIE Customer: Eric Dostal Date: 1' 30 0 09/30/2009 Order #: Signature: A Salesperson: Paul Picard Signature: /AMA � �,��► • 1 50% Deposit required at time of order. 2 Final payment is to be made to installation team on the morning of the last day of installation. 3 If customer will not be present at time of install, payment is to be made prior. 4 Checks returned NSF will be assessed a fee of $50.00 to cover fees incurred by Pella Failure to pay your final bill will result in finance charges of 1 -1/2% per month (18% Annual) and legal fees associated in the collection of owed monies. 5 Due to inclement weather or site conditions, it may be necessary to reschedule. 6 We cannot and will not guarantee specific dates or days of the week for installation. 7 Time given to complete a job is an estimate, extension of time is possible 8 An Install appointment will be confirmed at Verification. A courtesy reminder call will be placed 1 week prior. 9 Unforeseen rot repair will be quoted on site as additional work via a Change Order. 10 Substantial completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are covered by Warranty and do not affect affect the status of a project from being Substantially Complete. 11 In the event that any products are unable to be installed, the final payment will be recalculated. The cost of products not installed will be subtracted froin the balance due. A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion. 12 Order is not binding until approved by Pella Products management 13ieCiaitk Permits Type of Inst New Construction: (tear out installation) Completely remove interior and exterior Trim, completely remove existing window frame, install new window in rough opening, re -trim both interior and exterior of window / door. Pocket Install : (sash replacement, existing frame remains) © Remove interior or exterior stops, install new window in existing window frame opening, re -use existing or replace window stops (interior or exterior) Some glass loss will occur. Lead Paint Discloser: #1 n Home was built prior to 1978, Lead Paint discloser has been signed and "Protecting Your Family From Lead in Your Home" brochure has been given to Home Owner #2 ri Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will Authorized to install Yard Sign on 1st day of installation and remove 7 days afterward Fl Ensure someone over age 18 is present at all times while Pella employees are in the home. © ❑ Deliver and unload products © n Place drop cloths in work areas © n R emove & reinstall interior and exterior trim if applicable © n R emove & reinstall existing shutters and awnings by contract © ❑ R emove existing product and adjust or modify opening as needed For all service needs, © ❑ Provide all equipment necessary to install products please call: © ❑ Cut all wood and other materials outside of home (800) 957 - 3552 � Please make sure you I I ❑ Install all products purchased mention that your project © n Insulate and caulk around products was installed by Pella and reference your order © n Remove stickers and perform initial cleaning of all glass surfaces number © n D emonstrate proper operation of products © ❑ Confirm that all products are in working order NI Remove drop cloths, vacuum and remove all old products from premises ;f4► inish (paint or stain) product purchased ❑ © Cut -back or tie trees, bushes, shrubs from exterior wall n © Arrange to have alarm system disconnected and reconnected ❑ © Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor ❑ © Remove and reinstall existing window treatments, wall hangings and air conditioning units. ❑ © Remove and reposition furniture in work area ❑ © Secure pets in a safe manner ❑ © Remove valuable / breakable items from work area ❑ © Remove snow from area of worksite if necessary { 4 i I Customer: Eric Dostal Project Name: Dostal, Eric Si Fox Farms Road Florence MA 01062 Order Number: 739 Quote Number: 503773 Project Checklist has been reviewed Order Totals Taxable Subtotal $13,051.90 CredNI Card Approval Signature / Sales Tax i 6.25% $815,74 b Non- taxable Subtotal $4,447.40 ustomer ame {Pi prni) P - - - - ep Nam (Preasse p Total $18,314.64 �— Deposit Received $0.00 Amount Due $18,314.64 Customer Sign ture • 'Ella Sales Rep Sign re Dale Date For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website atwww_pella_oom Printed on 1111112009 Contract - Detailed Page 7 of 7 a Office Order Copy qui-1(f- • 73900 Number: 739I3LP131 Number. Order Number. Window Branch Store Name: Quote Number: 503773 Quote Description: Site visit 5 -26 -09 AS Project Name: Dostal, Eric 61 Fox Farms Road Florence MA Customer Information Deliver To Address Order Information Eric Dostal Lot # Sales Rep Name: Picard, Paul Cust Delivery Date: 12/28/2009 Address: Business Segment: Retail Quoted Date: 05/26/2009 61 Fox Farms Road 61 Fox Farms Road Market Segment: Single Family Replacement Contract Date: 11/24/2009 Order Type: Installed Sales Booked Date: 11/24/2009 Effective Discount: 2.808% Earliest LRD: 12/01/2009 FLORENCE, MA 01062 FLORENCE, MA 01062 Commission Split: Picard, Paul - 100% Contact Name: County: HAMPSHIRE Tax Code: MA Tax Exempt #: Payment Terms: Deposit/C.O.D. Customer PO #: Day Phone: (413) 218-6344 Owner Name: Accessories Managed Accessory Delivery Date Mobile Phone: Eric Dostal Fax Number: E -Mail: Owner Phone: (413) 218 -6344 Great Plains #: 53H2186344 Customer Number: 3414816 Delivery Instructions: 91s to exit 20. Turn right at 1st light. Continue several miles, turn left on Fox Farms Road. House on right. Installation Notes: 91 s to exit 20. Turn right at 1st light. Continue several miles, turn left on Fox Farms Road. House on right. Wells Fargo customer, not collection at install. • Printed on 12/08/2009 Office Order Copy Page 1 of 10 -- - - glee Leo- rrvrrwnwveal/i ilaxuacluwel6 Board of Building Regulations and Standards 77-17,4114, _ HOME IMPROVEMENT CONTRACTOR E st Registration: 142279 Expiration: 3/24/2010 Type: Supplement Card PELLA PRODUCTS, INC. PAUL PICARD 155 MAIN STREET GREENFIELD, MA 01301 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 Not vali ' wi hout signature . , Pella Products, Inc. 155 \lain Sti C'reenlield, N1,1„ 01301 Plione 4 ( ' . . . To: Builciiw1. lospeclo[ U'ront: 1);IvId \\lilt,: )w;tit11;ition Nlana‘2,er Date: januarN IQ, St.11.11'.,(1': Building Permit ,11wlications & 1)esignees Pella 1)voducts locoq)oratcd l'-: in WC husiness or repinciiig \■ iiik10\A :,110 doors for our customers Our process includes providirn!. a buildini2 permit for each and evon, proicisi I am a licensed Construction Super\ isor. 1),iiililmi2. permits \\ ill be applied lor usiiit my LSI. - 091 Vi( and our Lift '. I -12? I)I,,:ase had a copy 0 I ill \' licenses belo\\ „ NI A kkil.: 1w ii • - Otpoillnivrat "I PlIbliC "..111l i:.• it 113..:11C .1 Btu Illirou. Rctmlaii•mrs .und . ...Lull:J.111k (7...1nstr,,cton R.10,11aliti Pro: 00 04.1 - Unrtstritta-d U.; - 1 2 Parnily linvoei. L 'n CF. 5 Fic 'kr GO DAV° C WHITE : .,,,:, FNilurr 19 p4metx I cuercra r (Elkin u.f lb: 64 CARENTER ST , ..,....N , ...; 0 0." , t...::, Mossachkoetto 'As& Swhrling ( 'fide ORANGE MA 01364 X'' , . ,, ''''''' k titan Ira re‘ocation i•f Lim liversiL 1 11 Firfer in: IN WW.Mast.ciuniDPS r. . pu'Al in ry :1 Th ' Tr..- Lich installation \\ ill be staffed b our installers \\ 110 arc all licensed in accordance \Nith current 'ouiliiiine code s. rollo\\ in.2, ;lie conies of their current licene... Please accept these inch\ iduals as lin if von U\ c air( CIUL'SCIOP please conlaci Inc tisiin,1 the unnbc listed above, - 1 - _ _ . • PELLA PRODUCTS INC 155 MAIN STREET GREENFIELD, MA 01301 7 1 r:(/ PV7 0:i i (f7(, C i l Subject: Disposal of Debris The purpose of this letter is to certify that all the debris resulting from any project undertaken by Pella Products Inc. in your Town will be transported to a dumpster at our main facility at 155 Main Street, Greenfield, MA. Pella Products Inc.is under contract with Waste Management of Massachusetts for the disposal of the contents of this dumpster. Very Truly Yours, PELLA PRODUCTS INC. John P. Benjamin Accounting Manager ti w r SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : )r'r 1 i d . L� h [ � 09/ License Number / 621/) 5� (E ' ( ' f ()reeo AilA 0��C ,_ "C1/ Address Expiration ate f C Ca Ck)h ( eif - 0 / Signature Telephore 9. Registered Home Improvement Contractor: Not Applicable ❑ 1 /6 (ALA Tr IC 14/2 7 79 Company Name Registration Number Addr Expir to c� // / ' Telephone 7/ — 7 / T - 72 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build' permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CAR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 11. • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [D] Brief Des__uf1Ptigqnn of Propposed / Work: _1 h��tc� /lct a { - 1,5 tAlir7 .du)c . l� iii, -)( ex r ; �w' ne��a��L C. �r,� 3 - ir G C iz. eS Alteration of existing bedroom Yes No dding new be oom C_ Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �Y ! L 1 /G,S Gt , as Owner of the subject property / �— hereby authorize J �. (I f.( N OC u ( to act on my behalf, in all matters relative to work authorized by this building permit application. `4" sec c, oed (rn Er r, l2 • l D`1 Signature of Owner • Date f ( //(t � (tt� P; � � - i elf , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name 3 = i Signature of Owner /Agent Date ti r • P Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parking) ti of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES;. describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1.1 , II , I Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Nprthampton, MA 01060 Two Sets of Structural Plans phone 413- 587,1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office (f //71/611 F Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Fr tnx i1CLro S 'T© ' , rrr. /)ce RA /6'6 Z. Name (Print) Current Mailing ddr ss: � p, ( 4/ � 2 1�fi .__6Ny , Or Sc SiC " nee C(:h)lrc Telephone Signature 2.2 Authorized Auent: / < /� ( � /J U‘� ��� / ) / t J k€ r � lJi'1C�L'%JII E':(� /I Name (Print Current Mailing Address: 0 c C X72 -O/S 3 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 0 , t5 c5 4/1l /113C This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date * 61 FOX FARiu# `g3 ; BP- 2010 -0612 GIS #: COMMONWEALTH OF MASSACHUSETTS f CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0612 Project # JS- 2010 - 000894 Fst. Cost: $19000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 28793.16 Owner: DOSTAL ERIC & ELENA Zoning: URA(100)/ Applicant: PELLA PRODUCTS, INC AT: 61 FOX FARMS RD Applicant Address: Phone: Insurance: 240 MOHAWK TRAIL (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:12/17/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 12/17/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo