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17C-236 BERKSHIRE INS Fax:14135684284 Aug 6 2010 8:11 P.01 .. • ACORD, CERTIFICATE OF LIABILITY.INSURANCE f DATE (413) 773 -99X3 FAX: (413) 774 -3872 THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION Masa30ne Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 1H15 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# "� D INSURER Continental Western Pella Products, Inc. INSURERS: - ATTN: Jots Eenjamin INSURER 0: 155 Main Street INSURER D: - Greenfield MA 01301 -3258 INSURER E: ; QYERA .... THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 711E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. ,A RFC' TE LIMITS SHOWN MAY HAVE BEEN,g��ICED BY PAID CI AIMS LNSR A DD' POLICY EFFECTIVE POLICY EXPIRATION 1 R - • TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDNY) DATE (MM/DDNYI LIMITS GEN ERAL LABILITY FAC:H OCC,URIIUICE $ 1,000,000 DAMAGE TO RENTED COMMERCIAL GENERAL LIASILITY S(EA ) $ El 300,000 � , A •III OLAItSMADE I X I OCCUR CPA020470113 1./1/2010 MEDEXP(Any one person) $ 15,000 III PFRSONAL & AnV INJURY $ 1,000,000 III GENERAL AGGREGATE S 2,000,000 GEM_ AGGREGATE UMAT APPLIES PER PROM ICTS - COMP/OP AGG $ 2,000,000 13 P POLICY J LOC AUTOMOBILE LIABILITY CONISINED,$INGLELIMIT $ 1,000,000 ANY AUTO .... . {Ea acoda�t) A II ALLOWNED MAA020470213 1/1/2010 1/1/2011 BODILY INJURY (Per Ron $ © SCHEDULED AUTOS , X HIRED AUTOS BODILY INJURY 3 (Par arcidant) X NON -OWNED AUTOS PROPERTY DAMAGE S (Per accident) • GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ - ANY AUTO OTHER THAN EA A I' AUTO ONLY; A00 3 EXCEBSNMBRELLA LABILITY EACH OCCURRFF(:F $ 1 OCCUR Fl CLAIMS MADE AGGREGATE _ 3 DEDUCTIBLE $ - -. RFTFNTION $ v� T $ A WORKERS COMPENSATION AND X I T(�R` MSI I ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERJEXECUTIVE E.L EACH AQCIbf,N'T 5 500,000 OFFICER/MEMBEREXCLUDED? 9PCA020470513 1/1/2010 1/1/2011 E.L DISEASE - EAEMPLOYYE$ 500,000 If yes, daseribe under 500 000 SPECIAL PROVISIQNSbelow E.L DISEASE - POLICY LIMrr $ r OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEACW8IONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations usual t0 the sales Of windows & floors. CERTIFICATE HOLDER CANCELLATION (413) 736-3390 SHOu4D ANY OF TM ABOVE DESCRIBED POLICIES BE CANCELLED BEFom THE City of Northampton EXPIRATION DATE THEREOF, THE 188WNO INSURER WILL ENDEAVOR TO MAIL 212 Main Street 1.0 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Northampton, DOA 01060 FAILURE TO DO 30 SHALL mapOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRSSENTArvE Norma Laforest /SPG ACORD 25(2001/08) ©ACORD CORPORATION 1988 INS025 (o1o5).aes Page 1 of 2 The Commonwealth of Massachusetts Department of Industrial Accidents l ai. -„ :.: _ Office of Investigations 600 Washing ton Street . t r : '° Boston, MA 02111 ''''''4.1. www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): // � / du e / 3 ) —1/2 G. _ • Address: f55 /11 eVin S y rte City /State /Zip: 6 T'«,, j E � Ay? 0 /20 / Phone #: ' /J - 70. v / 3 Are you an employer? Check the appro box: Type of project (required): 1.114 I am a employer with 7() 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. El New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working ca employees and have workers' g for me in any capacity. ty 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.H Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.1,Z Other a /ct al., c✓'ou>> comp. insurance required.] Mb--)ci loo r 5 *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. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ' 7CY / c 7 / n u r _ CE n Policy # or Self -ins. Lic. #: 6-0 G i`"( Q c77 O 4 2 ! 7/ .3 Expiration Date: / • rJ 7 r} 0 /7 Job Site Address: 15 Er raLt i.Q t ` Lree Cit /State /Zip: �a r prt Q d I c( 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 certi under th' pains an penalties of perjury that the information provided above is true and correct. Si. nature: ♦ • , _ `� __ 12 Date: I j 1 I 1 6 I Phone #: (4I?)> 13( - 9' 7 �9 X I I O 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 #: ■ , ce, , g -62, ._ . _4, 4., 4.41 . 40/4 stiiit, ': Office of Consumer Affairs arid 'Business Regulation . _ 1 • .. ... 10 Park Plaza - Suite 5170 ' An ,, ZolOr Boston, Massp*usetts 02116 Home Improvement Itst ctor Registration _ .........,. ----- Registration: 142279 4 /1 ''"--------.-: -:---).= 7 ' ,,, ' Type: Private Corporation Expiration: 3/24/2012 Tr# 294515 PELLA PRODUCTS, INC. I I ..7.--:...- ';. GARY SHERMAN !i.17,1 ._.. _ -:-\ 155 MAIN STREET ... _,.. • ..=-1 GREENFIELD, MA 01301 ,..., ,.. jp) t v --- ___.„ 14 N : ---- . ... -- / //..:4 .<:./ 'Update Address and return card. Mark reason for change. n Address J Renewal Fi Employment — I Lost Card DPS-CA1 0 50M-04,104-G101216 g2e ectittmcitetietzat 44.Aarktaedialaelea Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before - the expiration date. If found return to e? Registration. Office of Consumer Affairs and Business Regulation '''*'', ExpiratktieVV412 Tr# 294515 v-11_-_-----: :j'4 i 2279 10 Park Plaza - Suite 5170 - , --- ', 0 . 4- 5, w. Type c'IV.I.::''' , . Boston, MA 02116 t:P.5)p93gration PELLA PRO DU q1S , GARY S HER MAWaV-; ■ r , W 155 MAIN STREET AO / T,::,"''; ..,-;.: egra.044...--.5.--. '' . .). ....•142ge • A oil A i A jr ALAIIANA GREENFIELD, MA 01Stb.:-' ' Undersecretary ,.. I ot vali/ itho signature • Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Phone: 413- 772 -0153 Cell: 413 - 834 -8799 To: Building Inspector From: David White — Installation Manager Date: January 19, 2009 SUBJECT: Building Permit Applications & Designees Pella Products Incorporated is in the business of replacing windows and doors for our customers. Our process includes providing a building permit for each and every project. I am a licensed Construction Supervisor. Building permits will be applied for using my CSL #091496 and our HIC, # 142279. Please find a copy of my licenses below. tf . 11 t te{ats crr tta:lt441tthint40 Ptttsh ± .. ftekaI'd 01 tai otaiInv, itottuittlikulk A ttii 'I fl4t4retk (,,4) at ,tit e r i$ . y d t ■ _ a.azv,. lib- Vomit-143(4 i,� raa ?tam 14:- 1 2 Futility Mums s DAVID C r r3 TE t 4 aT t S .. , 16111re tot oos A cut- mut+Alio* of Ow t,t uv+sch ttK Stutu guildittg -t+ arty. ORANGE„ MA CO 354 .- : 4, ? tituu: scat ruulw ation ut this license. Rv.fcr to: Nvi,aAV Mus < ;tri /1)k ".;„‘,_ mom „r F . t gyp 1.1'1 To Whom It May Concern: I, - &JA∎c L\(\, \, , as property owner, give permission to our contractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in my home, located at 3 (Q�.w 9 �� E. � () c Q \t\(_.0 OA 0 i � � Please accept this letter in place of my signature on the permit application. Thank you, '(\()( Lov■Jcp,\ \ Please Print Name c t D(A) / eowner's Signathre Date • s 8.1 Licensed Construction Supervisor:. `� Not Applicable ❑ 1 Name of License Holder : h\J (\, U.3h t Pet 1( � Inc _ aq J 14 ( , License Number 61.1 r :e: . 1 : 03• I131II Address Expiration Date ttfiik Lc, 6413)712 -OIS"3 Signature Telephone nor, llfr' =i sr «� a�b' Not Applicable ❑ Ye■‘IcA ?rnrkUd I nt . I 21 Company Name Registration Number 1 5 S iJ1c i * . 6rP,2.nfi d YYIr‘ 0 13o I 3la.1.0 1 I c� Address ' Expiration Date Telephone (q (3)11 — 0153 • 0' sa r "� , # ' , - Y'^��` 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 buildin permit. Signed Affidavit Attached Yes No ❑ 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. CMR 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 ., D rai • o ' x ; ro ": X '0'4 7 "?'• �`. ,,. .K S ' r „ '' 'r ^r .cam '` x , air ..x '• �.. � � � ,e^ New House ❑ Addition ❑ Replacement Wye►' Bows Alteration(s) J Roofing LJ Or Doors L� Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other [0] Brief De cription of Proposed Work: i • • ' • • ea • a. as, . . . a a . . r_ • Q (Q 4 t • Cl2. . . SaCT r0.1 CC\ G.e Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet 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 POC1Lr2� �c \ -( \\ — replGC -Q Pte} W r\CA.Uw% 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 '�,np%c,�^Ir`x- G"a' ? •°tf+ 'S� >+u.ifP Y ,R �' K f :� F < p $ s.y� q ` a� S3 •s•§f� 9 5.3 "344 1 ask �� � �� f z I, \ Oh n C'1' 1.-(103\e\\ (\ , as Owner of the subject property J hereby authorize - 4A rkR rbdvc - S In C-- to act on my behalf, in all matters relative to work authorized by this building permit application. See h oe ntfc & 1114) tb Signature of Owner D to 1, J V\ l •k ) h t as Owner /Authorized Agent liereby 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. 1YaVla (.t)k1 — Print Name Q;Atc C, tt) IA Signature of Owner /Agent Date .* , Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning f This column to be filled in by N 0 l r� k Building Department Lot Size 1 11 11 Frontage 1 11 11 1 Setbacks Front 1 1 1 1 1 1 Side L:1 1 R:1 1 121 1 R:1 1 .1 1 1 Rear 1 1 1 1 . 1 1 Building Height 1 1 1 1 1 Bldg. Square Footage 1 1 1 1 f 1 1 1 1 Open Space Footage (Lot area minus bldg & paved 1 1 1 1 1 1 1 1 ( 1 parking) # of Parking Spaces 1 1 1 1 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 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 1 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW CY YES 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 ® 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 0 NO er IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Y r & � r „ v LL T BP-2011-0444 GIS #: COMMONWEALTH OF MASSACHUSETTS 17C - 236 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- 2011 -0444 Project # JS- 2011- 000722 Est. Cost: $8183.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 8189.28 Owner: MCLAUGHLIN JOHN M & JULIA C Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 73 BARDWELL ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:11 /10/2010 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 11/10/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner