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28-012 (7) . . SITE RESPONSIBILITIES Customer: Blake *, Gail Date: - 09/17/2009 Order #: 0 Signature: < /n Salesperson: Michael Balthazrr Signature V, .Q, Q r 1 50% Deposit required at time of order. s q 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 retumed 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 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 from 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 13 Pella will secure all necessary Building Permits Type of Installation: 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 gn 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 I. Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will NA Authorized to install Yard Sign on 1st day of installation and remove 7 days afterward © Ensure someone over age 18 is present at all times while Pella employees are in the home. © n D eliver and unload products 0 Place drop cloths in work areas © Remove & 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 © Provide all equipment necessary to install products 0 Cut all wood and other materials outside of home © I � 1 Install all products purchased © I 1 Insulate and caulk around products © ri R emove stickers and perform initial cleaning of all glass surfaces © Demonstrate proper operation of products n C onfirm that all products are in working order © 0 Remove drop Goths, vacuum and remove all old products from premises © l l F inish (paint or stain) product purchased © Cut -back or tie trees, bushes, shrubs from exterior wall © Arrange to have alarm system disconnected and reconnected © Arrange to have any plumbing or electrical repairs or changes by For all service needs, appropriate licensed contractor please call (800) 957 - 3.552 © Remove and reinstall existing window treatments, wall hangings and Please make sure you air conditioning units. mention that your project © Remove and reposition furniture in work area was installed by Pella ❑ © Secure pets in a safe manner and reference your order number © Remove valuable / breakable items from work area Remove snow from area of worksite if necessary FROM Ber lcshire Irisurarice Group (WED)OCT 7 2009 1: 19/ST. 15:15/No. 7527319028 P 3 • ACORD, CERTIFICATE OF LIABILITY INSURANCE 10 /7 /2009 PRODUCER (413) 773 -9913 FAX: (413) 774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MassOne Insurance Agency 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 Wes tern Pella Products, Inc. INSURER B: 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 INSRD TYPE OF INSURANCE POLICY NUMBER POLICY W DDIYY POLICY (MMIDD/YY) EXPIRATION LIMITS LTR INSRD _ ( ) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 3 0 0.., 0 $ X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) A CLAIMS MADE X 1 OCCUR CPA020470112 1/1/2009 1/1/2010 MED EXP (Any one person) $ 15;.,000 PERSONAL & ADV INJURY $ 1 , 0 0 0 A 0 0 GENERAL AGGREGATE $ 2,0004:00. GENII.. AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGO $ 2,000,000 POLICY JECT � LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea $ 1,000,00D. Ea accident) ANY AUTO A ALL OWNED AUTOS MAA020470212 1/1/2009 1/1/2010 BODILY INJURY (Per person) $ X SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY $ (Per accident) X NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ . ANY AUTO OTHER THAN EA ACC $ -- --- AUTO ONLY: AGG 5 _____. EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ ;_ f} - • 7 OCCUR CLAIMS MADE AGGREGATE 5 : , . . DEDUCTIBLE $ RETENTION $ .i. A WORKERS COMPENSATION AND X ) TORY LIMITS IDER . , EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 500,000' OFFICER/MEMBER EXCLUDED? 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 OPERATIONS /LOCATIONSNEHICLES /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 Gail Blakesley EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO ..MAIL 272 Sylvester Road 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,_BUT Florence, MA 01062 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 ACORD 25 (2001/08) © ACORD CORPORATION 1988 INS025 (0108)08a Page 1 of 2 f The .Commonwealth of Massachusetts • 0.= Department of Industrial Accidents i = . + Office of Investigations 600 Washington Street R Boston, MA 02111 ;z �,r�' www..mass gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers A Information . - . Please Print Legibly /i .� � � Name ( Business /Organization /Individual): r / 7'6P/'I , I7 C. Address: /S : ��irj S 9, 9 - , City /State/Zip -ree /d Mg / /30/ Phone #: V /,1 721- o /617 Are you an employer? Check the appropriate box: Type of project (required): 1. Rj I am a employer with . 7 7 ff . 4 -. 0 I am a general contractor•and I: • ' .' employees (full and/or part- time).* . have hired the sub- contractors 6. ❑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. 0 Demolition - • - wbrkin . forme in any capacity. 'employees and have workers' g . y P tY $ 9. ❑ Building addition . [No workers' comp. insurance comp. insurance: 10.0 Electrical r or additions required.] 5..0 We are.a corporation and its ep aus officers have exercised 11.0 Plumbing repairs or additions • 3. ❑ I am a homeowner doing all work myself. [No workers' comp. - right of exemption per MGL 12.0 Roof repairs • insurance required.] t .c. 152, § 1(4), and we have no .. . employees. [No workers' 13.0 Other • . comp. insurance required:] - *Any applicant that checks box #1 mast 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 anew 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: ./6076/ ./ if S ci r An Ce ( i vy, any _ Policy # or Self -ins. W. #: (f) G eatil /J ,:2D_19'e .'S / og, • Expiration Date: D /- 0/7 ez ? 0/0 Job Site Address: . 2 7 2 S, ki e, - er .T OA City /State/Zip. J .(S(1'h 010 6 2- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).- Failure td 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 ce u der the pains and penalties of perjury that the information provided above is true and correct. Signature: d Date: DEC J 2008 Phone #: is- . d / 6.� 02 Official use only. Do not write in this area, to be completed by city or town officiat 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 #: • • • • • • Board of Building Regulations and Standards . ' ° t = ; HOME 1M OVEMENT CONTRACTOR . = « r ? Reels tr oa: _42279- r :474,7,1m , . • PELLAPR• a 4114 . g. _ tN - 155 MAW STT3EET _ • • - G.REENFIELD, MA-01301- Administrator • • • • • • 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. '.l:tM! :ltu. tttt - Dop. *t 'nr c P' ih aet i t * Board of Building Re letion% Add StAnder ei« 1, Construction Satpervis+ r ultimate ilk- Unrestricted Lien ; CS 9i+ S tC: - 7 2 Family Botaes icted 4q;,, 013 DAV1O G ATE ig Failure to poetess r torrent edltioa of the CARPOITER sane State Building i �`' '" �' to Baer Ow motional of Ole *moo €x t;r,: i Pdi/ 1 t > r m: ?►mss GtrrJ kl"S t ,.,.tt+i.,. T: WIG arOlitAli 8.1 Licensed Construction Supervisor:. Not Applicable ❑ Name of License Holder : fLl1 i d 41 09 444 II_ n License Number J5LS f can �S +reer, Gi-ee . e,L1 01 301 1 20i1 Address Expiration D to 3JC.L&JF , €n3) 772 - 01S3 Signature Telephone h , a Not Applicable ❑ Tel A Tro Aic,45 Tint' . 1T 2.2 7 9 Company Name Registration Number JS'S /4 a44 sfre e -i Green -MA MA 0 130 I 1 2 �# 2010 Address Expira bn Dat Telephone (413) 772 - 0 1.7"..3 ; Workers Compensation Insurance affidav t must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil g 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 ,Ste_ C►yM 149 } a l> � N ESN g 8 �� Fi '� AF3 gig, e x -A 7 • Nt. 2 ' x .,n. .a, }4+ «..' o , � � '�� �' ��� � s��� 7 .�'�'� -c, w�pm�r.� New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors. 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks [[] Siding [DJ Other [0] Brief Descriptiop of ProI�sed I �� 1 Work: Zr�St0.�(aiinn n y U iny t OinkO�S . ��S►n e1c is 41 Drn �. id() Sj7dC6 Alteration of existing bedroom Yes 1 No Adding new bedrJm `mss Ciut( es' Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 'Yf A °, :�_ � 8 �.' `aHt7 ®. ?b� �d$•. .A '� '( 9,' B a l a f � 5 x' ® - .,. � sly ".�. 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. floogplain 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 i y"> ,; .<'rx' 'pi'p a "t ..b�(6•y �� ^t}a��S Gs<'h..g`,�+,'.e„� +`fie '` "(K �f` ..,}t . 7 1 !$lfaJy�a � �� . L . k �"ill1L kr f + % °!'L(° .A4Y, , °' ,.. • ; a . evIrl t � , 1r° u t I , ( a i t 3' akes e i , as Owner of the subject property / �. hereby authorize 'Pe I, a ?CO �uf, lS t rIC to act on my behalf, in all matters relative to work authorized by this building permit application. See S't net.. Co,kra.c 1 e g •O 9 Signature of Owner Date I. �ekkO. ?roLic4 , Sync . , as Owner /Authorized Agent 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. M i G1 ae 13a I-�a7 rr� Print Name V f 0 • T • O c l 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 This column to be filled in by Building Department Lot Size 1 11 11 1 Frontage 1 1 1 1 1 1 Setbacks Front 1 1 1 1 1 1 Side L:1 1 R:1 1 L :1 1 R:1 1 1 1 1 1 Rear 1 1 1 1 1 1 Building Height , ' 1 1 1 Bldg. Square Footage 1 1 1 1 1 1 1 1 1 1 Open Space Footage % (Lot area minus bldg & paved 1 1 1 1 1 1 1 1 1 I ling) - - -- # 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 0 YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® 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 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: I 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 IFYES,_siescribe 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . .. .✓ 3n • 11 : 1414 5 4%9-' °F k X 13 City of Northampton Building Department :: �.�, r�' 4. p 212 Main Street ' -°'r �� 13oom 100 k3 � � Nort�i�mpton, MA 4`1060 ,r,4� ,-,(4 ., ia. @� ! - • phone 41-87 -1240 Fax 413 - 587 -1272 -��_ • • APPLICATION TO CONSTRUGT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ON OR TWO FAMILY DWE ass ad r rX : 5 ; st '� s 1.1 Property Address: ...,at $�a�CeSle ac r f•'.,--:,..; ., ' � .' ' 1, S .2.-77-L y (Yes '�o � � _ � `f � L a t h '" t' �` S o - 4 • ' i F E Nr i 3zk a v °. ?a t � � x i is ,r „,' ° at�l �`1 ti �, tih ii a k !'� ,4 ; s a ,. �. _ 2- Y� Y s_yy`+ R.:c''� e, ,t �. r„� K c` `"z4 i + m. c . �' .., ##� 'v. •f,`�Fk '�.��"�,„..,, � ,:a\ .' ._ .. s. ,t` "' sy .+�• r #t i •k<<a'u 2.1 Owner of Record: Gal l�lr�kesley 272 g (vesftr �oa orpince. NIA 0in6�- Name {Print) • Currer Mail' s: fl3� .sR 2 56 9 c :[ [ a, • Teleph ne . Signature . 2.2 Authorized Agent: I t t to l�'- &z.rr- ' . j: �. i ll Name (Print) Current Mailing Address ��� \�— ( 73 736 -423 . Signature Telephone ... .. ... . .. P l'��.°"� ����' Ja i .J:Y .�v.�rr!i > \�: < � Item Estimated Cost (Dollars} to be Y r` - , com•letedb .ermita•• `', } i a: ". .;� -.. s < - fir.. a . : ; :: : �_ ... , . ' ., .. -.ate- f,C�E'A \ .. kj � y \ 1. Building 1 �"'��� �a G Z F. V AY rT" Y E 2^ Electrical E� � r 3 3 � y f }r l- A7 ,,,„..- ..' ''Y,t o S l 3. Plumbing €if `��,5 : 4y , 4^ Mechanical (HVAC) �� rl =�4 := a 1, ' k s F 5. Fire Protection r , & 4 : k 'J5 ,.. 6. Total 1 +2 +3 +4 +5 - U E . k a..: z p .: ` .o f•• .. ,!� > .:1:33' ' L. %- ^. . .... . . -. /... : r '^... _..., ... :._v. ` ��a.J:'.':{ : . : 7,: y ..:.�,...i: s . j < : .a vxY:. ":j•:' � :r r > ;, 3 , < s �;:�' " ry 'ka \'�/'�•1 t� .i. z > '12T' )Y. %i.,{ a '-'44 s1 ¢ c a,, } YL << % .. . :a ;t .. ._ ,; • • 272 SYLVESTER RD ' BP-2010-0421 G1S #: COMMONWEALTH OF MASSACHUSETTS BI ck: 28 012 ' 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 -0421 Project # JS- 2010 - 000574 Est. Cost: $1971.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 34891.56 Owner: BLAKESLEY BERNARD A & GAIL A Zoning: RR(100)/ Applicant: PELLA PRODUCTS, INC AT: 272 SYLVESTER RD Applicant Address: Phone: Insurance: 240 MOHAWK TRAIL (413) 772 - 0153 WC GREENFIELDMA01301 ISSUED ON :10/19/2009 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 10/19/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo