17C-087 (4) Pella Products, Inc.
155 Main Street
Greenfield, MA 01301
Phone:413-772-0153
Cell: 413-834-8799
To: Building Inspector
From: Trevor Bross—Installation Manager
Date: June 8,2015
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#CS-096558 and our HIC, It 182150. Please find a copy of my licenses below.
IM Massachusetts -Department or Pubic Sa`o;r Unrestricted-Buildings of any use group which
Board of Building Raguial ons and Standardo contain less than 35,000 cubic feet(991m)of
Con%truction Supeniarr
License: CS-0965584 enclosed space.
TREVOR BROSS
10 GEORGE STREET
Greenfield MA OT301
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
"ornmissioner 03/01/2016 For DPS Licensing information visit: www.Mass.Gov{DPS
— /I
�L" Office of Consumer Affairs&Busimess Regulation License or registration valid for individul use only
t\ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found refurn to:
k ;;Registration: 182150 J Type: Office of Consumer Affairs and Business Regulation
IT? t 10 Park Plaza-Suite 5170
Expiration: 6/1/2017 Individual
Roston,MA 02116
TREVOR BROSS
TREVOR BROSS �-...��
10 GEORGE STREET
GREENFIELD,MA 01301 Undersecretary Not valid without signature
Each installation will be staffed by our installers who are all licensed in accordance with
current building codes. Following are copies of their current licenses. Please accept
these individuals as my Designees:
Willard Brown CS106010 Vladimir Shevchuk CSSL099209
Scott Bowdish CSSL100232 Curt Boyle CS78514
Dave Ruffner CS57308 Bill Leger CS89338
Chris Gamache CS86946 Brian Thompson CS67121
Andy Kimball C1,385981
If you have any question,please contact me using the numbers listed above.
- 1 -
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: loco C kt.� Yw SF . Florr�cL _ M III- yl ocoZ
The debris will be transported by: ?e Ilca Prvd,ch Inc,
The debris will be received by: '?tlta Pro&,Khs 1f%T155 ma:� St- Cw Jot
�i 30l
Building permit number:
Name of Permit Applicant ?el\a Vro6Lxtz 1 nL (Trcvor- (Smpss)
11 ILA 115
Date Signature of Permit Applicant
L
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Ogice of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADnlicant Information Please Print Legibly
Name (Business/Organization/Individual): Pella Products, Inc.
Address: 155 Main Street
City/State/Zip:Greenfield, MA. 01301 Phone#:413-772-0153
Are you an employer?Check the appropriate box: Type of project(required):
1.X■ I am a employer with 49 4. [E] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. F01 Remodeling
ship and have no employees These sub-contractors have g, E] Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*My 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:Hanover Insurance Group
Policy#or Self-ins. Lic.#:WHN-9399766-02 Expiration Date:01/01/2016
Job Site Address: too �Q Sh J� City/State/Zip: F(O( E?a� MA o 1 0fa Z
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 certify under thepains and penalties ofperjury that the information provided above is true and correct.
® r 1 � qll,5
Sigrtatur e: —"
� ""'—��-
Date:
Phone#: Above
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 1 io�r %!'Ox �? -09('S S%
License Number
Jo -:-2�/ t /Icp
Address Expiration Date
3 115�K 31-1
Sign ur a ep one
9.Realstered Home Improvement Contractor: Not Applicable ❑
Tow bfos5 (Petta, Qrodvch lr�l Ica a 150
Company Name Registration Number
O Gear 5� okloo\
Addre Expiration Date
Telephone 4I S 17
FOK
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,g 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 buildirwfpermit.
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.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 uerson 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 buildine 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [_� Addition ❑ Replacement Vyjr(dows Alteration(s) F_� Roofing
Or Doors i
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[a
Brief D scri tion of Pro oseq
Work: uSi cxis6na O / 1�dtrLm'-S
Alteration of existing bedroom_ Yes No Adding new bedroom Yes ✓ No
Attached Narrative a � „� �� �� Mdreo� Renovating unfinished basement o
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 Bathr oms
c. Is there a garage attached?
d. Proposed Square footage of new construction._ Dim sions
e. Number of stories?
f. Method of heating? Fireplace or Wood oves Number of each
g. Energy Conservation Compliance. Massche Energy mpliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is co struction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finis d 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, Andrea `LGsAAOr% as Owner of the subject
property
hereby authorize PL°(IQ PrdCluC�%
to act my behalf, in all matters relative to work authorized by this building permit application.�_M L&=:� X01 30 � IS
Signature of Owner Date^
I, Pe Ila %oclo Cks k n L 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.
TrtVO(- Pe la d �. Inc
Print N
( I Ig (,s .
Signatur f 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
tXIS�ry IRe 1 a 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)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Findin er been issued for/on the site?
NO ® DON'T KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Regis of Deeds?
NO Q DON'T KNOW YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Cl Obtained Q , Date Issue
C. Do any signs exist on the property? YES Q 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, exca on, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
C ty of Northampton Status of Permit:
NOV _ ?N, 1 B ilding Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability
Room 100 Water/Weil Availability
pHF`i.OF8U1 D.YJ;31N.`.F'.�7tGN�
NORTHAtvff(nN,h1A 01060 o ampton, 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
too ue4Y4 >* Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A Ad. t& LA aik, loo C,hr25.} J Sk . F Iu M A o 10(0 L
Name(Print) Cu rr nt Mai in ddr
l is-4 'i-rqg 3j
Telephone
Signature
2.2 Authorized Anent:
1 rc,Vor 3ross (PelieL Pfoctuck 4 n c I% mcr A Sr , Grf p n j tic I Fla 013 01
Name(P- t) Current Mailing Address:
N I'S- -7 x 31�
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by ermit applicant
1. Building ,0.�g ,$ (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing O Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 0
6. Total= (1 +2+3+4+5) _10'516. 2jS I Check Number t/ ajfz
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
100 CHESTNUT ST BP-2016-0655
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-087 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2016-0655
Project# JS-2016-001099
Est. Cost: $7038.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 096558
Lot Size(sq.ft.): 11064.24 Owner: LEYDON ANDREA
Zoning.URB(100)/ Applicant. PELLA PRODUCTS, INC
AT. 100 CHESTNUT ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON:11/10/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 7 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 11/10/2015 0:00:00 $40.00
212 Main Street:,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner