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12C-104 (8) BP-2023-0668 35 RICK DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-104-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0668 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2023 Contractor: License: Est. Cost: 10548 PELLA PRODUCTS, INC 096558 Const.Class: Exp.Date: 03/01/2024 Use Group: Owner: MOULTON, GLORIA TRUSTEE &MOULTON, ERIC Lot Size (sq.ft.) Zoning: RI/WSP Applicant: PELLA PRODUCTS, INC Applicant Address Phone: Insurance: 155 MAIN ST 6H15382 GREENFIELD, MA 01301 ISSUED ON: 05/23/2023 TO PERFORM THE FOLLOWING WORK: 8 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: r, . • . >2 . If Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner MAYigi 1 2Q23Che Commonwealth of Massachusetts �g Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY a��uttnml^ Ir�s�Fcii ;ns USE ,,-,:3TI-t4,,IT, Building l;e' t Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building P rmit Number: Rig- 2 3 t 1 Date Applied: K vi,� %. 5-23-2o23 oyT //f7 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers t_.-, Ay+, Dr* NRAnnYn 01C. Oi oLl-Lc a 1.1 a Is this an accepted street?yes Y no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R ' lhCet 3fin0 Zoning District Proposed Use) Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private Cl Zone' _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.( Owner' f►�CWtiXi n1 renr►_ 11mA a1016g Name(Print) City,State,ZIP 3b ?\cA,, --iv e LI 1 --59Co-C`f 1(o No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other I)Specify: Brief Description of Proposed Work2: g�( 9, V-404 i e isti►�'1i1� O)1h no .bul� (,itVJS r J - Facer C. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1()154.(-lam 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier x 3. Plumbing $ a 2. Other Fees: $ 4. Mechanical (HVAC) $ �}( List: 5.Mechanical (Fire $ �// Suppression) }�/ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ IA �( Jg c0 ❑Paid in Full 0 Outstanding Balance Due: l SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ,any f )p rEvor S License Number`1 D Expirttion pate Name of CSL Holder CI 6 Or List CSL Type(see below) Li No.and Street j Type Description Green e kx 'W, I Q1 O`er Unrestricted(Buildings up to 35,000 Cu.ft.) i' Restricted 1&2 Family Dwelling City/TgxS te,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 4413-5n- la Twin 130 ,a loties,001 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement-^ Contractor(HIC) 4��� U�t�AC_ s J—� C Registration Number E pirati n Da e C papy,N 1 i e 1 Registjant Name and Stred Email address (3rein r eld, Ovl W Cii3(64 413k5ia l,00 City/Town,State,ZIP Telephone SECTION 6: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 building permit. Signed Affidavit Attached? Yes No .0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorizel—reDc)► - }' rbs,S ?i Pa dills to act on my behalf,in all matters relative to work authorized by this building permit application. ce-e ktetaled j g jai Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and alties of perjury that all of the information contained in this application is accurate to best-e - owledge and understanding. 61492, Print Owner's or Authorized Agent' ame(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Contract - Detailed 00Pella Window and Door Showroom of West Springfield Sales Rep Name: Bonini, Paul 69 Ashley Avenue Sales Rep Phone: 413-736-9239 West Springfield, MA 01089 Sales Rep Fax: 413-736-3390 Phone: (413) 736-9239 Fax: (413) 736-3390 Sales Rep E-Mail: pbonini@pellasales.com Customer Information Project/Delivery Address Order Information Gloria Moulton Moulton Gloria 35 Rick Dr Florence MA Quote Name: 250 Vinyl DH Windows 35 Rick Dr 35 Rick Dr Order Number: 739Y2EB041 FLORENCE, MA 01062-1045 Lot# Quote Number: 16506062 Primary Phone:(413)5260516 FLORENCE, MA 01062-1045 Order Type: Installed Sales Mobile Phone: County: HAMPSHIRE Payment Terms: C.O.D. Fax Number: Tax Code: MASS E-Mail: gloria.moulton©gmail.com Quoted Date: 2/16/2023 Great Plains#: 1004871036 Customer Number: 1008835404 Customer Account: 1004871036 Customer Notes: Project includes windows,installation, materials,disposal, building permit, sales tax. 250 series vinyl double hung windows. Pocket replacement installation. Order Verification visit will be scheduled after contract and deposit. Dimensions will be confirmed and then installation date will be scheduled soon after. For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 5/8/2023 Contract-Detailed Page 1 of 11 Customer: Gloria Moulton Project Name: Moulton Gloria 35 Rick Dr Florence MA Order Number: 739Y2EB041 Quote Number: 16506062 Line# Location: Attributes 15 Kitchen/LR/ExtraBR/ Pella 250 Series, Double Hung, 812.8 X 1244.6, White Item Price Qty Ext'd Price $1,294.17 4 $5,176.68 1 71 1: Non-Standard SizeNon-Standard Size Double Hung,Equal �� `"' �� PK# Frame Size: 32 X 49 - 2133 General Information: Standard,Vinyl,Block, Foam Insulated,3 1/4",3 1/4",Sill Adapter Included, Head Expander Included U Exterior Color/Finish: White Interior Color/Finish: White _ _ Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock,White, Standard Vent Stop,No Limited Opening Hardware Viewed From Exterior Screen: Half Screen, InViewT"" Performance Information: U-Factor 0.28,SHGC 0.28,VLT 0.53,CPD PEL-N-211-00205-00001,Performance Class R, PG 35,Calculated Positive DP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111, Clear Opening Width 26.954, Clear Opening Height 19.089,Clear Opening Area 3.57309, Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, Wrapping Information: Pella Recommended Clearance, Perimeter Length= 162". Frame Size:812.8 X 1244.6 PF-1 -Interior Pocket Installation Qty 1 AC-963-OTHER-3 Qty 1 LP-1 -Lead safe practices this opening Qty 1 Line# Location: Attributes 20 Den Pella 250 Series, Double Hung, 1016.0 X 1244.6, White Item Price Qty Ext'd Price $1,343.98 1 $1,343.98 I 7.--1 1: Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 40 X 49 2133 General Information: Standard,Vinyl,Block, Foam Insulated,3 1/4",3 1/4",Sill Adapter Included,Head Expander Included Exterior Color/Finish: White Interior Color/Finish: White I_ Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock,White,Standard Vent Stop, No Limited Opening Hardware Viewed From Exterior Screen: Half Screen, InViewTM Performance Information: U-Factor 0.28,SHGC 0.28,VLT 0.53,CPD PEL-N-211-00205-00001,Performance Class R, PG 30,Calculated Positive DP Rating 30.Calculated Negative DP Rating 30,Year Rated 08111, Clear Opening Width 34.954,Clear Opening Height 19.089, Clear Opening Area 4.63359, Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, Wrapping Information: Pella Recommended Clearance, Perimeter Length= 178". Frame Size: 1016.0 X 1244.6 LP-1 -Lead safe practices this opening Qty 1 PF-1 -Interior Pocket Installation Qty 1 AC-9B3-OTHER-3 Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 5/8/2023 Contract-Detailed Page 2 of 11 Customer: Gloria Moulton Project Name: Moulton Gloria 35 Rick Dr Florence MA Order Number: 739Y2EB041 Quote Number: 16506062 Line# Location: Attributes 25 Kitchen Sink Pella 250 Series, Double Hung, 711.2 X 838.2, White Item Price Qty Ext'd Price 1 $1,169.65 1 $1,169.65 run 1:Non-Standard SizeNon-Standard Size Double Hung,Equal PK# Frame Size: 28 X 33 2133 General Information: Standard,Vinyl,Block,Foam Insulated,3 1/4",3 1/4",Sill Adapter Included,Head Expander Included U Exterior Color/Finish: White Interior Color/Finish: White 1 Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Viewed From Exterior Screen: Half Screen, InViewlm Performance Information: U-Factor 0.28,SHGC 0.28,VLT 0.53,CPD PEL-N-211-00205-00001,Performance Class R,PG 35,Calculated Positive DP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111,Clear Opening Width 22.954,Clear Opening Height 11.089,Clear Opening Area 1.767617, Egress Does not meet typical United States egress,but may comply with local code requirements Grille: No Grille, Wrapping Information: Pella Recommended Clearance,Perimeter Length=122". Frame Size:711.2 X 838.2 LP-1-Lead safe practices this opening Qty 1 AC-9B3-OTHER-3 Qty 1 PF-1-Interior Pocket Installation Qty 1 Line# Location: Attributes 35 Local Promotional Discount Item Price Qty Ext'd Price ($1,269.76) 1 ($1,269.76) For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 5/8/2023 Contract-Detailed Page 3 of 11 Customer: Gloria Moulton Project Name: Moulton Gloria 35 Rick Dr Florence MA Order Number: 739Y2EB041 Quote Number: 16506062 Line# Location: Attributes 50 LIVING ROOM Pella 250 Series, Double Hung, 1019.1750 X 1250.950, White Item Price Qty Ext'd Price I $1,523.43 2 $3,046.86 En 1: Non-Standard SizeNon-Standard Size Double Hung,Equal (NI PK# Frame Size: 40 1/8 X 49 1/4 2133 General Information: Standard,Vinyl, Block, Foam Insulated,3 1/4",3 1/4",Sill Adapter Included, Head Expander Included I Exterior Color/Finish: White Interior Color/Finish: White Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Viewed From Exterior Screen: Half Screen, InViewTM Performance Information: U-Factor 0.28,SHGC 0.28,VLT 0.53, CPD PEL-N-211-00205-00001,Performance Class R, PG 30,Calculated Positive DP Rating 30,Calculated Negative DP Rating 30,Year Rated 08111,Clear Opening Width 35.079,Clear Opening Height 19.214,Clear Opening Area 4.680611, Egress Does not meet typical United States egress, but may comply with local code requirements Grille: No Grille, Wrapping Information: Pella Recommended Clearance, Perimeter Length= 179". Frame Size:1019.1750 X 1250.950 LP-1 -Lead safe practices this opening Qty 1 PF-2-Exterior Pocket Installation Qty 1 EAC-1 -Exterior Aluminum Capping(Coil Stock) Qty 1 AC-9B3-OTHER-3 Qty 1 Line# Location: Attributes 55 int stops PFP - PC to order Prompt for Price (detail in line notes) Item Price Qty Ext'd Price $500.00 1 $500.00 For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 5/8/2023 Contract-Detailed Page 5 of 11 DocuSign Envelope ID:BE641126-4F08-4AFA-876E-5E584EE32776 l.,ustu"'er.uturla iviuultuil r'u)ect'Jame: Moulton Gloria 35 Rick Dr Florence MA Order Number: 739Y2EB041 Quote Number: 16506062 Gloria Moulton Paul J. Bonini Order Totals Customer Name (Please print) Pella Sales Rep Name (Please print) Taxable Subtotal $5,386.35 ( Docus' ned by: ,e—°OeaSi9ned by: Sales Tax @ 6.25% $336.65 A p,..u)a$-ov6v6 6jature �E�►( p Signature 4/22/2023 4/12/2023 Non-taxable Subtotal $5,365.00 Total $11,088.00 Date �Docus' nedby: Date Deposit Received $0.00 Amount Due $11,088.00 7.N. BiWpAroval Signature ** The date given for installation and/or delivery is an approximate date. Due to unprecedented demand and global shortages of raw materials, your installation and/or delivery date is subject to and likely to change. Pella Products Inc. cannot be held responsible for any additional costs, or lost time associated with manufacturing delays outside of our contract. Although we will do our very best to meet these dates, we ask for your understanding and patience during these times. **Initials Below: 'DS ► I For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 4/12/2023 Contract-Detailed Page 10 of 10 DocuSign Envelope ID:BE641126-4F08-4AFA-876E-5E584EE32776 Pella Products Inc. 155 Main Street Greenfield, MA 01301 To Whom it may Concern: I,Gloria Moulton , as property owner, give permission to our contractor, Pella Products Inc.to obtain a building permit for the installation of windows and/or doors in my home. Located at; 35 Rick Dr Florence MA Please accept this letter in place of my signature on the permit application. Thank you, ,.—DocuSi ned by: Signature: 1 ,F —0E3239F9FOBE456.. Date: 4/22/2023 �....140 PELLPRO-01 CHRISTINE A�o,Rv CERTIFICATE OF LIABILITY INSURANCE vs,a2D3"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. 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). PRODUCER Fat{eCT Christine Sullivan Phillips Insurance Agency,Inc. PHONE 413 594-5984 FAX 97 Center Street (A/c,No,Ext):(413) IAic,No):(413)592-8499 Chicopee,MA 01013 iss:christine@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:EMC Insurance Companies 21415 INSURED INSURER B:EMCASCO Insurance Co Pella Products,Inc INSURER C: 155 Main St INSURER D: Greenfield,MA 01301 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POUCY NUMBER POLICY EFF POUCY EXP UNITSLTR INSR WVD ,(MMIDDIYYYYI (MMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 6A15382 1/1/2023 1/1/2024 PREM SESD(EaENo E ence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000'000 X POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea accident) COMBINEDSINGLE LIMIT $ 1,000,000 X ANY AUTO 6Z15382 1/1/2023 1/1/2024 BODILY INJURY(Per person) $ - OWNED SCHEDULED — AUTOSRE� ONLY _ AUTOS BODILYBODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUUTOS ONLY PROPERTY a�adent)DAMAGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE 6J15382 1/1/2023 1/1/2024 AGGREGATE $ 4,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X PER OTH- ATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6H15382 1/1/2023 1/1/2024 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEmBeR EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Installation Floater$100,000 Included Operations usual to the sale and installation of doors&windows. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Florence(Northampton)BuildingCommissioner's THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Office 212 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ,t a Department of Industrial Accidents` Office of Investigations Lafayette City Center 2Avenue de Lafayette, Boston, MA 02111-1750 °" � •`� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Pella Products, Inc Address: 155 Main st City/State/Zip:Greenfield MA. 01301 Phone #:413-774-7231 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 50 4. ❑ I am a general contractor and I 6. 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions 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 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: EMC Insurance Company Policy#or Self-ins. Lic. #:6H 15382 Expiration Date:1/1/2024 Job Site Address: 35 Rick Dr City/State/Zip: Florence, MA 01062 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 ce ' i :der the pains an ies of perjug that the information provided above is true and correct. Signature: c Date: 05/08/23 Phone#: 413- 12-5968 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5.O'lumbing Inspector 6.0Other Contact Person: Phone#: PELLA PRODUCTS INC. 155 MAIN STREET GREENFIELD, MA. 01301 Date: 01 To: (l;(.t.in i-C fbrenc '. ala ! n Subject: Disposal of Debris The purpose of this letter is to certify that all debris from any project undertaken by Pella Products, Inc. in your town will be transported to a dumpster at our main facility; 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. Joy Grover Accounting Manager Pella Products, Inc. 155 Main Street Greenfield, MA 01301 Office:413-512-5968 Cell:413-834-8799 To: Building inspector From:Trevor Bross—Installation Manager Date: February 17,2022 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 my HIC#142279. Please find a copy of my licenses below. Commonwealth of Massachusetts Construction Supervisor Oivision of Occupational Ltcensure Unrestricted -Buildings of any use group which contain Board of Building ReOutMwnsavStandards less than 35,000 cubic feet(991 cubic meters)of enclosed I JnRs. �t IIII space. J, 3 CS•096558 $ tirtis:0310112024 TREVOR BRtSS., \ . • tr F 10 GEORGE il r GREENF _________Z _.,,,. ,�k�OGiN.Lh Failure to possess a current edition of the Massachusetts Co 113611 0011 n 4 u A ao State Building Code is cause for revocation of this lcensr. f7i.R`J�R � For ln1om atIon about this license Call(.17)7274200 or visit www,mass.povtdpi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT_CONTRACTOR expiration date. If found return to: TYPE:Supplertient Card Office of Consumer Affairs and Business Regulation Registration-'•, Expiration 1000 Washington Street -Suite 710 14227E ` . 03123t202, Boston,MA 02118 'ELLA PRODUCTS.INC `•. .,x ' 'REVORBROSS �,\. /;rf(_'. 1:_,.. .. 55 MAIN STREET _ t '- 3REENFIELD,MA 01301 �•• s_,_ _ .. [ 1ders f'er z,y `Not valid without signature Each Installation will be staffed by our installers who are all licensed in accordance with current building.codes. Below listed are our installers and their license numbers.Please accept these individuals as my designees. Willard Brown CS106010 Vladimir Shevchuk CSSL099209 Scott Bowdish CSSL100232 Bill Leger CS89338 Christian Lambert CS065102 Robert Kairnes C511330 Igor Kravchuk CS094911