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Home My WebLink AboutBuilding Permit # 2/16/2016 %AORTpi BUILDING PERMIT TOWN OF NORTH ANDOVER O� 5�,.'' OM APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received ATEA 0' .SSgC use Date Issued: ` C IMPORTANT: Applicant must complete all items on this page , .. �� ^"�' �.. .,.. � �'r�'.„ax��fi�✓^ � ^��ts ,,'g'�"M�i r��„z 1�%r,;„�,r,;�i'Y,� ,. ,'�i�l�r�.��ati�wi i r. �?,.> �.��„ i<.r e�'�r xr�'r,u,' . " imiAP �PARCEL� �w�,�� r: �zf 5ar i t z .r rr a + G" .tf.�r x f7!?l a ts'rt z./r rriyrd/° G' - `", { ?fid r✓rrF.. r s xr x3, 1, ,x r;lcl z ��„�.�r'*t fY��r�'�i'�,.�ir,1�'�,r.'rz� r.., ..G, ,i c.:3„ " a,.,,r w, <!',�f;Y7,,:u i .,, «.r.,.m) .,l.rY.,.,,.'v... .x�.�,✓,.+d15,,.J, r,,,,.�Y;'� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I r f k et 'nds% ,F r',r l` ❑ Ul/atershe ID`strict ;r / ❑�5e tic,��„❑Well � , � r � ,x �;,, ❑ Floodplain, d,q W la � � T.�, � .��,�r<r +n,:5 a' a�' �� m��” ✓ U.�.p��s�I�r s-. < � ads r �::r �^ -.a x' 3r f � , rx �� .> r u.,� _, �. ,� .:� �,�.�»t �f'�v' '�.w'l� ...✓ ��jAy�v..FW .,rs �r � ;..t ''�. %^ F � ,?. 5 zv,... „orR:'� l`.s�=�,rr.. .x. u `"�, a.� r..�^�r � x xi.;ri?4�vy.,'k l,�„S'. r�,�, ,,�"6��, '"� ..w .a„f y�..r„u'r ,.� l rl JF .:/-rai 'r�G 3 .. F r(�r;.., -.✓ YYf J n�tx >., ,. � � ,�.x�r ��r s:xv✓ €r:' r1 �J r f .xr r9 1 r rro-r r s i / Y N��VV�tP,r/�eWer�6""rc �,x.,K�r ✓sr,.,� .,..,..s 1r;xry "frfr�r-.n. ..1 '�.�a✓r;,.T;,� �.1,; ��P,�, �,,��i�.�,'�..�A a,-,C.ie^,r°.r�"�`xi,'✓,'r 4,r„� �F DESCRIPTION OF WORK TO BE PERFORMED: J, A2 -wt I ” Identification- Please Type or Print Clearly OWNER: Name: Phone: �dF� Address: C 3 11;1-v e �L/ „fr r,�w ,3 %i ;°tlfr >N: r r Jsr" r l` r ,✓..: ='r✓�' 'rr":'Y r.� r y I�,r "� �r,. x^: 'yE-r�m�;,-c;�.�7.r,,°":..�izxt//l�:"n�'h,�4rarrlt�p��Fo--�f..9.�r.��l.r rr<x3�,rrr�W,r,Nr^5�r'?rr'`r�1aUr��''/„�rmx.�;��"?^.�`:v„.,^.r1�erl€rt t'a5rI tt1�°1r,G,�r".f,xrcI,./.'.:r�«•r:'�..+3�G€'^f r,l%,r'.`�km�>7.`:3._t_�;.%,✓rrr.�.e✓1nzrrr"vI,Fu r~/',Hyrr:xaYry.1 r,�xri'r f a✓,c`;z r /r rrr,....:! rJIc✓€r+.:-P...:n.,hol nz,ze^.:...r r Ftiz')t.,x-,..,r�l/'""r"'' y,rs`r,...ad�r.rG„r'r✓�r t�..7�rLFh�ontr00. tmaY.':;sY„�lia'rfSwf`�a�'i”rFz:r�fc�'�r-r'r r�'f,,✓,Y✓nf„�y'3`>{1F,,r Y.i,.;..,rq,x.If R,yxr�,�/l* Fr s >hr r rrxtl ,F' r�Z1` �z 5 �If��✓ rz., r, I f„r ,€ .� w r F, :r/�/',. i ek' �g rr'7rN t �r-� �~Q- Y'h` s t r .. gum ':r s �' � �� s � r I I^ ,✓ � rT' ' ' as<r� ,,� ,>a•� 1 rx� f � r r r rlx s ,m .v rY,!'t�2 „' r, r ;��sa'��..,.� .�',-'/,../F yam' � x`�? :d��i /l,crr / ad r: Xfi 3' > .,.rr r6 `� .;.?' r, f��..-✓fftJz ,`rv✓��y✓;.,.�x ., ”. � '^ :: �ur2" °,;ui`- r`'Sr '„�'Y?rc "'i.�iJ i' C/�': �'x,��o r,l�if� P >€��Ii�'trr -,�`i `��r",�x my..^xxr�� :. '''�`rr',rr .,s� :„✓.•,,„r�r,� ..�;�,� z�,;rx; .-: 'a „r �Y��r"� 3/��✓�''� 4�t'� �� Y%�'ll',��rtc��„�;.a��if`k.Z"�' �5�,�1`r,+' ,.� � � ^� � �� G � Y . r, ; �I,.q r„":, .`,, z,"' .y�2"? ',"a',?✓ 'f/l6 ati �i"z'l , r t til l .,�r �� r:!^rr'"� 7,:�^'F 0011 %,a>'. ✓.r" -.'r'4' '"f,” ! �Y �t Ho ell y prouement'License x, rxr. � � rF p r ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING'PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ / FEE: $ 6 Check No.: I "m�j Receipt No.: 6C) NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature.of Agerit70wner: Signature of cont�acfor ��, FORTH Town of ndover No. t � Z nO h verb VSsVebe.AA"' \ 1. cocHIC"tc..e—cx �.O AORATED )P.? S u BOARD OF HEALTH Food/Kitchen A LD Septic System PERM [T a. BUILDING INSPECTOR THIS CERTIFIES THAT v Foundation has permission to erect .........:................ buildings on .. ...........`... �. .............................. ................. "lli `......................................... Rough .... ... .... .. . .....A..�... A Chimney to be occupied as .......1....... 1004 provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR LESS CONST CTS TS Rough Service ............... ............................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building inspector. Burner Street No. Smoke Det. Contract - Detailed Pella Window and Door Showroom of Haverhill3 Sales Rep Name: McLoughlin, Daniel 45 Fondi Rd HIC#183279/Tax ID#26-1413183 Sales Rep Phone: 978-373-2500 Haverhill, MA 01832 Sales Rep Fax: Phone: (978)373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: mcloughlindv@pellaboston.com Customer Information Project/Delivery Address Order Information Aj Mansor Mansor,Aj,1646937 Quote Name: Bay Window Center Panel 63 Hay Meadow Rd 63 Hay Meadow Rd Order Number: 741DVO046 NORTH ANDOVER,MA 01845-1405 Lot# Quote Number: 7520109 Primary Phone:(978)2584218 North Andover,MA 01845-1405 Order Type: Installed Sales Mobile Phone: County: Payment Terms: Fax Number: Tax Code: MA TAX 6.25 E-Mail: Quoted Date: 1/28/2016 Great Plains#: 9836876 Customer Number: 1007411201 Customer Account: 1003155420 Line# Location: Attributes 10 None Assigned Delivery/Setup- Delivery/Setup Item Price Qty Ext'd Price $206.80 1 $206.80 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 1/28/2016 Contract-Detailed Page 1 of 5 Customer:Aj Mansor Project Name: Mansor,Aj,1646937 Order Number: 741 DVO046 Quote Number: 7520109 Line# Location: Attributes 15 Bay Window Fixed Support Product, Direct Set Fixed Frame,64 X 72,White Item Price Qty Exfd Price $1,371.58 1 $1,371.58 1:6472 Fixed Frame _ PK# Frame Size: 64 X 72 764 General Information: Interior Glazed,Factory Assembled, Standard,Clad,Pine,5",3 11/16",No Certification Exterior Color/Finish: Standard Enduraclad,White Interior Color/Finish: Bright White Interior Glass: Insulated Dual Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Grille: No Grille, Viewed From Exterior Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,No Interior Trim,3 11/16",5",Factory Applied,Pella Recommended Clearance, Frame Size:64"X 72" Perimeter Length=272",Glazing Pressure=50. PI—Pocket>72 inch-Pocket>72 Inch Height Qty 1 PI FF-Full Frame Pocket Qty 1 Line# Location Attributes - 20 None Assigned Minimum Unit Value Add- Min. Order Setup VA 3 or Less Windows Item Price Qty Ext'd Price $176.00 1 $176.00 Thank You For Purchasing Pella® Products PELLA WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale.All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture within the wall system.Neither Pella Corporation nor Pella Windows&Doors will be bound by any other warranty unless specifically set out in this contract. However,Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress)information does not take into consideration the addition of a Rolscreen[or any other accessory]to the product.You should consult your local building code to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. Variations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. INSYNCTIVE PRODUCTS:In addition,Pella Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 1/28/2016 Contract-Detailed Page 2 of 5 Customer: Aj Mansor Project Name: Mansor,Aj,1646937 Order Number: 741DVO046 Quote Number: 7520109 Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. Project Checklist Review (Installed Orders Only) Before the Installation the Homeowner agrees to do the following: Obtain Condo Association Approval Obtain Historic Approval Remove existing shutters and awnings Remove air conditioners Remove existing shades, drapes,window treatments, wall hangings, and personal belongings Move furniture at least 3 feet away from work area Tie or cut back trees, bushes and shrubs in the work area Arrange to have alarm system and doorbells disconnected Arrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor Provide a door handle and lockset for entry door if Pella handle and lockset is not purchased. Before the Installation Pella agrees to do the following: Obtain Building Permit(When required) Prefinish products when purchased in contract During the Installation the Homeowner agrees to do the following: Keep pets safely away from work area Keep children safely away from work area Allow Pella Installer room to work safely within your home During the Installation Pella agrees to do the following: Deliver and unload products purchased per contract Place and remove drop cloths in work area then vacuum, and remove all debris at end of day Remove existing product, including storm windows, and dispose of it unless otherwise specified Install all products using method specified in contract per Pella Installation Instructions Replace interior and/or exterior trim only if purchased If Purchased, install exterior primed pine wood trim or Composite. Composite will be unfinished. If Purchased, install interior trim matching wood window finish or White trim for Impervia and Encompass Install non-Pella entry door lockset provided by you. Pella is not responsible for it's quality or performance After the Installation the Homeowner agrees to do the following: Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings Re-install existing shades, drapes,window treatments,wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners For more information regarding the finishing, maintenance,service and warranty of all Pella@ products,visit the Pella®website at www.pella.com Printed on 1/28/2016 Contract-Detailed Page 3 of 5 Customer: Aj Mansor Project Name: Mansor,Aj,1646937 Order Number: 741 DVO046 Quote Number: 7520109 Remove stickers from product and save for energy rebate and tax purposes Wash all interior&exterior glass surfaces Fill nail holes and joints on interior trim if windows are to be stained (after staining) Clean up exterior casing issues due to storm window removal if full wrap or new exterior trim is not purchased Project Checklist has been reviewed Customer Atial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits Expiration Date: / Charge final payment to same account (Upon substantial completion) Customer initial For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 1/28/2016 Contract-Detailed Page 4 of 5 Customer: Aj Mansor Project Name: Mansor,Aj,1646937 Order Number: 741DVO046 Quote Number: 7520109 Project Checklist has been reviewed AJ Mansor Dan McLoughlin Customer Name (Please print) Pella Sales Rep Name (Please print) Order Totals Taxable Subtotal $957.98 C ome ignr a� Pella Sales Rep Signature Sales Tax @ 6.25% $59.87 1-28-15 1-28-15 Non-taxable Subtotal $796.40 Date Date Total $1,814.25 Deposit Received $0.00 Credit Card Approval Signature Amount Due $1,814.25 Customer to give measure tech a check for 50% Deposit ($907.13) For more information regarding the finishing, maintenance,service and warranty of all Pella@ products,visit the Pella®website at www.pella.com Printed on 1/28/2016 Contract-Detailed Page 5 of 5 PELLA WINDOWS AND DOORS CONTRACT 7 PAYMENTS 1. TERMS AND CONDITIONS Pella shall be entitled to stop the Work upon written notice to Owner for any material default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part of the contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part of the Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Date or,if earlier,the date on which the Work is substantially 2. OWNER completed and payment of the Purchase Price made subject to a holdback as provided above.Correction of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove remedy for defective workmanship,and is provided in lieu of any and all other all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED,WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible for and have control over construction means, FOR A PARTICULAR PURPOSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WHETHER FORESEEN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work. IL HOME IMPROVEMENT CONTRACTORS The materials and equipment furnished under the Contract will be good quality All home improvement contractors and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director of the Home Improvement Contractor Registration Program defects not inherent in the quality required or permitted,and the Work administered by the Board of Building Regulations and Standards. Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its subcontractors identified in this agreement have been registered. for damages or defects caused by abuse,modifications not executed by Pella, Any inquires about Pella or any of its subcontractors relating to registration improper or insufficient maintenance,improper operation or normal wear and should be directed to:Director,Home Improvement Contractor Registration, tear. Pella will keep the premises and surrounding area free from 10 Park Plaza,Room 5170,Boston,MA,02116,617-973-8787,888-283-3757 accumulation of waste materials or rubbish caused by performance of the or visit the HIC website at http://Nvww.inass.gov/ocabar/ Work. 12. PERMITS(MA customers only) 4. CHANGES Pella is obligated to and will obtain the following permits for this project: Building-. Homeowners who secure their own permits will be The Owner may order in writing changes in the Work consisting of additions, excluded from the guaranty fund provisions of Massachusetts General Laws, deletions,or modifications("Change Order"). Any Change Order shall chapter 142A. include an adjustment to the Price and the Substantial Completion Date,as determined by Pella. Pella reserves the right to approve or disapprove any In addition to the rights and warranties enumerated in this agreement,you may Change Order and any such Change Order must be signed by both Owner and have additional rights under Massachusetts General Laws,chapter 142A and Pella to be effective. 780 Code of Massachusetts Regulations R6. 5. SUBSTANTIAL COMPLETION 13. NOTICE OF CANCELLATION Owner understands and agrees that the Substantial Completion Date is an You may cancel this agreement if it has been signed by a party estimate only and that the actual date on which the Work is completed may be thereto at a place other than an address of the seller,which extended to allow for Change Orders requested by Owner or if the time to may be his main office or branch thereof,provided you notify complete the Work is affected by conduct of the Owner,weather,labor disputes,availability of subcontractors,acts of God,fire or other causes the seller in writing at his main office or branch by ordinary reasonably beyond Pella's control.If for any reason the Work is not fully mail posted,by telegram sent or by delivery,not later than completed by the Substantial Completion Date(including any extensions midnight of the third business day following the signing of this contemplated above),but is substantially completed by such date,i.e.,the agreement. Product has been installed,but minor parts or components are missing or need to be replaced or repaired,a hold back proportionate to the cost of remaining See the attached Notice of Cancellation for an explanation of parts or work to be completed is acceptable.However,the holdback will not this right. exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. 6. FINANCING Do not si n this QMtract if there are any blank spaces. If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the full amount of the requested C mer sidmiture financing shall have been received from the financial institution. If 1-28-15 Date DISPUTES THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A Pella Windows & Doors Contractor e il,0"7, r y Home er NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR, THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. NOTICE OF CANCELLATION Date of transaction: 1-28-15 You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so,then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Pella Windows and Doors, at 45 Fondi Rd., Haverhill, MA 01832 not later than midnight of 2-2-15 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) � The Commoffart�eotdtia d1fWrassacdtrasetcs Dep arrtaaaeaad of Iaaa usoidal Accsl ergs i . O,ffke Of inpesfigadons I Congress street,suite I## Boston,MA 02114-2617 _ >w aaaassogovfdlla Workers' COnlmpensaition Insurance AfradaAtt: Budders/Cont actors/E9ectricaans/P9aambers A&fleatnt Information Please Print Legibly Name(Business/organization/ladividual):_ E///,A 1 V , R oc)w UX _ Address: 4v City/State/Zip: Phone#: q'76o y ,_ Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with 9 4• ® I aro a general contractor and 1 employees(full and/orpart-time). * have hued the sub-contractors b E]New cons�uction 2.® I am a sole proprietor or partuer- listed on the attached sheet. 7, Wetuodeling stip and have no employees These sub-contractors have g• ®Demolition working for the in any capacity, employees and have workers' insurance•$ p• ®Building addition coraF• [No workers'camp.insurance required] 5. ® We are a corporation and its 10.®Electrical repairs or additions 3.® 1 ani a homeowner doing all work officers have exercised their l l.®Plumbing repairs or additions myself.[No workers'camp. right of exemption per MGL 12.E]Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 1311 Other comp.iasurauce required.] 'Any applicant that checks box#1 must also rill out the section below showing their workers'compensalionpolicy infonnntion. r 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-conttactors and state whether or not those entities have employees. If the sub-connuctors have employees,they must provide their workers'comp.policy number. fearer an emplgver that is providing!workers'compensatdon insuratece for nate employees. Below is the poliep and joh site infor matdoat, Insurance Company Name:_X4 (1 L0,J_e 1 Tpq S 0_ Policy#or Self-ins.Lie.ff: 406o Ll 0 to q Expiration Date: Job Site Address: City/State/zip: Attach a copy of the!workers'compensation policy declaration page(shovying the policy number and ei-plratiion 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 statetneat may be forwarded to the Office of --lavestigatio>zs-ofthe-DLk-for-instwa—ce cov1erage verification. -- ----- f do hereby certify ander the pains land penuldes�f fEP#dtY that the iPE ltrtlydlt1078 pPatvarled above as true and correct. Signature: =�—= _ Phone Official use onlg a Do not write fan this area,to be colupleted by ci0 or lotwrt of�rcial City or Tovvgn: PermnitiLieense it Issuing Authority(ch-cle moue): , _ A ��F& CERTIFICATE OF LIABILITY INSURANCE 06129,2015MNIIDom" 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 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 NAME CT OomlhyA Codett,CIC,RPLU Fred C.Church,Inc. 41 Wellman Sheet PHONED 978 3227231 FAX Nc; (978)454 (800)2 -1865 051 (Air.NE-MAIL dGorieH@fredeaurch.com (600)225-5-011065 ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURERA: Citizens Insurance Company ofAmedca 31534 INSURED -INSURERS: New Hampshire Employers Insurance Company 13083 New England Window&Door LLC 45 Fond!Road INSURER G., Haverhill,MA Di632.1302 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:54457 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 BYPAID CLAIMS, INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICYNUMBER MMIDD/YYYY) [1AIWDDfYYYYl LIMITS GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 0,000 PREMISES Ea occurrence _L! CLAIMS-MADE IJ OCCUR MED EXP(Any one person) § 10,000 A X CG0001 ZBNO161407 7/112015 71112016 1,000,000 PERSONAL 8 ADV INJURY S GENERAL AGGREGATE § 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG § 2,000,000 POLICY JPO- ET X LOC § AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) S AUTOOSUNED SCHEDULED BODILY INJURY(Per accident) § HIRED AUTOS FNON-OWNED PROPERTYDAMAGE S AUTOS Pe accident § UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE 8 DED RETENTION S § WORKERS COMPENSATION X WG STATU• 0TH- AND EMPLOYERS'LIABILITY M 5 YIN ANY PROPRIETOWARTNERIEXECUTIVE E.L.EEACH ACCIDENT $ 500,000 B OFFICERIMEMBEREXCLUDE07 NIA 400040101 711@015 T/112016 500,000 (Mandatary In NH) E.L.DISEASE-EA EMPLOYE $ If ea,describe under 500,000 DESCRIPTION OF OPERATIONS below I I I E.L.DISEASE-POLICY LIMIT 1§ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE cre�Lll = I' Msl Cert Holder 3 4 O iM88-20W ACORD COPPORATION. All rights reserved. iA �en5e: CS-089853. WILL IANI R NICHOLS 57 PEARTREE RID HAVERHdLLi NU 1830 a 10/26/2016 ' .I f • .�J�B�O?lt llt0/1CGPCI��12 C�n'TGCIJJCYC�!(JP�J •" � ice of Consumer Affairs&Business Regulation License or registration valid.for individu'l use only E IMPROVEMENT CONTRACTOR before the expiration date. if found return to: 0.fice of Consumer Affairs and Business Regulation egistration. 183279 Type: 10 Park Plaza-Suite 5170 Expiration; 9124/201'7 Supplement Card Boston,MA 02116 NEW ENGLAND WINDOW&DOOR;.LLC. PELLA WINDOWS&DOORS William Nichols 45 FONDI ROAD * < � �£•,>.� i > � s HAVERHILL,NAA Q1832Undersecretary Not valid-without signature