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Home My WebLink AboutBuilding Permit # 5/3/2016 w .,f 0 (LED BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N®: Date Received °tea ��ATEO PpP "R,4� Date Issued: acr'u l POVRT AN'Te A i licant must com Tete all items on this age H LOCATION . Prin PROPERTY OWNERRd 0 ti Print MAP NO: PARCEL ZONING DISTRICT: Historic District yes no Machine Shap Village yes no W�b TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building � One family Addition C i Two or more family Industrial I Alteration No. of units: Commercial Repair, replacement Assessory Bldg J Others: Demolition D Other Septic C...I Well C_.0 Floodplain E]Wetlands [1 Watershed District Ei Water/Sewer �m" . , �� ,. J ." 4\ f,W "a �J d",w '. wr� C ' i Identification Please'Type or Print Clearly) OWNER: Name:," '„ _i'- J Phone: ( µ> Bi.r Address: �.. °� �� a��-�,.� "J LA A 0 1 elel-"".) CONTRACTOR Name: ERNS , 6VL(- Phone: IX Address: ,s r4 (S' is o -4- Supervisor's Construction License: ,r Exp. Date: � , .,,� �wi it �w Home Improvement License: W Exp, Date: t ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$126.00 PER S.F. '-) 1 Total Project Cost: $ I?) i FEE: $ Check No.: '11 0 Receipt No.: "Z NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 1 Signature of Agent/Owner � (7, Signature of contractor rmm 4 t%ORTH Town of ndover ® ti' 10 ih Vel Mass, COC HIC HE wICK �1. S ll BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ... ................ BUILDING INSPECTOR gFoundation has permission to erect AOV ................ ......... buildings .... .... .W.16......... .. .. ....�... Rough to be occupied as ..... ............ ... ........ . .. ... . ...... h ..... .... ... . . ............ Chimney provided that the person acceptin 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTPTION Rough Service . .. .. .. .........7G� 4�Si .. ... Final BUIOR GAS INSPECTOR CCuEancj1 Permit Required to OccupV Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected r ve the Building Inspector. Burner Street No. Smoke Det. Page 1 a 5f"RVIN co".Py North Shore Window Solutions, LLC {NSW S) DESIGN GALLERY 239 South Main Street, Middleton, MA 01949 Phone: 978-762-0007 FAX,866-809-3136 z complelt- windo-Aand door 0ioym)om Massachusetts HIC Reglstratfnn#172 85 by NSIMS INSTALLED PROJECTS PROPOSAL DATE: 3/29/2016 NSWS REP: Linda Keating PROPOSAL#: KEETON-032916 Customer Name:Susie Keeton Project Address:95 Appleton Street,North Andover,MA 01845 Primary Phone (where we can reach you prior to and during project.).-978-807-7255 Email:susiekeeton@gmail.com ye . kee'1On WORK TO BE PERFORMED: Install I Full Frame 2 wide casement windo -`nt"xisting RO (kitchen sink) Specs: eqo Marvin Integrity Wood U'[trex Exterior- Ultre.x; Stone White Interior: Pine; Prefinisbed White- Fac Dry---ApVlJcd Glass: Low E 2 w/Argon <-V'K f Grilles., one o Screens: Charcoal Fiberglass Mesh; White Surround --- Hardware: Satin Nickel similar to existing Interior Trim: Pine, Exterior Trim: PVC similar to existing Family Room and Living Room Install 2 3-Wide Full Frame Casement Window Units into existing Rough Openings 2 Casement Hankers w/Picture Window in the Middle Specs, Marvin Integrity Wood Ultrex Exterior: Ultrex; Stone White Vo Interior: Pine;Prefinished n (X,-21 ed,,, Glass: LowE ) W/Ago Grilles: None f1.5 . I� -1/9 Hardware: White ) """'X Screens: Full; Charcoaal las es I; lite arilound Interior Trim: Pine; similar to existing Exterior Trim: PVC Similar to Existing $ 10,605.00 _ _. �� Duo '20 X�- a -r"C' 1, At L I Page 2 Gf 5 Install I Entry Door into Existing Rough Opening Specs: ThermaTru Smooth Star Entry Door (S90) Exterior-, Factory Painted Mocha Chip Interior: Factory Painted Mlocha Chip Ailaterial Type. Smooth Fiberglass Product Style:3/4 Lite Glass Style: Rain Glass Hinge: Ball Bearing; Brushed.Mickel Prep: Bore for Lock and Deadbolt 44% 1v Sill: Composite Adjustable; Satin Nickel Finish Hardware- Emtek; , Apollo Entry Handle Set with Geneva Lever and Modern Rectangle Rosette Emtek Interconnect Locking Mechanism (Panic Lock) Color: Satin Nickel Weatherstripping: Bronze Interior Trim- Pine;Similar to Existing Exterior Trim.- PVC, Similar to &kist.ing $ 2,862.00 -*11:4"rhe Price includes a FIVE YEAR installation warranty*444, TOTAL PRICE (Materials, Labor, and Sales Tax). $13,467.00 TERMS. 1/3 total price deposit required, 1/3 total price required upon delivery, 1/3 total price payable at completion of above mentioned work to be performed. WORK INCLUDEDS THE INSTALLATION OF WINDOWS AND/OR DOORS;ALL NEC1r,5$ARY FRAMING MATERIALS, ROOFING SUPPLIES WHERE APPLICABLE;NEW INTERIOR AND EXTERIOR CASING,SILLS,AND STOOLS AS NEEDED,THE REMOVAL AND REINSTALLATION OF INTERIOR STOPS AS REQUIRED:CAULKING SUPPLIES,NECESSARY INSULATION,SHIMS,AND FLASHING SUPPLIES; SUFFICIENT SIDING TO REPLACE THAT REMOVED DURING INSTALLATION AS REQUIRED; SUFFICIENT DRYWALL SUPPLIES TO REPAIR THE INTERIOR 161ALLS FROM THE INSTALLATION,ALL NECESSARY FASTENER AND ADHESIVES;REMOVAL OF CONSTRUCTION DEBRIS.Permit fee not included,Will be billed independently to customer at lace value of permit. THANK YOU FOR THE OPPORTUNITY TO HELP YOU! www.nswsf arm arvin.com 7- C G 2e d UTvqUnoW UGIT J.cZ-4 n f) hTW 1 7 r.-- QTn7 /TO /C' Page 3 of 5 Contract m Installed Projects North Shore Window Solutions LLC. dba Marvin Design Gallery by NSWS 239 South Main Street, Middleton, MA 01949 Phone:978-762-0007 FAX:866-809-3136 Massachusetts HIC Registration: 72535 Contract#: KEETON-032916 CUSTOMER NAME: Susie Keeton STREET ADDRESS:95 Appleton Street,North Andover,MA 01845 PHONE:978-8077255 This contact applies solely to the labor and materials required to install the exterior windows and doors specified on the attached proposal which is included as part of this contract.It hidden conditions such as,but not limited to,rot,insect damage,or substandard framing per the NIA Building Code, intertpre with the proper installAtion of the products, fhe work will stop immediately. Such situotignu will be referred to NSWS's representative to determine the appropriate action.Such action may include NSWS's subcontractor performing repairs at additional cost, however ahy oontractor of the homeowner's choosing ma+y be employed to perform the additional work. NSWS also reserves the option to decline supervision of such work at which time additional charges would be billed to the homeowner directly by the subcontractor. Any new charges incurred through NSWS will be due upon completion of the additional work,Billable rate P590.00 per an hour plus materials. Alw CUSTOA18S INITIALS DEFINITIONS,INCLUSIONS,AND EXCLUSIONS ®FULL FRAME REPLACEMENT:these windows will usually be installed from the outside of the horse.The installation will include windows ar doors, all necessary framing materials,roofing supplies for bay and bow windows where applicable,new interior and exterior casing,sills,and stools,caulking supplies,necessary insulation,shims,flashing supplies,sufficient siding to replace that removed during installation,sufficient drywall supplies to repair the Interior walls from the installation:and any nscessary favteners,and adhesives needed to complete the installation. ❑INSERT OR SASH REPLACEMENT:these windows will usually be installed from the inside of the home.The installation will include the windows, caullking supplies,necessary insulation,shims,and fasteners.The interior stops will be removed and reinstalled. EXCLUSIONS:NSWS will not be responsible for any existing items that are made unusable due to the installation of new windows or doors. These items include,but are not limited to:blinds, shades,curtains,shutters,storm windows,storm doors,wallpaper,air conditioners, awnings,window and door hardware,etc.Unless specifically listed in the proposal,the items rot included will be:new interior and exterior casing, sills,or stools,or replacement of the existing window frame,A change order may be issued to comer extra charges to fix or replace items not included, NSWS will not be responsible for alarm systems encountered during installation.The homeowner will be responsible for contacting and schsdulinq the alarm service company to perform any necessary alterations to accommodate the new wirtdv%.VS. Any required electrical work is not included in this proposal. If existing wiring needs to be relocated or eliminated in order to accommodate any new windows and or doors to be installed,this may result in added cost. Any additional cost for electrical will be handled as a Change Order and is the responsibility of the customer and not included in this proposal TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE North Share Window Solutions LLC.(NSVVS)agrees to perform the work,furnish the material and labor specified above,clean the site and dispose of waste for ttte sum of-�$13,467.00 PAY-MENTS WI:.L BE MADE ACCORDING TO THE FULLO1ri+ING 5C HEDULE: $4,469.00 (33%OF TOTAL SALE PRICE UPON SIGNING CONTRACT) $4.4n (33°/o OF TOTAL UPON COMMENCEMENT OF WORK)+PERMIT FEE $4.4-89 (BALANCE UPON COMPLETION OF THE CONTRACT) Payment for this work is subject to additions or deductions in accordance with the provisions of this contract and any subsequent written change orders.Upon completion of contracted work,if manufacturer warranty service is required to correct any defect in the windows/doors, the homeowner may holdback up to 10%of the contract total until such service is performed.The actual amount of the holdback will be determined by the homeowner and the NSWS representative,but in no event shall exceed 10%of the contract rice r the item(s)which is the subject of time defect.Credit Caird information to be provided to NSWS as security,even if paying by check: • ,,,,'Customer Initials At the time of the final payment specified above,NSWS will certify,at the request of the owner,a complete release of all liens arising out of the contract. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of NSWS,which may be the main office or branwi thereof,provided you notify NSWS in writing at the main office or branch by ordinary mail posted,by telegram sant or by delivery,to be reviewed by NSWS no later than midnight of the third business day following the signing of the agreement. See attached notice of Cancellation for an explanation of this right,Terms continued on pages 2&3 are integral parts of this contract.***Do not sigh this contract if there are any biankc.spaces*"- 1 CUSTOMER SIGNATU l. NS�V i NATURI5 /�k DATE: DATE- D GSed uTie .LITlC3W utazj 19:4fin WH RZ: TrTi :R PIT 07/TP.!f'. Page 4 of 5 The follow'rny acts or occurrences shall not constitute default on the part of North Shore Window Solutions LLC.(NEWS)in connection with ltd date of substantial completion and shall entitle NSVVS to reasonable extensions of time to perform under the contract.acts of god,strikes,acts of war, emerg encies,failure of N&WS's suppliers or vendors to timely deliver materials to MWV8,failure of the owner or i=w agents to supply NSINS with job site availability on a timely basis,or any other acts or conditions not within the direct exclusive control of NSVVS. 1.INSURANCE: A. NSWS'S LIABILJTY INSURANCE,NSWS agreers to keep in force at it's awn expense during':he entire period of construction on the project such liability insurance as will protect it from its claims,under workmen's compensation and ocher employee benefit laws,for bodily injury and death,and for property damage,that may arise out of work under this contract,whether directly or indirectly by NSWS,or directly or indirectly by a subcontractor paid for or employed by-NSWS for the above referenced project.The minimum lability limits of such insurance shall nit be less than the limits specified by lase for that type of damage Maim, 13. OWNER'S LIABUTY INSURANCE.Orrneits)agrees to maintain in force their own liaollity Insurance during the construction on this project. and rvservas the right to purchase such additional insurance as In their opinion is necessary to protect them against claims arising out of NSWS's operation,without diminishing NSVVS's obligation to carry the insurance specified herein on his part to be carried. C. PROPERTY DAMAGE INSURANCE ON WORK SITE.Owner agrees to maintain at his expense during consiruction of the property,damage insurance on the work at the site to its full Insurable value,including interest of owner,NSWS,and subcontractors,against Are,vandalism,and other perils ordinarly included in extended coverage.Losses under such insurance will be adjusted with and made payable to owner,N.$WS, and subcontractors,against fire,vandalism,and other perils ordinarily included in extended coverage.Losses under such insurance will be adjusted with and made payable to owner as trustee for the parties insured as their interests appear.Upon request,owner shall rile a copy of all such po-lides with NSVV'S within a reasonable time after construction begins herein. D. WAIVER OF WORK SITE DAMAGE CLAIM TO EXTENT OF INSURANCE COVERAGE.Owner and NSWS hereby waive all claims against each otherfor Are damage or damages from other perils covered by insurance provided In paragraph"C"of this section. 2.WORK QHANGF-8;Owner reserves the fight to order chariges in the nalum of additions,deletions,or modifications,without invalidating the contract, and agrees to corresponding adjushnents in[lie contract price and time for completion.All changes will be authorized oniy by a written change order signed by owner Or by his agent,The change order will include confirming changes in the contract and completion time.VJork shall be changed,and the contract price and completion time shall be modified only as set out in the wrlYen change order.Any adjustment in the contract price resulting in a credit or a charge to owner shall be determined by mutual agreement of 6'-e parties,or by arlaitration,before starting the work involved in the change. 3.TRASK AND CLEAN-UP,NSAl$is responsible for interior and exterior dean-up in rooms and areas directly impacted by the construction,including crash removal and vacuuming.Dumoster expenses,as needed,are Included in the total price. 4.TERMINATION:If owner cancels this contract•without legal cause after any right to rescind period,he shall pay NSWS the amount of expenses incurred to that date plus 15%of the contract price.If NSWS cancels this contract prior to commencement o'construction,NSWS shall return to owner any amounts paid to that date.That shall be the owner's sole remedy in law or equity. 5.COMPLETION CERTIFICATE BY OWNER:On completion of NSWS's work,owner shall execute and deliver to NSWS a completion certificate confirming that the owner of his agent has inspected NSWS's work and that the work has been satisfactorily completed to the owner's satisfaction or Rarnizing any deficiencies or the specific complaints in NSWS's work. 6,LIMITED WARRANTY.NSWS WARRANTS ITS INSTALLATION ONLY TO BE FREE FROM DEFECTS IN WORKMANSHIP FOR A PERIOD OF FIVE(6)YEARS FROM COMPLETION,THE GOODS INSTALLED HEREUNDER ARE SUBJECT ONLY TO ANY WARRANTIES OF THE MANUFACTURED.,ANY WARRANTY HEREUNDER EXTENDS ONLY TO OWNER AND IS NOT TRANSFERABLE TO SUBSEQUENT PURCHASERS OF THE REAL PROPERTY OR TO OWNER'S HERS, REmESriNTATIVES, SUCCESSORS,OR ASSIGNS.IF A DEFECT IN WORKMANSHIP COVERED BY THIS WARRANT`f OCCURS, NSWS WILL AT ITS OPTION REPAIR,REPLACE;OR PAY OWNER THE COST OF REPAIRING THE DEFECTIVE WORK AT NO COST To OvvNER,To OBTAIN WARRANTY PERFORMANCE, NOTIFY NSWS OF ANY DEFECT OF CLAIMS FOR BREACH,AND THIS SHALL BE THE OWNER'S SOLE REMEDY IN LAW OR EQUITY.THE PROVIDED SAID LIMITED WARRANTY IS SUBJECT TO THE FOLLOWING EXCLUSIONS: A. THE GOODS INSTALLED HEREUNDER ARE SOLO ON AN'AS IS'BASiS BY NSWS.THE ENTIRE RiSK AS THE QUALITY AND PERFORMANCE OF SUCH GOODS IS WITH OWNER, SHOULD SUCH GOODS PROVE DEFECTIVE, OWNER,AND NOT NSWS ASSUMES THE ENTIRE COST OF ALL NECESSARY REPLACEMENT OR REPAIRS.THE GOODS INSTALLED HEREUNDER CARRY THE MANUFACTURERS'WARRANTY ONLY AND NSIWS WITHOUT IN ANY WAY ASSUMING RESPONSIBILITY OR LIABILITY THEREFORE AGREES TO EXTEND OR PASS ON TO MINER SO FAR AS IS POSSIBLE MANUFACTURER'S WARRANTIES. B. DEFECTS AND FAILURE FROM MISTREATMENT,-NEGLECT,OR FROM OTHER CAUSES BEYOND NSWS'S DIRECT CONTROL SUCH AS MOISTURE, EXPOSURE TO SUN,CRACKED,BUCKLED,WARPED,OR OTIHER%VISE DEFECTIVE SURFACES AND SUBSURFACE,SETTLING,OR STRUCTURAL DEFECTS_ G. 'WORK PERFORMED BY,OR MATERIALS,APPLIANCES OR EQUiPMENT INSTALLED BY OTHERS NOT IN THIS CONTRACT. D. EXCLUSIONS AND LIMITATIONS-OWNER'S RIGH'i'TO REPAIR.AND REPLACEMENT ARE THE EXCLUSIVE REMEDIES AND NSWS SHALL NOT BE LIABLE FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM THE WORK PERFORMED BY NS'JVS OR FROM THE GOODS PROVIDED FOR IN THIS CONTRACT, THIS LIMITED WARRANTY iS THE ONLY EXPRESSED WARRANTY NSWS GIVES. IMPLIED WARRANTIES,INCLUDING BUT NOT LIMITED TO WARRANTIES OF it4ERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE,ARE LIMITED TO A DURATION OF 60 DAYS FROM THE DATE OF INSTALLATION. THiS AGREEMENT SHALL BiND THE CUSTOhAMS HEIRS,BENEFICIARIES, EXECUTORS, ADMINISTRATORS, SUCCESSORS, INQUIRERS,AND ASSIGNS OF THE PARTIES HERETO. 9 GSed UT-ejunoW uoaI 1V TU ; DD :6 9TOZ/TE/U Pago 5 of 5 REQUIRED PERMITS THE FOLLOWING BUILDING PERMITS ARC REQUIRED.IT IS THE OBLIGATION OF THE CONTRACTOR TO SECURE SUCH PERMITS AS THE HOMEOWNER'S AGENT.LIST ANY'AND ALL NECESSARY CONSTRUCTION-RELATED PERMITS. NOTE:OWNERS WHO SECURE THEIR OWN PERIAITS OR DEAL WITH UNREGISTERED CONTRACTORS ARE EXCLUDED FROM THE GUARANTY FUND PROVISIONS OF MGL C. 142A. As required per town of North Andover Permit billed separately of this proposal based on total project cost,payable by customer to NSWS NOTE:ALL HOIAS IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE P.£GISTERED AND ANY INQUIRIES ABOUT A CONTRACTOR OR SUBCONTRACTOR RELATING TO A REGISTRATION SHOULD BE DIRECTED TO; DIRECTOR,HOME IMPROVEMENT CONTRACTOR REG>STRATION ONE ASHBURTON PLACE,ROOM 4301 BOSTON,MA 02108 617-72T-8598 LESS OTHERWISE NOTED WITHIN THIS DOCUMENT,T HE CONTRACT SHALL NOT IMPLY THAT ANY LIEN OR OTHER SECURITY UNLESS HAS BEEN PLACED ON THE RESIDENCE, ARBITRATION NSWS AND THE HOMEOWNER HERESY MUTUALLY AGREE 114 ADVANCE THAT IN THE EVENT THAT NSWS HAS A DISPUTE CONCERNING THIS CONTRACT,NSWS MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND 13US114ESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED T 'SUBMIT TO iTRATION AS PROVIDED IN M.G.L.CA 42A. NSWS: DATE' L t CUSTOM.R: UATE: /tip. NOTICE.THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREENIENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT iNITLA T ED BY NSWS.THE OWNER MAY INITIATE ALTERNATIVE DISPUTE P.ESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. ACCELERATION OF PAYMENT HOMEOWNER'S FINANCIAL INSECURITY-A CONTRACTOR MAY NOT DEMAND PAYMENTS IN ADVANCE OF THE DATES SPECIFIED 014 THE PAYMENT SCHEDULE IN CASES WHERE THE HOMEOWNER DEEMS HtI01HERSELF TO BE FINANCIALLY INSECURE.CONTRACTOR'S FINANCIAL INSECURITY-IN INSTANCES WHERE A CONTRACTOR DEEMS HIMIHEP.SELF TO BE FINANCIALLY INSECURE,THE CONTRACTOR MAY REQUIRE THAT THE BALANCE OF FUNDS NOTYET DUE BE PLACED IN A JOINT ESCROW ACCOUNT AS A PREREOUISITE TO CONTINUING THE CONTRACTED WORK.WITHDRAWAL FRONT SAID ACCOUNT WOULD REQUIRE THE SIGNATURES OF BOTH PARTIES, NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE DATE THAT THE CUSTOMER SIGNS THIS CONTRACT. AFTER THREE BUSINESS DAYS,AN ORDER FOR NON-STOCK WINDOWS ANDIOR DOORS MAY NOT RE CANCELLED. IF YOU CANCEL WITHIN THREE BUSINESS DAYS,ANY PROPERTY TRADED IN,A14Y PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY 14EGOTIABLE INSTRUMENTS 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 RESIDE14CE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DEUVEP,ED TO YOU UNDER THIS CONTRACT OR SALE:OR YOU MAY,IF YOU WISH,COMPLY,KITH 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 CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION.IF YOU FAIL TO IAAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO 50,THEN YOU IREMA114 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 NSWS INSTALLED SERVICES,AT 239 South Main Street,Middleton,MA 01949140T LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia V� Workeys' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibl Name (Business/Organization/Individual): 906k, st-w t W 11,5Aoy') C�1 1 l6 t Address: '�t � �� siy . 01 City/State/Zip: Phone Are yqu an employer?Checic the appropriate box: Type of project(required): 1. I am a employer with-1—_employees(full and/or part-time).* 7. ❑New construction 2•❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[_J I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.# /00,14. 1�Other k11At)f,�l� � 6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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 attz aft employer that is providiltg workers'cotnpernsation irtsurmtce for nzy employees. Below is the policy and job site information, Ihi (' Insurance Company Name: � 1� `� `�� R i'lo d Policy#or Self-ins.Lie.#: E qJ�� Expiration Date: �� ! l Job Site Address: � �k City/State/Zip: t4 , All Awe r ►" E Attach a copy of the workers' co 'ensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 at penalties of perjury that the information provided ab ve is true and correct. Signature:ature: _ Date: Itl 2J t Phone# 01ga � w Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Iicensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to early workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia qINSURANCE-_E05/12DATE(MM1DDl1'YYY) AA ® CERTIFICATE F LIABILITY /2015 i ` I, , , , j�� Y AND CONFERS NO RIGHTS UPON THE C RTIFICATE HOLDER. THIS CERTIFICATEIS ISSUEED AFFIRMATIVELY VE YER NEGATIVELY VELY AMEND, XTEND OR ALTER THE COVERAGE AFFORDED BY THE POL CIESIS CERTIFICATE DOES NOT 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 ce lof the ololicyScertaiinDpoliic polliicies SU quiire an endorhe sement st be enCis A statement on this Ucertificate I does no�onfDersrights ttoothe the terms and conditionsP certificate holder in lieu of such endorsement(s). Patricia Tedesco NAME: 860.496.9713 PRODUCER PHONE $60,4$2.5591 (A/C,No): Burns, Brooks & McNeil E-MAIL tedesco@burnsbrooksmcneil .com www.burnsbrooksmcneil .com ADDRESS: p NAI.# INSURERS)AFFORDING COVERAGE 147$$ 69 Water Street P.O. Box 717 Torrington, CT 06790 INsuRERA: National Grange Mutual 14788 INSURED North Shore Window Solutions, LLC INSURER B: National Grange Mutual 239 South Main Street INSURERC: Middleton, MA 01949 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 15-16 REVISION NUMBER: THIS IS TO CERTIFY THAAND NG ANY REOUIREIJI N TERM ED CONDITIONVO ANY CONTRACTT OR OTHER DOCUMENT MOTH REO PECTT OLWHICH THIS INDICATED. CERTIFICATE AND CONDITIONS MAY PERT SUCH PAIN,THE OLICIES.LIMITS INSURANCE MAY HAVE BEEN REDUCED BY PA DIC LAIMS.ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSPOLICY EFF POLICY E P LIMITS INSR TYPE OF INSURANCE I INSR WVD I POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LTR BPT68 57 05/15120151051l5/2016 EACH OCCURRENCE £ 1,000,00 GENERAL LIABILITY5 500,000 PREMISES(Ea occurrence) X COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) S 10,000 CLAIMS-MADE a OCCUR PERSONAL&ADV INJURY S 1, 0100 A X GENERAL AGGREGATE 5 2,OOO'00 PRODUCTS-COIv1PIOP AGG s 2,000,000 'GEN'L AGGREGATE LIMIT APPLIES PER: (s POLICY X jECO LOC M2T6857 05/1512015105/15/201 (Ea accident) s 1,000,00 AUTOMOBILE LIABILITY BODILY INJURY(Per person) S ANY AUTO BODILY INJURY(Per accident) S B ALL OWNED X SCHEDULED P AMA S AUTOS AUTOS (Per accident) NON-OWNED S HIRED AUTOS AUTOS UMBRELLA LIAB X OCCUR CUT68 57d 0511512015 0511512016 EACH OCCURRENCE � 2,000,000 X AGGREGATE B EXCESS LIAB CLAIMS-MADE s X RETENTION S 10,00 1 TORY OTH- WCT6857 0511512015 0511512016 X we sT Tu- DED ER WORKERS COMPENSATION AE.L.EACH ACCIDENT I s 500,000 AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIV N N/A E.L.DISEASE-EA EMPLOYEES 500,000 A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-POLICY LIMIT s 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) E: Evidence of Insurance CANCELLATION CERTIFICATE HOLDER 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 Patricia Tedesco, CIC To Whom It May Concern O 1ggg.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs 2thd Business Regulation _C) 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 172585 Type: Supplement Card Expiration: 7/10/2016 NORTH SHORE WINDOW SOLUTIONS LL DENNIS LASSELL 239 SOUTH MAIN ST - MIDDELTON, MA 01949 Update Address and return card.mark rre sn for t Card – E] Address ❑ Renewal ElEmployment ❑ SCA1 0 20M-05111 �/ / v M M ON([le6,IIIl OI CC[JJC[C�[[Je J e of Consumer Affairs&Business License or registration valid for individul use only ess Regulation �rbefore the expiration date. If found return to: = DME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation l I Type: 10 Park Plaza-Suite 5170 --W h egistrationc„:1.72585 Supplement Card Boston,MA 02116 Expiratior9:;7/10/2016 PP NORTH SHORE WINDOW SOLUTIONS LLC DENNIS LASSELL _ 239 SOUTH MAIN ST `` Not va' without signature MIDDELTON,MA 01949 Undersecretary =_ _—---- 1Massachusetts -Department of Public Safety � �M�AS,SACHUSBTTS- DRIVER' 'Board of Building Regulations and Sta ndard s i LICENSE p ---- ------- 6_�t � USA _ 1.l)11J L141L1V11 JU�C111)1.11 [ ,�" License: CS-091857 9aEND 4d NUMBER 1 � NONE 5700 S3624 DENNIS E LASSES. rr 3-DOB 571 West Street _ 5IX M 1 _ Q - � Leominster MA 61453�� e. E L _ I z0 ISE -. � w ,c,i_ a Expiration B 571 WEST ST- _ 11/02/2016 LEOMINSTER,MA 01453 Commissioner i " —s DD 10202010 R.V 07.15-2009*VETERAN