HomeMy WebLinkAboutBuilding Permit # 5/18/2016 l
BUILDI NG PERMIT �oRr�,
o���tFo ,bA''�o
TOWN OF NORTH ANDOVER �� � :' ab
APPLICATION FOR PLAN EXAMINATION ® ',
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Permit ego#: Date Received �RQ�RHTEO
�ceaus``�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION / � 5v:�,�,t,�. Se--
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP �� PARCEL: _ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑ Addition ❑ wo or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ; � , ❑ Floodplain ❑Wetlands ❑ Watershed Distract
, �71Natei/Seuver , .
1
DESCRIPTION OF WORK TO BE PERFORMED:
r
Identification- Please Type or Print Clearly
OWNER: Name: , Phone:
Address:
Contractor Name: �G�� �(�w�n� �f� lj� �, i�4,Rlqone: !Z 2 -74S-�
Email:
Address: 2—
Supervisor's Construction License: � i 2, Exp. Date:
Home Improvement License: / W j -2 3 Exp. Date: 2-9r-1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.: Z20 S i`Y
NOTE: persons contracting with unregistered contractors do not have access to the guaranty fund
®RT
i own olAndo v er
2 1,.
0 :
% LAKE h verb ass,
COC HICNEwICK ��•
®S RATED
ll BOARD OF HEALTH
Food/Kitchen
PERMIT LI) Septic System
THIS CERTIFIES THAT � BUILDING INSPECTOR
has permission to erect .. buildings on ...-/ ............. Foundation
........................ ....... ..........................................................
Rough
to be occupied as l..`,�i /G�'.�'�. y
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 IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS T Rough
............... Service
.................. ...... .............. ....... s.`.v....... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to OccupV BuRough
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 Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Contract - Detailed
Pella Window and Door Showroom of Haverhill
m 45 Fondi Rd r Sales Rep Name: Griseto, Anthony
Sales Rep Phone: 978-490-9666
Haverhill, MA 01832 Sales Rep Fax:
Phone: (978) 373-2500 Fax: (978) 373-7274 G Sales Rep E-Mail: GRISETOAC@pellaboston.com
Customer Information Project/DeliveryAddress Order Information
Paul Tanglis Tanglis,Paul,NorthAndover,MA,1714461 Quote Name: 2 Encompass Doors 2 Storm Doors
149 Summer St 149 Summer St
Order Number: 741AGO623
NORTH ANDOVER, MA 01845-4816 Lot# Quote Number: 7790574
Primary Phone:(978)7715573 NORTH ANDOVER,MA 01845-4816 Order Type: Installed Sales
Mobile Phone: County: ESSEX Payment Terms: Deposit/C.O.D.
Fax Number: Tax Code: MA TAX 6.25
E-Mail: pltanglis@yahoo.com Quoted Date: 4/26/2016
Great Plains#: 10616400
Customer Number: 1007880725
Customer Account: 1003740108
Line# Location: Attributes
10 Delivery Delivery/Setup-Delivery/Setup Item Price Qty Ext'd Price
$197.40 1 $197.40
For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com
Printed on 5/1012016 Contract-Detailed Page 1 of 8
Customer: Paul Tanglis Project Name: Tang lis,Paul,NorthAndover,MA,1714461 Order Number: 741AGO623 Quote Number: 7790574
Line# Location: Attributes
15 Back Door Encompass By Pella, Entry Door Inswing, White Item Price Qty Ext'd Price
$2,643.08 1 $2,643.08
1: Entry Door
PK# Unit Type: Right Inswing,Standard Sill,No Fire Rating
787 Panel Style: 1/2 Light
Glass: Tempered Low-E Air Filled
Grilles: No Grille
Panel Selection: Oak,Painted,White,Stained,Early American
Frame Selection: Wood,Pine,Composite Threshold,Primed,Wood,Primed
Viewed From Exterior Hardware Options: Latch Bore with Deadbolt,2 3/8",Steel Spring,Satin Nickel, Bronze Anodized
ES Single-Install Single Entry Door I Qty 1
PVC Upgrade>48-PVC Upgrade greater than 48 inches If Qty 1
Paint ED Frame-Paint Encompass ED Frame Only I Qty 1
Schlage Lever&Db-Satin-Schlage Lever&Deadbolt-Satin 1 Qty 1
Entry Trim Finish-Finish Paint/Stain Entry Interior Trim Only Qty 1
Line# Location: Attributes
20 Front Door Encompass By Pella, Entry Door Inswing, White Item Price Qty Ext'd Price
$2,433.86 1 $2,433.86
1: Entry Door
PK# Unit Type: Right Inswing,Standard Sill,No Fire Rating
787 Panel Style: 6 Panel
Panel Selection: Oak,Painted,White,Stained,Early American
Frame Selection: Wood,Pine,Composite Threshold,Primed,Wood,Primed
Hardware Options: Latch Bore with Deadbolt,2 3/8",Standard Steel,Black,Bronze Anodized
Viewed From Exterior
Schlage Lever&Db-ORB-Schlage Lever&Deadbolt-Oil Rubbed Bronze Qty 1
Entry Trim Finish-Finish Paint/Stain Entry Interior Trim Only Qty 1
ES—Single-Install Single Entry Door If Qty 1
PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1
Paint ED Frame-Paint Encompass ED Frame Only . 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 5/10/2016 Contract-Detailed Page 2 of 8
Customer: Paul Tanglis Project Name: Tanglis,Paul,NorthAndover,MA,1714461 Order Number; 741AGO623 Quote Number: 7790574
Line# Location: Attributes
25 None Assigned Entry Systems, Storm Door Fullview Interchangeable Unhanded, White(91025) Item Price My Ext'd Price
$668.641 $668.64
1:to 81 Unhanded Storm Door
PK# General Information: Clad
787 Exterior Color/Finish: Standard Enduraclad,White
Sash/Panel: 1 5/8"Extruded
Glass: Clear
Hardware Options: Standard,Oil Rubbed Bronze
Model: 4601
Viewed From Exterior
ES—Storm Door Express-Install Storm Door Express(4601,4602,3900,3010,3020) Qty 1
Line# Location: Attributes
30 None Assigned Entry Systems, Storm Door Fullview Rolscreen Unhanded, White (P390052331) Item Price city ExVd Price
-- $701.53 1 $701.53
1:to 81 Unhanded Storm Door
PK# General Information: Clad
787 Exterior Color/Finish: Standard Enduraclad,White
Sash/Panel: 1 3/8"Extruded
Glass: Clear
Hardware Options: Standard,Satin Nickel j
Model: 3900
Viewed From Exterior
ES—Storm Door Express-Install Storm Door Express(4601,4602,3900,3010,3020) Qty 1
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 apart 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
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.
For more information regarding the finishing,maintenance, service and warranty of all Pella@ products,visit the Pella®website at www.pella.com
Printed on 5/10/2016 Contract-Detailed Page 3 of 8
Customer: Paul Tanglis Project Name; Tanglis,Paul,NorthAndover,MA,1714461 Order Number: 741AGO623 Quote Number: 7790574
Product Performance Information:
U-Factor,Solar Heat Gain Coefficient(SHGC),and Visible Light Transmittance(VLT)are certified by the National Fenestration Rating Council(NFRC).Manufacturer stipulates
that these ratings conform to applicable NFRC procedures for determining whole product performance.NFRC ratings are determined for a fixed set of environmental conditions
and a specific product size.NFRC does not recommend any products and does not warrant the suitability of any product for any specific use.
Design Pressure(DP),Performance Class,and Performance Grade(PG)are certified by a third party organization,in many cases the Window and Door Manufacturers Association
(WDMA).The certification requires the performance of at least one product of the product line to be tested in accordance with the applicable performance standards and verified
by an independent party.The certification indicates that the product(s)of the product line passed the applicable tests.The certification does not apply to mulled and/or product
combinations unless noted.Actual product results will vary and change over the products life.
For more performance information along with information on Florida Product Approval System(FPAS)Number and Texas Dept.of Insurance(TDI)number go to AN el la.com
/performance.
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 followina:
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
For more information regarding the finishing,maintenance, service and warranty of all Pella@ products,visit the Pella®website at www.pelia.com
Printed on 5110(2016 Contract-Detailed Page 4 of 8
Customer: Paul Tanglis Project Name: Tanglis,Pau l,NorthAndover,MA,1714461 Order Number: 741AGO623 Quote Number: 7790574
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
Remove stickers from product and save for energy rebate and tax purposes
Wash all interior& exterior glass surfaces
Fill and joints on interior trim if windows are to be stained (after staining)
/� up exte ' r casing issues due to storm window removal if full wrap or new exterior trim is not purchased
1 - oject Checklist has been reviewed
Customer ini
Product Only Addendum has been reviewed
Customer initial
Credit Card Account#: Last 4 Digits
Expiration Date: /
p 0 � �
Charge final payment to same account
(Upon substantial completion) Customeriniti
For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pellae)website at www.pelia.com
Printed on 5/10/2016 Contract-Detailed Page 5 of 8
Customer:Paul Tanglis Project Name: Tanglis,Paul,NorthAndover,MA,1714461 Order Number: 741AGO623 Quote Number: 7790574
Project Checklist has been reviewed
/Customer Name (Please print) Pella Sa s p N§je (Please print Order Totals
k! Taxable Subtotal $3,515.51
Customer Signature P Ila SalesSiPlOture Sales Tax @ 6.25% $219.72
��'����° Non-taxable Subtotal $3,129.00
Date Date Total $6,864.23
Deposit Received $0.00
Credit Card Approval Sign ure Amount Due $6,864.23
For more information regarding the finishing, maintenance,service and warranty of all Pellag)products,visit the Pella®website at www.pelia.com
Printed on 5/10/2016 Contract-Detailed Page 6 of 8
tomer:Paul Tanglis Project Name: Tang lis,Paul,NorthAn dover,MA,1714461 Order Number: 741AG0623 Quote Number: 7790574
Lead Safe Installation Customer Performance Expectations
In order to ensure a proper Lead Safe Installation, it is essential that we have you complete the below tasks prior to your installation:
❑ ALL furniture needs to be moved at least 8 feet away from any window or door being replaced
❑ ALL personal items, wall hangings, and collectibles must be removed prior to your installation date
❑ All blinds and any interior window treatments need to be removed prior to your installation date
❑ Any non-movable furniture(for example: pianos, entertainment centers, built in cabinets, etc) st be cleared of items nd be s rface dusted r r
to installation
❑ You will be responsible for replacing all furniture and personal items after your inst ation
c ,
❑ Other items:
What to Expect the C ntainment/Work Area to Look Like
❑ In order to ensure your safety, we will be taking meas es to minimize dust/debris does not spread beyond our work area. This may include the
use of plastic sheeting on the floors and/or walls, c tion signs, sealing of heating and cooling air vents, and asking that you turn off your HVAC
system during our work.
❑ During your Lead Safe Installation, you m also see your installation professional wearing Personal Protection Equipment.
❑ For your own safety, we are not pe fitted to allow you inside the work area during the removal of your current product or the installation of your new
windows/doors.
By signing the form below, I a affirming that I understand all the expectations noted above and that I have agreed to have all items completed prior to
my installation commencin . understand that failure to have these items completed will result in the re-scheduling of my installation and that my
installation date will be eduled for the next available date.
Customer Signature
Date
For more information rPnarriinn h f- h
_„ g., �g, maintenance,service and warranty of all Pella®products,visit the Pella®website at vwwv.pella.com
Tinted on 5/10/2016
Contract-Detailed Page 7 of 8
Customer: Paul Tanglis Project Name: Tang lis,Paul,NorthAn dover,MA,1714461 Order Number: 741AG0623 Quote Number: 7790574
Pre-Renovation Form
Occupant Confirmation
Pamphlet Receipt
I have received a copy of the lead hazard information pamphlet informing me of the potential risk of lead hazar xposure from renovation activity to be
performed in my dwelling unit. I received this pamphlet before the work began.
Printed Name of Owner-occupant
Signature of Owner-occupant Signature Date
Renovator's Self Certification Option (for tenant-occupied dwellings only)
Instructions to Renovator-If the lead hazard information pamphlet was delivered bu tenant signature was not obtainable, you may check the appropriate box
below.
Declined - I certify that I have made a good faith effort to deliver t ead hazard information pamphlet to the rental dwelling unit listed below at the date
and time indicated and that the occupant declined to sign the c irmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with
the occupant.
Unavailable for signature -I certify that I have made ood faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed
below and that the occupant was unavailable to sig he confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit by
sliding it under the door or by:
(Fill in how pamphlet was left)
Printed Name of Person Certifying Delive Attempted Delivery Date
Signature of Person Certifying De' ery
Unit Address
Note Regarding Mailing Option --As an alternative to delivery in person,you may mail the lead hazard information pamphlet to the owner and/or tenant.
Pamphlet must be mailed at least 7 days before renovation. Mailing must be documented by a certificate of mailing from the post office.
For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com
Printed on 5/10/2016 Contract-Detailed Page 8 of 8
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 hvo 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 Pella9. LIMITED Yi20DUCI'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 Ti iE 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 WARRAN'T'Y 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 One Ashburton Place,Boston,MA 02108,617-727-8598
accumulation of waste materials or rubbish caused by performance of the 12. PERMITS(MA customers only)
Work.
Pella is obli ated to and will obtain the following permits for this project:
4. CHANGES Buil in- . Homeowners who secure their own permits will be
excluded from the guaranty fund provisions of Massachusetts General Laws,
The Owner may order in writing changes in the Work consisting of additions, chapter 142A.
deletions,or modifications("Change Order"). Any Change Order shall
include an adjustment to lie Price and the Substantial Completion Date,as In addition to the rights and warranties enumerated in this agreement,you may
determined by Pella. Pella reserves the right to approve or disapprove any have additional rights under Massachusetts General Laws,chapter 142A and
Change Order and any such Change Order must be signed by both Owner and 780 Code of Massachusetts Regulations R6.
Pella to be effective.
13. NOTICE OF CANCELLATION
5. SUBSTANTIAL,COMPLETION You may cancel this agreement if it has been signed by a party
Owner understands and agrees that the Substantial Completion Date is an thereto at a place other than an address of the seller, which
estimate only and that the actual date on which the Work is completed may be may be his main office or branch thereof,provided you notify
extended to allow for Change Orders requested by Owner or ifthe time to
complete the Work is affected by conduct of the Owner,weather,labor the seller in writing at his main office or branch by ordinary
disputes,availability of subcontractors,acts of God,fire or other causes mail posted,by telegram sent or by delivery,not later than
reasonably beyond Pella's control.if for any reason the Work is not fully midnight of the third business day following the signing of this
completed by the Substantial Completion Date(including any extensions agreement.
contemplated above),but is substantially completed by such date,i.e.,the
Product has been installed,but minor parts or components are missing or need See the attached Notice of Cancellation for an explanation of
to be replaced or repaired,a hold back proportionate to the cost of remaining
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 sign this contract if there are any blank spaces.
Irpayment 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
Financing shall have been received from the financial institution. Customer st n ure
1�i10,
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. I42A
Pella Windows & Doors
Contractor
Homeowner
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: - 5- 12 —&
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 Bondi Rd., IIaverhill, MA 01832
not later than midnight of JI Y� (three business days from the date of
transaction above).
I hereby cancel this transaction.
(Date) (Buyer's signature) Do NOT sign here unless you wish to cancel
l't ttnrrtn
The tt:-okwoeaFvetcfth oj-Hassttchtdsem3J. _ _F
e par anem of Industrial Aecdaien
Office of Iatvestigctlions
I Congress Street, suite 100
Boston,MA 02114-2017
1i Mw.MaSIKgov/dice
Workers' Compensation Insurance Affidavit. BuiRde rs/Co ntrae>toy s/Electlrieuans/P8um bees
Applicant Information Please Print Legibly
Name(Business/Organization/lndividual): /A , est 0"M bJz.V9 L��a
Address:
City/Mate/Zip: ' t C '� Phone#:
Are you an employer?Check the appropriate box: 'Type of project(required):
1.W1 am a employer with -:7—, 4. ❑ I am a general contractor and 1
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. PKRennodeling
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. insurances
® are a corporation required.] . 5. We oration and its 10.EJ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
cornnp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contn1dors 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. ff the sub-contractors have employees,they must provide their workers'comp.policy number.
Iam an e/npkier that isproviding workers'compensation insurance for nay employees. Belo►v is thepolicy andjob site
information.
Insurance Company Name: (4c; le s c o .
Policy#or Self-ins. Lic.#: 4060 Ll 0 10 Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
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 snider the pains and penalties of pet,jury that the inforinration provided above is trace and correct
Sig natu e• - ---- g Date
Phone#:
Official use onlj. Ido not write in this area,to be completed by situ or town official
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of Health 2. ftiMng Department 3. Uler& 11, Electrical brnspmtor 5. Plumbing lnspe,ctor
5. other
EITIF1 o
ATE F LI ILITY INSURANCE
65��1�110661ryDMIYYI
THIS CERTIFICATE IS NOT
A5>�MATTER OF INFOItMAT1ON ONLY ANC CLpNFER5 NO RIGHTS UPON THE CERTIFICATE HOS II EI .THIS
CERTIFICATE. THIS
CORS NOT AFFIRMATIVELY OR NEGAT(1/ELY AMEND, ERTEN®OR ALTER THE COVERAGE E CERTI IC TE THE POLICIES
BELOW. TH1T CERTIFICATE E ,AND THE
CER
NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT If the I certificate holder is an ADDITIONAL INSURED,the poltcy(ies)tROsthe endorsed If SUBROGATlOiN IS WANED,ser6jeot
the farms and can�lions Of the policy,certain Policies may retpHlre�n endoLselnenL A sia[eRient o0 this a UBROG does not col ,-subject
a tto
he
certificate holder in lieu®f such end®r`emen 5p,
PRODUCER
Fred C.Church,Mn NAME; OWhyA Codon GIC,RPLU
41 WaOmanSlree!
Lowell,MA01851 PHONE 9703072;3, FAH
(000)225.1865 FAiAIL Nur (976)454-iH55
ADDRESS.- dnmb0�edcchurdr eom
URE IlAFFORDING COVERAGE
'o4rnaan®C HAICtF
INSUfl® INSLIRERA: CIflompanyafAmadca 33534
New t5t91endWrndowAOoarLLC - N-Raul INSURER H. E"loyans,Insuranra Company 13093
45 Fonds Road INSURER G:
HauediN,MA 01832-1302
INS UR:RD:
INSURER E:
COVERAGES CERTIFICATE NUMBER- INSURER F:
5MI57
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEp BELOW HA}/E g�IS5UE0 TO THE INSUREQ NA SMEp AUO EION EFQR THE PODGY t'Efl1OD
ICERTIFICATENDICATED. NOTWITHSTANDING O ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
EXCLUSIONS MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND G4NDITONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN THE
HYPOID CLAIMS.
Nan AOOL SUER
LTR TYPEOFUNSURANCE DIICYEFf POWOCYENP ,
GENERALLUTBW7Y POUCYNUMBER x!13
LIMITS
H COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000,0OR
DAMAGETR)REN1E0 100,000
CLAIMS•MAt7E H OCCUR REMISES a ectwrenes S
A H CG0001 MEDE%P(Anyonapetson) S 0XII
20NB161907 7!1/2015 7/1/2016
------------
PERSONAL a ADV INJURY g 1.000,000
GENLA13GREGATELIMIT APPLIES PER: GENERALAGGP,EGATE 5 2000,000
PDLICY H J C� H LOC PRODUCTS-COMPIOPAGO 9 2,000.000
AUTOMOOILELUt01LITY 8
ANY AU70 COMBINmSINGLELIMtT
ac dent S
AUTO SCHEDULED BODILYINJURY(Parpersan) S
ALTOS
UTp6WNED SDOILYINJURY(PQraatdanq S
HIREOAUiOS g
PROP DAMAGE $
Pa acddent
UMBRELLA VAS OCCUR S _
EXCESS CLAIMS-MATTE EACHOCCURRENCE 8
OED RETENTIONS AGGREGATE S
WORT ERS COMPENSATION
AND EMPLOYERS'LIAmurr S
][ WC Si�7U E�
B ANYPRDPRIt70RIPMTNERMECITi(VE®
MEMO LUDED? NIA 900640181 500,000
(Mandatory In Niq 7(1/2015 77112016 EL EACH ACCIDENT 8
06 P ONOFOPERAT1ON5herow ELDISEASE-EAEMPLOY $500,000
EL DISEASE-POLICY UMIT S 500,000
DE"MPTtONOFOPERAIIONSILOCATdONSIllEH(CLES(ptiadapCOno 101,AddiGonatRamarhsSclmdote woORspace h;g.7edl
CERTIFICATE HOLDER
CANCELLATION
a CS-089853
� k4
WILLIAM R NICHULS
$7 PEARTREE RO` U:`
HAVERIIILL MA-
1,01830 a
i
/rP (('n/7J%nOJJ/(/('CYT C/�l(aJJC/CIJ!(JCCIJ•�' -
ice of Consumer Affairs&Business Regulation License or registration valid for individul use only
rVIE IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 183279 T
Office of Consumer Affairs and Business Regulation
Type:YP 10 Park Plaza-Suite 5170
Expiration: 9/24/2017 Supplement Cjird Boston,MA 02116
NEW ENGLAND WINDOW&DOOR, LLC.
PELLA WINDOWS&DOORS '-
William Nichols
45 FONDI ROAD
HAVERHILL,!U; 121832 . Undersecretary Not valid.without signature