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Building Permit # 11/16/2016
.. taC 7y r BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR.PLAN EXAMINATION Permit No#- Date Received �� SsACHus, Date Issued: ORTANT:Applicant must compute all items on this;page Pnnt'� I?ROPRTY C7INNER ®` Pent 1�D Year Stfuc#ere: yes no MAP PARGEL: - ZaNING 01STRICT Hrstdrrc District: yes do , M6chine:5hop;Vrll0ge_, yes h..Q TYPE OF IMPROVEMENT PROPOSED USE Residential Non Residential ❑ New Building kOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial tj�jRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other C7 Septie - Cl Well' [iRbbdp[a[ri ❑ We I- ds L7, Watershed Qistricf DESCRIPTI®N OF 11VORK T® UE PERF®RMED: L� Ideiatification- Please Type or Print Clearly' OWNER: Name: V� s , �-c Phone: ' Address: r Contractor Name P, e. 7m. Address: Supervisor's �anstructrori J!. �°7 j Exp_. Date C; l LL Home irnpovern� rrtTLrcerise - ARCH ITECTIENGINEER Phone: Address: Reg. leo. FEE SCHEDULE;S ULDING PERMIT;$72.00 PFR$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S : � J®1 al ProjectCost: $ FEE: $ Cher-k No.: Receipt No,, NOTE: Persons contracting witIl unregistered contractors do not have:access to the guaranty fund 5i i�aue>of.A _entl0virer ignature df corit_r'acfor' . . ....��af�c�+4Ykta�!ga=M`z °avw'.'°'�f+C,`"'S!F -.....��. . u!a� _ .y,i+ •-=r�A-y�(�:'.d'"'"` .. - _ ,, s - _>G'S.'4.,,:�' ... - .. -_ t%O R T1y own of M No. - �, h ver, Mass,) �p 2oip o K9 CoCMar'"Ew x �- S U BOARD OF HEALTH Food/Kitchen PERMIT T'. LD Septic System THIS CERTIFIES THAT ......0.1:4., 04%400- ..... . ,. BUILDING INSPECTOR .4 . /�_..... ..., ... Foundation has permission to erect .......................... buildings on �t .......,... I. .� �. Rough to be occupied as ...... .... ..... .�/rwt ..V�..4 !1�.......,. Chimney provided that the person accepting is 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 CONSTRUC N STA Rough ....., .. .. . Service ... .... ... ........,.. Final BUILDI.NG.I.NSPECTOR GAS INSPECTOR Occupancy Permit Required to Oceupv Buildin 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 r Pella Window and Door Showroom of Haverhill Sales Rep Name: Griseto,Anthony e 45 Fondi Rd Sales Rep Phone: 978-490-9666 /// Haverhill, MA 01832 Sales Rep Fax: Phone: (978)373-2500 Fax: (978)373-7274 Sales Rep E-Mail: GRISETflAC@pellaboston.com __ .....x,•':__sm.m..w---.__. _ __.-..-...�_...,-_ .....__..,�"...,...y- v:p::v.a.:g-- 05; ..........................-.T_.__—_ _ _ _ _ "itl]:W�94GnGC� »':11�"'•'.. :_ :n :nG .F..,un.-.-a-�..;ni.�.-.....»».... .•�:�:w N.;;...,._._.__-.._. '.... ,�,MOW -��T_n�,.•r:..u�r,.cam :u niun7: �.. - J 7:ih -.:1_..-'-' 0P. �. CC _ k'n^tea"_• `r..d:°nti� .^:75/. (�u�• .IIO�}clioilGA[wc4GaPtFF•.-_...:_��?�^,��!-•.��-' __- ::!_�•}x> �C'AxiMa;srr:��ac.�SY' .L:_�«L...«...�. .� .µ �lR1.i' -�_.-J-'^ ._']-^Ml• ', MiF� � � �-�=�-��-Com.__—_ --T.^�^ L ---•n•-n•m I~5-'-._ _ _1�'!�`�=:` c- �[�• :....,��.�!{* "�'i.:x��m.zionur_--_._.__.._._..'.:.:............�_ _ _—�'.'-"-",��r�:..�:..2,.�..c.,:;?,:,�.r�x,..•�_, —._.—_ - Joe Musumeci Musumeci,Joe,NorthAndover,MA,1818606 Quote Name: 15 Wide Proline Casement 63 Quail Run Rd 63 Quail Run Rd Order Number: 741AGO746 FORTH ANDOVER,MA 01845-5324 Lot# Quote Number: M715 Primary Phone:(978)6886530 North Andover,MA 01845-5324 Order Type: Installed Sales Mobile Phone: County: PaymentTerms: DepositlC.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: mxdbag@yahoo.com Quoted Date: 111812016 Great Plains#: 11295924 Customer Number: 1008165772 Customer Account: 1004087125 i�...:..- _.._.. .«.>T.l.z4:�::::^�.pC.n•�x+tl1�r_.-..— wh^ �v>:rrcc:-::ctwr.c..:• __�:.ba W........._..._._..___—ern: ..r.,�+, :_.•,.-.T, -sB—x�:.i�u ,���1'A:r.Z_a_.__�"-- �;�i.r,e.�.a:----,u.�.aa :r.-.-�+�-_._.....—».,.:_.an,:x��srM��_.;�_�-,:_.�_eay�rcT ,='�-�_-r�s.�rG-os,�:srr�..s.s�;a.i[•!un�v��=*���.�o__L_r_i_-a.� .>"d::.:.�. r u —!__r—,..��fiFula -:W�r-re-;_:�m•:�r�";�;t—.+a•e;nn:_-iE %wi= "Inw,w�.,&a;e�::e,;xs,�.�..,.�.:.�•ti�_�..«a.��_ 10 Delivery Delivery/Setup-Delivery/Setup Item Price Qty ExVd Price $206.80 1 $206.80 For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella0 website at www.pella.com Printed on 11!9/2016 Contract-Detailed Paue 1 of 6 Customer:Joe Musurned Project Name: MusUmeci,Joe,NodiAndoverMA,1818606 Order Number: 741AGO746 Quota Number 8453715 -- - 0094-, 15 LR Front ProLine, 5-Wide Casement, White Item Price Qty- Exfd Price $5,746.49 1 $5,746.49 --I-SizeNon-Standard Size Left Casement PK# General Information; Clad, 116" &I IWO 1 a,Um. 824 Exterior Color I Finish: Standard Enduraclad,White Interior Color I Finish., Prefinished White Interior Glass: Insulated Low-E AdvancedComfort Low-E Insulating Glass Argon Non High Attitude Hardware Options: Fold-Away Crank,White,No limited Opening Hardware Screen: Full Screen,White,InViewTO Viewed From Exterior Performance Information: U-Factor 0.25,SHGC 0.27,VLT 0.50,CPD PEL-N-14-00469-00001,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Grille: RMB,No Custom Grille,314",Traditional(2W4H),Prefinished White,White,Shipped Separate Vertical Mull 1. FactoryMull,Standard Joining Mullion,Mull Design Pressure-20 2:SizeNon-Standard Size Left Casement General Information: Cl9d,-5',3 11116" Exterior Color/Finish: Standard Enduraclad,White Interior Color Finish: Prefinished White Interior Glass: Insulated Low-E AdvancedComfort Low-E Insulating Glass Argon Non High Altitude Hardware Options: Fold-Away Crank,White,No Limited Opening Hardware Screen: Full Screen,White,InView1w Performance Information: U-Factor 0-25,SHGC 0.27,VLT 0.50,CPD PEL-N-14-00469-00001,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DID Rating 50,Year Rated 08 Grille: RMB,No Custom Grille,3/4",Traditional(2W4H),Prefinished White,White,Shipped Separate Vertical Mull 2: FaCtoryMull,Standard Joining Mullion,Mull Design Pressure-20 3-SizeNon-Standard Size Fixed Sash Set General Information: CG-7,'13 11116" Exterior Color I Finish: Standard Enduraotad,White Interior CoIoF1 Finish: Prefinished White Interior.- Glass: Insulated Low-E AdvancedComfort Low-E Insulating Glass Argon Non High Attitude Performance Information: U-Factor 0-24,SHGC 0,30,VLT 0.56,CPD PEL-N-22-00532-00001,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Grille: RMB,No Custom Grille,34",Traditional(2W4H),Prefinished White,White,Shipped Separate Vertical Mull 3: FactoryMull,Standard Joining Mullion,Mull Design Pressure-20 4.,SizeNon-Standard Size-Right Casement General Information: Clad,5",3 11116" Exterior Color/Finish: Standard Enduraclad,White Interior Color I Finish-, Prefinished White interior Glass: Insulated Low-E Advanced Comfort Low-E Insulating Glass Argon Non High Altitude Hardware Options: Fold Away Crank,White,No Limited Opening Hardware Screen; Full Screen,White, InVje*Tm Performance Information: U-Factor 0.25,SHGC 0.27,VLT 0.50,CPD PEL-N-14-00469-00001,Performance Class R,PG 50,Calculated Positive DIP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Grille- RMB,No Custom Grille,3/4",Traditional(2W4H),Prefinished White,White,Shipped Separate Vertical Mull 4: FactoryMull,Standard Joining Mullion,Mull Design Pressure-20 5:SizeNon-Standard Size Right Casement General Information: Exterior Color I Finish: Standard Enduraclad,White Interior Color/Finish: Prefinished White Interior Glass: Insulated Low-E AdvancedComfort Low-E Insulating Glass Argon Non High Attitude Hardware Options. Fold-Away Crank,White,No Limited Opening Hardware Screen: Full Screen,White,InViewrm Performance Information: U-Factor 025,SHGC 0.27,VLT 0.50,CPD PEL-N-14-00469-00001,Performance Glass R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Grille- RMS,No Custom Grille,3/4",Traditional(2W4H),Prefinished White,White,Shipped Separate For more information regarding the finishing,maintenance,service and warranty of all Pella(D products,visit the Pella@ website at www.pella.com Printed on 11/9/2016 Contract-DetEfiled Paqe 2 of 6 ..........-----................ Customer Joe Musumeci Project Name: Musumed,Joe,Norh4dover,MA,1818606 Carder Number. 741AGO746 Quote Number: 8453715 Vertical Mull 1: FactoryMull,Standard Joining Mullion,Mull Design Pressure-24 Extra Rayer EXT-Extra Layer Exterior Trim Qty 4 Finish FF Trim-Finish PaintlStain FF Interior Trim Only Qty I FF>96 wide-Install Full Frame Window>96 inches wide Qty 1 PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1 Misr.Labor-Miscellaneous Labor. 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 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 Insynetive 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.pellacom. By installing or using Your Insynedve Products you are acknowledging the insynotive Software Agreement and Privacy Policy are part of the terms'of sale. 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 fined 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 lime 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 www.pella.eom erformaan . Project Checklist Review (installed Orders Only) For more information regarding the finishing,maintenance,service and warranty of all PellaO products,visit the Pella®website at www.pelia.com Printed on 911912016 Contract-Detailed Paae 3 of 6 Customer:Joe Musurried Project Name: Musumed,Joe,NotiAndover,MA,1818606 Order Number. 741AGO746 Quote Number:8453715 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 C Arrange tohave alarm system and doorbells disconnected Arrange to have any' yT=ng 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 Durin theInstallation the Homeowner agrees to do the following: Keep pets safely away from work area Keep children safely away from work area Allow Pelta Installer room to work safely within your home _Durinci the Installation Pella agrees to do the following: Deliver and unload products purchased per contract r--,Place and remove drop cloths in work area then vacuum,and remove all debris at end of day r--. 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 ---^IfPurchased, install exterior primed pine wood trim or Composite. Composite will be unfinished. If Purchased, install interior trim matching wood window finish ortritsa tri-#er Impervia and Encompass Install non-Pella entry door lockset provided by you. Pella is not responsible ble for its quality or performance After the Installation the Homeowner an 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 r` 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 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 Pro Qct Checklist has been reviewed Customer \ or more informs ion regarding the finishing,maintenance,service and warranty cf all PellaO products,visit the Pella®website at www.pella.com P on 111912016 Contract-Detailed PaQe 4 of 6 ....................... Gustomer:Joe Musumeci Project Name: Musumeci,Joe,NorthAndaver,MA,1818606 Order Number. 741AGO746 Quote Number: 8453716 Product Only Addendum has been reviewed Customer initial 'r 5' Credit Card Account#: Last 4 Digits Expiration Date: tJ (" t Charge final payment to same account (Upon,substantial completion) Customer,initial For more information regarding the finishing,maintenance,service and warranty of all PellaG products,visit the Pella®website at www_pelia.com Printed on 111912015 Contract-Detailed Pane 5 of 6 Customer:Joe Musumed Project Name: Musumed,Joe,Northkdover,MA,1818606 Order Number: 741AGO746 Quote Number. 8453715 inject Checklist has been reviewed ....., :qp�i-,"s.�"+_�ni-sietdic"+. DScLL SSV Yet pC'_ ' ,/A I _._.- Oust er me (p A.pin;) Pea Sal a E prirA) Taxable Subtotal _ $4,175.69 Sales Tax @ 6.25% $260.98 usto r S. K, ta ign `I f/� I r ,� Non-taxable Subtotal $1,777.60 ! 1 f� _ / Total $6,214.27 Dane Date Deposit Received $3,107.14 VzJ - Amount Due $3,107.13 re it CaPpMvaf T re For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pelta®website at www.pella.com Printed on 11/9/2016 Contract-Detailed Pace 6 of 6 PELLA WINDOWS AND DOORS CONTRACT 71 PAYMENTS I. TERMS ANI)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 atter 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("Owns")to supply the products(the"Products"),and perform S. CORRECTION OF WORK the work(the"Work")described or referred to in such Contract, Icor 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 pate or,If earlier,the date on which the Work is substantially Z. 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 windowmounted 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 alt payments then due, responsible for the removal or installation of these types of items. Pella is not responsible for pro-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella Shoff warrant all Pella products,but only in accordance with the Polls The Owner shall provide complete access to thework site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRAN'T'Y SCALL 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 FTTNFSS 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 meohinery,transportation,and WHETHER FORLSEBN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work, it. HOME EVIPROVEMENT CONTRACTORS The materials and equipment famished under the Contract will he 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 d by the Hoard 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 p should he directed Director,Home Improvement Contractor Registration, improper or insufficient maintenance,improper operation or normal wear and tear. Pella will keep the premises and surrounding arra free from One Ashburton Place, ,Boston,MA 02108,617-727-8598 accumulation of waste materials or rubbish caused by performance of the 12. PERMITS(il'fA customers only) g Work. Pella is obligated to and will obtain the following permits for this project: A NOES BU Iltilll 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 the 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 CANCELLA'T'ION 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 bo may be his main office or branch thereof,provided you notify extended to allow for Change Orders requested by Owner or if the 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 this right, parts or work to be completed is acceptable,however,the holdback will not. g exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Pric%whichever is lass. Do not sign this ntract If there are any blank spaces, S. FINANCING 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 financingshatl have been received from the financial institution. Costo Signa D 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. 1.42A Pella Windows & Doors Contractor m owne u 0 o NOTICE:THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THF 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. NO'T'ICE OF CANCELLATION Date of transaction: dq k 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 thetas 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. Iiable 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,IM 01832 P not later than midnight of (three business days from the date of transaction above). filly'?4/ I hereby cancel this transaction. (Date) (Buyer's signature) Do NOT sign here unless you wish to cancel W a 1&e Commonwealth of Afassaclaus'eav r Department of. ndas'trialAcciderxts ' 1 Congress Street,Suite 104 T Boston,MA 02114.2417 J www.mass.golv/dia s 1 Orlcers'Compensation Insurance Affidavit:Builders/Contractors/Eiectricians/Plulnbers. TO BE MED WITEi TEE 1'ERMrFMG AUfHt Roy. A licant Information PIease Print Legib Name(E3usineSdCOrg=iZatian/Individual): � CityfState/Zip: age492 1 phone#: Are you an employer?Check the appropriate box: Type o:�on t(required): �I am a employer with employees(futl,aod/orpart time). 2.❑I am a sole proprietor or partnership and have no employees wo 7. El struction working for me in WIY capacity.[No workers'comp.insurance required.] $• ,,, ing 3.©1 am a homeowner doing all work myself[No workers'comp,insurance required.]t 9. ��7 Don 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Baddition ensure that all contractors,eitbcrhave wodars';compensationins uranccorare°sole lI_ El"re irsaradditions m...a,d. .• �� ���w . , ..,. propnetars with nn employees. P., S. I am a general contractor and I have hired the sub-cantractoaa listed on the attached sheet. I2: Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insnrance.t 13•❑Rirs6.❑We are a corporation acrd its officers have exercised their right ofexemption per MGL c. 14.❑O 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoamatiaa Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit inclicatang such tC utractors that check this box must attached an additional sheet showing the name of sub contractors and skate whether or not those entities have" employees. If the sub-contractors have cmplayees,they must provide their workers'comp.policy number. l am an etVloyer that is providing workers'coinpreivat ion instrance for my employees. Belmv is the policy tend fob site inforinado- Insurance Company Name: Ah C Policy#or Self ins.Lie.#: Expiration Date: Job Site Address: �X o "l l IJCity/State/Tip: Attach a copy of the worlters'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a foe up to$I,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORIC 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. X do hereby certify under the pains and penalties of perfury that the information provided above u true and carred j Phone#: EFOther only. Do not write in this area,to be completed by city or town ojidaL Ci tyna Permit/Lieeuse# hority(circle one):. Health 2.Building Department 3.City(Towu Clerk 4.Flectrieai Inspector:7aector son• Thane# '•�5 CERTllll ICA fl E OF LA9-40r=1'U u )1 NSUtlm/r'gNCE am/Zalli rnonYYYt 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: It the certificate holder Is an ADDITIONAL,INSURED,the policy(les)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 Rea of such endorsement(s). PRODUCER NAME: CT Fred C.Cho0i.MuG OomlhyA 030011,G€C,RPLU 41 Vvellman street PHCN nIAI E 9703221231 FAX (AUCNo; (076)454-1065 Lowell,MA 0105f EMAIL dcadel €red {600)225-5055 DORESS; CrhurCO.Cea1 ENSURERS AFFORDING COVERAGE NA1C F INSURERA: CdIZODS#esvrence Company GlAmedca 35534 INSURED INSURERS: Hanover lnwrance Company 22292 New England Window d Door LLC;Pella Wndcvs 6 Doors INSURER C: Massechuseds Ray€asuranra 12306 45 FondiRoad NmHam*ke Weyer;Insurance Company 11063 Havartill,MA 05932-1302 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:50593 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, -EXCLUSIONS-AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LLS - €TI INSFI,OL TYPE OF INSURANCE AD ... .. . _ €?OLICY NDMBER POLICY EFF POUCYFXP.._..MMMD. MMIDn ._._ __._.. ._....,.. _.SITS,......_._-._ .. . .. GENERAL LIABILITY =OCCURRENCE $ 1,600,000 % COMMERCIAL GENERAL LIABILITY PRrMI5M(Ea=vrmncel $ 100'0511 CLAIMS-MADEX❑OCCUR MED EXP(Any one person) $ 10,056 A % CGOD01 ZEN0161407 7!112016 71112017 PERSONA46ADVfNJURY ,$ 1.0001000 GENERALAGGREGATE $ 2.000,000 GENE.AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGG $ 2.006.050 POLICY MPRa X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 009,600 as den, X ANYAUTO BODILY INJURY(Perpamfo) $ C ALLOVVNED SDHEOULED ADN0t52t59 7/112076 711120f7 AUTOS AUTOS BODILY INJURY(PeraGfJdenl) HIREDAUTOS uyos h1E0 Pe08ER9 UAMAGE $ x CA0001 a X UM13RELLALIAS X OCCUR EACH OCCURRENCE $ 9,000,000 D EXCESSUAB CLAIMS-MADE UHN0167305 71IRDIG NU2017 AGGREGATE $ e,008,000 DED I I RETe4TIDN$ $ WORKERS COMPENSATION % VvC 609,0WSTATU• OTYi- AND EMPLOYERS'LIABIL1tt � D A14Y PROPMETORIPARTNERIEXECUTIVEELL,EACH ACCIDENT $ aFFICE€UMEMBEt EXCLUDED? NIA 6007024 71172016 7118017 500,000 (Mandatary to NH) E.L.DISEASE•EA EMPLOYE $ 1(yes,desutbe under 500,500 DESCRIPTION OFOPERAMNS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(Attach ACORD 101,Additional Remarks Schedule,Ilmora space R required) CERTIFICATE HOLDER CANCELLATION New England Wndmv&Goor LLC 45Fond3 Ron d SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Haverhill,mA ama0 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE cluntB Mstf1 58593 Cert Holder# 151 52 1900.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i Massachusetts Department o, r Board of SUi#din e iic Safe#y 9 Regu�atiorss and Sta:aciards License: C$-089853 C L13-11Structio i Supervisor iT3x 4 N, nh WILLIAM R NICHOLS 57 PEARTREE RD HAVERHILL MA 01830 Com, missioner Expiration- 10/26/201& � - CJJJfiC/IrlJnfl.J j . ee of Consumer affairs&Business ltegulatiau. License or registration valid for individul use only VIE IMPROVEMENT CClvTRACTOR .''1 before the e=xpiration date, If found return to: registration 1.83279 Office of Consumer Affairs and Business Regulation �;.�.,, Type Expiration 9/24/201.7 10 Park plaza-Suite 5170 NEW ENGLAND_W N DOU4f. Supplement E`rd Boston,MA 02116 DOOR;.LLC. PELLA WINDOWS&000RS William Nichols 45 FONDI ROA17 HAVERHILL,MA 01832 Underseeretary Not valid without signature