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Building Permit # 12/15/2016
... .............. tkORT BUILDING PERMIT oFtza ,5�� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '' V permit No#: / Date Received '17 nRArEn Fe� { SACT lust pate Issued: MP - IMPORTANT: Applicant must complete all items on this page L.00ATINr K not PROPERTY ®WNER Pant 9 0E}Year Structure yes rid 11/fA1' PARES Z®N1NGDISTRICT H�sfor�c ®istncf yes nfl Machine. age ` es na, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building imine family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other - 7, Septic well C] Floodplain ❑1Net[ancis ❑•Watershed »istrtc DESCRIPTION OF WORK To RE PERFORMED: Identification-- Please Type or Print Clearly' OWNER: Name: t r Phone: ZS Address: )S1 / - `o - Conttacfof Names P t - t&,A, Address c:.; Supervisor's onstrr coon Ltcense� Exp. Date l - Ex Dade ` - Horne Irripro�erent-License _... p.:: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDINGORWT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BI SED ON$125.00 PER S.F. Fotal Project Cost: $_Z& � �"�' _ FEE: $ Check No.: el' Receipt No,: L/ — NOTE: Persons contracting with unregistered contactors do not have:access to the gr aranty fund 5igratu�e=of_AgenflOwrle,r Signature of cohtiractor � To jA0RTFi wn � _ ,. . Andover 0 No. it . * mpllqr , h ver, Mass, 1 • �'®� b coc"Icnew1[N , .QS R4 TED V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .......................� .. � ((� �� AA&�q� BUILDING INSPECTOR ...... ....... ....... .............. .. . .... .... ................. 4e a' has permission to erect .......... ............... buildings on ..,..I. ....... #A. Foundation ....r.r...,....... .... }} ....... . .... . ...............I........'..�..I..OR. ............. Rough to be occupied as ................... Chimney 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-saws 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 CONSTRUCT S Rough t�� Service ............ . ............,........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Re uired to Occupy 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 �j Pella Window and Door Showroom of Haverhill Sales Rep Name: Gless, Benjamin 45 Fondi Rd ��S ' Sales Rep Phone: 978-360-0818 Haverhill, MA 01832 S Z� Sales Rep Fax: Sales Rep E-Mail: glessba@pellaboston.com Customer Information Project)©eli��ry,Address �rc[er Information Lindsay Healy Healy,Lindsay,1824726 Quote Name: Healy-Front Door/StormIKitchen Slider 151 Abbott St 151 Abbott St Order Number: 741 BG0185 NORTH ANDOVER,MA 01845-4803 Lot# Quote Number: 8504037 Primary Phone:(720)2566348 NORTH ANDOVER,MA 018454803 Order Type: Installed Sales Mobile Phone: County: ESSEX Payment Terms: DeposittC.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: Imhucknall@yahoo.com Quoted Date: 11/28/2016 Great Plains#: 11361375 Customer Number: 1008191176 Customer Account: 1004115830 Line# Location: Attributes 10 None Assigned Delivery/Setup-DeliverylSetup Item Price Qty Ext'd Price $185.65 1 $185.65 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 11/29/2016 Contract-Detailed Page 1 of 6 Customer: Lindsay Healy Project Name: Healy,Lindsay,1824726 Order Number. 741 BG0185 Quote Number: 8504037 Line# Locatisn Attributes 15 None Assigned Pella Brand,3-Wide Entry Door Sidelight,68,5 X 81.75,White,4 9116" Item Price Qty Ext'd Price $5,351.40 1 $5,351.40 1:1488 Fixed Entry Door Sidelight PK# Frame Size: 15 112 X 81 314 1972 Unit Type: Fixed Inswing,Standard Sill Dimension Options: No Cut Down General Information: 5 718", 1 5116",4 9116" Panel Style: Full Light i"K:3 :24 Glass: Tempered Low E Air Filled Viewed From Exterior Grilles: Simulated Divided Light,718"Contour,Match Interior Panel Finish,Match Exterior Panel Finish,Traditional,Typical, 1,5 Panel Selection: Mahogany,Painted,White,Painted,White Frame Selection. Clad,Pine,Oak Threshold,No Panel Reinforcement,Standard Enduraclad,White,Wood,White Hardware Options: Bronze Finish Sill Unit Accessories: No Wrought Iron Performance Information: U-Factor 0.19,SHGC 0.06,VLT 0.09,CPD PEL-M-17401756-00001 Vertical Mull 1: FactoryMull,Standard Joining Mullion-Doors,Frame To Frame Width-0",Mull Design Pressure-20 2:3688 Entry Door Frame Size: 37 112 X 81 314 Unit Type: Left Inswing,Standard Sill,No Fire Rating,No Fire Rating Dimension Options: No Cut Down General Information: 5 718",1 5116",4 9116" Panel Style: Craftsman Light Glass: Tempered Low-E Air Filled Grilles: Simulated Divided Light,718"Contour,Match Interior Panel Finish,Match Exterior Panel Finish,Traditional,Typical,3,2 Panel Selection: Mahogany,Painted,Real Red,Painted,White Frame Selection: Clad,Pine,Oak Threshold,No Panel Reinforcement,Standard Enduraclad,White,Wood,White Hardware Options: Latch Bore with Deadbolt,2 318",2 118",No Integrated Sensor,No Handle Set,Standard Steel,Oil Rubbed Bronze,Bronze Finish Sill Unit Accessories: No Dentil Shelf,No Bang Panel Performance Information: U-Factor 0.19,SHGC 0.06,VLT 0.09,CPD PEL-M-174-01777-00001,Calculated Positive DP Rating 30,Calculated Negative DP Rating 30,Year Rated 08 Vertical Mull 2: FactoryMull,Standard Joining Mullion-Doors,Frame To Frame Width-0",Mull Design Pressure-20 3-.1480 Fixed Entry Door Sidelight Frame Size: 15 112 X 81 314 Unit Type: Fixed Inswing,Standard Sill Dimension Options: No Cut Down General Information: 5 718",1 5116",4 9116" Panel Style: Full Light Glass: Tempered Low E Air Filled Grilles: Simulated Divided Light,718"Contour,Match Interior Panel Finish,Match Exterior Panel Finish,Traditional,Typical, 1,5 Panel Selection: Mahogany,Painted,White,Painted,White Frame Selection: Clad,Pine,Oak Threshold,No Panel Reinforcement,Standard Enduraclad,White,Wood,White Hardware Options: Bronze Finish Sill Unit Accessories: No Wrought Iron Performance Information: U-Factor 0.18,SHGC 0A6,VLT 0.09,CPD PEL-M-174-01756-00001 Vertical Mull 1: FactoryMull,Standard Joining Mullion-Doors,Frame To Frame Width-0",Mull Design Pressure-20 Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,4 9116",5 718",Factory Applied,Pella Recommended Clearance, Perimeter Length=301". Frame Size:68.5"X 81.75" Entry Trim Finish-Finish PaintlStain Entry Interior Trim Only Qty 1 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www_pelia.com Printed on 11/29/2016 Contract-Detailed Page 2 of 6 Customer: Lindsay Healy Project Name: Healy,Lindsay,1824726 Order Number: 741 BG0185 Quote Number: 8504037 Fluted Comp Trim -Fluted Composite Trim Package Qty 1 ES—Single with SIT-Install Single Entry Door with Sidelight and/or Transom Qty 1 PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1 Llne# - Location. Attributes 20 None Assigned Pella 350 Series, Double Sliding Door Fixed!Vent Left, 70.25 X 79,White Item Price Qty Ext7d Price $4,058.35 1 $4,058.35 1:Non-Standard SizeNonStandard Size Fixed I Vent Left Double Sliding poor PK# Frame Size: 70 114 X 79 ti General information: Yes,Standard,+I-50,+1-50,Vinyl,Nail Fin,Foam Insulated,6", 1 318",4 518",No Sill Riser 1572 Exterior Color/Finish: White Interior Color I Finish: White Glass: Insulated Dual Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude a- hardware Options: Keylock Included,Oil Rubbed Bronze,White,Steel Viewed From Exterior Screen: RolscreenO,White,Conventional Fiberglass Unit Accessories: No Accessory Option Performance Information: U-Factor 0.29,SHGC 0.27,VLT 0.51,CPD PEL-N-161-00931-00001,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Grille: No Grille, Wrapping Information: No Interior Trim,Pella Recommended Clearance,Perimeter Length=299". Frame Size:70.25"X 79" Finish Patio Trim-Finish PaintlStain Patio Door Interior Trim Only Qty 1 PD-2 Wide-Install 2-Wide Sliding Patio Door Qty 1 PD RolScreen-Install RolScreen(Per Panel) Qty 1 PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1 `Line# ' Location: Attributes 25 None Assigned Entry Systems, Storm Door Fullview Rolsereen Unhanded, 36 X 80,White Item Price Qty Ezra Price (P390054332) $727.71 1 $727.71 1:3680 to 81 Unhanded Storm Door PK# Frame Size: 36 X 80 r-'7-77 1972 General Information: Clad Exterior Color I Finish: Standard Enduraclad,White Sash I Panel: 1 3/8"Extruded Glass: Clear .A Hardware Options: Standard,Oil Rubbed Bronze Viewed From Exterior Model: 3900 Wrapping Information: Perimeter Length=232". Frame Size:36"X 80" ES Storm Door-Install Storm Door Qty 1 Thank You For Purchasing Pella® Products For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 11/2912016 Contract-Detailed Page 3 of 6 Customer: Lindsay Healy Project Name: Healy,Lindsay,1824726 Order Number: 741 BG0185 Quote Number: 8504037 PELLA WARRANTY: Pella products are covered by Pelia'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 Roiscreen[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. 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 www.pella_com /perform ance. 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. For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 11/29/2016 Contract-Detailed Page 4 of 6 Customer. Lindsay Healy Project Name: Healy,Lindsay,1824726 Order Number: 741 BG0185 Quote Dumber. 8504037 Before the Installation Pella agrees to do the following: Obtain Building Permit(When required) Prefinish products when purchased in contract During the Installation the Homeowner agrees to do the following: Keep pets safely away from work area Keep children safely away from work area Allow Pella Installer room to work safely within your home During the Installation Pella agrees_to do the following: [deliver and unload products purchased per contract Place and remove drop cloths in work area then vacuum, and remove all debris at end of day Remove existing product, including storm windows, and dispose of it unless otherwise specified Install all products using method specified in contract per Pella Installation Instructions Replace interior and/or exterior trim only if purchased If Purchased, install exterior primed pine wood trim or Composite. Composite will be unfinished. If Purchased, install interior trim matching wood window finish or White trim for Impervia and Encompass Install non-Pella entry door lockset provided by you. Pella is not responsible for it's quality or performance After the Installation the Homeowner agrees to do the following_ Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings Re-install existing shades, drapes,window treatments,wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners Remove stickers from product and save for energy rebate and tax purposes Wash all interior&exterior glass surfaces Fill nail holes and joints on interior trim if windows are to be stained (after staining) Clean up exterior casing issues due to storm window removal if full wrap or new exterior trim is not purchased Project Checklist has been reviewed Customer initial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits 4277 Expiration Date: / 04/2018 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 11/29/2016 Contract-Detailed Page 5 of 6 Customer.Lindsay Healy Project Name: Healy,Lindsay,1824726 Order Number 741BG0185 Quote Number: 8504037 Charge final payment to same account (Upon substantial completion) Customer initial Jefroject Checklist has been reviewed UPWsaylHealy Ben Gless Order Totals mer a (Pleas rmt) rl P la Sales Rep Name se print) Taxable Subtotal $7,802.22 Sales Tax @ 6.25% $487.64 Customer Signature ture 11/29/2016 11 912016 Non-taxable Subtotal $2,520.89 Total $10,810.75 Date Date Deposit Received $5,405.38 Amount Due $5,405.37 Credit Card Approval Signature For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pelia®website at www.petia.com Printed on 11/29/2016 Contract-Detailed Page 6 of 6 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 defau It or failure by Owner,including but not limited to,the Owner's Those 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 fella Windows&Doors,Inc.("Pella")and the persons)identified on the Product Order{"Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"Is a required part of the Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Data or,if earlier,the date on which the Work is substantially 2 OWNERcompleted and payment of the Purchase Price made subject to a holdhack 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 correot Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers ere not receipt of all payments then due, responsible forthe removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LEMTED PRODUCT WARRANTY windows. Pella shat I warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6;00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible for and have control over construction means, FOR A PARTICULAR PURPOSE), methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WIIErM FORESEEN Olt UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work, 11. ROME 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. I far damages or defects caused by abuse,modifications not executed by Pella, Any inquires about Pella or any of its subcontractors relating to registration improper or insufficient maintenance,improper operation or normal wear and should be directed to:Director,home Improvement Contractor Registration, tear. Pella will keep the premises and surrounding area free from 10 Park Plaza,Room 5170,Boston,MA 02116,617-973-8787,888-283-3757 accumulation of waste materials or rubbish caused by performance of the or visit the INC website at http://ivww,mass.goy/ocabr/ Work. 12, PERMITS(NIA customers only) 4. CHANGES ,pell i�obligaicd to and will obtain the following permits for this project: ti U I CI I n . Homeowners who secure their own permits will be The Owner may order in writing changes in the Work consisting of additions, excluded from the guaranty fund provisions of Massachusetts General Laws, deletions,or modifications("Change Order"). Any Change Order shall chapter 142A, include an adjustment to the Price and the Substantial Completion Date,as determined by Pella. Pella reserves the right to approve or disapprove any In addition to the rights and warranties enumerated in this agreement,you may Change Order and any such Change Order must bo signed by both Owner and have additional rights under Massachusetts General Laws,chapter 142A and Pella to be effective. 780 Code of Massachusetts Regulations R6, 5. SUBSTANTIAL COMPLETION 13. NOTICE OF CANCRUATION Owner understands and agrees that the Substantial Completion Data is an You may cancel this agreement if it has been signed by a party estimate only and that the actual date on which the Work is completed may be thereto at a place other than an address of the seller,which !. emended to allow for Change Orders requested by Owner or if the time to may be,his main office or branch thereof,provided you notify complete the Work is affected by conduct of the Owner,weather,labor ' the seller in writing at his main office or branch b ordinaryj disputes,availability of subcontractors,ants of God,fire or other causes g y I reasonably beyond Pella's control.If for any reuson the Work is not fully mail posted,by telegram sent or by delivery,not later than completed by the Substantial Completion Date(Including any extensions midnight of the third business day following the signing of this contemplated above),but is substantially completed by such date,I.e.,the agreement. Product has been installed,but minor pails or components are missing or need to be replaced or repaired,a hold back proportionate to the cost of remaining S ec the attached Notice of Cancellation for an explanation of parts or work to be completed is acceptable.However,the holdback will not this right. exceed the amowit of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. 6, FINANCING Do not sl fih' ontract if there are any blank spaces. Ifpayment of the Price is financed with a financial'institution through Pella,all E financing paperwork must be completed upon signing of this Contract and die requ isite approvals and authorizations for the full amount of the requested financing shall have been received from die financial institution. Customer signature 11129/201 Date DISPUTES THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT, PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c, 142A Pella Windows and Door NE 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: 11/29/2016 You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Pella Windows and Doors, at 45 Fondi Rd. Haverhill MA 01832 not later than midnight of 12/2/2016 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) uv _T to Car�zt io�x�e�t of 1�arsaclzzrse�s Departmeta of llizdustrirtlAccdefas 1 Congress Street,Suite.140 Boston,AZ4 02114-2017 � wttr massgoy/did YVorkers'Compemsatiou fusuranre Affidavit:Btt%Iders/Contractatsll[ectriciarts/Pltz3ubers. TO BE FRED�'Ff TIIE rEft&IlI MC,A�()R'TI � licant:fayzarn9at�a9a Please Print Legibly NaiIIe{Businessl0rgauizzi�on/r�dividual): Address: y city/staff/zip:1-kV Ems. e =i phone#: Arey❑rr au employer?Check the appropriate box: Type of projmt(requir4: I am a empioyerwith i� empiayees(fidl,andl❑rpart lime}. 2.E]f am a sale pr❑prie€or or partnership and have no employees w❑dring for me is I El New construction kuy cap-dy-[No wmkcr&'comp.fi mance ragtui`eij S. kaemodeling 3: --i amx ahmmetlwtterdo' 'ani r,�kk ,��,,CdJ� 9 '�Demol9tron � ,.. mySet�INp w❑FP.. camp lncrnanrr re 4 I am a homeowner amd well be h[nt�g coniractnls to g❑nduct al!.urotl=©n my property: I tvtll 10[��Iurldzng addition .. ..v em�iire tha€al![anbactnr e3erltays workers e�uaf3❑mjs❑ra❑rx❑rarer❑ie: .,... �: ���.�'a :� __N..E ,z� y_. .1__ -._ LtliCc rEpamora�f]OnS _ propnetmrswrthmoemployees. •--. ._ ,...:_..0_...�:_. 5.❑I am a general coutractmr and I have hired the sub-coatractors fisted❑n the attached sheet .12:E]Plumbing repairs or additions Thew sub-cOnuEdOrs have employees and have wort='comp.fi0=,,t I3-❑Raof repaim G.[1 We are a corporation amd ifs officers have exercised tbeirright of enempti❑a per MGL c. la-❑Other 152,§1(4),and use have no employees.[No workers'camp.immrrrmce regmir d_] *Any ap wn m thatvho checks box 91 most also IM out the section below showing their workers'campemsatinn policy int ati❑s. Homeowners who subm�this affidavit indicating they are ding all work aid then hire outside cotk=tmrs mast submit a new affidavit hidicafing smb_ #C❑❑hactmrs that ebwkft boxmaust aftecbed au additional sheetshowing the name ofthe sub-coubac or,and swe whetheroe not those eilatie5 have eorpinyees. Ifthe sub-motractrrrs have employees,they must provide their workers'comp.policy number. 1-aPn ffu employer that is providing wariness'conrpemadon insurancefor my errrplayees.Below is thepoHey and jab site infarnza�iolz _ .Insurance Company Name: Policy#or Self-ins,Lic.#: lI Expiration Dater An Job Site Address: City/state/zip: Attach a copy a the worlcers'£et99pettsati A policy declaration page(showing the poUcyarumber and expiration date). Failure to sectrM coverage as required under MGL,c.152,§25A is a criminal vio14011 PIMliable by a fine up to$I,5oo.00 andlor one-year imprisonment;as well as civil penaltics in the farm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy oftWs statement may be forwarded to the Office ofluvesfig-atitons ofthe DLA for insurance coverage verification. I do hereby ce 4t ander tfze pains mad penaWes Of pe+fury iltai die hifonnalion-provided above is true acrd cormd Signature:Ue _,L Date,- Phone ate:Phone JJ kiBl Use Qg� DO 910E vr',te in this I vPE to he conTZded by chy or f0}V11 Ugjdat City Qll ®67&9" Petll dtl L.iieen e# Issuing kathority�drde ane)_. 1.Board of Health 2.Badding Department I CitY]Town'Clerk 4.Electrical Inspector 5.k1ambing Js9speetmr f.Other Contact Person-.` PN---4- A wCERTIFICATE OF LIABILITY INSURANCE 07107rzal6MMroomrY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the polley(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Dorothy A.Codell,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman Street PHONEE 1- 978 3227231 FAX No: (978)454-5885 Lowell,MA 01851 E-MAIL dcarlell®fredc (880)225-11365 ADDRESS: rt,urnh.rnm INSURERS AFFORDING COVERAGE NAIL P INSURER A: Citizens Insurance Company efAmedca 31534 INSUREDNew Hampshire Employers Insurance Company 13083 New England Window&Door LLC INSURER B= INSURER C 45 Foridi Road Haverhill,MA 01832-1302 INSURER€]: INSURER V: INSURER F: COVERAGES CERTIFICATE NUMBER:58475 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 BF 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. !LTR P01,10Y Err TYPE OF INSURANCE ADSL SUBR POLICY NUMBER iMMtDDtYYYY1 (MMMONYYY1LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,0Oo,000 X COMMERCIAL GENERAL LIABILITY PREM SES RENTED 5 100,000 CLAIMS-MAGE T OCCUR MEG EXP(Any one person) S 10,004 A X CGO001 ZON8161407 7112018 7112017 PERSONAL.&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPtOPAGG $ 2.000,000 POLICY M PRO rq LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT e acdtleul ANYAUTO BODILY INJURY(Per person) 5 ALL OWNED77 SCHEDULED BODILY INJURY(Per accidenQ S AUTOS AUTOS H REO AUTOS NON OWNED PROPERTY DAMAGE $ AUTOS (Para an S UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DEO RETENTIONS $ WORKERS COMPENSATION X IAC STATU- -- ANO EMPLOYFRS'LIABILITY YIN B ANY PROPRiETORIPARTNEMEXECUTIVE 8007024 7!120te 7112017 E.L.EACH ACCIDENT $ 5�'� OFFICERIMEMBER EXCLUD ED? NIA -- IMandatory€n NH) E,L.DISEASE-EA EMPLOYE $ 500'000 If yes,dascdbe under500 00O DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood Street,Suite 2043 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NAh Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE c&enla 2ou Met1JW75Cert Hoider# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD Massachusetts Depar-, of°o Boarri of Suii in u iie :Sa€eiy Re License, gu�ations and StandiFds 853 9111ILI_$AM FZ 1L CHOL5 .57 PEARTREE RD HAVERHILL MA 91830 ' i con"nmassiorExpiration: '.�.''-ti '�:'!,•r irrt,a�rlrr:irrr-rrr/,E%�, '� �'-,�frrt;krrrlrGirfJ cc of Const"ner Afi'a rs&business Regulation. ]Licen'se E i!VlPROVEMNT or registrations valid:�or individui use m0i<y COiV7 RACTOR before the expiration date.If found return to: egistratiora: ,783279;. Office of Consumer Affairs and andBusre .Type: ' E�:piratian _9l242Qgi 10 Park 1'aaza- ss regulation NEW ENGLAND W11VDp}n/. SuPPiement f ,rd Suite 5170 &€ dQR, LLC. Boston,MA 02116 PELLA WINDOWS&DOORSI *Iliam Nichols 45 FOND)ROAD HAVERHILL,mic,07832 Undersecretary " ' Not vafid.witbout sigraatu.e