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HomeMy WebLinkAboutBuilding Permit # 3/1/2017 � NOf2T(y BUILDING PERMIT ��0��giED TOWN OF NORTH ANDOVER � � _..• APPLICATION FOR PLAN EXAMINATION Date Received t u axt.4YED WE""'�� i permit No#: � ���Ac9 US Date Issued MP O Et I T Applicant licant must c0nlPlete all item.s an this page.. ._ L0GAT I0N F'nnf WNER 1?ROF' RTY Cj r fy yes no. Pnnt' DSD Year StrUcture a . % MAF' . F'ARGEL: � C7NING lbISTRIST: Historic !District yes no Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-- Residential ❑-New Building I One family ❑Two or more family D Industrial Li Addition L1 Alteration No, of units: Ci Commercial epair, replacement C�Assessory Bldg _ P Others: C7 Demolition C7 Other -. - q"�liaod G lata : ❑-­ W_ Netlards L1 Watershed 17isr tct E1 Septic Ei Well p U Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly' OWNER: Name: ` 1Phone�at Address one . .0 ontractor Name., ° . , a Address: _ a�, 4111y°t-,ff, lli°0� i,���.. . mm Exp. bates Supervisor's Construction License, a..l �� E . D Nome Imp ovement License._ xp ARCH ITECTIENGINEER__ Phone: Address:-.-,.---.. Reg. Io. - FEE SCHEDULE:BULDING PERMIT:$12.00 PER$'1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. oat Project Cosi: $ � �,�� w � w FEE: $ �� - _ Check No.: _ C"` Receipt No,.. I IOTE: persons contracting with, unregistered contractors iso not have:access to the guaranty fiind St natut e at contactor Signature o Ag rttlOwr er V%O THv's do% ver 'g Town of 4 :, *, a 0 1 No. ]E h ver, MassA? 0/7 P COCNICIilWKK 4 S � BOARD OF HEALTH Food/Kitchen PERMIT T now Septic System THIS CERTIFIES THAT �.r. .� 10.+. ,%.%kS... ... a BUILDING INSPECTOR has permission to erect ... buildings on .S .. / �A/ g �r�, , , plc Foundation Rough to be occupied as ..........I.......V�. ............................................... ... 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-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 I IN 6 MONTHSELECTRICAL INSPECTOR. LESS ., CTT . Rough Service ......................................... Final BUILDING INSPECTOR GAS INSPECTOR ccupaucy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Contract - Detailed Pella Window and Door Showroom of Haverhill Sales Rep Name: Gonya, Nathan 45 Fondi Rd I Sales Rep Phone: 978-360-1287 Haverhill, MA 01832 Sales Rep Fax: Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail. gonyanb@pellaboston.com 1 Customer Information Pro ect[Delivery Address Order Information Scott Ellis EIIis,Scott,1847228 Quote Name: 250 phase 3 5 Green Hill Ave 5 Green Hill Ave Order Number. 741 NG0190 Lot Quote Number: 8710262 NORTH ANDOVER,MA 01845 4312 Order T e Installed Sales Primary Phone:(401)9326739 NORTH ANDOVER,MA 01845-4312 YP County: Payment Terms: Mobile Phone: Tax Code: MA TAX 6.25 Fax Number: Quoted Date: 212412017 E-Mail: Ellisl022@ve(izon.net Great Plains#: 9480145 Customer Number. 1007259409 Customer Account: 1002968809 Attributes Line# Location: Item Price Qty Ext'd Price 10 None Assigned Delivery/Setup-Delivery/Setup $190.11 1 $190.11 g, maintenance,service and warranty of all Pella@ products,visitthe Pella@ website at www.pella.com more information regarding the finishin1 of 5 Printed on 212512017 Contract-Detailed Customer:Scott Ellis Project Name: Ellis,Scott,1847228 Order Number: 741NG0190 Quote Number: 8710262 Attributes' �Lin Location: Item Price Qty Ext'd Price 15 Back Bedroom Pella 25� Series,2^Wide©Dobie Hung,73.5 X 53,Whifie $2,011.79 1 $2,fl11.79 1:Non-Standard SizeNon-Standard Size Double Hung,Equal 24 Frame Size: 36 112 X 53 PK# General information: Standard,Vinyl,Nail Fin,Foam Insulated,3 114",1 118",2 118" i 1979 Exterior Color 1 Finish: White g Interior Color/Finish: White ,_, �.:5_ M.0 Glass: Insulated Dual Low-E NaturalSun Low-E Insulating Glass Argon Non High Altitude Hardware Options. Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Viewed From Exterior Screen: Full Screen Performance Information: U-Factor 0.28,SHGC 0.44,VLT 0.53,CPD PEL-N-211-00023-00002,Performance Class R,PG 35,Calculated Positive DP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111 Grille: GBG,No Custom Grille,314"Contour,Traditional(4W2H/4W2H),White,White Vertical Mull 1: FactoryMull,112"Integral Mullion 2:Nan-Standard SizeNon-Standard Size Double Hung,Equal Frame Size: 36 112 X 53 General Information: Standard,Vinyl,Nail Fin,Foam Insulated,3 114",1 118",2 118" Exterior Color/Finish: White Interior Color I Finish: White Glass: Insulated Dual Low E NaturalSun Low E Insulating Glass Argon Non High Altitude Hardware options: Cam-Action Lock,White,Standard Vent Stop,No Limited Opening Hardware Screen: Full Screen Performance Information: U-Factor 0.28,SHGC 0.44,VLT 0.53,CPD PEL-N-211-00023-00002,Performance Class R,PG 35,Calculated Positive OP Rating 35,Calculated Negative DP Rating 35,Year Rated 08111 Grille: GBG,No Custom Grille,314"Contour,Traditional(4W2H 14W2H),White,White Vertical Mull 1: FactoryMull,112"Integral Mullion Wrapping Information: No Interior Trim,Factory Applied,Pella Recommended Clearance,Perimeter Length=253". Overall Rough Opening Dimensions: 74 X 53 112 Frame Size:73.5"X 53" Qty 1 PVC Upgrade>48-PVC Upgrade greater than 48 inches Lead Safe Install-Lead Safe Install Qty 1 FF-48-96 wide-Install Full Frame Window 48-96 inches wide Qty 1 Trim Stool and Apron-Add Stool and Apron Trim to Picture Frame 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 o t r,s 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. For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 2/2512017 Contract-Detailed Page 2 of 5 1 Customer: Scott Ellis Project Name: Ellis,Scott,1847228 Order Number: 741NG0190 Quote Number: 8710262 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. ARBITRATION AND CLASS ACTION WAIVER("ARBITRATION AGREEMENT") YOU and Pella and its subsidiaries and the Pella Branded Distributor AGREE TO ARBITRATE DISPUTES ARISING OUT OF OR RELATING TO YOUR PELLA PRODUCTS (INCLUDES PELLA GOODS AND PELLA SERVICES)AND WAIVE THE RIGHT TO HAVE A COURT OR JURY DECIDE DISPUTES.YOU WAIVE ALL RIGHTS TO PROCEED AS A MEMBER OR REPRESENTATIVE OF A CLASS ACTION,INCLUDING CLASS ARBITRATION,REGARDING DISPUTES ARISING OUT OF OR RELATING TO YOUR PELLA PRODUCTS.You may opt out of this Arbitration Agreement by providing notice to Pella no later than ninety(90)calendar days from the date You purchased or otherwise took ownership of Your Pella Goods.To opt out,You must send notice by e-mail toeilawebsu ola.c om,with the subject line:"Arbitration Opt Out"or by calling(877) 473-5527.Opting out of the Arbitration Agreement will not affect the coverage provided by any applicable limited warranty pertaining to Your Pella Products.For complete information,including the full terms and conditions of this Arbitration Agreement,which are incorporated herein by reference,please visit www. ella.com/arbitration or e-mail to eilawebsu ort ella.com with the subject line:"Arbitration Details"or call{877)473-5527.D'ARBITRAGE ET RENONCIATION AU RECOURS COLLECTIF("convention d'arbitrage )EN FRANCAIS SEE PELLA.COMIARBITRATION.DE ARBITRAJE Y RENUNCIA COLECTIVA("acuerdo de arbitraje")EN ESPANOL VER PELLA.CONVARBITRATION. Product Performance Information: U-Factor,Solar Heat Gain Coefficient(SHGC),and Visible Light Transmittance(VLT)are certified by the National Fenestration Rating Council{NERC}.Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product performance.NERC ratings are determined for a fixed set of environmental conditions and a specific product size.NERC does not recommend any products and does not warrant the suitability of any product for any specific use. ertified by a third party organization,in many cases the Window and Door Manufacturers Association Design Pressure(DP),Performance Class,and Performance Grade(PG)are c (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 /performance, Project Checklist Review (installed Orders Only) Before the Installation the Homeowner ag rees to do the followin : 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 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website atwww,pelia.com Printed on 212512017 Contract-Detailed Page 3 of 5 Customer: Scott Ellis Project Name: Ellis,Scott,1847228 Order Number: 741NG0190 Quote Number: 8710262 Tie or out 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 lnstalia#ion Pella agrees to do the followin Obtain Building Permit(When required) Prefinish products when purchased in contract During the Installation the Homeowner agrees to do the followin Keep pets safely away from work area Keep children safely away from work area Allow Pella Installer room to work safely within your home Durin the Installation Pella a rees to do the followin 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 followin : Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings treatments,wall hangings, and reposition furniture Re-install existing shades, drapes, window 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 4: Last 4 Digits For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.peli.ge 4 of 5 Printed on 212512017 Contract-Detailed Customer:Scott Ellis Project Name: Ellis,Scott,1847228 Order Number: 741NG0190 Quote Number: 8710262 Expiration Date: Charge final payment to same account {Upon substantial completion.} Customer initial ❑Project Checklist has been reviewed Nathan Gonya Order Tota{s Scott Ellis (Please 1,024.84 Customer me (Tease t� Pel! Sal a Na e ( Taxable Subtotal Sales Tax @ 6.25% $64.05 Custom lgnatu Pella Sales Rep Sig re Non-taxable Subtotal $1,177.06 2/25117 2125117 Total $2,265.95 Date Date Deposit Received $0.00 Amount Due $2,265.95 Credit Card Approval Signature For more information regarding the finishing, maintenance,service and warranty of all Pella@ products,visit the Pella®website at www.pelia.com Printed on 2125/2017 Contract-Detailed Page 5 of 5 PELLA WINDOWS AND DOORS CONTRACT 7 PAYMENTS Pella shall be entitled to stop the Work upon written notice to Owner for any 1. TERMS AND CONDITIONS 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 persou(s)identified on the F Product Order("Owner")to supply the products(tile"Products"),and perfann S. CORREC'T'ION OF WORK the work(the"Work")described or referred to in such Contract. For Product Pella shall correct installation Work not in conformance with the requirements Only purchases,a signed"Product Only Addendmn"is a required part of the of the Contract,if notified in writing by the Owner within two years after the contract. Completion Date or,if earlier,the date on which the Work is substantially completed and payment of the Purchase Price made subject to a holdback as 2. OWNER 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 alt 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 than due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9 LIMITED PRODUCT WARRANTY 'f 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 Pei la's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUC I'S AND PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, deliver the Products and perform the Work. EXPRESS OR IMPLIED,WRITTEN OR ORAL(INCLUDING WITHOUT LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS 3. PELLA FOR A PARTICULAR PURPOSE). Pella will be responsible for and have control over construction means, _ methods,techniques,sequences and procedures and for coordinating all 10 NO CONSEQUENTIAL DAMAGES portions of the Work.Pella will be responsible for the Work of its Pella UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE,FOR Contractors who will install the Products. CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, Unless provided otherwise in the Work description,Pella will provide and pay WHETHER FORESEEN OR UNFORESEEN, for all labor,materials,equipment,tools and machinery,transportation,and other facilities and services necessary for the proper execution and completion 11. HOME IMPROVEMENT CONTRACTORS of the Work. All home improvement contractors and subcontractors shall be registered with The materials and equipment furnished under the Contract will be good quality the director of the Home Improvement Contractor Registration Program and new unless otherwise required or permitted,fire Work will be free from administered by the Board of Building Regulations and Standards. Pella and defects not inherent in the quality required or permitted,and the Work any of its subcontractors identified in this agreement have been registered. conform with the requirements of this Contract.Pella shall not be responsible Any inquires about Pella or any of its subcontractors relating to registration for damages or defects caused by abuse,modifications not executed by Pella, should be directed to:Director,Home Improvement Contractor Registration, improper or insufficient maintenance,improper operation or normal wear and 10 Park Plaza,Roam 5170,Boston,MA,02116,617-973-8787,888-283-3757 tear. Pella will keep the premises and surrounding area free from or visit the HIC website at hu :Il-ww.mass. ovlocabar! accumulation of waste materials or rubbish caused by performance of the 12 PERMITS(MA customer's only) Work. Pella is obligated to and will obtain the following permits for this project: 4. CHANGES Buildin 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 ht 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 Owner understands and agrees that the Substantial Completion Date is an You may cancel this agreement if it has been signed by a patty estimate only and that the actual date on which the Work is completed may be thereto at a place other than an address of the seller,which extended to allow for Change Orders requested by Owner or if the time to may be his main office or branch thereof,provided you notify complete the Work is affected by conduct of the Owner,weather,labor 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,b telegram sent or by delivery,not later than reasonably beyond Pella's control.If for any reason the Work is not fully p y g completed by the Substantial Completion Date(including any extensions midnight of the third business day following the signing of this contemplated above),but is substantially completed by such date,i.e.,the agreement. Product has been installed,but minor parts or components are missing or need to be replaced or repaired,a hold back proportionate to the cost of remaining See the attached Notice of Cancellation for an explanation of parts or work to be completed is acceptable.However,the holdback will not this right. exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. 6• FINANCING Do not si n thus contract if there are any blank spaces. J. 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 'Illill 110 requisite approvals and authorizations for the full amount of the requested Customer rgnature12 ' 17 financing shall have been rcecived from the financial institution. 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 /omeow 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: 2125117 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 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) Die conanonwealth of Afasvachusetts Department of Jndustr,idAccidetzts I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov1dia Workers'Compensation insurance Affidavit:BuBders/C.ontractors/ElectriciarLsfplumbero. TO BE FILED VaTH THE'Ph-RlMTTf NG ALrMORITI"- Applicant Information, Please Print Legib �! I rg): Name(Busiuess/OrganizafloL dCh.9y City/Stateffip: 1 M* 6103 Phone#: A4&QEq Are you an employer?Check the appropriate box: Type of project(required): 4-01 an a employer with r--ple'YMS(f4andlor'part-tinac),� 7. E]New construction 2,E]I am a sole pmplictororpartnership and have no employees working forme in 8. emodeling any capacity.[No workers'comp.insurance requirrA] 9. El Demolition corequired) 3.0 Tama homeowner doing all work myself[NoworLers' rop.insUranCe 10 0 Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on ray propMly. I will 11. Electrical repairs or additions F] ensure that all contractors either have workers'compensation insurance or are sole- proprietors with no employers: .12: Plumbing repairs or additions 5,E]I am a general contractor and I have hired the sub-coutractors listed on the attached shceL 13.❑Roof repairs These suh-contractors have employees and have workers'comp.insurance.t 14. Other 6. We are a corporation and its officers have exercised their right of exemption per MGL r. 152,§1(4),and we.have no.MPIUY=.LNG workers'comp.inamince required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infounatim t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. til—Datractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not these entities have employ=. If the slab conhactars have employees,they must provide their woflcers'comp.policy numbor. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information_ InsuranceCompany Policy#or Self-ins.Lic. Expiration Date--7--J-7L7— Job Site Address: City/swzip: Attach a copy of the workers'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 fine up to$1,500.00 and/or one-year imprisonment as Well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a .day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here-by certify under the pains acid penalties of perjury that the information provided above is true and correct S.. Date: Phone#: Qfficial use only. Do not write in this area,to he completed by city or tow"offidaL City or Town: Permit/License# Issuing Authority(circle one):. 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person:— Phone#. qC40MY CERTIFICATE OF LIABILITY INSURANCE DATE€MMrDDnYYY, D7r47not6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(€es)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). CON CT Dorothy A.Ca Hatt,CIC,RPLU PRODUCER NAME: Fred C.Church,Inc. PHONE 9703227231 FAX (978)454-1685 41 V*Irnan Street AI a Ext• AIC No Lowell,MA 01051 E-MAILdcadell(Miredochurch.Cnm (800)225-1865 AD11RE55: INSURERS AFFORDING COVERAGE NAIO N INSURER A Citizens Insurance Company Of America 31534 INSURED INSURER B: New Hampshire Employers Insurance Company 13083 New England Window 3 Door LLC INSURER C 45 Food l Roed 3NSURER D Haverhll,MA 01832-1302 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:58475 REVISION NUMBER: INIS IS TO DICATED.CATED.CNOTTWITHSTANDING ANIYIREQUIREMENT,TERM OR CONDTION OFHAVE BEEN ISSUED TO THE INSURED NAMED ANY CONTRACTOR OTHER DOCUMENT VAT EFR THE RE SPECT TOtIPERIOD IS 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. I ILTR ADDLS B POLICYFFF POLICYEXP LIMITS SR TYPE OF INSURANCE POLICY NUMBERMMIDDIrYYY MM/DD GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 PREM SES X De $ 100,0911 COMMERCIAL GENERAL LIABILITY Ea OCCurrnrR(Any one person [� MED EXP ) S 10,000 CLAIMS-MADE L .1 OCCUR A X CG0001 7131481(51407771L2018 711!2017 PERSONAL6ADV INJURY S 1,000,404 j. 2,800,900 GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 8 a,g94,949 POLICY MPRO- X LCCS COMBINEDSINGL LIMIT AUTOMOBILE LIAUILITY a accidedl BODILY INJURY per person) S ANY AUTO ALL OWNED SCHEOULED BODILY INJLfRY(Per acddem) S AUTOS AUTOS PROPERTY DAMAGE S NON-OWNED er aCGden HIREDAUTOS AUTOS S UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE S S DED RETENTION 5 WORKERS COMPENSATION X TORYUMITS IMG STATU- tlTH- AND EMPLOYERS'LIABILITY S��OW ANY PROPRIETORIPARTNEWEXECUTIVE Y� 8447424 7112016 7112417 E.L.EACH ACCIDENT $ B OFFICERWEMBER EXCLUDED? N!A 500,000 (Mandatory in NH} E.L.DISEASE-EA EMPLOYE S 600,000 If yes,dasoV under E,L.DISEASE-PC11..ICY LIMIT S DES CRF TION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attaoh ACORD 101,AddWoeal Remarks Schedule,B more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover 1000 Osgood$free[,Suite 2043 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Nrth Andover.MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE chemo Ms1N Celt Holder{! ©1989-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 'Massachusetts Depar-ment.o'i -Pudic Safety Soard of Building Regulations and.Standiards License: CS-089853 WILLFAM R NICHOLS a r: 57 PEAR3REE RD ;l HA.VEIRHILL MA 6,930 Commissioner 10126120:18 7J1 JJ1f,.^1!.'NCillii 1 'I(!!Jj(I('i lLlri�i - . lee of Consumer Affairs&Business Regulation' License or registration valid for individul use only E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: -t�j- Office of Consumer Affairs and Business Regulation egistration: 183279 Type= AO Park Plaza-Suite 57170 >. Expiration.p' 9124/2017 Supplement&:,rd Boston,MA 02116 NEW ENGLAND WINDOW&DOOR,LLC. PELLA WINDOWS&DOORS William Nichols 45 FONDI ROAD s f iAVERI iILL,ltA1i 01832 Undersecretary Not valid.without signature