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Building Permit #244-2017 - 104 COLONIAL AVENUE 9/7/2016
n � NORTH BUILDING PERMIT °F�t,Eo bgtio TOWN OF NORTH ANDOVER 3 o APPLICATION FOR PLAN EXAMINATION At �i7r4' Date Received �sRA�awreo�Pa��y Permit No#: gSsgcNuS Date Issued:Aiill PORTANT: Applicant must complete all items on this page LOCATION 1 Q L QJ 07L- '9rint PROPERTY OWNER�'ntf- Print 100 Year Structure yes Ono MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building �L t e family 11 Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: 11 Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ p Well Floodplain El Wetlands D Watershed District ❑_Water/Sewer W -- DESCRI TPN OF WORK TO BE PERFORMED: P'. AA y-,`f- t Als 000 kz-- i Identificatio - Please Type or Print Clearly OWNER: Name: �C'o SLn� Phone: •22p• Zt}® Address: tO tZ L-0f,,, A Contractor NameQjJ; [nr tc b,& �.1airPhone: 19r7,19 Email Address:.. CfK- FoAz)r_ % L4AAWU OyIA= -2, Supervisor's Construction License: � Exp. Date: /JfJ •Z,6 "11 Home Improvement License: l ���7 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ _ FEE: $ ?2k Check No.: '�2-- Receipt No.- -f)6 y I J NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location I bt L 1 No. 44`.� \� Date vt�� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# In ., _ Building Inspector �� i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ TanWng/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ f Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i k I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I CONSERVATION Reviewed on Signature I COMMENTS { HEALTH Reviewed on Signature i COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: FIREDE-PAR�TMENTD - _ ,. Temp�Dump�ster�on�site LocatedOsgood o Street Locatetl�at ---��- FreD:epartment,�ignature/date - _. t COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1o0-$1oo0 fine NOTES and DATA— (For department use) II i ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4 Building Permit Application 4 Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4. Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 1 NORTH '9 Town of 6 ndover p - A+ No. _ lot CPI h ver, Mass, CODCMICK9WKK y1' GATED U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ............... .. 5t BUILDING INSPECTOR .. .... .. .1 ... '. Foundation has permission to erect .......................... buildings on a!`..��... .. ...�>��............. .�.� ► Rough tobe occupied as .......... .. ........ ... .......:. ... .. `'� ................................ Chimney provided that the person acceptin this permit shall In every respect c10 orm 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 CONST TIO Rough Service .. .......... .. ............ . ...... .......... Final BUILD INSP CTOR GAS INSPECTOR Occupancy Permit Required to 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: McLoughlin, Daniel ® 45 Fondi Rd Sales Rep Phone: 978-373-2500 Haverhill, MA 01832 �!!! Sales Rep Fax: Phone: (978)373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: mcloughlindv@pellaboston.com Customer Information Project/Delivery Address Order Information Scott Hansen Hansen,Scott,1775758 Quote Name: Storm Door and Patio Door 104 Colonial Ave 104 Colonial Ave Order Number: 741 DV0119 NORTH ANDOVER,MA 01845-6349 Lot# Quote Number: 8185236 Primary Phone:(440)2202901 North Andover,MA 01845-6349 Order Type: Installed Sales Mobile Phone: County: Payment Terms: Deposit/C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: shansen03@gmail.com Quoted Date: 8/22/2016 Great Plains#: 11052574 Customer Number: 1008076389 Customer Account: 1003977351 Line# Location: Attributes 10 None Assigned Delivery/Setup- Delivery/Setup Item Price Qty Ext'd Price $235.00 1 $235.00 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/23/2016 Contract-Detailed Page 1 of 6 Customer: Scott Hansen Project Name: Hansen,Scott,1775758 Order Number: 741DVO119 Quote Number: 8185236 Line# Location: Attributes 15 Porch Pella 350 Series, Double Sliding Door Vent Right I Fixed,71.5 X 79.5,White Item Price Qty Ext'd Price $4,446.91 1 $4,446.91 1:7280 Vent Right/Fixed Double Sliding Door Interior Color/Finish: White PK# Frame Size: 71 1/2 X 79 1/2 `'�' ' •� 816 General Information: Yes,Standard,+/-50,+/-50,Vinyl,Nail Fin,Foam Insulated,6", 1 3/8",4 5/8",No Sill Riser Exterior Color/Finish: White I t i Glass: Insulated Dual Tempered Low-E Low-E Insulating Glass With Window Fashions Air Filled Non High Altitude Hardware Options: Keylock Included,White,White,Steel Viewed From Exterior Screen: Sliding Screen,White,Premium,Conventional Fiberglass Unit Accessories: Blinds-Between-The-Glass,White Performance Information: CPD Not Rated,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50 Wrapping Information: No Interior Trim,Pella Recommended Clearance,Perimeter Length=302",Glazing Pressure= 175. Frame Size:71.5"X 79.5" PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1 PD-2 Wide-Install 2-Wide Sliding Patio Door Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 Line# Location: Attributes 20 $750.00 Off Item Price Qty Ext'd Price ($750.00) 1 ($750.00) For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 8/23/2016 Contract-Detailed Page 2 of 6 Customer: Scott Hansen Project Name: Hansen,Scott,1775758 Order Number: 741DVO119 Quote Number: 8185236 Line# Location: Attributes 25 5%Same Day Item Price Qty Ext'd Price ($196.60) 1 ($196.60) Line# Location: Attributes 30 2% Pay in Full Item Price Qty Ext'd Price ($74.71) 1 ($74.71) 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 Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 8/23/2016 Contract-Detailed Page 3 of 6 Customer: Scott Hansen Project Name: Hansen,Scott,1775758 Order Number: 741 DVO119 Quote Number: 8185236 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 wwwpella.com /performance. Project Checklist Review (Installed Orders Only) Before the Installation the Homeowner agrees to do the following: Obtain Condo Association Approval Obtain Historic Approval Remove existing shutters and awnings Remove air conditioners Remove existing shades, drapes, window treatments, wall hangings, and personal belongings Move furniture at least 3 feet away from work area Tie or cut back trees, bushes and shrubs in the work area Arrange to have alarm system and doorbells disconnected Arrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor Provide a door handle and lockset for entry door if Pella handle and lockset is not purchased. Before the Installation Pella agrees to do the 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 For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 8/23/2016 Contract-Detailed Page 4 of 6 Customer: Scott Hansen Project Name: Hansen,Scott,1775758 Order Number: 741 DVO119 Quote Number: 8185236 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 me nitial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits Expiration Date: / Charge final payment to same account (Upon substantial completion) Customer initial For more information regarding the finishing, maintenance, service and warranty of all Pella@ products,visit the Pella®website at www.pella.com Printed on 8/23/2016 Contract-Detailed Page 5 of 6 Customer: Scott Hansen Project Name: Hansen,Scott,1775758 Order Number: 741 DVO119 Quote Number: 8185236 ❑Project Checklist has been reviewed Scott Hansen Dan McLoughlin Order Totals Customer Name (Please print) Pella Sales Rep Name (Please print) Taxable Subtotal $3,191.91 �fl Sales Tax @ 6.25% $199.49 4e4,Si#gnaWe Pella Sales Rep Signature Non-taxable Subtotal $468.69 8/23/16 8/23/16 Total $3,860.09 Date Date Deposit Received $3,860.09 Amount Due $0.00 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 8/23/2016 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 default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part ofthe contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part ofthe Pella shall correct installation Work not in conformance with the requirements contract. ofthe Contract,if notified in writing by the Owner within two years after the 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 all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO 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 WHETHER FORESEEN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work. 11. HOME IMPROVEMENT CONTRACTORS The materials and equipment furnished under the Contract will be good quality All home improvement contractors and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director ofthe Home Improvement Contractor Registration Program defects not inherent in the quality required or permitted,and the Work administered by the Board of Building Regulations and Standards. Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its subcontractors identified in this agreement have been registered. for damages or defects caused by abuse,modifications not executed by Pella, Any inquires about Pella or any of its subcontractors relating to registration improper or insufficient maintenance,improper operation or normal wear and should be directed to:Director,Home Improvement Contractor Registration, tear. Pella will keep the premises and surrounding area free from 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 HIC website at http://www.mass.gov/ocabar/ Work. 12. PERMITS(MA customers only) 4. CHANGES Pella is obligated to and will obtain the following permits for this project: __Building_. 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 be 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 CANCELLATION Owner understands and agrees that the Substantial Completion Date 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 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 ofthe Owner,weather,labor disputes,availability of subcontractors,acts of God,fire or other causes the seller in writing at his main office or branch by ordinary reasonably beyond Pella's control.If for any reason 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 ofthe 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 exceed the amount of the completion costs or 10%ofthe remaining unpaid this right. balance ofthe Price,whichever is less. 6. FINANCING Do not sign his contract if the a are any blank spaces. If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing ofthis Contract and the requisite approvals and authorizations for the full amount ofthe requested & Custo t financing shall have been received from the financial institution. 8123 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 & Doors Contractor 00 Ho owne 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: 8/23/16 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, NIA 01832 not later than midnight of 8/26/16 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia IMOrkers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaus/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORR Y. Applicant Information Please Print Le ibI Name(Business/organization/Individual): nom, Address: q S FpN A L City/State/Zip.- 14A r EeL M# 618.3 2 Phone#:�7 g'Z�a�•��� Areyou an employer?Check the appropriate box Type of project(required): IVP am a employer with Z,r—employees(full.andlorpart-time).* 7. ❑New construction 2.F1 I am a sole proprietor or partnership and have no employees working forme in 8. Wroodeling any capacity.[No workers'comp.insurance required] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. El Demolition 4.[]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have work='compensation insurance or are sole_ 11.Q Electrical repairs or additions proprietors with no employees. .12.'E]Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employ=and have workers'comp,insurance.. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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 then•workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such .Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information_ Insurance Company Name: Policy#or Self-ins.Lic.#: (���(��• Expiration Date: 77,1-177 Job Site Address: City/State/Zip: 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct Simature: —Date: 5-- 7-/i�, Phone#: Official use only. Do not write in this area to be completed by city or town off cat City or Town: Permit/License# Issuing Authority(circle one):. 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to-the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 - Tel.#617-727-4900 ext 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www-mass.gov/dia A� CERTIFICATE OF LIABILITY INSURANCE 07107/2016 THIS 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(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.Corlett,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman Street BONN 978 3227231 A/C No; (978)454-1865 Lowell,MA 01851 E-MAIL (800)225-1865 ADDRESS: dcorlett@fredcchurch.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: Citizens Insurance Company of Amedce 31534 INSURED INSURER B: New Hampshire Employers Insurance Company 13083 I New England Window 8 Door LLC INSURER C: 45 Fondi Road Haverhill,MA 01832-1302 INSURER D: INSURER E: 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 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. INSR TYPE OF INSURANCE ADDL SUBR POUCY EFF POLICY EXP LTR POLICYNUMBER MM/DD MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE M OCCUR MED EXP(Any one person) $ 10,000 A X CG0001 ZBN8161407 7/12016 7/12017 PERSONAL&ADV INJURY $ 1.000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2.000,0.0 POLICY X1 JET PRO- X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED AUTOSULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LUIB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE GATE $ DED RETENTION$ AGGREGATE $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N/A 8007024 7/12016 7/12017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover rtOsgood Street,845 2043 Nh Andover,MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE rt THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Client# Mst# 58475 Cert Holder# 79b1b ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD �W?71',�f Pkiblic 3af . �anaftl � • • l s.ncir?l.L+i>n�,.t#e i�i.*}JJr ' ► `—� '{ LJcen!'e: OS-089853 WILLIAM R NICHOLS 57'PEARTREE RD`. `• - `'s `' HAVERHILL MA 01830 'T r._ r -' F4}iq�ki s Commissioner 10/26/2016 • m C�lea��r�iro�rrucn�l/r� /r(rr.f.�rrc�r<1e111 Once of Consumer Affairs&Business Regulation License or registration valid for individul use only IAbefore the expiration date. If found return to: E IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation • �� egistration: 183279 Type: . 10 Park Plaza-Suite 5170 Expiration: 9/24/2017 Supplement C'Ord Boston,MA 02116 NEW ENGLAND-WINDOW-&DOOR, LLC. PELLA WINDOWS&DOORS' William Nichols '45 FONDI ROAD HAVERHILL,1V4A 01832 . Undersecretary Not valid-without signature