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Building Permit #361 - 114 STONECLEAVE ROAD 12/1/2009
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ` Permit NO: Date Received k Date Issued: I IMPORTANT: Applicant must complete all items on this page k LOCATION J j q -,TJ—oyi e Q1 ue— = ,�-� Print PROPERTY OWNER �fca�- -,1 a,,,d ,,,�, $���ttLLr Print MAP NO: t0V B_PARCEL:I�&VONING DISTRICT: R lI Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family i io Two or more family Industrial Alteration No. of units: - Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer Pn r DESCRIPTION OF WORK TO BE PERFORMED: e e Sag [.yc � Identification Please Type or Print Clearly) OWNER: Name: �c Gl..cwc�Q, tAnciV1}t- Phone: q 7516 67y-3 Address: 1 f Lt Ifo-,tiec/eve jqzKC46ye,✓ CONTRACTOR Name: Z4j llhjw,,«, c4y1 �ltr, Phone: So 5 56,g--3 a 9 T Address: 2"1 . Z',- c 4 L* . Supervisor's Construction License: q 7 Z 2 6 Exp. Date: 16 r� Home Improvement License: (.Z t Exp. Date: ARCHITECT/ENGINEER DoAo L& 1r ers e.(- Phone:_! 3 '77,2- 3q00 Address: Reg. No. 3 S FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$1 00 PER S. Total Project Cost: $ ;�� Q0---FEE: $ �S Check No.: Receipt No.: NOTE: Persons contracting withirnregistered contractors do not have access to tpf gu ran fund Signature of Agent/Owner - Signature of contractor � i Building Department f 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o. Engineering Affidavits for Engineered products NOTE: 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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: Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL . .. Public Sewer Tanning/Massage/Body Art Swimming Pools, Well W Tobacco Sales Food Packaging/Sales Private(septic tank,etc:�/""' Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments t Conservation Decision: Comments Water$ Sewer Connection/Signature & Date Driveway Permit DPS' Toivn�Erighee4:. Siigk.t ire: Located 384 Osgood Street .FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department-signature/date COMMENTS - I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I Total land area, sq. ft.: 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.$100-$1000 fine NOTES and DATA— For department use) I t i ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Location 7 W No. �ZDate NORT1y TOWN OF NORTH ANDOVER O 41 F w A Certificate of Occupancy $ 9 cHu I Building/Frame/Frame Permit Fee $ s� sE Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ Check # 2260 Building Inspector BUILDING PERMIT of tkORTH qti 4f_t,t�. .,.a,6.6 0 TOWN OF NORTH ANDOVER °3 ..s - - °� APPLICATION FOR PLAN EXAMINATION s Permit NO: Date ReceivedATED ��SSACHUS Date Issued: IMPORTANT:Applicant must complete all items on this page €.. ..� -. -.. zZr -s- -.' % C ^, .� "11*"` ••.•.�yr... 7VvT� � �1`' �.m -'-. '�. '. . 3k`�srr ''S- ti �a'''"` ^* �.-.-. >=s gra. '1� �`��b . „n 3� max .:�g- ,, } 'n.'k 'RI -�r� . TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential uildingOne family Additio more family Industrial eration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other �,. --x U """' -a• y�7 rT :: .n' g za. Z'�-�c*-` . y repicll e�r� . IeC 4IFit . TaS13Prs 7i5 ('t 3 3 W'�3GLe���fi1�fY�i�'3`�F,l >� '� �Ixa' fir" '.'i's4"� `rxz t". ,��"�',�`����"'-�Si a �^ ag2 'kT�S•.s.-` 3 ams:.,.:=aa�_��$ '0 DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phonk,ns ) �a 2 �-1 k 3, Address: <l"(NO ag- INIM s`Fn*c-t�if-r- -��.;sd" ..R40-1 W-M ff 10, Yyf'.?L_ `.P n vyv - s� "3�Yi -� UN MaKm 4m 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: $ Z7Z_•�;`u�J FEE: $ ' Check No.: Receipt No.: NOTE: Persons contrawith gxregister ed contractors do not have access to the guaranty fund Sraature of ure Agen /O�nr i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o 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/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ' ❑ Building Permit Application o 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 j ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i i 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Pians TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on "l Signature COMMENTS Al V I j HEALTH Reviewed on Si nature= COMMENTS Pi U✓ ,� �� T �y- ..fes. / - L.� 4a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osggod Street i �E �ARI ea�aste` a �teres `� o pre f>Yr�z , s S dare` M! tra�ea�t � n�tt��e�ta 3 ^ L �Y bb i� ICO II lE1NT.S n 3 . -r � y K y Dimension Number of Stories:__Total square feet of floor area, based on Exterior dimensions. Total land area,sq. ft.: k m a 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.$100-$1000 fine NOTES and DATA— (For department use i _ l 1 i i i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 NORTH ® o ... .f 4Andover . _ �`y z .. dover, Mass., y T O LAKE CO CKICKE WICK yt ADRATED pPa\ -`� `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT - .:................... ..................................................-.-..........:........:.................................................................. Foundation has permission to erect........................................ buildings on ../....L/. ..........:...................................................... ..... ..... Rough to be occupied as........................ ...... ..........�Z.x .,&........................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. rvlAj) ���� G�,� Adon/0N PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough /�f�4.'.. .... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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 j' Street No. SEE REVERSE SIDE Smoke Det. ,. T Residential Property Record Card PARCEL ID:210/104.B-0138-0000.0 MAP:104.6 BLOCK:0138 LOT:0000.0 PARCEL ADDRESS:114 STONECLEAVE ROAD FY:2009 PARCEL INFORMATION Use-Code: 101 Sale Price: 0 Book: 01363 Road Type: T Inspect Date: 01/20/2003 Tax Class: T Sale Date: 12/31/78 Page: 0735 Rd Condition: P Meas Date: 01/20/2003 Owner: Tot Fin Area: 2312 Sale Type: Cert/Doc: Traffic: M Entrance: X ADAMS,RICHARD D Tot Land Area: 1.46 Sale Valid_: N Water: Collect Id: RRC JOANNE ADAMS Grantor: Sewer: Inspect Reas: C Address: 114 STONECLEAVE ROAD Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 6 Main Fn Area: 1576 Attic: NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2.00 Bedrooms: 3 Up Fn Area: 736 Bsmt Area: 952 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 224,769 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 20125 0.462 3,511 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2312 VALUATION INFORMATION Foundation: CN Bath Quat: T RCNLD: 290802 Current Total: 519,100 Bldg: 290,800 Land: 228,300 MktLnd: 228,300 Kitch Qua[: T Eff Yr Built: 1983 Mkt Adj: Prior Total: 534,300 Bldg: 306,100 Land: 228,200 MktLnd: 228,200 Heat Type: HW Ext Kitch: Year Built: 1978 Sound Value: Fuel Type: O Grade: G Cost Bldg: 290,800 Fireplace: 1 Bsmt Gar Cap: Condition: A Aft Str Vail: Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Aft Gar SF: 884%Good P/F/E/R: /100/100/87 Porch Type Porch Area Porch Grade Factor P 168 SKETCH PHOTO P 14t 68 94t .K;. , . 10 FM 26 23 73698pi3q. 376 S 16 6 5884 Sq.R F3 - 34 34 26 114 STONECLEAVE ROAD Parcel ID:210/104.B-0138-0000.0 as of 9/10/09 Page 1 of 1 Zj.794 ".920" 'CD IBD-3" -J� 3.741 3.74,1 -4 5.375" 0.062" Chi cr I. 0.06- 0.D62 po.,Br 0,055" RAJ 73 CL 6B 4 3,.81 0 CD - Ii,A (D �IVII-\1120WI1200pl;:I�l\Mi�- JAMI3(2) C> WINPOW/Pocx rl�pm, 12 VVY"JI22V P00P I'TAMI' 511-1, HFAI21-'T I-VA12FI?ARM O C) 2055" 1.000" 2.155 1.938" .5bo" '.9970" E CL 0.055" 07-055- CD 0.055 1.000" LP CD �D C)') 0,080" L 0.0 5:5 L LO-OBO" P05-r(D 2.625" I i 2.500" 2.00" 2,438 4.770" 3.970" o Li cn �08 cn >- 1,000" a_ D :�E < C) cri C� -i CD .,j r, V) 0 W z -i to 2 0 0 0 6 0 z G 0� D Lo =5 .08" a :D 0.080" 5.810 OF 6 PAIQ�I, HAN6�P 6A5E �P4 7A—TE--DE—C-2-00-1-1 C? 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COLUMPIHAW6L P/,5,PCF 9 0?0 COOItP COLUMN PIP 12 ICO),512A2Z COi,5FA01,6 Co,5111�-INC, '#8 X 5A45 P�P PANEL fW(6 fOfA )nU5ECW TO TAVLE5 2 AW12 51tCi q fop MAKJMuj/5PjN6 CfMEIqCo-LMN5 r)QtP rO)v 50125, TO fffil,�5 2 t 5HLLT�r0i'MAYRIMI SPACING ftftw COUJ/4q5 2#8)'51"1"5A5 CkG!,AM r&r @20 F5'`I1O'J7OJjfA_LOP42 I"K6 rA5fIA ......... .. 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TABLE IWCLUPC5 1`POF FKNFl,IZA2 1,01,125 0 A i 4 OF 4 PilfEl?fO fAftC A POP APPLICP FOOT PEACfIOW Af 5U?F`O10\f5 17909-089-809 :XJ n 669E-9b6-LL8 0 6 L LE089-809 :Hd zz 'uony �A �461REWdsSl&-'E 1953 pTj! I' hi j 'ilfll ti Fjl� WINDOWS SIDING , x PATIO ROOMS f +_ I, .To Whom r tom It May Concern: I hereby authorize Antonio (Tony) Dasilva to act on my behalf pe.rtaining to all matters regarding building permits, and to act as my representative on behalf oi`our con-1pany. Please feel free to call me with any concerns. s38nsO1DN3 HDaod ?iI Swoo8 O"vd o O VINYL REPLACEMENT Sincerely,ncerely, WINDOWS Ant 1011), .1 ovl to saoo0 waols D1V1S1011 anagel' S STORM DOORS& Champion of Boston South .:Y3€ -Mh t{ d �BmIdtaytcl a lFr. c r�i sir iaa�;ils. CS 97226 t , . Rn t.rd ui'13vilttin{RL tI t(inm ctrl tta11(hIr s WINDOWS Construction Supervisor License HfC 127179 x. rat License: C3 L7, n n 7 C Birthdate: 5/6/1952 rr l$t4� w saoo Aa1N3'v Ouvd o Office (508) 580-3119 ,: rA, s Expiration: 5/6/2010 Tr' 9"2: Fax (508) 580-6064 Restriction: 00 PATIO&ENTRY DOORS Cell (978) 804-6199 >s ANTHONY COVIELLO- 27 COLONIIAL DRIVE < _ CLIi11 TON. tvlA 01510 Co �---- nunissinncr WIaj(INV 9NIOIS IANIA 0 c VINYI SIDING ANDTRIM 7. 'v; 4\ Bim.d uI'f:uilding l:c�ulatiuns and titandardti y License or registration valid for indivi dui use()IllyHJUE IMPROVEMENT CONTRACTOR before the expiration date. tf found return to: SMOONIM Registration: '127-17g Board of"Building Regulatioru and Standards Expiration: 9,110010 Tt# 277297 One Ashburton Place Rm 1301 1N3W3DV1d3N 1ANIA C Type: Ltd Liability Corpor Boston, !Via.02108 Ci 1 AMPION WINDOW& PATIO ROOM SOUTH A dTHOiNY COVIEL.LO 7 S T OCKWELL DR. rt AVON, MA 02322 Adminish'atu Not valid /r bout�igl'ature F "� ' SWOOb olivd JNI41S SMOGNIM OfOCJ/ E961 �N � yIQtJ� AvOrv, 22 PH" 5nR-SRn-R11g ■ R77-gar.-Rtigg ■ FX• c�nR-SRn-rnrA FACTORY DIREC*FPTMS I J , ` 75 Stockwell Drive o Avon, MA 02322 �Il t D HIC 127179 •TIN 043450124 508-580-3119 . 877-946-3699 . 508-580-6064 F x a WINDOWS • SIDING PAT Date t V�c).`7 f r Home Phone :ity -_ t &Altr ! State -F—= Zip Business Phone(Mr./Mrs.) Replacement Windows • Storm Doors •Vinyl Siding, Trim & Shutters • Glass & Screen Patio Rooms • Entry& Patio Doors WHOLESALE & RETAIL PATIO ROOM CONTRACT CHAMPION TO MEASURE,MANUFACTURE,FURNISH AND INSTALL THE FOLLOWING CUSTOM MADE PRODUCTS FOR THE AMOUNT STIPULATED BELOW: AII•,Season Vinyl Patio Room From Nominal 6"Components With Outside Dimensions Of Approximately A: X B: X C: SSeason Aluminum Patio Room From Nominal 4"Components With Outside Dimensions Of Approximately A: _ X B:_J;k _X C: Converted Screen Room From Nominal 4"Components With Outside Dimensions Of Approximately A: X B: X C: ! Aluminum Screen Room From Nominal 2"Components With Outside Dimensions Of Approximately A: X B: X C: 1 E(lg">R SLAB rE1; ,INO YES NO -3"� ❑ Under Customer's Existing Roof ❑ @--Room Deck Approximately X Material ,I'— ❑ On Customer's Existing Concrete Slab ❑ .2-Open Deck Approximately X_ Material O ;_.EJ-On Customer's Existing Deck ❑ Q-steps: Wood❑ Concrete ❑ Approx.Number Of Risers_Open U Closed❑ ❑ .DD ear Out Existing:Slab ❑ Deck ❑ ❑ i3-Railing Approximately lin.ft.Material ❑ 2-Footers For Existing Slab U O-Skirting Approximately lin.ft.Material ❑ 1 1-Tear Out Existing:Walls O Screens❑ Roof❑ Rails ❑ ❑ -3-Pour New Open Concrete Slab Without Footers Approximately_X_ ❑ _Q-.3/4"Sub Floor ❑ E�-Pour New Concrete Slab Withl Footers Approximately X U Q,Insulated Polydeck ❑ Insulate Under Deck 5 I'AP, I f C`lampion Patio Room wall systems consist of a series of sliding windows on top of approximately 16"tall knee walls and/or full view sliding doors(see layout).Windows i:d doors include locking system,synchlock interlocks,stainless steel wheels and sliding screens.Champion to determine exact size of units at final field measure.All glass i terr:pere6 safety glass,and all walls include build-out and leveling system as necessary. ❑See Attached Drawing I'ES NO ;1-' :J Super Frame,Wing&Trim Color: White❑ Tan❑ Bronze U & 3/16"Triple Strength Non-Insulated Glass I ; I 0-0"❑ Double Pane Insulated Champion Comfort 365"Glass ( I '_ ! I I SLI ! ISI I I j'-(- ❑ -'a`Argon Gas Filled I.G.Units(All Season Room Only) U ID--Fixed Glass Knee Walls Location: A 8 C ❑'"' ❑ Knee Wall w/Aluminum Skin: White❑Tan❑ Bronzeul_� U 1, Knee Wall w/Vinyl Skin: White❑Tan❑ iI I l i • I I : J l�-Build Up❑ Build Down❑ Location: A O B(3C❑ I ;----�-�-F {-�-i-� I I It 1-�--�- ❑ l Fixed Transom Glass Location: A ❑ B❑ C❑ l i I 1 1 !II _ I I i I l D E-d" Cap Existing Posts ❑ Key Lock LAYOUT SKETCH OK X=ACTIVE 0=FIXED =FULL VIEW �i I F,Kph; =KNEEWALL -- - C-impion's superfoam roof system is a nominal 4" (R-19) or 6"(R-30) expanded poly-styrene insulated foam panels with an embossed laminated aluminum skin and tl I rurally broken I-Beams. 't E:5 ]NO YES NO •EI tudio Roof System Color: White❑ Tan❑ 4"❑ 6"❑ ❑ C4-Gutter& Down Spout To Grad J .1-3-Gable Roof System Color: White❑ Tan❑ 4"❑ 6"❑ ❑ 3-Shingles(To Match As Close As Possible) I G—Gable Glass❑ Wing Glass ❑Number Of Pieces: O 0,-Skylights:Vented U Non-Vented❑ Quantity: J Q Gable Tie-in(Includes Shingles On Saddle Only And Vertical Vinyl Fill On Inside Of Saddle) 1iKES 'ES 1140 Q E1 Storm: Outswing Color Style Left Hinge ❑Rig41t Hinge❑ ISLO Location: A ❑ B❑ C❑ D 01 Entry: Inswing U Outswing U Color Style Left Hinge ❑Right Hinge❑ IS LO Location: A❑ B O C❑ :lHLER 'ES NO YES NO <?f Heat/Cool Unit: ❑ Q-Blinds:Color Style Height Location: A❑ B❑C❑ Q1'Carpet X Color Cut To Fit Loose Laid GI- Electrical Package Including: Wall Sockets, Wall Switch(es)& Hook UPS Of Customer Provided Ceiling Fan(With Ivory Wire Mold) !C g JNIJLflE1NTS Ir t.rior Rot�f Slopes To ADprOX: ft. Attaches To House:Wall❑ Gutter Board❑ Fascia Board❑ Approx.Height ft C;a)-ion 1;N t Responsible For ExistioTFoundations.51ructures,Or Exi tin H f n ition. VIA\ elf i vV0 YEARS FREE IN HOME SERVICE BUYER'S RIGHT TO CANCEL Total sale price $ L&7 BUYER IMAY CANCEL THIS CONT RAC T BY DELIVERING WRITTEN NOTICE Down payment- _ U Q — I'D THE SELLER AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD Initial balance S + Substantial completion payment 3 JSJNESS DAY AFTER THE DATE OF THIS TRANSACTION. BUYER MAY USE (Due following completion of room structure PRIOR to M THIS CONTRACT AS THAT NOTICE BY WRITING "I HEREBY CANCEL"AT installation of:Custom Glass,Carpet,Electric,Blinds) -HE BOTTOM AND ADDING BUYER'S NAME AND ADDRESS.THE NOTICE FINAL BALANCE -� (Due in full fallowing completion of project) I OUST BE DELIVERED TO THE SELLER AT THE ADDRESS SHOWN ABOVE. ❑ Bank Financed ( ❑ Cash on Completion .411 T ueiia!is guaameed to be as specified.All work is to be completed in a workmanlike manner according to standard practices.This contract is alid only with proper signatures. Champion shall not be held responsible for time and nr!c ial delays strikes.acts of God or any other matters beyond�tsoo "ol.Buyer and Owner agrees that the equity in this property is securi lh'' this contract calls for made to order goods,it is not subject to ca c Ilalicn except as stated above.start installation on or about�weeks from above date.Estimated date of substantial completion s 1411 a s lis ed above.Champion to remove and haul away all job related de.it AII:ales Aad discounts allotted.All contractors and subcont7Sctors must be registered by the Board of Building Regulations and Standard any inquiries elating to registration should be directed to this agency.Champion sh II)oah any,hrd all necessary permits as the Own is agent unless othe.wise directed by Buyer.If Buyer secures permits,he or she may be exc'�from the gua ntyllund provision of G.L.C.142A.It Champion must pursue Buyer or IlL tirn of ariounts past due,Buyer will be liable for Ch pbr3 easonable fees and casts.including attomey's fees.A FINANCE CHARGE'7 ad at the ra of 1-12 percent per month(18%ANNUAL PERCENTAGE RATE) wil C+addrd to de�squ�t ccounts.AII installati,%a pletion dates are approximate and subject to change without notice.Verbal p�mises n cause misunde 'd rigs.therefore this contract constitutes the entire understanding of 1i parties.and nV,lt�understanding•coUamral•verbal or otherwise.shall be binding.unless signed by both parties.Thank you for you order.Do not s' n this contra tct_ area y blan aces. X 4 , y - 1 iuyrds/iignature Ch &R-Represe X � // I Uyer's:signature Champion Manufacturing Authorized Officer rr r 1 L':CNr05-1107-BS OChampion,2006 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers *Applicant Informationy - Please Print Legibly Name(Business/Organizarion/Individual):_�I ��_ C��wcQOt�lCo • ® A25/6'n �04. Address: 757 Sh�,r-k"vc(I City/State/Zip: h, e) Phone#: 58 80 3 t 9 Are you an employer?Check the appropriate box: Type of project(required): 1.Q{I am a employer with (a 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # 7• W Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that cher s box ul must also iui out the secuon below showing tne.:wolkeri'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: S,e v, �r y Policy#or Self-ins.Lic.#: 11 Expiration Date: Job Site Address: ala ,Stoy..y C i ty t? a. City/State/Zip: V. APA 011k.5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or,one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi�fy/under the pains and penalties of perjury that the information provided above is true and correct Signature: `I/� Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing 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 contract 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-contractor(s)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 re•�m-ed to the city or town that the applicadon jvr the perm t 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 permittlicense 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 780 CMZ: STATE BOARD OF BUIMDING RrGUI,ATIONS PND WNDARDS APPENDICES CONSUMER INI TOR-ATION FORM - "SUNROOMS" A%IassachUsettu,State Building Code(784 CMR 6101.3.2.2). The Massachusetts State Building Code(780 CMR)includes provisions'to ensure that houses and house additions deet energy efficiency standards.This supplernental CONSUINER; FORMATIONFORM is to be filed as part of the building permit application .when a builder/coniractor or homeowner, constrtrcfinglinstalling a house addition with very large percentage of glass to opaqu wall,seeks to utilize a special energy conservation exemption option for "sunroom" additions to an exisiting house (780 CMR, 6101.3.2.2). This FORM is not intended to prevent.a homeowner from.selecting a"Sunroom" of any size, configuration, orientation-form forn of colistraction or percent blazing; but rather is �]nly intended to assist homeowncrs in becoming aware of some of the important energy.conservation aid year-round comfort . considerations involved in selecting and utilizing a"sunroom."addition. The connection of"sunrootn"strictures to residential buildings may create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the.main hot sc.In the selection and construction/installation of"sun ooxns",included below is anon=requi t d,open-ended l st of product and desigli considerations that a homeowner may wish to consider before actually construc`Ginglin tailing a"sunroorn".II is.recommended that consilmers cUeadly review these options with their designer,.b ilder, or contractor, in order to minimize potential energy consumption and/or house discomfort issues. li]add ition,the qualifications and reputation of the.company or individuals to be.hired are important considerations. s. CT.-Mi3),$IGI� COi SI1_3ERA1JQNSRFULL'E TO I 9' Solar Orientation and Natural Shading 0 Type of Giazing Insulating value ,Solar treat gain ® .Frame materials Glazing fo frame sealing and Basketing materials/seal duralbility and/or weather tightness of the sunrciom ® Adequate.ventilation-Operable windows and Barrs. Applied Shading System 0 Insulation level in floors,walls,and ceilings a Pcas�,ilhle Sunroorrr isolatiorh from the main house via a wall an&or door ol•slider e Heating and Cooling Mrethods:Efficiency,Zoning and Controls flomeowner A.cknowledgrrient The Massachusetts State Building Code,780 CMR 6.10.1.3.2.2,requires that the actugi Lit o e ow e (riot the owner's agent or representative)acknowledge receipt.of this CONsuNIER Iiv 0n4A MN RN:prior to issuance of a Build-iiia Permit for a project that includes `'sunrooin" additions to an.existing residential building, .In accordance with this requirement,the undersigned hereby acknowledges that sh-/he.haE read the information in this ^umert concerning sunrcom comfort and energy conservation. Sig -'Ire of Actual Bui?ding Owl:er Date /94"4 YY J Print Name Andress of Permuted Project r Owner Address(if different than pr,�iect location) Owner's telephone number �`�! �'+:l Lt i t � KJ-r SwF• TO ..._ ... �,•. tiss �,.:., sir, v::� ... ..,./'�._ •i V,.-"!ND0'v'•,' .}; -. .:' -101MS j i -A 7 ..t' i el (�..ll(' �I"1,�i i!i'�. ., are the O Mlle,• X17 ill h :i` i!( ! 1. .. ...-.. _.._.._ .. r .. ward.�_ _':1 i C I. .. ... . ...... . dicscG iii:( 1 'I' ;�:jji a ! 1 ':; ^,`;'.i rl. 'i n • tC . . ii:.;� �_., C: :Gi and _, . ... ..• ..:10:' Champion ''.�•i.. -:Ci\:". ShIng and _. 6c, .�"�(J(_1i!!S. _..._. :l� ;.i:a•`.G3'.??v' L=1 ac-.. a; .i��'r iF:11`' .i�! ..?<7;.. > _r. .. .. COMMAng g t^!JjCi:l. _��''r'u _U.i"ih'.'._ C' .1.' , under die pain` had j.i'_1! 1him Of I , I. i . ... .,..:n .._,.�`.G_.!.! JL��,i:•� !�i�j"1"' •.��.\-v GCC \%�!Gi.L�!�.....a�� ��I. �_ )`.,{ . homby casify that he subject prGpen; is a p;^,,e nva a,- . O17'C',!): and 1 "m1 11'd:': ., one ;; ?t_!e i(:r cel l...!Jl Gly. .F'r 7' 71 a LTG ^CG ��C:. ��: j- 1.;�. ,r, r�. .r; . --�G=- 0' __) [�Os'e 0�__..S ��:"Cij�C" '.'_tet i.��.!iii),_-_ iC�Lli:,%: ..,..,.�.ir..., n,--il '.:)_'t li•i!e. ai.0 to _;ay it it `I _ I I I j 1 ACORD CERTIFICATE OF LIABILITY INSURANCE OPID LS DATE(MM/DD/YYYY) CHAMP-1 12/01/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Roedi.n.g Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2734 Chancellor Dr ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Crestview Hills KY 41017 Phone: 859-341-0202 Fax:859-341-3709 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: OHIO CASUALTY _ 24074 INSURER B: INDIANA INSURANCE COMPANY 22659 Cham Bpion Window & Patio Room of oston South LLC INSURER c: Sentry Insurance 75 Stockwell Drive #7 INSURER D: Avon MA 02322 — - INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. [Mill AIJIJ'� XPITN LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYY ECTIVE DATEPICYMMIDD�/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BKA53758486 12/01/09 12/01/10 PREMISES(Eaoccurence) $300,000 CLAIMS MADE 1_x I OCCUR MED EXP(Any one person) s5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY ECT X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) I HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ( AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: , AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $10,000,000 B X I OCCUR F-1CLAIMSMADE CU8319330, 12/01/09 12/01/10 AGGREGATE $10,000,000 RDEDUCTIBLE $ X RETENTION $O $ WORKERS COMPENSATION AND X TORY LIMITS ER C EMPLOYERS'LIABILITY 901623201 9 00061 1 12/01/09 12/01/10 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Directors & Officers Liability $2,000,000/$2,000,000 Employment.Practices Li $2,00,000 with $100,000 deductible per claim Fiduciary Liability $2,000,000/$2,000,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Marc Tessel ACORD 25(2001108) ©ACORD CORPORATION 1988 vi ip" oaf �ti ! 0 0 ° 0 .�� � ..25sY`0•..:.,.:.:51,� t .... M?;y.fSCMyni:%?;?`> � Q►!�f%1 V j Otc'jfif� 2rrrml — t'� 1 040ye-e r'!yts5 GYCic� OJ GradePolyethelene v�sc,�iufo+.�O«Qe� Concrete Slab m o � 6 ° 0 0 ° 6K& 011 "�Gt�F�c�ti 0 0 ° 0 00 0 P.s:.1 e 5� 1 0 0 0 00 0 Concrete 0 0 0 0 .0 0 00 0 0 S ORDER NO: 461 ITEM: 1 DATE: 11/25/09 Floor Plan H 2 U Whdow55375 1tC H H 2 Up WlydowS5376 AtAlUt Srppipd Pam 37 I 2 LIP Door%,375 I 2 up Door 77315 I uc Dimensions Attachment Height: 118" B Wall Height:86.875" B Wall Width: 144" A Wall Width: 144" C Wall Width:36" Roof Overhang: 6" PAGE: 1 of 1 ORDER NO: 461 ITEM: 1 DATE: 11/25/09 A Wall m y 144" Dimensions Attachment Height: 118" B Wall Height: 86.875" A Wall Width: 144" Roof Overhang: 6" Layout 1"(Fascia)+0.5"(Non-Thermal H)+26.75"(Foam)+0.5"(Non-Thermal H)+55.375"(2 Lite Window)+ 0.5"(Non-Thermal H)+55.375"(2 Lite Window)+4"(Corner Post) PAGE: 1 of 1 ORDER NO: 461 ITEM: 1 DATE: 11/25/09 B Wall OD CD v v 144" Dimensions Attachment Height: 118" B Wall Height: 86.,875" B Wall Width: 144" Roof Overhang: 6" Layout 4"(Corner Post)+0.875"(Foam)+0.5"(Non-Thermal H)+55.375"(2 Lite Door)+0.5" (Non-Thermal H)+77.375"(2 Lite Door)+0.5"(Non-Thermal H)+0.875"(Foam)+4"(Corner Post) PAGE: 1 of 1 ORDER NO: 461 ITEM: 1 DATE: 11/25/09 C Wall N CD Lj 0Y V N AFFILIATE SUPPLIED 36" Dimensions Attachment Height: 118" B Wall Height: 86.875" C Wall Width:36" Roof Overhang:6" Layout 4"(Corner Post)+30"(Affiliate Supplied Panel)+0.5"(Non-Thermal H)+ 1"(Fascia) PAGE: 1 of 1 ORDER NO: 461 ITEM: 1 DATE:' 11/25/09 Roof N W N o`S A 6" N N • W 4. A 156" Dimensions Attachment Height: 118" B Wall Height: 86.875" B Wall Width: 144" A Wall Width: 144" C Wall Width:36" Roof Overhang: 6" PAGE: 1 of 1