HomeMy WebLinkAboutBuilding Permit #401-2017 - 140 COLONIAL AVENUE 10/14/2016 JwAk AD LF- BUILDING PERMIT L NORTH w.
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TOWN OF NORTH ANDOVER `-'1'' 46
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APPLICATION FOR PLAN EXAMINATION
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Permit No#: 401 - &l Date Received �9"0 rED 0, cy
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Date Issued: �
IMPORTANT: Applicant must complete all items on this page
LOCATION 0 C6JOV)lal AUe
PROPERTY OWNER �_ 11 �� (W, 10
Print 100 Year Structure yes Ono
MAP��PARCEL: 13 6 ZONING DISTRICT: Historic District s
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
f ation No. of units: ❑ Commercial
qepair, replacement ElAssessory Bldg El �O�t h eers-
emolition ❑ Other _
Septic ❑Well ❑,Floodplain ❑Wetlands ❑ Watershed District '
0'Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Ttwa ,4t,3�_N 0
open
Identification- Please Type or rint Clearly
OWNER: Name: Hivit F&0 r` (' Phone:
Address: � � �O(�J� , A ATavu,) feiA oiW
Contractor Name: Del)ni3 Phone: 918 a00 7
Email Q,Ani S V M �,Cvin. ,art
Address: al m
0
Supervisor's Construction License: Exp. Date: 12J 201 �o
4
Home Improvement License: ( 1 Exp. Date: -7 13 76 t
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: $ t0,5d l0 FEE: $
Check No.: Receipt No.: /
NOTE: Persons contracting with unregistere contractors do not have access to the guaranty fund
Location I-r a
No. 40 Date A0/4-
i5
• - 405
TOWN OF NORTH ANDOVER
,
Certificate of Occupancy $
Building/Frame Permit Fee $ lZ��
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
043 Building In p ctor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody 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
PLANNING & DEVELOPMENT Reviewed On Signature_
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
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
NTS Tern Demi e,"o'R
FIE�DEPAR:ME pk psfer°ontsite... yesa �
1{Located at'124,Main Streeth '.
Fire Depaitimentsignaturtie%date .� .�� f "
\ r+"#. a•,jt4 1 `i a" ?:, a J tr J.; Y.: j 'Z t. .. t i y': {,c. any r;a.
I J fT
a.
, . A.
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
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)
LJ Notified for pickup Call Email
Date Time Contact Name _
Doc.Building Pennit Revised 2014
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
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
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
NORTH q
Town of sAndover
O - „" 0
T � y
2 h ver, Mass,
COCNICKl WICK y�. T
��s RATED i.P ,�5
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ........... ��.... ..,�OW�IIIVi�............................................ ......
BUILDING INSPECTOR
has permission to erect buildings on .....it ,L,��' I� .4 Foundation
Rough
to be occupied as Y) AA WChimney
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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTR ON Rough
Service
... .. .. ..... ... ......... .. ...
BUILDING MsAcifR Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
d
Page 1 of 4
? V'N North Shore Window Solutions LLC NSWS
D E S. I G N GALLERY 239 South Main Street, Middleton, MA 01949
Phone:978-762-0007 FAX:866-809-3136
U ,a complete window and door Aowroom
Massachusetts HIC Registration#172585
by NSWS
INSTALLED PROJECTS PROPOSAL
MP
DATE:4/2/2016 NSWS REP: Linda Keating PROPOSAL#: FAN-040216
Customer Name:Michael and Kathleen Fanning
Project Address:140 Colonial Ave,North Andover,MA 01845
Primary Phone(where we can reach you prior to and during project):413-209-0159
EmaiJ:kafanning89@yahoo.com
WORK TO BE PERFORMED:
Install 13-Wide Full Frame Double Hung Window Unit into existing Rough Opening
Similar to Existing
Specs:
Marvin Clad Ultimate Double Hung Next Generation with a Picture Window
Exterior:Aluminum Clad; Stone White
Interior: Pine;Prefinished White-Factory Applied
Glass: Low E 2 w/Argon
Grilles: Grilles Between the Glass; Similar to Existing Grille Configuration
Hardware: Bronze
Screens: Full; Charcoal Fiberglass Mesh
Interior Trim:Pine; Similar To Existing
Exterior Trim:PVC; Similar to Existing
****The Price includes a FIVE YEAR installation warranty****
TOTAL PRICE (Materials, Labor, and Sales Tax): $10,050.00
TERMS: 1/3 total price deposit required, 1/3 total price required upon delivery, 1/3 total price payable
at completion of above mentioned work to be performed.
WORK INCLUDEDS THE INSTALLATION OF WINDOWS AND/OR DOORS;ALL NECESSARY FRAMING MATERIALS,ROOFING
SUPPLIES WHERE APPLICABLE;NEW INTERIOR AND EXTERIOR CASING,SILLS,AND STOOLS AS NEEDED;THE REMOVAL
AND REINSTALLATION OF INTERIOR STOPS AS REQUIRED;CAULKING SUPPLIES,NECESSARY INSULATION,SHIMS,AND
FLASHING SUPPLIES;SUFFICIENT SIDING TO REPLACE THAT REMOVED DURING INSTALLATION AS REQUIRED;
SUFFICIENT DRYWALL SUPPLIES TO REPAIR THE INTERIOR WALLS FROM THE INSTALLATION,ALL NECESSARY
FASTENER AND ADHESIVES;REMOVAL OF CONSTRUCTION DEBRIS.Permit fee not included.Will be billed independently to
customer at face value of permit.
THANK YOU FOR THE OPPORTUNITY TO HELP YOU!
www.nswsformarvin.com
Page 2 of 4
Contract - Installed Projects
North Shore Window Solutions LLC. dba Marvin Design Gallery by NSWS
239 South Main Street, Middleton, MA 01949
Phone:978-762-0007 FAX:866-809-3136
Massachusetts HIC Registration: 172585 Contract#: FAN-040216
CUSTOMER NAME: Michael and Kathleen Fanning
STREET ADDRESS:140 Colonial Ave,North Andover,MA 01845
PHONE:413-209-0159
This contract applies solely to the labor and materials required to install the exterior windows and doors specified on the attached proposal which is
included as part of this contract.If hidden conditions such as,but not limited to,rot,insect damage,or substandard framing per the MA Building
Code, interfere with the proper installation of the products, the work will stop immediately. Such situations will be referred to NSWS's
representative to determine the appropriate action.Such action may include NSWS's subcontractor performing repairs at additional cost,
however any contractor of the homeowner's choosing may be employed to perform the additional work.NSWS also reserves the option to
decline supervision of such work at which time additional charges would be billed to the homeowner directly by the subcontractor.Any new
charges incurred through NSWS will be due upon completion of the additional work.Billable rate @$90.00 per ma hour plus materials.
CUSTOMER INITIALS
DEFINITIONS,INCLUSIONS,AND EXCLUSIONS
®FULL FRAME REPLACEMENT:these windows will usually be installed from the outside of the home.The installation will include windows or doors,
all necessary framing materials,roofing supplies for bay and bow windows where applicable,new interior and exterior casing,sills,and stools,caulking
supplies,necessary insulation,shims,flashing supplies,sufficient siding to replace that removed during installation,sufficient drywall supplies to repair
the interior walls from the installation,and any necessary fasteners,and adhesives needed to complete the installation.
❑INSERT OR SASH REPLACEMENT:these windows will usually be installed from the inside of the home.The installation will include the windows,
caulking supplies,necessary insulation,shims,and fasteners.The interior stops will be removed and reinstalled.
EXCLUSIONS:NSWS will not be responsible for any existing items that are made unusable due to the installation of new windows or doors.
These items include,but are not limited to:blinds,shades,curtains,shutters,storm windows,storm doors,wallpaper,air conditioners,
awnings,window and door hardware,etc.Unless specifically listed in the proposal,the items not included will be:new interior and exterior casing,
sills,or stools,or replacement of the existing window frame.A change order may be issued to cover extra charges to fix or replace items not included.
NSWS will not be responsible for alarm systems encountered during installation.The homeowner will be responsible for contacting and
scheduling the alarm service company to perform any necessary alterations to accommodate the new windows.
Any required electrical work is not included in this proposal. If existing wiring needs to be relocated or eliminated in order to accommodate any new
windows and or doors to be installed,this may result in added cost. Any additional cost for electrical will be handled as a Change Order and is the
responsibility of the customer and not included in this proposal
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
North Shore Window Solutions LLC.(NSWS)agrees to perform the work,furnish the material and labor specified above,clean the site and dispose of
waste for the sum of:$10,050.00
PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE:
$3,350.00 (33%OF TOTAL SALE PRICE UPON SIGNING CONTRACT)
$3,350 (33%OF TOTAL UPON COMMENCEMENT OF WORK)+PERMIT FEE
$3,350 (BALANCE UPON COMPLETION OF THE CONTRACT)
Payment for this work is subject to additions or deductions in accordance with the provisions of this contract and any subsequent written
change orders.Upon completion of contracted work,if manufacturer warranty service is required to correct any defect in the windows/doors,
the homeowner may holdback up to 10%of the contract total until such service is performed.The actual amount of the holdback will be
determined by the homeowner and the NSWS representative,but in no event shall exceed 10%of the contract price4pir the items)which is
the subject of the defect Credit Card information to be provided to NSWS as security,even if paying by check Customer Initials
At the time of the final payment specified above,NSWS will certify,at the request of the owner,a complete release of all liens arising out of the contract.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of NSWS,which may be the main office or
branch thereof,provided you notify NSWS in writing at the main office or branch by ordinary mail posted,by telegram sent or by delivery,to be reviewed
by NSWS no later than midnight of the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.Terms continued on pages 2&3 are integral
parts of this contract.***Do not sign this contract if there are any blank spaces***
CUSTOMER SIGNATURE NSWS dGNATURE --?
DATE: DATE:
Page 3 of 4
The following acts or occurrences shall not constitute default on the part of North Shore Window Solutions I.I.C.(NSWS)in connection with the date of
substantial completion and shall entitle NSWS to reasonable extensions of time to perform under the contract:acts of god,strikes,acts of war,
emergencies,failure of NSWS's suppliers or vendors to timely deliver materials to NSWS,failure of the owner or its agents to supply NSWS with job site
availability on a timely basis,or any other acts or conditions not within the direct exclusive control of NSWS.
1.INSURANCE:
A. NSWS'S LIABILITY INSURANCE.NSWS agrees to keep in force at it's own expense during the entire period of construction on the project
such liability insurance as will protect it from its claims,under workmen's compensation and other employee benefit laws,for bodily injury and
death,and for property damage,that may arise out of work under this contract,whether directly or indirectly by NSWS,or directly or indirectly
by a subcontractor paid for or employed by NSWS for the above referenced project.The minimum liability limits of such insurance shall not be
less than the limits specified by law for that type of damage claim.
B. OWNER'S LIABILITY INSURANCE.Owner(s)agrees to maintain in force their own liability insurance during the construction on this project,
and reserves the right to purchase such additional insurance as in their opinion is necessary to protect them against claims arising out of
NSWS's operation,without diminishing NSWS's obligation to carry the insurance specified herein on his part to be carried.
C. PROPERTY DAMAGE INSURANCE ON WORK SITE.Owner agrees to maintain at his expense during construction of the property,damage
insurance on the work at the site to its full insurable value,including interest of owner,NSWS,and subcontractors,against fire,vandalism,and
other perils ordinarily included in extended coverage.Losses under such insurance will be adjusted with and made payable to owner,NSWS,
and subcontractors,against fire,vandalism,and other perils ordinarily included in extended coverage.Losses under such insurance will be
adjusted with and made payable to owner as trustee for the parties insured as their interests appear.Upon request,owner shall file a copy of
all such policies with NSWS within a reasonable time after construction begins herein.
D. WAIVER OF WORK SITE DAMAGE CLAIM TO EXTENT OF INSURANCE COVERAGE.Owner and NSWS hereby waive all claims against
each other for fire damage or damages from other perils covered by insurance provided in paragraph"C"of this section.
2.WORK CHANGES:Owner reserves the right to order changes in the nature of additions,deletions,or modifications,without invalidating the contract,
and agrees to corresponding adjustments in the contract price and time for completion.All changes will be authorized only by a written change order
signed by owner or by his agent.The change order will include confirming changes in the contract and completion time.Work shall be changed,and the
contract price and completion time shall be modified only as set out in the written change order.Any adjustment in the contract price resulting in a credit
or a charge to owner shall be determined by mutual agreement of the parties,or by arbitration,before starting the work involved in the change.
3.TRASH AND CLEAN-UP:NSWS is responsible for interior and exterior clean-up in rooms and areas directly impacted by the construction,including
trash removal and vacuuming.Dumpster expenses,as needed,are included in the total price.
4.TERMINATION:If owner cancels this contract without legal cause after any right to rescind period,he shall pay NSWS the amount of expenses
incurred to that date plus 15%of the contract price.If NSWS cancels this contract prior to commencement of construction,NSWS shall return to owner
any amounts paid to that date.That shall be the owner's sole remedy in law or equity.
5.COMPLETION CERTIFICATE BY OWNER:On completion of NSWS's work,owner shall execute and deliver to NSWS a completion certificate
confirming that the owner of his agent has inspected NSWS's work and that the work has been satisfactorily completed to the owner's satisfaction or
itemizing any deficiencies or the specific complaints in NSWS's work.
6.LIMITED WARRANTY:NSWS WARRANTS ITS INSTALLATION ONLY TO BE FREE FROM DEFECTS IN WORKMANSHIP FOR A
PERIOD OF FIVE(5)YEARS FROM COMPLETION.THE GOODS INSTALLED HEREUNDER ARE SUBJECT ONLY TO ANY
WARRANTIES OF THE MANUFACTURER.ANY WARRANTY HEREUNDER EXTENDS ONLY TO OWNER AND IS NOT
TRANSFERABLE TO SUBSEQUENT PURCHASERS OF THE REAL PROPERTY OR TO OWNER'S HEIRS,REPRESENTATIVES,
SUCCESSORS,OR ASSIGNS.IF A DEFECT IN WORKMANSHIP COVERED BY THIS WARRANTY OCCURS, NSWS WILL AT ITS
OPTION REPAIR,REPLACE,OR PAY OWNER THE COST OF REPAIRING THE DEFECTIVE WORK AT NO COST TO OWNER.TO
OBTAIN WARRANTY PERFORMANCE,NOTIFY NSWS OF ANY DEFECT OF CLAIMS FOR BREACH,AND THIS SHALL BE THE
OWNER'S SOLE REMEDY IN LAW OR EQUITY.THE PROVIDED SAID LIMITED WARRANTY IS SUBJECT TO THE FOLLOWING
EXCLUSIONS:
A. THE GOODS INSTALLED HEREUNDER ARE SOLD ON AN"AS IS"BASIS BY NSWS.THE ENTIRE RISK AS THE
QUALITY AND PERFORMANCE OF SUCH GOODS IS WITH OWNER.SHOULD SUCH GOODS PROVE DEFECTIVE,
OWNER,AND NOT NSWS ASSUMES THE ENTIRE COST OF ALL NECESSARY REPLACEMENT OR REPAIRS.THE
GOODS INSTALLED HEREUNDER CARRY THE MANUFACTURERS'WARRANTY ONLY AND NSWS WITHOUT IN ANY
WAY ASSUMING RESPONSIBILITY OR LIABILITY THEREFORE AGREES TO EXTEND OR PASS ON TO OWNER SO
FAR AS IS POSSIBLE MANUFACTURER'S WARRANTIES.
B. DEFECTS AND FAILURE FROM MISTREATMENT,NEGLECT,OR FROM OTHER CAUSES BEYOND NSWS'S DIRECT
CONTROL SUCH AS MOISTURE,EXPOSURE TO SUN,CRACKED,BUCKLED,WARPED,OR OTHERWISE DEFECTIVE
SURFACES AND SUBSURFACE,SETTLING,OR STRUCTURAL DEFECTS.
C. WORK PERFORMED BY,OR MATERIALS,APPLIANCES OR EQUIPMENT INSTALLED BY OTHERS NOT IN THIS
CONTRACT.
D. EXCLUSIONS AND LIMITATIONS-OWNER'S RIGHT TO REPAIR AND REPLACEMENT ARE THE EXCLUSIVE
REMEDIES AND NSWS SHALL NOT BE LIABLE FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM
THE WORK PERFORMED BY NSWS OR FROM THE GOODS PROVIDED FOR IN THIS CONTRACT.
THIS LIMITED WARRANTY IS THE ONLY EXPRESSED WARRANTY NSWS GIVES. IMPLIED WARRANTIES, INCLUDING BUT
NOT LIMITED TO WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE,ARE LIMITED TO A
DURATION OF 60 DAYS FROM THE DATE OF INSTALLATION.
THIS AGREEMENT SHALL BIND THE CUSTOMER'S HEIRS,BENEFICIARIES,EXECUTORS,ADMINISTRATORS,
SUCCESSORS,INQUIRERS,AND ASSIGNS OF THE PARTIES HERETO.
Page 4 of 4
REQUIRED PERMITS
THE FOLLOWING BUILDING PERMITS ARE REQUIRED.IT IS THE OBLIGATION OF THE CONTRACTOR TO SECURE SUCH PERMITS AS THE
HOMEOWNER'S AGENT:LIST ANY AND ALL NECESSARY CONSTRUCTION-RELATED PERMITS.
NOTE:OWNERS WHO SECURE THEIR OWN PERMITS OR DEAL WITH UNREGISTERED CONTRACTORS ARE EXCLUDED FROM THE
GUARANTY FUND PROVISIONS OF MGL C.142A.
As required per town of North Andover
Permit billed separately of this proposal based on total project cost,payable by customer to NSWS
NOTE:ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE REGISTERED AND ANY INQUIRIES ABOUT A
CONTRACTOR OR SUBCONTRACTOR RELATING TO A REGISTRATION SHOULD BE DIRECTED TO:
DIRECTOR,HOME IMPROVEMENT CONTRACTOR REGISTRATION
ONE ASHBURTON PLACE,ROOM 1301
BOSTON,MA 02108
617-727-8598
UNLESS OTHERWISE NOTED WITHIN THIS DOCUMENT,THE CONTRACT SHALL NOT IMPLY THAT ANY LIEN OR OTHER SECURITY
INTEREST HAS BEEN PLACED ON THE RESIDENCE.
ARBITRATION
NSWS AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THAT NSWS HAS A DISPUTE CONCERNING
THIS CONTRACT,NSWS MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE
SECRETARY OF T EXECUTIVE OFFIC OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE
REQUIRED S MIT TO S C ABI ATION S PROVIDED IN M.G.L.C.142A.
NSWS: DATE: IZ 3 /Asl
ref I-
CUSTOMER: DATE: l " I�• t� IJ
NOTICE:THE SIGNATURES OF THE PARTIES ABOVE AP ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE
SETTLEMENT INITIATED BY NSWS.THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT
SEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
HOMEOWNER'S FINANCIAL INSECURITY-A CONTRACTOR MAY NOT DEMAND PAYMENTS IN ADVANCE OF THE DATES SPECIFIED ON THE
PAYMENT SCHEDULE IN CASES WHERE THE HOMEOWNER DEEMS HIM/HERSELF TO BE FINANCIALLY INSECURE.CONTRACTOR'S
FINANCIAL INSECURITY-IN INSTANCES WHERE A CONTRACTOR DEEMS HIM/HERSELF TO BE FINANCIALLY INSECURE,THE
CONTRACTOR MAY REQUIRE THAT THE BALANCE OF FUNDS NOT YET DUE BE PLACED IN A JOINT ESCROW ACCOUNT AS A
PREREQUISITE TO CONTINUING THE CONTRACTED WORK.WITHDRAWAL FROM SAID ACCOUNT WOULD REQUIRE THE SIGNATURES OF
BOTH PARTIES.
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE DATE THAT THE
CUSTOMER SIGNS THIS CONTRACT.
AFTER THREE BUSINESS DAYS,AN ORDER FOR NON-STOCK WINDOWS AND/OR DOORS MAY NOT BE CANCELLED.
IF YOU CANCEL WITHIN THREE BUSINESS DAYS,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT OR SALE,AND,ANY NEGOTIABLE INSTRUMENTS 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 CONTRACT OR SALE;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 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 NSWS INSTALLED SERVICES,AT 239 South Main Street,Middleton,MA 01949 NOT LATER THAN
MIDNIGHT OF (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyers Signature:
The Commonwealth of Massachusetts
w Department of Industrial A cciden ts
_ a
1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
11—orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): NORTH SHORE WINDOW SOLUTIONS
Address:239 S. MAIN ST.
City/State/Zip:MIDDLETON, MA 01949 Phone#:978-762-0007
Are you an employer?Check the appropriate box: Type of project(required):
l.E✓ I am a employer with 8 employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance?
14.[D Other WINDOWS
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 roust 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.
I ani an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:NATIONAL GRANGE MUTUAL
Policy#or Self-ins.Liicc..#:WCT6857E Expiration Date:5/15/2/0171 4
Job Site Address: 1 d C'd I h aA A J e- City/State/Zip: � � t1 l�Cd J�� �� c)
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 pair s andpenalties of perjury that the information provided above is tru t
and correct.
Signature: UJs /�`� Date:
Phone#: q 75 -7 b (DO 0 1
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.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 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 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 burn 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
Office of Consumer Affairs d Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home ImprovemLht,;ontractor Registration
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www.nswsformarvin.com