HomeMy WebLinkAboutBuilding Permit #169-2016 - 289 Webster Woods 8/6/2015 f' ' BUILDING PERMIT NORTy
� O�,t�Eo 6 qMA
TOWN OF NORTH ANDOVER 3 -
APPLICATION FOR PLAN EXAMINATION * ,�
F 1.
Permit No#: Date ReceivedAC
gSSACHUSE�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION oc.,?7 61/M,8 sTer4n tyaab-s Z-4yVC .
Print
PROPERTY OWNER SLI bfirls NA S' AtZ-
i Print 100 Year Structure yes no
MAP PARCEL:O/ d-3 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes o
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
;'Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic 0 Well 11 Floodplain ❑Wetlands El Watershed District:
o Water/Sewer -
DESCRIPTION OF WORK TO BE PERFORMED:
&e-1,413 I AAA W1 A cttJ Cse -�1c2 r n Lvt��`�✓
o yd 6- No *ty'r l U
Identification- Please Type or Print Clearly
OWNER: Name: *4a rA �� - /r/�9u fI/L Phone: 97e 6&06—L-7 J
Address: 2 E 7 wee ts Zt�M
1 Zb2
Contractor Name: kd� S� 01J 914hone: 0mr
Email: deon's <E m wS iir- mwV
Address: �,Z�T IJ AIrJ ST I/V1tODLE-TON nl `�
Supervisor's Construction License: q 165q Exp. Date:
Home Improvement License-.. d— � Exp: Date: 10
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: $ ( 114� FEE: $ ���(n
Check No.: ��7, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
--
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ '
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e 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
a J
'Tanning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
_ Imo- fl�7
FIREDEPARTMEN Temp Dumpstr�on site�::�yes ..� . #
{L> -417-1
ocated at 12,4 Main Street
Fire Departmentgnatur�e/,date .
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 q pp 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 ease)
I
® 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
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
4 Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
4, Workers Comp Affidavit
4- 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
Location 2% ! WP 6-s- e z-- ��c."`S
No. 1 2-o Date
• - TOWN OF NORTH ANDOVER
w_ Certificate of Occupancy $
Building/Frame Permit Feery
Foundation Permit Fee $
Other Permit Fee $
4TE ` TOTAL
Check#` -:�
Buildirbans ector
25171
NORTf
Town of tAndover
O
161(e h
4 s - �- 4 2a 5
o �A«� h ver, Mass,
coc«cNlWIC« �1'
S U
BOARD OF HEALTH
Food/Kitchen
PER ..MIT T LD Septic System
1
`� �-_ '$4 Ar BUILDING INSPECTOR
THIS CERTIFIES THAT
Foundation
has permission to erect ...................:...... buildings on �.... � .` ............. .. ....
Rough
to be occupied as .. . ta.w... 1 ►.114 ...... !!�4 !!�.'.. RQ.���.... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the applicatio 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
ELECTRICAL INSPECTOR
S
UNLESS CONSTRUCTION RTS Rough
Service
.................. ........ ...... .. ........................... Final
B
I.L.
INSPECTOR
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.
Page 1 of 4
OVILS
North Shore Window Solutions, LLC (NSWS)
239 South Main Street, Middleton, MA 01949
Phone: 978-762-0007 FAX:866-809-3136
-b�catiplelv- wtifido-y�'ahsl Ivor sko' (60
Massachusetts HIC Registration#172585
INSTALLED PROJECTS PROPOSAL
DATE: 6/3/2015 Cally NSWS REP: Matt Tiffany PROPOSAL#: NAJJ-6315
Customer Name:Elie Najjar Djg(
Project Address:287 Webster Woods Lane , No. Andover, MA. 01845
Phone:978-682-5679 Mobile:508-523-4279 Email:dnajjar@nelgpc.com
WORK TO BE PERFORMED:
Funish and install Marvin Clad RT2 RO 69.x 72 1/2" Specificationsa as follows:
Exterior : stone white
Interior: Pre-finished White ,
Grills: GBG to match existing ''.e I &
Glass: Low E2 with Argon
Jambs: 6 9/16
Exterior Casing: BMC with A246 subsill-"O'
Interior casing : to be reused (due to custom detail)
****The Price includes a FIVE YEAR installation warranty****
TOTAL PRICE (Materials, Labor, and Sales Tax):.$6,195.00
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.
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#: NAJJ-6315
CUSTOMER NAME: Elie Najjar
STREET ADDRESS:287 Webster Woods Lane ,No.Andover,MA. 01845
PHONE:978-682-5679 MOBILE PHONE:508-5234279 EMAIL:
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 P
r ourPlus materials.
STOMER 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:$6,195.00
PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE:
$2,065.00 (33%OF TOTAL SALE PRICE UPON SIGNING CONTRACT)
$2,065 (33%OF TOTAL UPON COMMENCEMENT OF WORK)
$2,065 (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 hom�ggpp r an the NSWS representative,but in no event shall exceed 10%of the contract price for the items)which is
the subject of the defeci�" ustpmer 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'
IJSTOMER SIGNATURE NSWS SIGNATURE
Page 3 of 4
DATE: DATE:
The following acts or occurrences shall not constitute default on the part of North Shore Window Solutions LLC.(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 specked by law for that type of damage claim.
B. OWNER'S LIABILITY INSURANCE.Owners)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,inclu Jing interest of owner,NSWS,and subcontractors,against fire,vandalism, and
other perils ordinarily included in extended coverage.Losses ui ider such insurance will be adjusted with and made payable to owner,NSWS,
and subcontractors,against fire,vandalism,and other perils or inarily included in extended coverage.Losses under such insurance will be
adjusted with and made payable to owner as trustee for the par Jes insured as their interests appear.Upon request,owner shall file a copy of
all such policies with NSWS within a reasonable time after con truction begins herein.
D. WAIVER OF WORK SITE DAMAGE CLAIM TO EXTENT OF I NISURANCE COVERAGE.Owner and NSWS hereby waive all claims against
each other for fire damage or damages from other perils coverE d 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+ndthout 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
No Andover,MA
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 MUTUALLYAGREE 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 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.
NSWS: DATE:
r^
CUSTOMER: DATE:
NOTICE:THE SIGNATURES OF THE PART BOVE APPLY 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 HIMIHERSELF 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).
HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
Commonwealth o Massachusetts
The .f
Department of Industrial Accidents
n - r X Congress Street,Suite 100
Boston,MA 02114-2017
.` www mass.gov/dia
ie�M SJ�v`
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plum ers.
TO BE FILED WITH THE PERMITTING AUTHORITY. please Print Le 'bl
A ` licant Information
Name(Business/Organization/Individual):
Address: �� �. 1•�a�n � �1�l��n m� ('�1��
Phone#: "-UZ
City/State/Zip:
T p p Type of project(required):
Are yo an employer.Check thea ro riate box:
em to ees full and/or part-time).* 7. ❑New'd6nstruotion
1• am a employer with — P Y
2.F1 I am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling
any capacity.[No workers'comp.insurance required.] 9, ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 1 0❑Building addition
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
e sole 11.0 Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or ar
proprietors with no,employees. lz d Plumbing repairs or additions
5.❑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 j= Other W 1 d4O W'S
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 boat#1 must also fill out the section below showing their workers'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 state whether or not those entities,have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site
information. #loot,
Insurance Company Name: P4' 6VMS
``''11 Expiration Date ' }
Policy#or Self-ins.Lic.#: 1!" d� 0
City/State/Zip.
Job Site Address: V1
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under ta STOP WORK ORDER 25A is a criminal violation and a fine of up to$250.00 a
by a fine up to$1,500-00
and/or one-year imprisonment,as well as penalties in the form of
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do hereby certify un er the pains and penalties of perjury that the information provided a �v is true and,correct.
Date: Y� ,^[(`j S
Signature-
Phone
i afore: ��
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.Plumbing Inspector
6.Other
Phone#:
Contact Person:
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 defied 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
Pleasb 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 certificates)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 bein1 requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you*' e 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.
f
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
thai 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-NUSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
i
ACORD, CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDIYYYY)05/12/2015
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 uUNTA T NAME: Patricia Tedesco
FAX
Burns, Brooks & McNeil A/cC,No,Ext: 860.482.5591 (A/C,No):860.496.9713
www.burnsbrooksmcneil .com ADDRIESS: ptedesco@burnsbrooksmcneil.com
69 Water Street P.O. BOX 717 INSURER(S)AFFORDING COVERAGE NAIC#
Torrington, CT 06790 INSURER A: National Grange Mutual 14788
INSURED North Shore Window Solutions, LLC INSURER B: National Grange Mutual 14788
239 South Main Street INSURER C:
Middleton, MA 01949 INSURER D:
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 15-16 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.
rA
POLICY E F L CY P
TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMBS
GENERAL LIABILITY BPT6857 05/15/2015 05/15/2016 EACH OCCURRENCE $ 1,000,000
I I K11 LU
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 500,000
CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 10,000
X - PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY X PROJECT LOC S
AUTOMOBILE LIABILITY M2T6857 05/15/2015 05/15/2016
(Ea accident) '$ 1,000,000
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED
B BODILY INJURY(Per accident) $
AUTOS X AUTOS
NON-OWNED Y AMA $
HIRED AUTOS AUTOS (Per accident)
$
X UMBRELLA LIAB X OCCUR CUT6857 05/15/2015 05/15/2016 EACHOCCURRENCE $ 2,000,00
B EXCESS LIAB CLAIMS-MADE AGGREGATE S 2,000,000
DED - X I RETENTIONS 10,000 S
WORKERS COMPENSATION WCT6857 05/15/2015 05/15/2016 X WC STATTS O R
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVi� E.L.EACH ACCIDENT S 500,000
A OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
E: Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
To Whom It May Concern Patricia Tedesco, CIC
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
JD
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 172585
Type: LLC
Expiration: 7/10/2016 Tr# 253325
NORTH SHORE WINDOW SOLUTIONS-LL
BRIAN CONSOLAZIO
239 SOUTH MAIN ST
MIDDELTON, MA 01949
Update Address and return card.Mark reason for change.
SCA t 0 20M-05/11 Address Renewal Employment E] Lost Card
CERTIFIED INSTALLER = t t Massachusetts -Department of Public Safety
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LEVEL: RLC-1b of Building San d Sta;,darus
a lam.,Urva tic'orl JU�JCI�IJUI
INSTALicense: CS-091857
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DENNIS E LASSEEF.
_ 571 West Street a' =
Leominster MA 6145
#700005821 Expires: 09/01/16
Lassell Sr., Dennis E. sponsored e2/
571 West Street Architectural Testing,Inc. J.�w.+ =xpiraiion
Leominster,Massachusetts 01453 Commissioner .11/02/2016 i
MARVIN `M�AS1SACI'�USETTS
INSTATI _ _
DESIGN GALLERY //�r�i'" s DRIVER'
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a complete window and door showroom 4�
by NSWS �aeaao .4a NUMa�t Rn. .
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Dennis Lassell
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239 South Main Street Middleton,MA 01949 �' L €
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978 762 0007 Mobile 978 914 3902 8 571 WEST ST
Dennis@nswsiormarvin.com r LEOMINSTER,MA 01453
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