HomeMy WebLinkAboutBuilding Permit #415-11 - 34 OLD VILLAGE LANE 11/15/2011 Fil
BUILDING PERMIT 0 "oE
�`? �'E a oc
TOWN OF NORTH ANDOVER F i
APPLICATION FOR PLAN EXAMINATION
4 P-0
Permit NO: Date Received �yssgcHus0,
Date Issued:
IMPORTANT:Applicant must complete all items on this page
ANSI
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TYPE OF IMPROVEMENT PROPOSED USE
Y- Residential Non- Residential
❑ New Building One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: Q Commercial
A Repair, replacement ❑ Assessory Bldg 1� Others:
❑ Demolition ❑ Other
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4 x f
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DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please TT�Ae-
rint Clearly)
OWNER: Name 6� �-� Phone:
Address: G(� (J� 11 -Z.- �''c� ct.
1 2,10
rw
t �ag' .x� `Ia�c" �.. `,rsrr i;�� -fxf .€ •�, Nam
20,
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ .9 L , C/'Sr(, -vv FEE: $ 1 2 3
Check No.: <<a(le) Receipt No.: 9 3 (.-15
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signa#uce �f Ageflwnr � f �gnarewc� rcQr ..�
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. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/ Driveway Permit
Located at 384 Osgood Street
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PARKIN11117 TO. DLift" sit e
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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
I
❑ Notified for pickup - Date
_...........................__....._...._.._...._..............................
Doc.Building Permit Revised 2007
I
I
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
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)
❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
i
104 Otis St.,Northborough,MA 01532 —,T&L WINDOWS,INC.,D/B/A `,Home Improvement Contractor
(508)919-0900•Fax:(774)987-3013 AenewalLig- �e#149601 (Expires 1/24/2012)
byAndersen. I Federal Tax ID#83-0404201
WINDOW REPLACEMENT MAndrnrnC qm y
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date of Agreement
r r
Buyer(s)Street Address,City,State,and Zip Code
kor
E-Mail Address Home Tele hone Number Work Telephone Number
Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen
("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached
specification sheet(s) (collectively,this`Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
Total Job Amount: �0 Estimated Starting
Method of Pymnt:ID Cash D Check D Mastercard D VISA
Datg:
_ 1� ❑Discover jVinanced,App#:
Deposit Received t9-3%): t U—' ( [
Name on Credit Card:
Balance at Start of Job(33N): Estimated Completion Date:
p Credit Card#:
Balance on Substantial S
Completion of Job(33%): rCC Exp.Date: CC Security Code:
By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initials of Job cannot be made by credit card and must be made by personal check,bank check,or cash.
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that
there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation
from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor.Buyer(s) hereby
acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a
completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first
written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
J&L Windows,Inc.d/b a newal by Andersen Buyers) Buyers)
Signature of Product Manager Signature Signature
TGA-.- 1—i , Il,1-10-.1 -
Print Name of Product Manager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
— — — — — — — — — — — — — — —�<- — — — — — — — — — — — — — — -�<— — — — — — — — — — — — — — —X
NOTICE OF CANCELLATION X NOTICE OF CANCELLATION
Date of.Transaction 10—It—IQ You may cancel Date of Transaction f()—U- Le . You may cancel
this transaction,without any pena ty or obligation,within I this transaction,without any penalty or obligation,within
three business days from the above date.If you cancel;any three business days from the above date.If you cancel,any
property traded in,any payments made by you under the property traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed i Contract of Sale,and any negotiable instniment executed
by you will be returned wi in 10 days following receipt I by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice,
and any security interest arising out of the transaction will I and any security interest arising out of the transaction will
be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the
Seller at your residence,in substantially as good condition I Seller at your residence,in substantially as good condition
as when received, any goods delivered to you under as when received,any goods delivered to you under this
this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if You wish,comply with the
with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of
shipment of the goods at the Seller's expense and risk. i the goods at the Seller's expense and risk.If you do make
If you do make the goods available to the Seller and the the goods available-to-the Seller and the Seller does not
Seller does not pick them up within 20 days of the date pick them up within 20 days of the date ofYour Notice
of your Notice of Cancellation,you may retain or dispose of Cancellation,you may retain or dispose of the goods
of the goods without any further obligation.If you fail to without any further obligation. If you fail to make the
make the goods available to the Seller, or ifou agree rd
s available to the Seller,or if you agree to return the
to return the goods to the Seller and fail to do so, then sto the Seller and fail to do so,then You remain liable
you remain liable for performance of all obligations under erformance of all obligations under the Contract.
the Contract.To cancel this transaction,mail or deliver a I To cancel this transaction, mail or deliver a signed and
signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written
other written notice,or send a telegram to Contractor.J I notice,or send a tollegram to Contractor.J&L Windows,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Chis Inc. d/b/a Renewal by Andersen, 104 Chis Street,
Street, Northborpugh MA 01532, BY NOT LATER THAN North ro h,MA 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OF- LU=�y_/0 ,(Date) OF — — O .(Date)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY WICEL THIS TRANSACTION.
Buyer's Signature Date I Buyer's Signature Date
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink
ORTH
T0VM of
, O over
O Yy w
o
over, Mass.,
O L LAKE /�,
�J COCHICHEWICK V
"IdADRATED P'P���C�
7S$ BOARD OF HEALTH
Food/Kitchen
PE.R IT T D
Septic System
BUILDING INSPECTOR
.........................
THIS CERTIFIES THAT.......... ... .!d CSR.... ............ Foundation
buildings on ...... . ......�� .... .. ..............�... Rough
has permission to erect... .........:.......... 9
� Chimney
.r ►� I.IV•l ............��...............
C 'mne
to be occupied as.�...�... ................ ......... ................. .................
provided that the person accepting this per it 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. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
z3 ELECTRICAL INSPECTOR
UNLESS CONSTRUC ST TS Rough
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
Street No.
Smoke Det.
SEE REVERSE SIDE
104 Otis Street,Northborough,MA 01532 J&L Windows,Inc.d/b/a
l�l.newai �\ HIC License#149601(expires 1/24/12)
Phone 508.919.0900•Fax 774.987.3013 Federal Tax ID# 83-0404201
byAndersen. -,,
WINDOW REPLACEMENT an Anda=Company
OF GREATER MAssActlOsePfs AND NEw HAA7 M11RE
WINDOW SPECIFICATION SHEET -
Buyer(s)Name Date of Agreement
'IbTe Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms
described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,
of which this Specification Sheet is a part.
WINDOW DETAILS
1. Contractor will Install a total of windows-in Owner's home,using the following individual quantities:
_Double Hung(DB) k Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom)
Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement(CDW) ❑ Standard handle ❑ Metro handle
Casement/Picture/Casement(CPM ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window(GW)
Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1
Awning Window(AW)
Picture Window(PW)
Bay or Bow Window
Patio Doors(see separate Door Specification Sheet)
2. XYes ❑ No Qty of Windows to be Custom Fit Replacement:
3. ❑ Yes,K No Qty of Sills to be replaced by Contractor:
4. [l Yes ❑ No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)
Exterior casings: ❑ Pine;K Maintenance-free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be: K HP Low-E®SmartSun m (Tax(2reditLkVhle) ❑ Other If other,please specify:
6. Exterior color to be: White Sand ❑ F-1F-1Canvas Terratone Cocoa Bean
7. Interior color to be: K E]White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak
Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner.
8. Hardware: CR White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style:
9. ❑ Yes g[No Install Lifts with Double Hun Windows
10. Screens: windows to have: E] Half or Full screens Screens to be:� Fiberglass F-1Aluminum ❑TruScene
GRILLE DETAILS
11.Windows have grilles:Z Yes ❑ No If yes:X Grille Between Glass(GBG)❑ Removable Interior Wood aNrwl❑ Full Divided Light(FoL)
Qtyl Qty: 2 Qty:A3 Qty: Qty- Qty: t Qty:
H DH H DH CW/PicWre Glide CPW or GPIA
Draw grille patterns above 'Use additional sheet if needed Owner approved(initials):( )
ADDITIONAL WORK DETAILS
12.❑ Yes K No Contractor will remove metal frames of windows. Qty of Units:
1319 Yes ❑ No Contractor willinstall new mt-ready or stain-ready casings.
Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine Maintenance-free material
14.ZL Yes ❑ No Contractor will install ne paint-ready or stain-ready inside or outsiA stops qty of openings:
Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material
15. Owner is aware that Contractor does not do any painting. ( 1 Owner Initials
16.❑ Yes Z-No Contractor will wrap exterior casings with aluminum coil stock of color.
Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17.2(Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
18. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19. Yes ❑ No Building Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not
included in the Contract Price and a separate check is required at the time of We for this fee.
20. Additional job details:
21. -Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shall be demandcd until the contract is completed to the satisfaction of all parties.
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING
AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the
terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both
the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet.
Rene of Greater MA and NH Buy s) Buyer(s)
By: -
' Signat=of Product Manager Signature Signature
Print Name of Product Manager Print Name Print Name
Tlie Commorveahli of hsassacliusetts
artment o Industrial Accidents
. Dep f
Office of Investigations
600 Wasldni n Street
Boston,MA 02111
w .mas�gav1dia
Workers' Compensation Inslrrance Affidavit:Buflders/Contractors/FIectricfam/Plumbers
Applicant Informatlan' Please.Print Led-1)
NaMe(Business/Organiz6onAzdividueI): J)en IJ G.ly N11 d el'"S e Y1
.Address:. g,
City/StedZig:,/V D f �i bo�a,_r 41 �� Phone
Are you an employer?Check the appropriate bozo Type of project (riquir•ed):
cnaral cantmctm end I
am a COnS doll
. 4. ❑'I g fi, Naw tzvc
. 1.�`I am a employer with V7 O contractors ❑
employees(faU'ma /or part-time).*' I'm birod the sub- 7ti deliag
2.❑I am a sole proprietor or partner- ,listed on line attacbod sheet t
end have no to . mt.sub-contractors have 8. Domoliti oa
• '
ship �P �
es
working for mq.ia eay capacity. wars comp.insozanoe. g, E]Budding addition
No wo±='comp:fim.maoe 5. ❑ Weare a corporation cad its 10.(]Blectdcal repairs or additions•
reed.] , officers bavo exercised their.
of ez
tion a M
GL
11. ?.I robing repairs or additions
3; I am a homeowner dela ell work •� � P
❑ g
myself[Ne�►orkzrs' comp: c.152,j1(4),cad we have no 12.0 Roof repairs
Insurance required.]t employees.•[No worlorra'
13.[]Other .'
cam,inaarance regn mcL]
'Azky nppIicamt that checlz hoz#1=mt also fm Ont die secdoa belox d owing•tbeir woxb=l compensation p6liey;niarmatioa.
t Hommm=who sdbmit this aiizdavit indteatmg they arc doiaE zDwo�and thm hm outside coatractms mmt submit a neo sM;6 yon indi�a rm such .
on>znclott tbnE check d�u box must attached as additional sheet sbca die name df the sib-coatr=Wa and thds warless'comp policy infenaaadoa
I am an employer that is prv4ding rarkera'eampemoon iasrcrarece far my employees Belaw.ia.the paficy rued jab ante
' inforneation, .
Insurance company Name,
Policy#or Self-ins;Lit.#: Expiration Data .
Sob Site Adtirtrss I:� �.(A�— c1 y/Statr,IZtp: d1�0 ,L�
Attach a copy of the workers'compensatianpolicy de anon pave(showL g the policy number and a piratiaa date).
Failnm to secure coverage as required under Section 25%of MGL c.152 can lead to ibo imposition of criminal penalties of a
fine up'tn$1,500.00 and/or one-year imprisonment,Ip well as civil penalties in mo foan of a STOP WORK ORDER and a fine
-of W to 5250.00 a day against the violator. Be advised that a copy of tion statement may be forwarded to the Office of
Investigations of the DIA for imur me coverage VCdfl ati=
t do hereby c sr the pains and penalties crjury that tfee information provided above ' irue'and correct
Date: l
5ienetnre: 1
Phone#'
Official use only. Da not write in this area,to bee m L-ted by city or tmnx official
'. City or Town: Permii(License#
Is ,suing Authority(tircle one):
1.Beaof Health 2.Building Department 3,6ly/Town Clerk 4.Der-tried Inspector 5.Plambin;Inspector
m l
6,Other
Phone
Contact Person: #:
i
itilaasachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 85707
BRIAN DENNISON .
86 CREST CIRCLE i J- L
r WORCESTER, MA.016C3. -
Expiration: -QJW012
('nnuniniuner Tri: 2622
. .. . . ' _... _ �.- - �i a "�o�r�ano�uaea�s o�.�aedae�ur�e� •
omee or canmmer Affalim&13 en Ragdatlan
HOME IMPRO VfRENT CONTRACTOR
ati
• Registo01
Explra 12 .
Card
RENEWAL BY
BRIAN DENNIS _
104 OTIS S
NORTHBOROUGH, Undemecmtul
I
ACORDn CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY)
0211012010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC 9
INSURED Renewal by Andersen INSURER A: Hartford insurance Compan
J and L Windows, Inc. INSURER @: Nautilus
104 Otis St INSURER c:
Northborough,MA. 01532 INSURER D:
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.
INBR A13D'Lr-
INSRD TYPE OF JNRURANr POLICY EFFECTIVE POLICY EXPIRATION
LTFt POLICY NUMBER 11 DATELIMITS
B GENERAL LIABILITY NC95B461 10/0112010 10/01/2011 EACH OCCURRENCE 6 1,000,000
COMMERCIAL GENERAL LIABILITY A
PREMISES g=urencel 100,000
i CLAIMS MADE =OCCUR MED EXP(Any one person) i 5,000
PERSONAL BADV INJURY s 1,0D0 ,000
GENERALAGGREGATE 6 2 ODO 000
GBJ'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 6 2 000 DDDQ
POLICY 71 PROT F7 LOD
q AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE"LIMIT
ANY AUTO (Ea eccldenQ 6 1,000,000
Xi ALL OWNED AUTOS
BODILY INJURY 6,
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY. 6
NON-OWNED AUTOS (Per nccldenl)
i PROPERTY DAMAGE 6
(Per accident)
GARAGE.LIABILfTY •• I r AUTO ONLY-EA ACCIDENT 6
l ANY AUTO EA ACC 6
, OTHER THAN
AUTO ONLY: AGG 6
EXCESSIUMBRELL.A LIABIUTY EACH OCCURRENCE 6
OCCUR F7CLAIMS MADE AGGREGATE i
• 6
DEDUCTIBLE
s
i RETENTION 5 6
A EMPLOYERS'LIABILITY WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/201'1 TORY LI 1- OTH-
ANY PROPRIETORMARTNERIEXECUTWE E.L.EACH ACCIDENT 6 5DO 000
If YeL /MEIiABER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 6 500,000
If yes,deserlbe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 6 500 0 0
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PRDVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE.CERTIFICATE HOLDER NAMED TD THE LEFT,BUT FAILURE T'0 DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
• AUTHOR2ED REPRFSENT•ATTVE
ACORD 25(20D1/08) I ®ACORD CORPORATION 1988
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ENERGY PERFORMANCE E .NGS
j U=Factor(U.S)4-P Solar Heat Cain Coefficient.
IAa A0111
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ADDITIOMAL PERFORM-ANCE.UATIM83 -
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Menuhctunrstlpuklas that gm�nWps mnldnn to eppuuuk'1J'rAC pmeaduns tertlaiannWnp whole pteduel ,
!, patlomuw,NPRC'nsthips am d�iano lmd lora tlxad nl of envuotimanuil conditions and a epacla:product sum r
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do"not Mcommand anypmduel end docanot wellenl ths.suua6tllty cleny pmdua hrany'spa�uaa.
iConsultnunuhelunvrs Utinstun laroMar produet p'erbaneAci Inlotmolloo. }
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R NEWAL BY ANDERSEN MA tilt License#decal T (expires 1/24/10)
Rpnp,A'�' Federal Tax ID#83-0404201
1.1,1.VY �i�� ._
byAndersen.
WINDOW REPLACEMENT ..A�d—c— OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE
104 Otis Street•Northborough,MA 01532
Phone 508.919.0900•Fax 508.919.0903
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date of Agreement
Buyer(s)Street Address,City,State,and Zip Code
E-Mail Address HqMe Telephone Number Work Tele hone Number
Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater
Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this
agreement and on the attached specification sheet(s)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after
Contractor has completed all work under this Agreement.
Method of Pymnt:❑Cash ❑Check ❑Mastercard Ll VISA
Total Job Amount: Estima Start' g Date: p Discover Okinanced,App#:
Deposit Received(33%): Name on Credit Card:
Balance at Start of Job(33%): Estimated Completion DDattee: Credit Card#:
Balance on Substantial We C J
CC Exp.Date: CC Security Code:
Completion of Job(33%):—
By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initials of Job cannot be made by credit card and must be made by personal check,bank check,or cash.
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that
there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation
from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor.Buyer(s)hereby
acknowledges that Buyer(s) 1) has read this Agreement,understands the terms of this Agreement, and has received a
completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first
written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
Renewal by AndersenofGreater MA and NH Buyer(s) � Buyer(s)
/
Signature of Product Manager Signature Signature
�nd � �'uChBT/•
Print Name of Product Manager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
�<- — — — — — — — — — — — — — — -X- - - - 7 — — — — —
�
NOTICE OF ANC ELATION X NOTICE OF C NC [ TION
Date of Transaction 0 .You may cancel I Date of Transaction O .You may cancel
this transaction,without y pena ty or obligation,within I this transaction,without a y penalty or obligation,within
three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any
Etraded in,any payments made by you under the property traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any neSlotiable instrument executed
by you will be returned within 10 days following receipt 1 by you will be returned within 10 days following receipt
by the Seller of your cancellation notice,and any security I by the Seller of your cancellation notice,and any security
interest arising out of.the transaction will be canceled. I interest arising out of the transaction will be canceled.
If you cancel, you must make available to the Seller at 1 If you cancel, you must make available to the Seller at
dence, in substantially as good condition as
your residence, in substantially as good condition as your rest
when received, any goods delivered to you under this 1 when received, any goods delivered to you under this
Contract or Sale;or you may,if you wish,comply with the I Contract or Sale;or you may,if you wish,comply with the
instructionssof the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of
the goods at the Seller's expense and risk.If you do make I the goods at the Seller's expense and risk.If You do make
the goods available to the Seller and the Seller does not I the goods available to the Seller and the Seller does not
pick them up within 20 days of the date of your Notice pick them up within 20 days of the date of your Notice
of Cancellation,you ma yy retain or dispose of the goods 1 of Cancellation,you may retain or dispose of the goods
without any further obligation. If you fail to make the I without any further obligation. If you fail to make the
goods available to the Seller,or if you agree to return the I 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 goods to the Seller and fail to do so,then you remain liable
for performance of all obligations under the Contract. 1 for performance of all obligations under thb Contract.
To cancel this transaction, mail or deliver a signed and To cancel this transaction, mail or deliver a signed and
dated copy of this cancellation notice or any other written 1 dated copy of this cancellation notice or any other written
notice, or send a telegram to Renewal by Andersen I notice, or send a telegram to Renewal by Andersen
of Greater Massachv etts d New Hampshire, 104 1 of Greater Massachu etts nd New Hampshire, 104
Otis Street,North oro h 01532,NOT LATER THAN I Otis Street,North h, 01532,NOT LATER THAN
MIDNIGHT OF m 0 .(Date) MIDNIGHT OF .(Date)
I HEREBY CANCEL THh TRANSACTION. X 1 HEREBY CANCEL TH S TRANSACTION.
� I
Consumer's Signature Date I Consumer's Signature Date
RbA Copy- White Customer Copy-Yellow Customer Copy-Pink
MA HIC License#149601(expires 1/24/10)
Renewal . RENEWAL By ANDERSEN Federal Tax ID# 83-0404201
byAndersen. '-
wixoow REPL�CEMERi .�,Ua..kc��.ro OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE
104 Otis Street•Northborough,Massachusetts 01532
Phone 508.919.0900•Fax 508.919.0903
SPECIFICATION SHEEP
Buyers)Name Date of Agreement
0. f✓l�`T`fi
The.Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices
and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT of which this Specification Sheet is a part.
WINDOW DETAILS
1. Con actor will Install a total of.17 windows in Owner's home,using the following individual quantities:
Double Hung(DB) ;(Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom)
Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle❑Metro handle
Double Casement(CDW) ❑ Standard handle ❑ Metro handle
Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window(GW)
Glider/Picture/Glider(GPW) ❑ 1:1:1 or❑ 1:2:1
Awning Window(AW)
Picture Window(FW)
Bay or Bow Window
Patio Doors(see separate Door Specification Sheet)
2. PfYes ❑ No Qty of Windows to be Custom Fit Replacement: 1
3. ❑ Yes VfNo Qty of Sills to be replaced by Contractor:
4. ❑ Yes (_No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)
Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be: KHP Low-E®SmartSunTM (Tax OtaditLk9ble) ❑ Other If other,please specify:
6. Exterior color to be:XWhitc ❑ Sand ❑ Canvas ❑Terratone❑ Cocoa Bean
7. Interior color to be: White ❑ Sand ❑ Canvas ❑Terratone❑ Pine ❑ Maple❑ Oak
Note: Interior color cah only be white,wood or same color as exterior. Wood interiors need to finished by Owner.
8. Hardware:PTVvhite ❑ Stone ❑ Canvas ❑ Brass Double Hung:
9. ❑ Yes 9 No Install Lifts with Double Hung Windows
10. Screens: windows to have: ❑ Half or gull screens Screens to be:)<Fiberglass ❑ Aluminum ❑TruScene r
GRE LE DETAILS
11.Windows have grilles:XYes ❑ No If ye Grille Between Glass(GBG)❑ Removable Interior Wood ONTM❑ Full Divided Light voo
Qty: - Qty: Qty: Qty: Qty: Qty:— Qty:—
H[EE
DH I I J D 7DHCW/Picture Glider CPW or G
Draw grille patterns above 'Use additional sheet if needed Owner approved(initials):( )
ADDITIONAL WORK DEPAIIS
12.❑ Yes KNo Contractor will remove metal frames of windows. Qty of Units:
13.❑ yes 0 No Contractor will install new paint-ready or stain-ready casings.
E] Pine El Maintenance-free material
Inter'�r casing qty of openings: Exterior casings qty of openings:
14.El Yes KNo Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings:
Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material
15. Owner is aware that Contractor does not do any painting. ( 1 Owner Initials
16.❑ Yes fkNo Contractor will wrap exterior casings with aluminum coil stock of color.
No e: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17. Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
18. yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19. \Yes ❑ No Building Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not
included in the Contract Price and a separate check is required at the time of sale for this fee.
20. Additional job details:
21.A Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shall be demanded until the contract is completed to the satisfaction of all parries.
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or
modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are
in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this specification Sheet-
Renewal
heet.
Bnewal by Andersen o��rea er and N�Buyer�(S), �,,,,. Buyer(s)
lure of Product Manager Signature / slgnahm
/orn 1J I [. > _(Z ph
Print Name of Product Manager Print Name Print Name
RbA Copy- White Customer Copy-Yellow
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
I uv� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers'
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): J C' u) ' Ie_r3 e.
>7� a. V ,�l')r�i YI
.Address:— 104
ty p /V b 4)x,3 Phone#: � (I /��1�'o/oo
Ci /State/Zi pr o/a ,
Are you an employer?Check the appropriate box: Type of project (required):
LE-1 am a employer with J0 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet $ emodeling
ship and have no employees These sub-contractors have 8. Demolition
working forme in any capacity. workers' comp.insurance. 9• ❑Building addition
[No workers' comp.insurance 5. 0 We are a corporation and its
10.E]Electrical repairs or additions .
e 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'
13. Other
comp.insurance required.]
°A iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t ng such.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating
;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'coinpensadon insurance for my employees. Below.is the policy and job site
information. ^^nn j� )
Insurance Company Name: l,/C f)e-c n ,,— l f1 1�t4 K&I n C e
/
Policy#or.Self-ins.Li � zz�,o
Lia.#: �t� l����� i`�`f�_ Expiration Date:
Job Site Address: _ Vy City/State/Zip:AJ
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.
Ido hereby cer d}er the pains and penalties,nf perjury that the information provided above is tr a and correct
Simature: 11 Date: ��/�
Phone#
Official use only. Do not write in this area, to be completed by city or town official.
fJ Y
City or Town: Permit/License# •
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Towii Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other ,
Contact Person: Phone#:
glne'Cla"nul-a--1
R- : Board of BuildingRegnlstnns snd Standards
'Cuns�ricticnsupenso L;csn��•,,,,,,
j
�icer90-107 "
s:,a. CS .
t 3irthc /471962 i
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1t1 HilOn
BP,1ANENNISON,.,
e0 CFEST CIP,CL_
WORC=STc'r�.,'I�iA C 603-. Commissianer,
IJE1I11nL Y"N ERSON
aRlAN:.D=N 1ISON
104'O�:ES STtEET
C !H O SUCH, M 01532
D?S-CA7 ea COtu1�i/ui-?C0420
.amu. .-... •. .... ..... /t! d c%Fia
Board'ofBuiIdirgriz^bulaiionszrdStandards
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104 OTIS y '
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Locatio
No. Pq Date
MORT►, TOWN OF NORTH ANDOVER
3? i • O
' Certificate of Occupancy $
Its�CNUsE<�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 0ASS- ,
226
uilding Inspector