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HomeMy WebLinkAboutBuilding Permit #464-13 - 37 GLENNCREST DRIVE 12/11/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0:�� Date Received Date Issued: I� ��� IMPORTANT: Applicant must complete all items on this page LOCATI 04 Ck (- 8 Print ` PROPERTYOWNER Print 100 Year Old Structure yes no MAP NO: Iby C PARCEL.005( ZONINGDISTRICT: Historic District yes no Machine Shop Villaqe yes no TYPE OF IMPROVEMENT PROPOSED USE Reside I Non- Residential ❑ New Building F4,ne family El Addition El Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WOKK I U bt-- t LKI-urcnntU: Identif,k�c^^atio Please Type orZint Cl artOWNER: Name: SySam ` CLL \e�'o5 `� ���� o-\<�e" Phone: 9�-1-N M-T`{�� Address: CONTRACTOR Name: &'� son Phone:.5P?- S\- a0s)560 Address: Supervisor's Construction License: Exp. Date: Home Improvement License: I 9 D Exp. Date: f5 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: $ �"'A 20"S (,)c> FEE: $ 1 -:� ?", oD ,. Check No.: 0 S Receipt No.: 2(, NOTE: Persons contracting with unregistered contractors do not have acce s t the guara ty and Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stam d Plans ❑ Locational=Tl�nNo. Date '� �-- Check .-1� a 26032 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee c 7� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector 7796 Date."?///& ...... r.�, � �., TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I This certifies that ..:V ..l ... S.1`¢ /.!'`. ��`� has permission for gas installation in the buildings of 4...C.1. 14- P ....................... at 15 ... 0/ ...... No Andoyr, ass. Lic. No..xv.3.(q. Fee. .... GASAPECTOR Check# /0& 9 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 PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE APPROVED Reviewed on Signature Reviewed on Signature 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 Tone Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'U4 Main Street Fire Department signature/date COMMENTS - 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 ® Notified for pickup - Date Doe.Building Permit Revised 2010 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 subm`sged with the building application Doc: Doc.Building permit Revised 2012 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: '14 0, %414-4 fr MA. Date: / / Permit# Building Location:_3 ( G ` a�C iC Owners Name: wl 4 c+ a t'(,C O Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [3— New: ❑ - Alteration: ❑ Renovation: ❑ Replacement: [- Plans Submitted: Yes ❑ No ❑ NCd Of LU Uj Z w U v= IX a w m= LU m co 1-- �O O z m 0 Z W O U X 0 w �-a. 2 M N w w p� R O OIY W W I— Q l— > Z W U w Lu m Z = f0 W w � 0 LU X = LLL Z W } Z O w co J F- F- O Z J O LL H= W Fw- w W U O O I=i 0 O Z=� O o0,. �� F>>> O SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR --S'FLOOR 4 1H FLOOR sni FLOOR 6 FLOOR 7 1H FLOOR 8 FLOOR Installing Company Name: 2- .� i / �/y'/.Q�r.1,y. 1 �.F—� Check One Only Certificate # Address: 190 4302L L% ,� City/Town:---l-1 . /9'�f �`�tete: �_� [corporation Business Tel: q T 8-(O � (� Z-7,0 Fax: $f¢vtt El Partnership Name of Licensed Plumber/Gas Fitter: E .-2 Q .� � � ❑Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes (LrIo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy D� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner 1:1 Agent By checking this box❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plum"Code,.pnd Chapter 142 of the General Laws. p of License: By TyPlumber Title E❑� Gd�s Fitter ISMaster ❑Journeyman ❑ LP Installer City/Town Si nature of LicensA Plumber/Gas Fitter License Number: 3 (� y /: 906U11 Date.'l �'< �•ti TOWN OF NORTH ANDOVER MOM PERMIT FOR PLUMBING This certifies that .. . PSS e. V I....�—''. YY�.�. J !!1 .............. d has permission to perform ............. ,plumbing in the buildings of CScr........ at ..3�...C.le,,\.C_.Lj.e �C.. �.� ..........., North An doass. Fee 7 .d0 . Lie. No.. 3��.�. "& "�'..�..-.. - PLUMBING INSPECTOR Check # L MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING g City/Town:Al X8ouF� MA. Date: x-12-�► Permit# Building Location: ) i Cs 1,a jCa.c a - �n , Owners Name: �ja4, j Ni: c��n t o s Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential M New: ❑ Alteration: ❑ Renovation: ® Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES L DEDICATED H z Z SYSTEMS w Y O Wz En LnN z d W Z F- YQ J U N ❑ Ln LU In W L7 Q Z y Z Q QLn O m 5 H H w Q h Y ❑ LL Q ❑ Q Z Lr C) a' Z y C Z 0 d 1- N N W F U d X ¢ ~ Q Q � 2 3 O � � _ ❑ H ❑ w in � � Z W U }. = C ❑ F,. U Z Q LL 3 Q 2 C) rt tY " _ W W R' 41 o W Q Q O > > O O Z Ln Q m m o o LL xo g g °� z° Q R a y 3 F- F S Ln w a a ❑ Ln W Q h 3 3 SUB BSMT. 0 ¢ 3 BASEMENT 1sT FLOOR 2"D FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR Installing Company Name: r1 `u=+-"` L ��- Check One Only Certificate # Address: 4 r°L����J� City/Town: tie_w� y State: ^'' `"1 ElCorporation BusinessTel:- �O�-`i� y� �� S'� El Partnership Fax: n Name of Licensed Plumber: ' o wall C cin-. i� ElFirm/Company INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes XNo ❑ If you have checked Yes, please indicate the .type of coverage by checking theappropriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only 3i nature of Owner or Owner's Agent Owner ❑ Agent ❑ hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Ely- �� Type of License: Title Plumber City/Town Master APPROVED (OFFICE USE ONLY) 19lourneyman Signature of Licensed Plumber License Number: 23(2-e L I COMMONWEALTH OF mASSACHUSETTS LICENSED AS A JOURNEYMAN PLUMBER t ISSUES THE ABOVE LICENSE TO: RUSSELL L SMITH s 28 FORTUNE LANE' ..NEWBURY NH MA 03255-5531 23128 05/01/12 7977 Rl 00 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MM 02111 yY www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Dn1lCRnt Tnfnrmaf;nn Name (Business/Organization/Individual): ( 11 Address: City/State/Zip: N �= w ,, N ti O — Phone #: Q,63- qP(4) 5%j - Are you an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their —1- ' Type of project (required): 6. ❑ New construction 7. (Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Itereb rtify under the pains and penalties ofperjury that the information provided above is true and correct. Si natur : 1 -jitcuu use only. Do not write in this area, to be completed by city or town official. City or Town: Perm it/T.iePnep fE issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 00 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy.; please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The COITU Aonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ;�Mo - W �o -- C O -O � LL -C : CC O � C LL OO0 W y Z Z co J d V1 f0 C LL cc W a N Z Q U W t � W W f9 C LL oc Q H U a Z _ J W LL O cc mC N Y \ O LL N >. L U O- .N O U d z c7 Z D J m C O -O � LL -C : CC a C E U � C LL OO0 W y Z Z co J d L to 7 w f0 C LL cc W a N Z Q U W t � W v V � N f9 C LL oc Q H U a Z _ -C 7 d' M C LL Z LU °c a C ui E5 LL L N � m Z N i N N -N O (n is .L .ti Ci v v O O d O ♦0 . U W _ a ia+= : co Z da � o o - N V J d � Cl) E o = i— ' c v Z OCFI) c�L NCD:C J • A �/ i m Z N d d d w N W N Lim > ~ cn . off° _ a xA- N 0 LLIZ '� o oa)Nz 0 O d 5~N M _ W W.- c > c � W J 2 F- -0 CL Z : 0 _ E- = L RS .O CL CD N cc d V m - d V— O O . d cQ N = r+ O 0 . 0 O O C L Q = .o 1 O L = O .r+ Q. 0-0 > is .L .ti Ci v v O RenewalMA Home Improvement Contractor MEMO License #170810 (Expires 12/23/2013) byAndersen. Federal Tax ID #41-1918413 WINDOW REPLACEMENT anAnd,rsenC..pany Renewal by Andersen Corporation 104 Otis St., Northborough, MA 01532 (508) 351-2200 • Fax: (651) 351-4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s) Name A' Date of Agreement 11--12 (2 Buyer(s) Street Address, City, State, and Zip Code .// A '/ yn 7 G �-CK cr epi ��iT�? h`�[Gt��t z/t 0 f E -Mail Address Nerve Telephone Number ^� Work Telephone Number a� a� iro cOacGo - �7l1-'179-/ 0t 1 7&( - 55-3 T1 ^5�2 It Ll Buyer(s) hereby jointly and severally agrees to pur`CI`ia'se the products and/or services of Renewal by Andersen Corporation ("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. ( v Total Job Amount: (t�2 Amount Financed Deposit Received (33%): 7 3 6 c/ Estimated Starting Date: /2 t✓�6%1 Method of Payment: ❑Check ❑Cash QVisa/MC ❑Discover Date of Transaction i i - 1.2 -12- . You may cancel Balance at Start of Job (33%): 0 Balance on Substantial Completion of Job (33%): Completion Date: / — 2 Lie', -nanced OAMEXEstimated If credit card is selected, please see Credit Card Payment Form. the above date. If you cancel, any 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 Andersen Cori ation By: Signature of Product Manager Print Name of Product Manager Buyer(s) Buyer(s) v3�062,y) 0, - 14" Z�& Signature Signature Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THETHIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF TINS RIGHT. �-c - - - - - - - - - - - - - - —g.c- - - - -- - -- NOTICE OF CANCELLATION X - - - - - - -�c— - - - - - - - - - - - - - - NOTICE OF CANCELLATION Date of Transaction //- / 2 - / 7- You may cancel I Date of Transaction i i - 1.2 -12- . You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If 1 this transaction, without any penalty or obligation, within three business days from you cancel, any the above date. If you cancel, any property traded in, any payments made by you under the 1 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 instrument executed by you will be returned within 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'l of your cancellation notice, and any security interest arising out of the transaction will 1 be canceled. If you cancel, you must make available to theI and any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at your residence, in substantially as good condition Seller at your residence, in substantially as good condition as when received, any goods delivered to you under I as when received, any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply 1 with the instructions of the Seller regarding the return Contract or Sale; or you may, if You wish, comply with the instructions Seller shipment of the goods at the Seller's expense and risk. I of the regarding the return shipment of 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 I Seller does not pick them up within 20 days of the date I Notice of Cancellation, may retain or dispose the goods available to the Seller and the Seller does not pick them u.p within 20 days of the date ofYour Notice Cancellation, Zyour you I the goods without any further obligation. If you fail to make the available to the Seller, if 1 of you may retain or dispose of the goods without any further obligation. If you fail to make the goods or ou agree to return the goods to the Seller and fail to do so, then 1 you remain liable for of all I goods available to the Seller, or if you agree to return the cods to the Seller and fail to do so, then you remain liable for performance obligations under the Contract. To cancel this transaction, deliver performance of all obligations under the Contract. mail or a I signed and dated copy of this cancellation notice or any I other written notice, or send a telegram to Contractor. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written I Renewal by Andersen Corporation, 104 Otis 1 notice, or send a telegram to Contractor. Renewal by Andersen Corporation, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough, MA 01532, BY NOT LATER THAN MIDNIGHT MIDNIGHT OF /I- / r -e 2- , (Date) OF t f - r / , (Date) 1 HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Date 1 RbA Copy - White Buyer Copy Buyer's Signature Print Name Date - Yellow Buyer Copy - Pink ©J8LLP2009.RBA-Ph.MANH Renewal byAndersen. WINDOW REPLACEMENT an Andersen Company -newal by Andersen Corporath 104 Otis St., Northborough, MA 01532 (508) 351-2200 • Fax: (651) 351-4810 WINDOW SPECIFICATION SHEET MA Home Improvement Contractor License #170810 (Expires 12/23/2013) Federal Tax ID #41-1918413 Buyer(s) Name Date of Agreement W 1(— (2— /2 The Buyers) 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. WIlVDOW DEMOS 1. Contractor will Install a total of _(,_ windows in Owner's home, using the following individual quantities: =J Double Hung (DB) Equal sash _ Cottage sash (1/3 top, 2/3 bottom) _ Oriel sash (2/3 top. 1/3 bottom) _ Flat sill are toGasoaws) Casement (CS) _ Hinge right _ Hinge left (as viewed from exterior) Double Casement (CD) %Z 2 Lite Gliding Window (GW) Casement / Picture / Casement (CT) _ 1:1:1 or _ 1:2:1 Glider / Picture / Glider (GPM _ 1:1:1 or -1:2:1 Picture Window Bay or Bow Awning Window _ # Lights Soffit / Roof Shingle / Copper Specialty Window Patio Doors (See Separate door spec sheet) Seat to be Primed / Oak / Pine 2.--'>-- Qty of Windows to be Custom Fit Replacement: 3. Qty of Windows to be Custom Fit Full frame (INCLUDES NEW INTERIOR & EXTERIOR CASINGS) Exterior casings: _ Pine _ Maintenance -free material _ Factory applied 908 Fibrex brickmold 4. Glazing to be: _ HP Low- E-4 T^+ _ Tempered _ Other If other, please specify: S'nro.-#4 Sk — 5. Exterior color to be: White _ Sand _ Canvas _ Terratone _ Cocoa Bean _ Dark Bronze _ Forest Green _ Black 6. Interior color to be: _v' -White _ Sand _ Canvas _ Pine _ Maple _ Oak _ Same as Exterior Note: Wood interiors need to finished by Owner. 7. Hardware: —`White _ Stone _ Canvas _ Estate Hardware: Style: 8. 0;�, Install Lifts with Double Hung Windows 9. Screens: windows to have: _Half or -"'FulI screens Screens to be: _Fiberglass _Aluminum✓ruScene GRIUZ DETAILS 10. � Windows have grilles: _ Grille Between Glass (GBG) _ Removable Interior Wood (INTW) _ Full Divided Light (FDL) (4).A) Owner approved (initials) Draw grille patterns below 'Use additional sheet if needed Qty Qty: Qtv: Otv: Otv: Otv. (lry ADDITIONAL. WORK DEMOS 11. �1/e Qty of —Sills _ Sill noses to be replaced by Contractor 12. Gi/o Contractor will remove metal frames of windows. 13. N✓o Contractor will install new _ paint -ready or _ stain -ready _ Interior _ Exterior casings in _ Pine _ Maintenance -free material 14. ffl� Contractor will install new _ paint -ready or _ stain -ready _ Interior _ Exterior stops in — Pine _ Maintenance -free material 15. ( ) Inds Owner is aware that Contractor does not do any painting. 16. Contractor will wrap exterior casings with coil stock ofcolor. Note: Wrapping may be required with storm window removal; removal of storm windows will leave screw holes in casing. 17. �PS Contractor will insulate, caulk and seal windows with 3 -Point system to prevent water and air infiltration. Removal and disposal of all job related debris, windows, storm windows and vacuum nightly included. Upon completion of the job and payment in full, a limited warranty shall be issued. 18. Ef 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. Ck #5-3 3 $ 1 eo 19. Yes ❑ No All discounts have been applied to this agreement price. 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/finance form(s). 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 by Andersen rporation By: �4 Signature of Product Manager .All k4 // T� Print Name oir Product Manager Bu er(s) Signatu e Print N. ne Buyer(s) _✓' , / 4;a4t- Signature Print Name The CatlW=Weaith Of kfas=hOCM J)epart�rcertt .of rniuslrid Accidenia Office of brveslig460?is 6#0 Washington Street' Boston; h A 0111 www.mass g -o Ilia WorkersCompensation Irswance AfB&Pitt: B¢�dersiContraeiorr.Mectricians/riumbers Avt�licant �aferma4ian Please Print -Le ib Name (Sncia�s/org�i�adlndividaell:_ Are you an employer.? Check the apprupdah'bar 1 '�, I am a employs with C5 4. ❑ I am a gcneeal contlacbr grid I -3 T- emPloYees (full and/orpert-hone),* bave hued the smb-contractors t 2, ❑ I am a sole propaietnr arpartnet- listed on the attached sheet ship and have DO eanplDyoes These snb-coo�isctnt� have . w•ark;ng far me in ffiY. Capacity, . ''�� �. msuraace, 5. ❑ We en a carporati:am and its [No�, comp �� ] of&ceas have =ercised thea . ri& of cspticm Per MQ. 3 ❑ I am a homeowms doing all work , [No work=' .=MP, c. 1:51, 11(4), end we have no insurance necluirnd.] t MF1oYM [No wads' camp. mans=e iogairt .) �9,p(-6 Type of project (re rdr ed): fi. ❑ New comstrnetion 7.. MLerwatan8 �, ❑ Danolitiom . . 9. ❑ Bnricifag addition 10.[]MWtacal=pain or adAsans 11.❑ Pium}xisg n pwn aQ additions 12.❑ Roof repairs L3.❑ Otia 'Amy aRfiant that dwcl5 box #1 meas ileo fm cot the cW6= below awowi qg the warms' WMP=Mfi= PofieYink=56oa• f Ha�ea�enra who cohmic tlzis af5davlt isu3irarhoe they els damg alt wast: and then hex ass�idc oo�setaa mmol aalmmil ►nese effidavk isi��g eoeb. ;C ' dW rh=L- this box =m= attsohed as ad"aoel iii showing the name of the'mb�and then wMiar' =* txoiiey ixdarmerioa. I on as M piv 97 $sad providi�rg tvorl�W eoMpOWM iax ursarance . for my =ploy= Below is &e poFry and job si& •Innnxrzren�ian. � -� C� • K Z t)�� � c � �1 5 � a - Compsny Name:_ 0 3oib Adaro,;s• 3 2- GA a# .Attach a copy of the worke=' carnpenssiiiDn policy dnckmf o page (ahaw*g the policy number =d exPkItion 'lite).. per-lare'ta Pea= coverage• as required mndm $ostium 25A ofMGL c. 152 can Iead to the imposition of cr4-asal Penalties of a fine -up to ;1,500.00 mxVcxr one-year kvrisoa z en as wolf as civz7paaalties in the foam of a SM? WORK ORDER and a fine of up to 5250.00 a tday against the v10IR6L Be advised -that a copy a -this statcmeuf map -be fimvaFded m the Office of kv=ftgitbm of the DIA for msoQance coverage vraificetiam .I de b7':1fL7,e p of Pe►To7' that the ircforzr on prv►►idrd above is t ut acrd cot�cct �►,�„� ���v 3s D, sial res� only. Do rot write ire fiiirz-er, to -be eompWad by C4 or IPM,a, fjirriaL . {ally ar Tow �g A1�hority•(cErr3e.one): L Boars} of Rmia I.. S'mirimg Department I Oty/Tavrn C IWk 4; Mctxiical Iaspedw 5. Piping -'bTbd w 6. •(?fir. - .. • -Contact'PIMM= I°hone # � � - • L; .4coR� CERTIFICATE OF LIABILITY INSURANCE DATE WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS 25/ 01D12YYY) 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(les) 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 1-612-333-3323 Hays Cavanies 80 South 8th Street Suite 700 Minneapolis, MN 55402 NOEA Jonelle Hargrove or Eric Johnson PHONE 612-333-3323 tFAAIXCNo): 612-373-7270 BAWL AD S` PRODucER CUSTOMER ID fe INSU S AFFORDING COVERAGE NAIC 4 INSURER A: OLD REPUBLIC INS CO 24147 INSURED Renewal By Andersen Corporation 104 Otis Street INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 INSURER C: INSURER D: Northborough, NA 01532 INSURER E: NSURER F : NWrB 21700 C15VERAGES CERTIFICATE MIIMRFQ• 24220A36 n�.�awn nvmooi�: 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. INSLTR TYPE OF INSURANCE J= WVD DL SUB POLICY NUMBER PDI EFF M DO EXP LIMITS A GENERAL LIABILITY MWZY 59828 10/01/1 10/01/13EACH OCCURRENCE $ 1,000,000 X — COMMERCIAL GENERAL LIABILITY DAMA TO RENTED PREMISES(Es occurrenoel E 500,000 CLAIMS -MADE OCCUR MED EXP (Any one person)" E 10,000 PERSONAL t: ADV INJURY $ 1,000,000 GENERAL AGGREGATE f 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG = 3,000,000 X POLICY JFCTPRO- LOC $ A AUTOMOBILE LIABILITY NWrB 21700 10 0-3-112-1-0 70-17 13 COMBINED SINGLE LIMIT X ANYAUTO (Essodderd) E 3,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per aodderd) $ SCHEDULED AUTOS PROPERTY DAMAGE 6 $ X HIRED AUTOS (Per eoddent) X NON -OWNED AUTOS i 8 X UMBRELLA LIAR X OCCUR 13273355 10/01/1 10/01/13 EACH OCCURRENCE $ 25, 000, 000_ EXCESS LIAR CLAIMS -MADE AGGREGATE $ 25, 000, 000 DEDUCTIBLE X RETENTION $ 2S,000 S A WORKERS COMPENSATION AND EMPLOYERS, LIABILITY MNC 117948 00 10/01/1 10/01/13 S X WCSTATU OTH- YIN ANY PROPRIETORIPARTNERIEXECUTIVE -- OFFICERIMEMBER EXCLUDED? N NIA E.L. EACH ACCIDENT $ 2,000,000 (Mandatory In NH) E.L. DISEASE -EA EMPLOYE $ 1,000,000 K s, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Atlaeh ACORD 101. Additlemi RMnaek. Seh.dul. of ........ ___ ,_ �_..�. Evidence of Insurance. Evidence of Insurance ericj SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. wwrnwm=u NEPRESENTATNE fc1 1IIRR.9nne ernen r_nponoArrnu wn .:_�._ �_____ _. 1 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -095707- BRIAN D DENNISbN 7 LAMBS POND CIRC & Charlton MA 01507 Expiration Commissioner 09/08/2014 �%e Tjr oryinovuuea�% o�,/�aaaaciu�aelt"a Office of Consumer Affairs & B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration: ,.:170810 Type: Expiration: 12/23/2013 Corporation i.;`_ a.. R WAL BY ANDERSEN CORPORATION BRIAN DENNISON �` L, 104 OTIS ST. NORTHBOROUGH, MA 01532 Undersecretary BMT PI C; x ?Wood" wafteaft 446a mew DESIGN PRMISURE VIF) * UUMSeKANSUMMO tm ' " , � n6.3n 1/- ft••.nw ,� p ®� Drra�irdlpd�h - WwdAFFrT c -4 SRTrn U -Facer Sour H� Cain C)CefflC}eftt 65 npr� ►QumMff �atvc� e'er • . ' , - Visible Tlansm�� - , . 0 A3. m-ar endmm� qmltl-- 1 x a An 9fsEh RbA.UDdn •WV7do11P N IrA� umwc DP fEf VI am i as Do nd n mwe nib ftG� node inspra6ob Save label f� i►nr� ' �h rn SPAS �' � tui • • � .. ', U 'i'- �' U.S./�1. �• �,��- �r • Renewal • ' Aim -1-37 •� - F*M 'EF•mtdt- , VMyMccd Compmb MSIR l' n on {�w-�4 srriarfSti 5Dual Pyp �ictWe - W Product T : ENERGi PELF !cE RATING U -Factor . sour'H4 GWn Coemcle`rt 0.27 i.s3 0x22 , AAA -pi %W feta mom m " �aorrm moM A[x�rTIoNAI PERFORMANCE RATINM msible Ttansmidanu'e �' .• '.'•-,� '� : '• � '(� q� ,'• •rte' •• • • � �.mV.�r��'makm°�'¢qd+°e�`Wi�epoeem.cWa�r�dn►""dEpma"` . 1}�c ue amomiaa IQa µq�ams • � rc P► ow t" 4 � uw rou eaaos DP•psf F-=dMon - t • • aovlawmiuu:emtim+ . � • .. .. .. 1 1o�-Qo51loo6-aoi . • . ►rte or F. �r,, k1E= eaoon tegwmuic y�µUioown H01476` • - �. ' - .. �� '. .•. .. � ; -' '• - .' •': .. .. �� _ rte• ,