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HomeMy WebLinkAboutBuilding Permit #123-12 - 5 ANDREW CIRCLE 8/10/2011 NORTH BUILDING PERMIT of�t�Eo q1'o TOWN OF NORTH ANDOVER 00 APPLICATION FOR PLAN EXAMINATION Permit NO: 7.. Date Received SSACHUS� Date Iss IMPORTANT: Applicant must complete all items on this page LOCATION. Print PROPERTY OWNER 5��.9-uy ,�.cuL� " Print '" MAP NO PARCEL: ZONING DISTRICT: _ Historic Distractyes 17 Machine Shop Village , yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Cts-BrtL=family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial R-R pair, replacement ❑Assessory Bldg ❑ Others: 1 ❑ Demolition ❑ Other p Septic _11-W II ❑ Floodplain El Wetlands E! Wit ershed Qistrict Q'Water/Sewer i DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: 7S•7n/ • -746 Address: AN10Rj L_J Ccr,.,- CONTRACTOR Name-t u,i(� ,,,�� Is1 isJ�� l�lon�;alv1,Phone: q74&-U-5-7.v55_ Address: &(I Supervi$or's Construction License: D�fCI� _3 . _F- . Exp. Date: rHome Improvement License: ls3y�_? Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDINGK600 MIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$125.00 PER S.F. Total Project Cost: $ — FEE: $ Check No.: `7�"� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund R� Signature of,Agent/OwnerCo A Signature of contractor t.y .---. Location :5 6241"AlVJ No. 1,23 -1 Date 0-1o.' NORTH TOWN OF NORTH ANDOVER 0 �. • O! j Certificate of Occupancy $ Building/Frame Permit Fee $ .;, Hwu Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ Check #—) 24L.r65 Building Inspector 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/Sall ® V Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si nature A COMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: 91�ature: g Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located;at 124 Main Street `Fire`Department signature/date. COMMENTS i i 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.$10041000 fine NOTES and DATA— For department use 1 ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 I� ❑ 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 2.2008 AORTH Town of rAndover. ... . No. Q LAKE � dover, Mass.,— �+ COCHICHEWICK V Ids RATED 7 BOARD OF HEALTH PERM .IT T D Food/Kitchen Septic System YBUILDING INSPECTOR THISCERTIFIES THAT................ .........................................0.0 .....................................I.................... Foundation has permission to erect............................�.......... buildings on ..-T......A4W=C40%#-I.........C..c�........................ Rough �, ,�a Chimney to be occupied as..............I............ 4.. .. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final - PERMIT EXPIRES IN 6 MO THS 3:9 ELECTRICAL INSPECTOR UNLESS CONSTRUCTI 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 FIR_E.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Contract - Detailed /►� Pella Windows&Doors Sales Rep Name: Badalaty Bruce ® NIC#129774/Tax ID#26-1413183 45 Fondi Road Sales Rep Phone: 978-423-4691 Haverhill, MA 01832 Sales Rep Fax: Phone: (978)373-2500 Fax: (978)373-7274 Sales Rep E-Mail: BadalatyBP@pellaboston.com Customer Information Project/Delivery Address Order Information Shaun Doyle WBB-Doyle,Shaun,5 Andrew Cir,North Andover,MA Quote Name: Impervia 5 Andrew Cir 5 Andrew Cir Order Number. 741 BB0023 NORTH ANDOVER,MA 01845-5227 Lot# Quote Number: 2930095 Day Phone: (978)7717641 NORTH ANDOVER,MA 01845-5227 Order Type: Installed Sales Mobile Phone: County: ESSEX Payment Terms: Deposit/C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: Quoted Date: 7/25/2011 Great Plains#: Line# Location: Attributes 15 Rear Door Impervia,Sliding Patio Door Vent I Fixed,70.75 X 79.5, Brown Qty 1 � 1.Non-Standard Size Vent!Fixed Sliding Patio Door PK# Frame Size: 70 3/4 X 79 1/2 469 General Information: Durecast,Block Frame,Foam Insulated Exterior Color/Finish: Brown Interior Color!Finish: Brown Interior Glass: Insulated Tempered Low E Advanced Argon Gas ?U.75 Hardware Options: Included,Color Matched Viewed From Exterior Screen: Sliding Screen,Conventional Fiberglass Frame Size:70.75"X 79.5" Grille: None, Wrapping Information: Standard Fin,Perimeter Length=301",Glazing Pressure=170. PD-2 Wide-Install 2-Wide Patio Door Qty 1 Composite Trim>48-Composite Trim Upgrade>Greater than 48 inches wide Qty 1 Thank You For Purchasing Pella® Products PELLA WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale.All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pelta products and proper management of moisture within the wall system.Neither Pella Corporation nor Pella Windows&Doors will be bound by any other warranty unless specifically set out in this contract. However,Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress)information does not take into consideration the addition of a Rolscreen for any other accessory]to the product.You should consult your local building code For more information regarding the finishing,maintenance,service and warranty of all Pelta®products,visit the Pella®website at www.pelia.com o:..,4,a.... 71701 Il11 A r+,..,t.,M n,4-11 A ❑__^ 4 ,.i G Customer:Shaun Doyle Project Name: WBB-Doyle,Shaun,5 Andrew Cir,North Order Number: 741BB0023 Quote Number:2930095 Andover,MA to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. Variations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. Project Checklist Review (installed Orders Only) Before the Installation the Homeowner agrees to do the following Obtain Condo Association Approval Obtain Historic Approval Remove existing shutters and awnings Remove air conditioners Remove existing shades, drapes,window treatments,wall hangings, and personal belongings Move furniture at least 3 feet away from work area Tie or cut back trees, bushes and shrubs in the work area Arrange to have alarm system and doorbells disconnected Arrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor Provide a door handle and lockset for entry door if Pella handle and lockset is not purchased. Before the Installation Pella agrees to do thgfol1gW_k= Obtain Building Permit(When required) Prefinish products when purchased in contract During the Installation the Homeowner agrees to do/the following: Keep pets safely away from work area Keep children safely away from work area Allow Pella Installer room to work safely within your home During the Installation_Pella agrees to do the following; Deliver and unload products,purchased per contract j Place and remove drop cloths in work area then vacuum, and remove all debris at end of day Remove existing product, including storm windows,and dispose of it unless otherwise specified Install all products using method specified in contract per Pella Installation Instructions Replace interior and/or exterior trim only if purchased If Purchased, install exterior primed pine wood trim or Azek.Azek will be unfinished. If Purchased, install interior trim matching wood window finish or White trim for Impervia and Encompass Install non-Pella entry door lockset provided by you. Pella is not responsible for it's quality or performance After the Installation the Homeowner agrees to do the followl0g; Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella@ website at www.pelia.com MAo. .,a Customer:Shaun Doyle Project Name: WBB-Doyle,Shaun,5 Andrew Cir,North Order Number: 741 BB0023 Quote Number: 2930095 Andover,MA Re-install existing shades,drapes,window treatments,wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners w Remove stickers from product and save for energy rebate and tax purposes Wash all interior&exterior glass surfaces Fill nail holes and joints on interior trim if windows are to be stained(after staining) Clean up exterior casing issues due to storm window removal if full wrap or new exterior trim is not purchased Project Checklist has been reviewed Customer initial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits Expiration Date: / 3. 1?6 6`0 Charge fmal payment to same account �- (Upon substantial completion) Customerinitial Project Checklist has been reviewed Order Totals e-c Taxable Subtotal $2,359.62 X Credlt Card Approval SignattWe Sales Tax @ 6.25% $147.48 Elb�-'fAJ ,)011- 9&u/C� � Non-taxable Subtotal $910.00 Customer Name (Please print) Pelle a es Rep Na a (Pleaee print) Total $3,417.10 x Deposit Received $1,708.55 Amount Due $1,708.55 Custompr Signatu a Pella Saes Re igna re Date 1, Date For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com oa a ��narona� r . a n n r o.,..., o ..t c Customer:Shaun Doyle Project Name: WBB-Doyle,Shaun,5 Andrew Cir,Nodh Order Number: 741BB0023 Quote Number: 2930095 Andover,MA Lead Safe Installation Customer Performance Expectations In order to ensure a proper Lead Safe Installation, it is essential that we have you complete the below tasks prior to your installation: ❑ ALL furniture needs to be moved at least 8 feet away from any window or door being replaced ❑ ALL personal items,wall hangings, and collectibles must be removed prior to your installation date ❑ All blinds and any interior window treatments need to be removed prior to your installation date ❑ Any non-movable furniture(for example: pianos, entertainment centers,built in cabinets, etc)must be cleared of items and be surface dusted prior to installation ❑ You will be responsible for replacing all furniture and personal items after your installation ❑ Other items: What to Expect the Containment/Work Area to Look Like ❑ In order to ensure your safety,we will be taking measures to minimize dust/debris does not spread beyond our work area. This may include the use of plastic sheeting on the floors and/or walls,caution signs,sealing of heating and cooling air vents, and asking that you turn off your HVAC system during our work. ❑ During your Lead Safe Installation, you may also see your installation professional wearing Personal Protection Equipment. ❑ For your own safety, we are not permitted to allow you inside the work area during the removal of your current product or the installation of your new windows/doors. By signing the form below, I am affirming that I understand all the expectations noted above and that I have agreed to have all items completed prior to my installation commencing. I understand that failure to have these items completed will result in the re-scheduling of my installation and that my installation date will be scheduled for the next available date. A & _ Customer Signature Date For more Information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com 15.:..1..A-- 711GI7l144 r`nnl.nnl Mnlnllnil 15nnn A ni C Customer:Shaun Doyle Project Name: WBB-Doyle,Shaun,5 Andrew Cir,North Order Number: 7418B0023 Quote Number: 2930095 Andover,MA Pre-Renovation Form Occupant Confirmation Pamphlet Receipt �( I have received a copy of the lead hazard information pamphlet informing me of the potential risk of lead hazard exposure from renovation activity to be erformed in my dwelling unit. I received this pamphlet before the work began. t L � L Printed Name of Owner-occupant Signature of Owner-occupa t Sigriature Date Renovator's Self Certification Option(for tenant-occupied dwellings only) Instructions to Renovator.-If the lead hazard information pamphlet was delivered but a tenant signature was not obtainable,you may check the appropriate box below. i Declined-I certify that I have made a good faith effort to deliver the lead hazard Information pamphlet to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with the occupant. Unavailable for signature -I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by: (Fill in how pamphlet was left) Printed Name of Person Certifying Delivery Attempted Delivery Date Signature of Person Certifying Delivery Unit Address Note Regarding Mailing Option --As an alternative to delivery in person,you may mail the lead hazard information pamphlet to the owner and/or tenant. Pamphlet must be mailed at least 7 days before renovation. Mailing must be documented by a certificate of mailing from the post office. For more information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pelia.com PELLA WINDOWS AND DOORS CONTRACT 7 PAYMENTS 1. TERMS AND CONDITIONS Pella sh O be entitled to stop the Work upon written notice to Owner for any mal deianit or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part ofthe contract set{nrth to t}s f a m pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door ILC d=- dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products'j,mad pecfsmm the work(the"Work")described or referred to in such Contract For Prodam & CORRECTION OF WORK Only purchases,a signed"Product Only Addendum"is a required part oftbe Fcfla sly correct installation Work not in conformance with the requirements contract cft a Cmaact ifnotified in writing by the Owner within two years after the Dare or,if eadier the date on which the Work is substantially 2. OWNER c=pkzcd md payment of she Purchase Price made subject to a holdback as pmvided abocr-Cen ecvon of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove truer krdclizitive wodananshiN and is provided in lieu of any and all other all shades;verticals,blinds,curtains,drapes or window mounted air seixieffim Puma's abon to coirrect Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not raxipt rf ar prymcms then drie. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. I D4rl7ED PRODUCT WARRANTY windows. Pella sh27-vanam aZ Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Dow 1hmi�Wary_THIS LIMITED WARRAN'T'Y SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SCILE 16-ARRA\"TY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SP€C1FTf 3ILY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR nStLs JUX ARU-IEN OR ORAL(INCLUDING WITHOUT 3. PELLALB41IATWN ANY FF RR 14TY OF MERCHANTABIL 11'Y OR FITNESS Pella will be responsible for and have control over construction means, FOR A PAR=-I- PLTJUSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. 1tiO C ONS EQLE1TLt1.DAMAGES Contractors who will install the Products. UNDER NO CIRCVMSTA-NXES SHAT L PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEW-EN AL LEEN rAI„DWIREGT'OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WHET'IIFRFORES OR L\'FORESEEN_ other facilities and services necessary for the proper execution and completion of the Work. 11. 110.31E 13IPROVEMENT CO\TRACTORS The materials and equipment furnished under the Contract will be good quality All home unprmrmem ca=xa=cs and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director of the Haran 1 s—C.-tiractor Remstrau°n Program defects not inherent in the quality required or permitted,and the Work administered by the Board cf Bm5ff=g Rtgnbitiom and Standards_Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its mad i--d:is- rgrmneat have been wgrstered. for damages or defects caused by abuse,modifications not executed by Pella, Any inquires abottt Pella or afiz s m reguuatroa improper or insufficient maintenance,improper operation or normal wear and should be directed to:Directs;H=!e ,%==Crim actor Registration, tear. Pella will keep the premises and surrounding area free from One Ashburton Place Boston.?rL3 _1 di:'-'2'$��$ accumulation of waste materials or rubbish caused by performance of the 12: PERMITS(hist ods asls7 Works Ila ISO m and w71 t'..s pnsjeet 4. CHANGES )L YV Horneow-nis wbe s==th*cvm petrnits wdI be excluded from the guaranty fiord pwvisL=cf3&ss3=bm=rs Coal Later, The Owner may order in writing changes in the Work consisting of additions, chapter 142A. deletions,or modifications("Change Order"). Any Change Order shall include an adjustment to the Price and the Substantial Completion Date,as In addition to the rights and waw is this agreement,yon may determined by Pella. Pella reserves the right to approve or disapprove any have additional rights under M GecomT Laves,d2p=142A and Change Order and any such Change Order must be signed by both Owner and 780 Code of Massachusetts Regutmi=s Rb. Pula to be effective. 13. NOTICE OF CANtlA'PI©i 5. SUBSTANTIAL COMPLETION You may cancel this agreement if it has been signed by a party Owner understands and agrees that the Substantial Completion Date is an thereto at a place other than an address of the seller,which estimate only and that the actual date on which the Work is completed may be may be his main office or branch thereof provided you notify extended to allow for Change Orders requested by Owner or if the time to complete the Work is affected by conduct of the Owner,weather,labor the seller in writing at his main office or branch by ordinary disputes,availability of subcontractors,acts of God,fire or other causes mail posted,by telegram sent or by delivery,not later than reasonably beyond Pella's control.If for any reason the Work is not fully midnight of the third business day following the signing of this completed by the Substantial Completion Date(including any extensions agreement. contemplated above),but is substantially completed by such date,i.e.,the Product has been installed,but minor parts or components are missing or need See the attached Notice of Cancellation for an explanation of to be replaced or repaired,a hold back proportionate to the cost of remaining this right parts or work to be completed is acceptable.However,the holdback will not exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. Do not sign this contract if there are any blank spaces. 6. FINANCING If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing ofthis C6ntract and the requisite approvals and authorizations for the full amount of the requested financing shall have been received from the financial institution.'- Customer si Date // 1 DISPUTES Job Named L LCi Date THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT;PELLA 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 Contractor Homeowner J NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION ISNOT SEPARATELY SIGNED BY THE PARTIES. I NOTICE OF CANCELLATION Customer Name: D©q�,t- �I t) T_ Date of transaction: You may cancel this transaction,without any penalty or obligation, within three business days from the above date. If you cancel,any property traded in,any payments made by you under the agreement, and any negotiable instrument 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 agreement; 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 your notice 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 Pella Windows and Doors, at 45 Fondi Rd.,Haverhill,MA 01832 not later than midnight of (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) A�® CERTIFICATE OF LIABILITY !NSURANCEF07106,2011DATEIMMIDDIYYYY) 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 pelicy(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 A T Dorothy A.Corlett,CIC,P.PW Fred C.Church,Inc. NAME: __ 41 Wellman Street PHONE 978 3227231 aC No,, 1978)454-1865 Lowell,MA 01851 (800)225-1865 ADE=MDRAILESS: dcorloq@fredcchurch.com INSURERS AFFORDING COVERAGE MAIC p INSURER A: Citizens Insurance Company of America 31534 INSURED INSURER B: Hanover Insurance Company 22292 New England Window&Door LLC INSURER C: Massachusetts Bay Insurance 22306 45 Fond[Road Haverhill,MA 01832-1302 INSURER D: Employers insurance Company of Wausau 21458 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:16761 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. _ iNTR 'TYPE OF INSURANCE A]DL SUB.I Poi Iry yLiugeo I,�,POLICY EFF F. . POLICY i rrq I GENERAL LIABILITY EACH OCCURRENCE `S 1,000,000 X PREMrDAMAISE O REN Ertsnce1 TED 100,000 COMMERCIAL GENERAL LIABILITY $ CLAIMS-MADE LX OCCUR I MED EXP(Any one person) $ 10,000 p ZgNg+gt407 I ?!1!2011 I 711120'.2 1'0'0'30 _ I PERSONAL&ADV INJURY $ GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: Name i PRODUCTS-COMPIOPAGG $ 2,000,000 X l PRO- I$ I POLICY � Address- _I LOQ _ I _1__ AUTOMOBILE L:AB!LrrY — i I 00A511cDSIL^tLI.AiT. 1OM OOD `7 1 �Ee secede^t S X ANY AUTO I i I Phone I BODILY INJURY(Per person) $ C ALL OWNED SCHEDULED i ADN8162!69 7!1/2011 1 71112012 AUTOS AUTOS I BODILY INJURY(Perazide l) S S I `--- X "HX NON-OWNED I I I ( PROPERTY DAMAGE — --- HIRED AUTOS AUTOS I I P,raceldonL I i BI X UMBRELLA L_19e_ I 9,000.e0 AGGREGATE k4OCCUR EACH OCCURRENCE $ EXCESS OAS CLAIMS-6AUHN°157305 7112011 7!112312 9,000,000 � $ DEG I RETENTION S ' II— $ 1.WORKERS COMPENSATION —�M X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N -- ANY PROPP,iciORIPART�:ERI`EY.ECUTIVE I I I c.L.EACH.eCC!r)ENT a 00,000 OFhIC$kltd'cMBER'cXCLUDED7 NIA YJCCZ112599570i1 71112ui'i 711!2012 I(Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,describe under D�SGRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 111.1DD DESCRIPTIONCIF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101:nddiiionoi Pomades Schedule;if more efface Nrequired) Troutofinsulauce I CERTIFICATE HOLDER CANCELLATION sn Englancl winoow a Dro. , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 45 Fondi Road - THE EXFIPATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Haverhill,MA 01830 ACCORDANCE WITF!THE POLICY PROVISIONS. I 1 AUTHORIZED REPRESENTATIVE Ciiant rAiu� -I Cert rlo[der;a "y'° O 198$_2010 ACORD CORPORATION. All rights reserved. ACRD 25(20110105) Tile ACORD nafAe and logo aee registered marks o*ACORD The Commonwealth of Massachu setts Department of Industrial Accidents " u Office of Investigations d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance affidavit: Builders/Co>lti•actors/Electricians/Plumbers Applicant Informationii !! Please Print Legibly Name(Business/Organization/Individual7: .V' A- UA i�sj 03 1 t r - Address:- City/State/Zip: V) hone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.[dam a with employer 2 4. F1 am a general contractor and I * have hired the sub-contractors 6. E]New construction employees(full and/or part-time). 2.❑ I am a•sole proprietor or partner- listed on the-attached sheet.. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition worlds forme in z3 ca act employees and have workers' G. U Building addition [No workers'comp.insurance cow tnsurance.t required.] 5. ❑ We a;".corpora±ion and its � 10.❑Electrical repairs or additions I 3.❑ ou cers have exercised their I LE]Plumbing repairs or additions I am a homeowner doing all work „�T right;if c�cemption per 1t2GL i i 12.^Roof repairs myself.tlx:,workers comp. L{.• insurance required.]t c. 152, 1(4),and wa have no 13.❑Other employees.[No workers --— comp.insurance required.] a� *Any applicant that checks box#1 must also 511 out the section below shovfiao their workers'comparsation policy information. t Homeowners who submit this affidavit indicstirg they are doing all work and then hive outside contractors must submit a new aiiidavit indicating such. tContractors that check Eris box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitieshave employees. If the sub-contractors have employees,they must provide their workers'comp.policy num5er. -� I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site. information. insurance Company Nama:Vk _C. C_[�U O A, Policy#or Self-ins.Lic.#: 3� lf�.— � �" Expiration Date: Joh Site Address: City./State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fai"rare.to secure coverage as squired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rine up to 11,101,10 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK_ORDER and a tine of up to$250.00 a day against the violator. Be advisad that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage"verification. -_ •I do hereby certify under the pains-andpenalties of perjury that the information provided above is true and correct. Signature: CA Date: R-10 —(j _ Phone#: Official use only. Do not write in this area,tb be com leted by city or town official O P ff y ICity or Town: _ _ Permit/License# I Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector t ti.Other IContact Person: phone#: e� i�[GC1000� i t �o"lmer i � Bos&tdau s Y ;ga ahon. r ' _O AAp2OVER -TCO LiTRA'O70R l F u '` Friitf Ca+d. i• FELLA�IUli�) WILi<' �y1CMOLR - ' '�iA19ER 0 .VAdsrseeretary l 1Massachusetts- Department of Public Sateth Board of Buildinit, Rc!-ulations and Standards Construction Supervisor License License: CS 89853 Y rod WILLIAM R NICHOLt8°�' 57 PEARTREE RD4'' HAVERHILL, MA 0: Expiration 10/26/2012 ('ununissi:mcr Tr##: 4529