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Home My WebLink AboutBuilding Permit #1064-2016 - 5 CROSSBOW LANE 4/12/2016 BUILDING PERMITNORTH q " 164�O TOWN OF NORTH ANDOVER `6 0 APPLICATION FOR PLAN EXAMINATION ( `l n0 w •y7m V� 1 R Permit No#: � ` � Date Received � �� I �s SSACHLIS�p°R,reo '9 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION s ��OSSaDh! Lnr Print PROPERTY OWNER Print 100 Year Structure yefen o MAP PARCEL: )2/3 ZONING DISTRICT: Historic District yno Machine Shop Village yo TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial t,'Repair, replacement ElAssessory Bldg ElOthers: y❑Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 9 y Identification- Please Type or Print Clearly OWNER: ' Name: �[� � Phone: G� L�7�Sl� "A Address: S e�2aSs >7 Contractor Name: e K)), Ane: & lut -z Email: �,� Address F 4c G( 4)1U L Supervisor's Construction License: Exp. Date: (D •u--i�- Home Improvement License: 193a�--727 Exp. Date: q`2—f-1 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHLDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ,;LOUD FEE: $ � aZ� Check No.: 2 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund rtnr — — _� 1 Location (b Ii-'3 No. �V�O -- A31(p Date Ili • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $30 — Foundation 30 "Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check# `r r• 7 ,• Building Inspector Y I J � Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE OF SEWER-AGE 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS � I CONSERVATION Reviewed on Signature I � I I (COMMENTS ` • I HEALTH Reviewed on Signature COMMENTS 1 l Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Na Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DE � Located 384 Cs_g._o..o_d Street T - TCQf_n,0®urnpster,+aon i'Locatedlats ain1Street F�ire�Department gnature/date: �''@-P.N NI S� _ ,. Y _ _ __ 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department i 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 6 Building Permit Application � Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or 'Decks I Building Permit Application I Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses f Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And i Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit E New Construction (Single and Two Family) I � 4 Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses i 4. Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORTH own Of _ ndo' ver h ver, Mass COAD-O CNIc"t WICK y1' �i4s R^TED U BOARD OF HEALTH PER T Food/Kitchen Septic System 1 BUILDING INSPECTOR THIS CERTIFIES THAT .................. ............................................. ." Foundation has permission to erect .......................... buildings on .... .. .....�......... - Rough to be occupied as .....I..... ........... �1 �1. .. ... � ......... ...... Chimney provided that the person ac this permit shall in every respect confor the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough Service ........... .... ... . .. .. .......... ......................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises— Do Not Remove Final No athing or Dry Wall To Be Done FIRE DEPARTMENT 1 Until Inspected and Approved by the-Buifding-Inspector.— Burner Street No. Smoke Det. Contract - Detailed s �j Pella Window and Door Showroom of Haverhill Sales Rep Name: Okeefe, Timothy 45 Fondi Rd HIC#183279/Tax ID#26-1413183 Sales Rep Phone: 978-423-5052 Haverhill, MA 01832 Sales Rep Fax: Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: OKeefeTA@pellaboston.com Customer Information Project/Delivery Address Order information Andrew Firmin Firmin,Andrew,5 Crossbow Ln,North Andover,MA,US,01 Quote Name: Firmin Encompass Slider 5 Crossbow Ln 5 Crossbow Ln Order Number: 741TA0747 NORTH ANDOVER, MA 01845-3037 Lot# Quote Number: 7655005 Primary Phone: (617)6945153 NORTH ANDOVER,MA 01845-3037 Order Type: Installed Sales Mobile Phone: County: ESSEX Payment Terms: Deposit/C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: acfirm@yahoo.com Quoted Date: 3/15/2016 Great Plains#: Customer Number: 1006196621 Customer Account: 1003666933 Line# Location. Attributes 10 KITCHEN Vinyl Windows 1 Doors By Pella, Double Sliding Door Fixed I Vent Left, 70.75 X 79.5, Qty White 1 1:7280 Fixed/Vent Left Double Sliding Door PK# Frame Size: 70 3/4 X 79 1/2 =" 772 General Information: Standard,Vinyl,Nail Fin With Mullion Groove,4 1/2"' l 7/16",3 1/16" Exterior Color/Finish: White Interior Color/Finish: White --------- --- Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Air Filled Non High Altitude Hardware Options: White,White Viewed From Exterior Screen: Sliding Screen,Standard Frame Size:70.75"X 79.5" Unit Accessories: No Accessory Option Grille: No Grille, Wrapping Information: No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length=301",Glazing Pressure=170. Composite Upgrade>48-Composite Upgrade greater than 48 inches Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 PD-2 Wide-Install 2-Wide Sliding Patio Door Qty 1 Delivery/Setup-Delivery/Setup 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. For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/15/2016 Contract-Detailed Page 1 of 4 Customer:Andrew Firmin Project Name: Firmin,Andrew,5 Crossbow Ln,North Order Number: 741TA0747 Quote Number: 7655005 Andover,MA,US,01 Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pella 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[or any other accessory]to the product.You should consult your local building code 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. INSYNCTIVE PRODUCTS:In addition,Pella Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. 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 the following: 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 Durinq the Installation Pelta agrees-to do the following: - Deliver and unload products purchased per contract 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 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/15/2016 Contract-Detailed Page 2 of 4 Customer:Andrew Firmin Project Name: Firmin,Andrew,5 Crossbow Ln,North Order Number: 741TA0747 Quote Number: 7655005 Andover,MA,US,01 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 Composite. Composite 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 following: Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings Re-install existing shades, drapes, window treatments, wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners 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 i tial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits 0388 Expiration Date: 50201— e g Char final payment a ment to same account L—P— (Upon substantial completion) Customer initial For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/15/2016 Contract-Detailed Page 3 of 4 Customer:Andrew Firmin Project Name: Firmin,Andrew,5 Crossbow Ln,North Order Number: 741TA0747 Quote Number: 7655005 Andover,MA,US,01 [Project Checklist has been reviewed Tim OKeef Andrew Firmin am (Please print) Pella Sales Rep NamJ 01ease aX I Order Totals; • .00 Taxable Subtotal $1,107.08 om Signature Pel p Signa a Sales Tax @ 6.25% $69.19 3/15/16 5/16 Non-taxable Subtotal $1,246.50 Date ` Date Total $2,422.77 Deposit Received $1,211.38 .Credit tarfl Approval Signature Amount Due $1,211.39 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 3/15/2016 Contract-Detailed Page 4 of 4 i PELLA WINDOWS AND DOORS CONTRACT PAYMENTS 1. TERMS AND CONDITIONS Pella shall be entitled to stop the Work upon written notice to Owner for any material default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part of the contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8 CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part of the Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Date or,if earlier,the date on which the Work is substantially 2. OWNER completed and payment of the Purchase Price made subject to a holdback as provided above.Correction of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove remedy for defective workmanship,and is provided in lieu of any and all'other all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. 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. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS.AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED,WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible for and have control over construction means, FOR A PARTICULAR PURPOSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR Unless provided otherwise in the Work description,Pella will provide and pay CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, for all labor,materials,equipment,tools and machinery,transportation,and WHETHER FORESEEN OR UNFORESEEN. other facilities and services necessary for the proper execution and completion of the Work. 11. HOME IMPROVEMENT CONTRACTORS The materials and equipment furnished under the Contract will be good quality All home improvement contractors and subcontractors shall be registered with and new unless otherwise required or permitted,the Work will be free from the director of the Home Improvement Contractor Registration Program defects not inherent in the quality required or permitted,and the Work administered by the Board of Building Regulations and Standards. Pella and conform with the requirements of this Contract.Pella shall not be responsible any of its subcontractors identified in this agreement have been registered. for damages or defects caused by abuse,modifications not executed by Pella, Any inquires about Pella or any of its subcontractors relating to registration improper or insufficient maintenance,improper operation or normal wear and should be directed to:Director,Home Improvement Contractor Registration, tear. Pella will keep the premises and surrounding area free from 10 Park Plaza,Room 5170,Boston,MA,02116,617-973-8787,888-283-3757 accumulation of waste materials or rubbish caused by performance of the or visit the HIC website at http:/hvww.mass.gov/ocabar/ Work. 12. PERMITS(MA customers only) 4. CHANGES Pella is obligated to and will obtain the following permits for this project: Building . Homeowners who secure their own permits will be The Owner may order in writing changes in the Work consisting of additions, excluded from the guaranty fund provisions of Massachusetts General Laws, deletions,or modifications("Change Order"). Any Change Order shall chapter 142A. include an adjustment to the Price and the Substantial Completion Date,as determined by Pella. Pella reserves the right to approve or disapprove any In addition to the rights and warranties enumerated in this agreement,you may Change Order and any such Change Order must be signed by both Owner and have additional rights under Massachusetts General Laws,chapter 142A and Pella to be effective. 780 Code of Massachusetts Regulations R6. 5. SUBSTANTIAL COMPLETION 13. NOTICE OF CANCELLATION Owner understands and agrees that the Substantial Completion Date is an You may cancel this agreement if it has been signed by a party estimate only and that the actual date on which the Work is completed may be thereto at a place other than an address of the seller,which extended to allow for Change Orders requested by Owner or if the time to may be his main office or branch thereof,provided you notify complete the Work is affected by conduct of the Owner,weather,labor disputes,availability of subcontractors,acts of God,fire or other causes the seller in writing at his main office or branch by ordinary reasonably beyond Pella's control.If for any reason the Work is not fully mail posted,by telegram sent or by delivery,not later;than completed by the Substantial Completion Date(including any extensions midnight of the third business day following the signing of this contemplated above),but is substantially completed by such date,i.e.,the agreement. Product has been installed,but minor parts or components are missing or need to be replaced or repaired,a hold back proportionate to the cost of remaining See the attached Notice of Cancellation for an explanation of 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 this right. balance of the Price,whichever is less. 6. FINANCING Do not sign this contract if there are any blank spaces. If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the full amount of the requested ustomer nature financing shall have been received from the financial institution. 3/15116 /15/16 Date DISPUTES 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 I Pella Windows & Doors Contractor 4omeo?wner 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 IS NOT SEPARATELY SIGNED BY THE PARTIES. i I NOTICE OF CANCELLATION Date of transaction: 3/15/16 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 3/18/16 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) The Commonwealth of Massachusetts dtintptkm Department of Industrial Accidents Office of Investigations 3' I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plum.bers Applicant Information Please Print Ledbly Name(Business/Organization/Individttal): F11A �i/��L� � bi)C)rz_ W=c _ Address: 45 &r City/State/Zip: tz ,t i 6JK3_2,__ Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.MI am a employer with --,-7S— 4. ❑ I am a general.contractor and I employees(full and/or;part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. JZemodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. E]Building addition [No workers' comp. insurance comp. insurance.* required.] 5. corporation We are a co oration and its 10.E] Electrical repairs or additions ❑ 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. o workers' comp. right of exemption per MGL Y � p 12.❑ Roof repairs insurance required.] ' c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees.i If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: N*4 F—rlrl Q Zcj. zs Policy#or Self-ins.Lie.#: gkox co 4 c i o 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 unprisonment,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. 1 do hereby certify under the ains and enalties of perjury that the information provided above is true and correct. Signature: -- — _ latet_iL Phone#: Of use only. Do not write in this area,to be completed by city,or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE a60CAM 9/2o15�M1DDMNV) FWeamil IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATMY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ORTANT IF the certificate holder is an ADDITIONAL INSURED,the ii'll (iesP must he endorsed IF SUBROGATION IS WANED, subject to terms and conditions of the policy;certain policies may require an endorsemenL A statement on this certificate does not confer rights to the ificate holder in lieu of such endorsement(s). PRODUCER .Church,N� NTA CT pmohyA Code@,GC,RPLU men Sbee[ NAME: MA 01851 PHONE 9183421291 FAX1978)454-185-1065 E IIAAILNa:ADDRESS: COVERAGE NAIC 5 INSURERA: aeasn5urancaCampanyofAmerice New Ham Nraland Windaw A Door LLC INSURER fl: Employers Insurance Company 13083 45 Fandi Road INSURER C: HaverbIll,MA 01632-1302 INSURER D INSURER E: COVERAGES 5445T IN5URERF: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE UST®BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVIIITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VIIITH CERTIFICATE MAY BE ISSUED OR MAY RESPECT To ALL Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THEI TERMS, EHGLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. INSR ADOL SUER LTR ABILITYTVPE INSURANCE POLICYHUMBER MMUDCYEEF PMITIo EXP Lima GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY OA ETU R 100,000 CLAIMS-MADE M OCCUR REMISES Ea uccunEw $ A X CG0001 MED EXP(Any one arson) $ 10,000 ZBN8161407 7/1/2015 7/112-016 1,000,000 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $2,000,000 GEN1 AGGREGATE OMIT APPLIES PER: POLICY X JRC X LOC PRODUCTS-COMP/OPAGO $2,000,000 AUTOMOBILE LIAERIM $ COMBINED SINGLE LIMIT ANY AUTO Ea accident ALL OWNED SCHEDULEDBODILY INJURY(Per person) I AUTOS NOI�WNED BODILY INJURY(Peracadenq $ HIRED AUTOS AUTOS PROPERTY DAMAGE (par. e acgden1 I UMBRELLA LIAB OCCUR S EXCESS LIAB CLAIM MADE EACH OCCURRENCE S AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY X WOST M7 U_ ETH- ANY PROPRIETOR/PARTNERIEXECU7IVE YINMRY B OFFICER/MEMBER EXCLUDED? NIA 400040101 500,000 (Mandatory In NH) 7/112015 7102016 ACCIDENT $ IT ee,describe under 500,000 pp EL015EASE-EA EMPLOY $ DESCRIPTION OF OPERATIONS helaur EJ-DISEASE-POLICY LIMIT $500,000 i DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORO 101,Addillonal Remarirs Schedule,it more space IS required) i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E)(PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE LININ THE POLICY PROVISIONS. ,1!'O77Y777l.WN(,.'!(I'//� - fce of Consumer Affairs&Business Regulation License or registration valid for individul vse only E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration: 183279 Type: Ex vatiori 10 Park Plaza-Suite 5170 p• 9/2412017:. Supplerrient C:1rd Boston,MA 02116 NEW ENGLAND WINDOW:&DOOR, LLC. PELLA WINDOWS&•DOORS' William Nichols 45 FONDI ROAD Z—) HAVERI§II.L,AAA 01832 Undersecretary Not valid.without signature ta seclu$aTic. s aid �$�tar�`{ a kis CS-989853 a' WILLIAM R NICHO_ LS 17 PEARTREE Rit + r HAVERHILL MA s J r AL1 1 X 1 1lt z^ 10/2612016