Loading...
HomeMy WebLinkAboutBuilding Permit #806-2017 - 5 GREEN HILL AVENUE 3/1/2017permit No#: Pate Issued: 1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IWORTANT: Applicant must complete all items on this LLI(DIU g_16@ o /4rI�M1 e- r-4 ' r-, 1 } s + a1;1 C L'J TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building k --One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic t°Well 0 Floodplain Wetlands WatershetlD strict Y _� ti+ _ DESCRIPTION OF WORK TO BE PERFORMED: !�kC yz- M,&—, Lia&"() �,i. No S-6 . Identification - Please Type or Print Clearly' OWNER: Name: S c Phone: �Iyl - 732 ,l.>•7 3 S Address: 5 4,,1, Contractor Name .I-� I x tti hone Z� 1 7a, x r ,i.1r.y►,.ar.{Sa��..y, �.+a{.i.f...Ape4.q'.!,�s y�y� It - r ..,�- n, J _'1.• J:w .,-J T^t^l+C�X..a+�sl1 '4'- .- .. . 3 A J _I �-- . . lt. :7.=� • Pt...j. C i . t_" . 1 S ... - - _t i.-; �. _K .4•s�'s•'i i- �..,c� � � ,y�� :►. x,IS 1� y,y � t ����, a �` rvisor s Consffluettor Licensee [ ``%fr � EExp Date ��w �•3..�y+� ���� >��....z��' � ]����•��� i�,fj�'�*� �e?`�7 ry�Y j�^�tr'•�'�` *�7 , �_r +. Y� .�+- r: w e�s L. xx•,.N;+?a'.. x r'._.rc� � t ` i * " ^?� • � s'="� y...�°�'`i�.#s ..C+� ,�,� n �, � �s��, t' ARCHITECT/ENGINEER Phone: _ Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 1 �I a — Total Project Cost: $ 0 FEE: $ Check No.: 1 Receipt No,. S7 DOTE: Persons contracting wztli unregistered contractors do not have- access to the guaranty fund S`ignatu'e_ofgenSignature of contractor,; 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 t Doc: Building Permit Revised 2014 -t Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE 1'F 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed Zoning Board of Appeals: Variance, Petition Planning Board Decision: Com nature Zoning Decision/receipt submitted yes k r Conservation Decision: Comments I` Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 3M Usgo, FIRE DEPARTMENT -'Temp Dumpster on site yes no Located at 124. Main Street Fire Department signature/date COMMENTS Street -Nmension 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 MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine No Doc.Building Pennit Revised 2014 Location 94x te l' // 44 No.gdb"i-017 Check # 1,� 99. Date 341, 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ X-- Building Inspector L 0 ON O J W LL 0 c Q m t \ -6 O O E u T U Q N p C z z m C O y "O 7 LL L 7 CC ? C E U — C LL O 0. z z J d L cc — C LL 0 0. ? V U NJ L O d' U > N — C LL O a CA ?co Q L W C LL zZ C Q ua W LL L v L' CO O Z v N N 0 C) O {n Z H C.) W aZ w0 U w/ W az V, U a _z 0 m �l N P; N S V v O E z CL O N IM A Q V .E W W LL 0 O cx a. CL � Q OM i V J � �CL0}'. �Z 0 CL V N CL _N 0 _ �+ y V O t4 U) , Z H C.) W aZ w0 U w/ W az V, U a _z 0 m �l N P; N S V v O E z CL O N IM A Q V .E W W LL 0 O cx a. CL � Q OM i V J � �CL0}'. �Z 0 CL V N CL _N 0 � k % ■ E a. U- LU CL a CL CL 0 0 0 0 0 $ $ 2 2 _ # \ 04 ll� ƒ \ \ a) o � \ L \ @ § 2 D \ / 2 E G @ 07 \ E 2 LL k § �$fE 101 q ¥ a / M — w q = a. E \ / - \ a \ o g =0m ar- r � / ¢ W 2�7 e@ k/ c CL /co/ 0 0 \ � E k41 .. § w E § ■� / d 0 -0 K x k O J o § o a J § ~ Cl) k � 7 « 3 � < ■ � : m w k Go < 0 U k < . c 9 2 2 00 k v W < j 04 \ \ c ° m 3 E 7 \ 2 \ \ CD \ < Q § I § 7 2 2 c 2 A 7 .. g � — 4 £ \ / § .. / � E § m � / / « E a 7 < a. § m a) 4) U k ®© 0 � § k J\ .0x i a w 0 v v q ¥ a / M — w q = a. E \ / - \ a N 0 N 00 0 00 L: E z 2 0 C� 0 rn 0 Z a� E z a� v co N N n v 0 U U w iv E cu z U a� O CL Mn LU 0 U CO N O U o CL a U O 0 m x 0 U LU w > 0 0 0 Z •N ''7CL CL u Y o 0 N N W �x s. m C7 3 ? °SYN 0 U U m U N m a E U U cd C y v ui ui y °' o c M M O U m O rn d c7 0 ° o e 4 3u w a a $ ° a� E c c 0 0 m m in m003 m U U O - m 0 C N U N C .o '... •_. E E °' :� a c J 0 0 CL oa L 000.��. o (D o a) C\ Ci Ci C7 Ci ) ° c Ln to n v o o d L M-2 o o O. O O U O ti y zo co CL cd to cd CL ccs m N O) O N 0 N m Q N N U ®t ,3 'O 3 .2 .D Ta Z V c V a.+ ted i. y+ N ° .. w S O� W c d _ 00 C a p v' z E a zE a m R O O N o.o � r. O c-1 O = c � p = E LL s. ❑ .� C 4 � O a N 0 0 a N E O O, 0 C to i. N z U z U 3 0 2'y �.- p M cn O tM M N O m v\ a0' a H V m y .fl 0 G + 3 N m fn O >N> is N m (n O N f0 t s O. •� V N -O i" y E Le) S (� C Jib > S m (D C H U U U O N a. •y a X di c �> > o c C� �a d oo m E V G.a C O O c m o v a� c m v W m 0 a ?� .` L- E ., y p � b cYj o E 5 m m o 3 E o m d: m o a c C; f' Q C, .o b 1� x m 070 O W :_ x m Vl -0 O W = O. m IV C G m LL cca U a m L0 C N U 6 Q N Y O a ?? 0 b 0 m rn a c win U ami `m oa win C9 `M° o �`- `m c ° L � °' 3 CIS c c ° 3 2}H_° c 3 =}I -=oma - .o Q O 0 = o LL 0 �i to 5 o iL 0 a) cn o m c a o' o y b 0 N J ._ W fes') 00 N -1 o0 M p h im X ` C LL y 0 0 C 'O C N z 7> N C (` N Z m> N O) C lV n jQ m � E O C O _ � O C O E d �, d O �=. U fd 3 in 5; �� om0a�°7i� w� omUa�0)-C ii a c E 0 O o �°� cd °' p Q M > M C oaM- •p f0 C maM7.2 •N a w LL' ... O C d) N C 'a .U-. Z 0 LL C a O Z 0 LL O ND (D N .�U. C = t%1 7 Q4) u LL Y �U.+ "0 N N oct M� o E z -JOrn g oM. O E o m azo :° ° a� " '° .�' m M N N O4) X C N 7 U C€ O 7 U N N C C N U C •O 7 U 0 C a Ci Q O a S. U ccz �;, LL C p C N O U m N C Q N U :) U m m C a. y C N `� s. 3 O. L m LL '0 w cc LL jp lL 'O C w m LL °' 0 0 •_p M '±+ N ar�OiEo��a�n��Z��rC°iEo`�acn�coiZ�0 '�° v 3 o a c. cr p IC6 4)— C V C h li C U m R N= O p y O LL U m = 7 L2 ?rn to N cd am � N Vito-�V m16C9�y�_ `� mL95C7��� O N °° 3-v +-• 1 w OC? d 2 O C€ M m GI i 2 p C E CO ja ._ C V m �i cd 0 3 O bq oEda`�'` tn�a°1iQO'd2oE°1d'�uyivy`orn .2cL > m LL - ❑ a� G> Z d rC « 2 c`a V d w •E r Z m d Sc °� A V d w an d d J LL H fl° U N a3 CL �LLC9w_=(9xv)c.wo jNuic9wE- mm co a. 0"j�p> c o r " °� -`� ° M cl b a+ LL Ch E 0 -- o X zo j o o C `o_ ��o Zn cn - w ;? � >, ao 0 _. co °� d O N ate+ U M 3 W Li (n > U .� 3 C ❑ 0 � 3 all 4) E Q 2 vOi mU t > R J °. O ° c o it N W L. a- 3U U ° a ff.. (D 0) co a 0 N LO N N c O O c CL N CD N 0 00 00 cu a E z w 0 C7 o N N v C2 0 0 w '.7 w 0 U) a`> 0 U O ❑ w �A CE O ° W AZ i cnc c E� n° °o L 'C3 0 A cz '��"qqr C ¢ 0 3 or. > ° a0�4Q ;: ° ° 3 a 0v�d� ° �EQU N o 3 O o'�civWf� E w to m -Ctib F Z y c'c C4 N 0 ^d 3 �wH cd o 0'>_E�tw U ° o H [ o ti R w o c, ° c 0+ WAS' cam° A° >, cl W d 04 0 `.U3 _ U3 '0 w a Q r� �• o. a > a0) rL ° K 3 a� 0 d b JQ CL A O U E$ a z a) a• o Oz� �� of o o >, i c ° o Z -� o E o ai C c o c -a c ^p E F0 eq "4r OdO N .0 cd N,Es E v� F, U H❑ 0 a C4 4. Cd a) o ° o 0 a >0 .0, to ato w o "18 11) a, c a o o y —° Cd E-+w��"wo00�oU^Z �a�i� � w _ a)W ZdWO�° �"Z0 c`mac cn m o w W 3 F U n.5>° 3 o a 0 o 2 L W Q n W ami o ?+� b a 0. Da O r- t - o a)'a ¢OdzO cco= i o °Y ¢ @ z Q W 3 N o °d 3 0 �. o .> En o In a ons 0� a) b O = uS O 0wWQ �n ca y Z E c -o .a 4. o o rn d 2 a4 o� 0 clu C% ca rn Gv, D O c 0i� C4 PG a c w a) 0 a 0 C w N co o o o a a) Q a 0 a a 0 in. V o ao ��axo°❑E >� �4w>, �� o N o > 42 d" W 00 O w a y 0 Y M0 0w WC's A WO -0 0 CA -0 cwp °o) 0 Y'3 E N 2 cd tH L .. ��, L CU U ° ,� L cl O o w cn En U U °�' c c° n Y 3 3 z O d a o, Q, ct C7 � �, ca �, E Y m o °) 0 W> °.�— Z x °c ti ac 0 3 c '� a o P4a)04 ��o"^ �°?� ��'�'° _o Ldp Om biom 3 boo U•�dUO.0 oa `d� (U 4) 03 -0 aUi ;w ° `d +� E o 3 vi 10 ctsE U, cQ-°aO�w ° o �O o .. U �.0 o Iz:■N ° CLcu ac3a 0> a a O n >" W .° a) c� E ami 0 ca N Q c m N U (Y �) U W F" O N E 3 A c7 00 W E N 1- o H -0 c° M A y co E. a '> Z° `" w° . 0 0 0 :. U O 3 c cd cn (0 Z t 0 0 0 a, c«: o N C i N 0❑ C .O N� �, c N , 1 — a a OpOz��0 ° `°x Q ami U <1—M . oq H ca F W 0 I v Z> t 0 w H °� c 0 Q V N c X .� 'X . U 0. ) � 0 U:) 3 a0) O H P: ,: Q)) Q °:.: v° � Qi w 0� N c6 N L y U2oNN JCS o �yA>A 04°:ww =0= E o° TEco00a) v>> OQ��3=�:�''„� 'owY�A� E L o��EEE> C o CC . E E > F" O o c ca o V 3 > 0 0 a) 0 .0.O 0 N 0 0 a.a) a3A E of .-0wU aM A ..a u w— G. m00wwfr-2 m O M 0 N N N C: 0 v a� .raw N CD N O 00 00 L' a) -0 E 7 z (D 0 C� W, w N CV r- 14- C2 - v00 0 U vi W N E z U m .o Q y W O U U) a`) O N 7 U O U N C O U a Na C 4j U L a) m a o c a.N m m >,N Y a) O me E m N a) � � C Ca a) C Oc0a � U m c'O 0) O Co �OUa) Oa) L -C-O5o "a-0 0,0_ NE O) U .r- (n -0 'p N >+ E C E Q a) L aNi�cc N m m m Y > > L U m mO m t L O - OO U 0 a) L m0)"O_ O C C > a)`L��2 �<< a) 0 L 7 O _C t_ m mma) Y4- CU m O N L L 3 O 3 E O ° E � N Oo aL O N N � C C N � N cv N ❑ U d Q Q YYQ N N NCLU m C E E O ,t0 N W Q U (Lp c O w Q C m w 0 N CA c y 3 :3 a) —O Q) Q) iv Q) _E:. N 3 L •c .. L O -0 O � N 0 w Q) N — = a) O 0 0 a)� � E o c O , .. >> > O V > N 0 — Q) a) � a O 0 C C C Q N Q.L N MM2 a_ EC_ c 0 L O N 3 oca- L) 0 U O U -0 Q. 0 0 ommCD cnE'c7 w " > 3 C m . 3:0, a) c c O 0 V UL C 7 O Os •— C Q -Q E a) rn-0 O a m L y_ >, c C> 0 N L N a) O Q U Q a�m0rnaEcm L v C c Ea �LCo-0«+EEN Q.. N 7 C 0 L U L U « 'C Q' .f O Q) U O p L CL 7 U U O) a) a) L O 0c ymc QOC L � �0 "�O n cL0 iOO mQOCONCO 0.—. -- in cu a) a) .N O a) '0 '6 a a)a X ac 0 0 wch in c m c 0— m m 0 L m> m V .0 L C C j a) O= m u U= m 0 0 m d O U LO 0 O a m 0 0 0 (V N N c 0 .o a> C �a a) N m t 2 7 Q O C a) InC ' L L L C O L w L 0 c c o � 0 �a) c_ a _c c a3i a) L N L O N O a C 'u ami co 0) o (� CL m t C a — N r- U c N m m O O E o Nc O N a) ?� a)0 N >' m m C O) N L 3 C CD � c 0 � a) a) "' N C O >i 0p) aL N O N O "N a)O- 0 . 0 O rn.S 0 C C -O m 0 N cO u�30c .« () -O N L 7 c(nOa 0 m Q m m N" N C -O (0 E oa) U m :) a) 0).SN N O L O cn L C N p p 0 N a)ac� E 0) c E E�m00a)'5M N O N a) c O w > O U) L c O_ a) .O m L a) N •X c" X 0 y N a) a) te a) O N N.— 0 O O O 7 m 0 a) m M. N O) . > m O (>6 C ,C C C N r a)'a)om'00m=� d O U LO 0 O a m 0 0 0 (V N N c 0 .o a> C �a \ \ k E f / S / z � EL: / * Lal \ / k CQ @ k p : . § « \ EL: k / ( 2 All � @ 3 m . \ / k � ) ■ o � $ )� § \CD § 3 ƒ U) e \ 0 U) M In. § 0 Q / «cl 2 Q . / \ . W U - a. F] All � @ 3 m . \ / k / S _J w $ / $ \CD § / o LO \ 0 k k 0 k 3 d G G 2 2 \ k_ _ ~ > + � - a Ica— L. ■ m k \ 0. / / / o \ All � @ 3 m . \ / k § cc _J w $ o § / o LO \ 3 I 0 o q 3 d LO % LO \ I / / \ a- PELLA WINDOWS AND DOORS CONTRACT 1. TERMS AND CONDITIONS These Terms and Conditions are an integral part of the contract set forth on the Product Order (the "Contract") between New England Window and Door LLC dba Pella Windows & Doors, Inc. ("Pella") and the person(s) identified on the Product Order ("Owner") to supply the products (the "Products"), and perform 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 contract. 2. OWNER Pella is not responsible for any existing security systems. Owner shall remove all shades; verticals, blinds, curtains, drapes or window mounted air conditioners, prior to the installation of the Products. Pella's installers are not 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 windows. The Owner shall provide complete access to the work site between the hours of 7:00 a.m. and 6:00 p.m. (Monday through Friday) for Pella's installers to deliver the Products and perform the Work. 3. PELLA Pella will be responsible for and have control over construction means, methods, techniques, sequences and procedures and for coordinating all portions of the Work. Pella will be responsible for the Work of its Pella Contractors who will install the Products. Unless provided otherwise in the Work description, Pella will provide and pay for all labor, materials, equipment, tools and machinery, transportation, and other facilities and services necessary for the proper execution and completion of the Work. The materials and equipment furnished under the Contract will be good quality and new unless otherwise required or permitted, the Work will be free from defects not inherent in the quality required or permitted, and the Work conform with the requirements of this Contract. Pella shall not be responsible for damages or defects caused by abuse, modifications not executed by Pella, improper or insufficient maintenance, improper operation or normal wear and tear. Pella will keep the premises and surrounding area free from accumulation of waste materials or rubbish caused by performance of the Work. CHANGES The Owner may order in writing changes in the Work consisting of additions, deletions, or modifications ("Change Order"). Any Change Order shall include an adjustment to the Price and the Substantial Completion Date, as determined by Pella. Pella reserves the right to approve or disapprove any Change Order and any such Change Order must be signed by both Owner and Pella to be effective. SUBSTANTIAL COMPLETION Owner understands and agrees that the Substantial Completion Date is an estimate only and that the actual date on which the Work is completed may be 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 disputes, availability of subcontractors, acts of God, fire or other causes reasonably beyond Pella's control. If for any reason the Work is not fully completed by the Substantial Completion Date (including any extensions 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 to be replaced or repaired, a hold back proportionate to the cost of remaining 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. FINANCING 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 financing shall have been received from the financial institution. PAYMENTS 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 failure to pay Pella the amount due within seven days after the date payment is due. CORRECTION OF WORK Pella shall correct installation Work not in conformance with the requirements 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 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 remedy for defective workmanship, and is provided in lieu of any and all other remedies. Pella's obligation to correct Work is conditioned on Pella's prior receipt of all payments then due. LIMITED PRODUCT WARRANTY Pella shall warrant all Pella products, but only in accordance with the Pella Windows & Doors Limited Warranty. THIS LIMITED WARRANTY SHALL BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WRITTEN OR ORAL (INCLUDING WITHOUT LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE). 10. NO CONSEQUENTIAL DAMAGES UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR CONSEQUENTIAL, INCIDENTAL, INDIRECT, OR SPECIAL DAMAGES, WHETHER FORESEEN OR UNFORESEEN. 11. HOME IMPROVEMENT CONTRACTORS All home improvement contractors and subcontractors shall be registered with the director of the Home Improvement Contractor Registration Program administered by the Board of Building Regulations and Standards. Pella and any of its subcontractors identified in this agreement have been registered. Any inquires about Pella or any of its subcontractors relating to registration should be directed to: Director, Home Improvement Contractor Registration, 10 Park Plaza, Room 5170, Boston, MA, 02116, 617-973-8787, 888-283-3757 or visit the HIC website at http://wwtiv.mass,gov/ocabar/ 12. PERMITS (MA customers only) Pella is obligated to and will obtain the following permits for this project: Building . Homeowners who secure their own permits will be excluded from the guaranty fund provisions of Massachusetts General Laws, chapter 142A. In addition to the rights and warranties enumerated in this agreement, you may have additional rights under Massachusetts General Laws, chapter 142A and 780 Code of Massachusetts Regulations R6. 13. NOTICE OF CANCELLATION You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached Notice of Cancellation for an explanation of this right. Do not si n this contract if there are any blank spaces. Customer ignature 2/25/17 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 Pella Windows & Doors Contractor I -AO* omeow er 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. NOTICE OF CANCELLATION Date of transaction: 2/25/17 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 not later than midnight of transaction above). I hereby cancel this transaction. (Date) 45 Fondi Rd., Haverhill, MA 01832 (Buyer's signature) (three business days from the date of 1'he Commonwealth ofHassachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, M4 02114-20.17 www massgovIi9a �erarkers' Compensation Insurance Affidavit: Builders/Contractors/E+lectriciam/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Oiganization/Individual): Address: City/State/Zip: [-'Ay en t It M# Phone #: Are you an employer? Check the appropriate box: 'Type of project (required): 439mm a employer with I? (full, and/or part-time). %. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in S..ltemodeling any capacity. [No workers' comp. insurance requhrA) 3.E] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 9. Demolition 4.❑ I mm a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition ensure that all contractors either have workers' compensation insurance or are sole- 111-F] Electrical repairs or additions .110 Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the aifached sheet 13. Q Roof repairs These sub -contractors have employees and have workers' comp. insurance•f 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] *Any applicant that rhecks box #1 must also fill out the section below showing their workers' compensation policy information. - t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-conhadors have employees, they must provide their workers' comp. policy number. I am an employer that is provid ng workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Lir & Ca Policy # or Self -ins. Lic. #: 600 �() 4 Expiration Date: 77-1-177 Job Site Address: City1Sb&JTArp: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenaldes of perjury that the information provided above is true and correct Officsal use only. Do not write in this area, to be completed by city or town o0maL 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 #: A� CERTIFICATE OF LIABILITY INSURANCE 07/0DATE 72016MMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Fred C. Church, Inc. 41 Wellman Street Lowell, MA 01851 225-1865 CONTACT Dorothy A. Corlett, CIC, RPLU NAME: PHC NE978 3227231 FAX No): (978) 454-1865 E-MAIL doorieft@fredochurch.com ADDRESS: tt@kedcchurch.com INSURERS AFFORDING COVERAGE NAIC q INSURER A : Citizens Insurance Company of America 31534 INSURED New England Window 8 Door LLC INSURER B: New Hampshire Employers Insurance Company 13083 INSURER C: 45 Fondi Road Haverhill, MA 01832-1302. INSURER D: INSURER E: INSURER F: COVERAGES CFRTIFICATF NIIMRFR• 58475 RFVICInN NIIMRFR• 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. INSR LTR TYPE OFINSURANCE ADDL SUBR POLICPOLICYNUMBER MMIDDYEFF POUCYEXP MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,00o PREMISES Ea oaurrence $ CLAIMS -MADE M OCCUR MED EXP (Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 A X CG0001 ZBN8161407 7/12016 7/12017 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICYF_5PRO- X LOC - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident)$ NON -OWNED HIREDAUTOS AUTOS PROPERTY DAMAGE m (Per acci $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATIONX WC STATU- OTH- B AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 8007024 7/12016 7/12017 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE9 $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below 500,000 E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 101T.- ACORD IfB -n r rrivi i s nWLUCR VArgL /=LLA I IUI7 Town of North Andover 1600 Osgood Street, Suite 2043 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Nrth Andover, MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN -] ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD - �e c . � o :d e � o � d o N a c � a � h C o 6Q � coo 40 4w..- C fes` bF0 O r 10 to w t4. O rn a, c 0 r CO N G J r a0+ d ` t Q a y rn L U :C z WE e cc ra MLU W J ._J^> m 2 .W Z r, N .. d W .C, V ca X .-•� .i 2 .O.N,-, v^ W r. Cr).. E.. O O N o o z_ ao a a rn a d W N xa Z 0 p Q Z m W Z a x -F Z Z ` Q T . t' G' Wg sow T '? J `° L, > +' Z CL v 2