Loading...
HomeMy WebLinkAboutBuilding Permit #583-2017 - 507 SALEM STREET 12/1/2016 Th BUILDING PERMIT of "0 D Q TOWN OF NORTH ANDOVER ..,•6=`� APPLICATION FOR PLAN EXAMINATION " '- Date Received Permit No#: y - 1� �AATE�I.PR •� • �SSgcHus�•c Date Issued: ORTANT:Applicant must complete all items on this page L n � D �+ t O 3 V _ -- -- - G - Pnnt 1DD,l`' 5tructure yes a rio MAPS ,•_..._' _a_ ARCEL .w_- ZONING DISTRICT: . .Historic Distract. tiyeY"1 Machine�Shop �,� 7° ❑ .'�._ -1, �f,,r_l:a.c:1_.,F-.-_.f..�,.na.cac�aCiec �s r_._� ate._ ta..�. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building A One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial 9-Repair, replacement rY lacement ❑Assesso Bldg ElOthers: ❑ Demolition ❑ Other 0 Septic Vltell ❑ Floodplain ❑Wetlands Watershed District .�❑_ Water/Sewe_ r: ��. ����:�_�_�...r.... Y*" _- •,,� `�� ��� ��; { DESCRIPTION OF WORK TO RE PERFORMED: I Identification- Please Type or Print Clearly' I 3' - A �' OWNER: Name: n�4 Ps 1 Z Phone: c-- -7,),3-9351 Address: Sw S S Contractor Name: �� .. � .( .� Phone Q-? ?4.97 7d,-S-' 7'_` �.. �.��,y :�'� r x" •y. i .. '"' . . �,� a .,„. ; J 'iw'. r '�”` t . } ..�.J�'�,•y:K r�-C3� �»� w.sr- ..-T. -_: -a.•. (moi" �.�'+Y M�+���'' d It`..i..-. Ac ,� = r ,��iiY�'.,"��..- I-`��'�(+ ;7r��b ty "..G'l I�>.. - � �� TY�1- y �• c lW •j`f ��LJG,�.":`L.�7 +Z•�"t� .++� f.._...r�� 'Ti.iEL# �,� r� y, F. GIRD y . Su-erv�sor s Const'ruction�License _:. �_. s : '-. . Ex _ Date f} Gc _�.¢ P� Hornellrnproverent°License ARCHITECT/ENGINEER Phone: Address: Reg. No.. FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST B ED ON$125.00 PER S.F. ;total Project Coit: $ "TDUa FEE: $ Check No.: Receipt No.. r210 NOTE: Persons contracting with unregistered contractors do not have:access to the guaranty fund Si'natu�e_of.A _ent%Ow�er' cy�, `ignatu.re of contractor.,? Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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 Pp Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And G.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 j 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) ❑ Co o n�__ Copy I f Contract lI dcL ❑ 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 Doe:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ r TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic �c tise t etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS P 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: Signature: Located 384 Osgood Street FIRE DEPARTMENT -' Temp Dumpster on site yes no Located at 124.Main Street Fire Department signature/date COMMENTS limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: =f ELECTRICAL: Movement of Meter location, roast or service dropyequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No � MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 Location No. 1 Date �2- /' ! • TOWN OF NORTH ANDOVER • � Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $_ _ Other Permit Fee $ TOTAL $ � Check# (/Building Inspector ORT F N H Town Of ndover. o - �, 7 Din LANE h ver, Mass O COCNIC Nl WI[N V S U BOARD OF HEALTH Food/Kitchen PERMI T Septic System THIS CERTIFIES THAT .. .. ......,. .,... .�.,!M. ........ . ..% „+,,,�,,,, BUILDING INSPECTOR has permission to ere . ....... buildings on ....��...... ... r� �, ,............ Foundation ................. ..... ............... � • ��� Rough tobe occupied as ....... .....t .. ...... ... ....� ........ .................................................. Chimney provided that the person acceptin his permit shall in every respect conf m to 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STRA 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 Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. NORTI� Town of _ ndover. O .I.,' .4 ml ti (� No. .T - ver Mass Din ". h .� COC NIC Nl WICK AORAtED s u BOARD OF HEALTH Food/Kitchen PERMI T Septic System THIS CERTIFIES THAT.. .. ........� a .. ..... ,�„�� � pi BUILDING INSPECTOR has permission to ere Foundation p .................. ....... buildings on ....�... ...... .... .. ..v�..... .�........... • • ��� Rough tobe occupied as ....... ..... .• ..... ... ....��........ .................................................. chimney provided that the person acceptin his permit shall in every respect con f m to 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC ST Rough Service ........ ....... ....... ... r.�....................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. v Contract - Detailed Pella Window and Door Showroom of Haverhill Sales Rep Name: McLoughlin, Daniel 45 Fondi Rd ' Sales Rep Phone: 978-373-2500 Haverhill, MA 01832 Sales Rep Fax: Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: mcloughlindv@pellaboston.com Customer Information Project/Delivery Address Order Information Tony Ruisanchez Ruisanchez,Tony,1815153 Quote Name: 350 Series Patio Slider 507 Salem St 507 Salem St Order Number: 741 DV0152 NORTH ANDOVER, MA 01845-3109 Lot# Quote Number: 8453783 Primary Phone: (305)7258381 North Andover, MA 01845-3109 Order Type: Installed Sales Mobile Phone: County: Payment Terms: Deposit/C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail: antonil970@aol.com Quoted Date: 11/8/2016 Great Plains#: 11272381 Customer Number: 1008157890 Customer Account: 1004087129 Line# Location: Attributes 10 None Assigned Delivery/Setup- Delivery/Setup Item Price Qty Ext'd Price $235.00 1 $235.00 For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 11/9/2016 Contract-Detailed Page 1 of 8 t Customer: Tony Ruisanchez Project Name: Ruisanchez,Tony,1815153 Order Number: 741DVO152 Quote Number: 8453783 Line# Location: Attributes 15 Deck Pella 350 Series, Double Sliding Door Vent Right 1 Fixed, 71.5 X 79.5,White Item Price Qty Ext'd Price $4,476.91 1 $4,476.91 1:7280 Vent Right/Fixed Double Sliding Door PK# Frame Size: 71 1/2 X 79 1/2 tirr— Interior 824 General Information: Yes,Standard,+/-50,+/-50,Vinyl, Nail Fin,Foam Insulated,6", 1 3/8",4 5/8", No Sill Riser Exterior Color/Finish: White Color/Finish: White Glass: Insulated Dual Tempered Low-E Low-E Insulating Glass With Window Fashions Air Filled Non High Altitude 71Z Hardware Options: Keylock Included,White,White,Steel Viewed From Exterior Screen: Sliding Screen,White,Premium,Conventional Fiberglass Unit Accessories: Blinds-Between-The-Glass,White Performance Information: CPD Not Rated,Performance Class R,PG 50,Calculated Positive DP Rating 50,Calculated Negative DP Rating 50,Year Rated 08 Wrapping Information: No Interior Trim, Pella Recommended Clearance,Perimeter Length=302",Glazing Pressure=175. Frame Size:71.5"X 79.5" Lead Safe Install-Lead Safe Install Qty 1 PD-2 Wide-Install 2-Wide Sliding Patio Door Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 Wrap Coil Stock-Full Capping per unit Qty 1 Line# Location: Attributes 20 40% Off Installation Item Price Qty Ext'd Price ($440.00) 1 ($440.00) For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 11/9/2016 Contract-Detailed Page 2 of 8 r Customer: Tony Ruisanchez Project Name: Ruisanchez,Tony,1815153 Order Number: 741 DV0152 Quote Number: 8453783 Line# Location: Attributes 25 5% Same Day Decision Item Price Qty Ext'd Price ($213.00) 1 ($213.00) 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 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. Product Performance Information: U-Factor, Solar Heat Gain Coefficient(SHGC),and Visible Light Transmittance(VLT)are certified by the National Fenestration Rating Council(NFRC).Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product performance.NFRC ratings are determined for a fixed set of environmental conditions and a specific product size.NERC does not recommend any products and does not warrant the suitability of any product for any specific use. Design Pressure(DP),Performance Class,and Performance Grade(PG)are certified by a third party organization,in many cases the Window and Door Manufacturers Association (WDMA). The certification requires the performance of at least one product of the product line to be tested in accordance with the applicable performance standards and verified by an independent party. The certification indicates that the product(s)of the product line passed the applicable tests.The certification does not apply to mulled and/or product combinations unless noted.Actual product results will vary and change over the products life. For more performance information along with information on Florida Product Approval System (FPAS)Number and Texas Dept.of Insurance(TDI)number go to www.pella.com /performance. For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com Printed on 11/9/2016 Contract-Detailed Page 3 of 8 Customer: Tony Ruisanchez Project Name: Ruisanchez,Tony,1815153 Order Number: 741DVO152 Quote Number: 8453783 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 During the Installation Pella 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 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 followinq: 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 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 11/9/2016 Contract-Detailed Page 4 of 8 . Customer: Tony Ruisanchez Project Name: Ruisanchez,Tony,1815153 Order Number: 741DVO152 Quote Number: 8453783 W Project Checklist has been reviewed Customer initial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits Expiration Date: / Charge final payment to same account (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.pelia.com Printed on 11/9/2016 Contract-Detailed Page 5 of 8 Customer: Tony Ruisanchez Project Name: Ruisanchez,Tony,1815153 Order Number: 741DVO152 Quote Number: 8453783 ❑Project Checklist has been reviewed Antonio Ruisanchez Dan McLoughlin Order Totals Custom Na (Please print) Pella Sales Rep Name (Please print) Taxable Subtotal $3,191.91 Sales Tax @ 6.25% $199.49 Customer Signature Pella Sales Rep Signature 11/9/16 Non-taxable Subtotal $867.00 11/9/16 Total $4,258.40 Date Date Deposit Received $2,129.20 Amount Due $2,129.2914 Credit Card Approval Signature For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com Printed on 11/9/2016 Contract-Detailed Page 6 of 8 PELLA WINDOWS AND DOORS CONTRACT 7. 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 p 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://www,mass.gov/ocabar/ Work. 12. PERMITS(MA customers only) 4. CHANGES Pella is obligated to and will obtain the following permits for this project: Buildin . 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. 13. NOTICE OF CANCELLATION 5. SUBSTANTIAL COMPLETION 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/o this right. exceed the amount of the completion costs or 10 of the remaining unpaid 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 r financing shall have been received from the financial institution. (Customer sina u , 1 1/9/16 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 Pella Windows & Doors Contractor Homeowner 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. Y 1 Q NOTICE OF CANCELLATION Date of transaction: 11/9/16 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 11/12/16 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) The catrrmonwealth offffassachuseav Department of lrrdetstria[Acc derztS ' 1 congress S'treg,Suite-too s Boston,M4 02114-2017 www_naassegov1i a INkkers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/plambers. Aticant Information TO BE FILED WITH THE pERMITnNG AUTHORI'T'Y. PIease Print Le "bl Name(Business/Organizaiion&ldivid',d): Address: Ir City/State/Zip- & eff as, , Phone#: m �� Are You an employer?Check the appropriate box: am a employer with—ployees({�1.anaorpart-time).* Type of project(required): 2. I am a sole rietor or artamship 7. ❑New construction ❑ PmP p and have no employees working for in any cap=ih'•[No wodcers'comp.insurance requhei) S• modeling 3.❑I am a homeowner doing all work myself[No workm,comp.Pima ince��e1 t 9. ❑Demolition 4.❑I am a homeowner and will be 10 huzng conhactnts to_gonductaU wor�on-my pmpeAy I�vill ��addl�oIl a conhaclnrserlherbavewo�s- m com�ensahon msnrance orare-sole_ _ propnetor;with no employees_ " Elecfncaie�aus or additi F Ons_tv S.❑I am a general contractor and I have hired the 12-❑Plumbing repairs or additions sub-Confra�' .listed on the attached sheet These sub-contactor have employees and have worlo rs'comp.msMM,A t 13.❑Roof repairs 6.❑We are a corporation and its ofcers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers' comp.insurance rrt)uired] fAny applicant that checks box#1 must also fll 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 cordractors must submit anew affidavit indicating such, $Cofactors that check this box must attached an additional sheet showing the name of the sub-rontmatms and slate whether or not those entities have empkayees. If the suh-conbactors have employers,'bey must Provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees Below is thepolicy andjob site information. p Insurance Company Name: k —PL l Policy#or Self-ins.Lic.#:-- o o Expiration Date:_ _7®/ Job Site Address: Ciiy/State/T,tp; 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 and penalties of perjury that the information provided above is true and correct Simature: Date: Phone#: o Offu'ial use only. Do not write in this area to be completed by city or town offrcial City or Town: Permit/License# Issuing Authority(circle one):. I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• A ' QD DATE(MMIDD YYY1) ys CERTIFICATE OF LIABILITY INSURANCE 07/D72916 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 CONTACT Dorothy A.Codeft,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 976 3227231 FAX (978)454-1865 Lowell,MA 01851 C o t: AIC No (800)225-1865 ADDRESS: dcedeh@fredcchurch.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: Citizens Insurance Company ofAmedca 31534 INSUREDINSURER 8: New Hampshire Employers Insurance Company 13083 New England Window 5 Door LLC INSURER C: 45 Fondi Road Haverhill,MA 01832-1302 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:58475 REVISION NUMBER: j 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 ADDTYPE OF INSURANCE INSR SUER POLICY NUMBER MMIDDPOUICY LTR NYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE 171 OCCUR MED EXP(Any one person) $ 10,000 A X CG0001 ZBN8161407 7/12016 7112017 pERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 17 POLICY PR6 X jECT X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT O,accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident) UMBRELLA LUIS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X I VC SORYTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN❑ NIA 5007024 7/12016 7112017 E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION 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 yp Client# Mst# 58475 Cert Holder# 19515 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Massachusetts Departrr�en t Board ofuiidin uhiic ,Safety. 9 Regulations of°o and Standards License: CS-089853 VLT rr,.dction SUperuisar .< ., .ka n i WILLIAM R NICHOLS a > k ' 57 PEARTREE RD s' HAVERHILL MA 0'1830. � a y C'n'missiotier Expiration: 1®/26/2®as a , It-'r r ce of Consumgr A ffairs&Business Regulation.' VIE IMPROVEMf N7; License or registration valid:for individul use only ;CONTRACTOR before the expiration date.'itf found return to: egistration 188 794 Office of Consumer Affairs-Suite 5870 and business Regulation =' Expiration .9/24,20h7 Type: 10]Park Plaza NEW ENGLAND-WINDOW g,•pp 0P Supplement C Ird Boston,MA,02116 PELLA WINDOWS &DOORS h . LLC. William Nichols i 45 FONDI ROAD HAVERHIL.L,MA 0.1832 . i UndersecretaryNot valid without signature i i `s I