HomeMy WebLinkAboutBuilding Permit #1210-16 - 81 HICKORY HILL ROAD 5/1/2018 t OF NORTH q
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION * ,�
Permit No#: Date Received
gSS�1CHU5�4
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 91 J�tcK y Ad 1(0
Print
PROPERTY OWNER 3iW#{xFet `6WS(E
Print 100 Year Structure yes no
MAP Z10 PARCEL: DL2 ZONING DISTRICT:QHistoric District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building `,ane family
❑ Addition ❑`Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO� BE PERFORMED:
0- c, I�J2 Tl2 _
Nb
Identification- Please Type or Print Clearly
OWNER: Name: =E&L 1r_Fez Phone: 7S.dz�'Z-
Address:
Contractor Name: 5 L4ARhone:
Email:
Address: yr Citi h, G;612e.,L _ -„st=
Supervisor's Construction License: Exp. Date: 16 -2-6-�
Home Improvement License: -7R Exp. Date: 91
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
a
Total Project Cost: $ �S/710z3 FEE: $
Check No.: /� � r- Receipt No.: _S 03 U
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Flans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped flans ❑
TYPE OF SEWERAGE DISPOSAL i
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
❑ I
Private(septic tank,etc. Permanent Dumpster on Site ❑ �
i
�I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
h
i
PLANNING & DEVELOPMENT Reviewed On Signature_
I
COMMENTS
I
f
CONSERVATION Reviewed on Signature
I
COMMENTS
I
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/ Driveway Permit
DPW Town Engineer: Signature:
FIREDEPAR 384
oca e Osgood Street
_� .� �TMEN.T, Tempi®urnpster onsite, tyes��.
i(Locatedd�at;124IVIain'S,treet:
�F,i,`re{Deparrtinents 'gnature/date
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`COMMENTS .
__
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
i
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 Permit Revised 2014
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
OTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
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
Location /
No. f ��" ~ �C Date
• - TOWN OF NORTH ANDOVER
u v Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
V
Check#
v!
" '' '� Building Inspector
i
NORTH
Town of �� Andover
0
Zs-' / /�
o h ver, Mass,
COCNICNl WICK
R�TEO jkr
U BOARD OF HEALTH
Food/Kitchen
T LD Septic System
PERMIT
VTHIS CERTIFIES THAT ...............................................................��SF ...,.,,,.,,,. BUILDING INSPECTOR
. ...... ..1...........,...... .
(� D Oc Foundation
has permission to erect buildings on ''t
Rough
............................. /
to be occupied as . .. . ...<.....:... .....'r...
p rJJ lrLl�ms`d/ ........... . Cx Chimney
. ........... ....................................
provided that the person accepting this permit shall in every respect conform 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS_ TRUCTION S RTS 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.
Contract - Detailed
Pella Window and Door Showroom of Haverhill Sales Rep Name: Kelly, Thomas
® 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: kellytl@pellaboston.com
Customer Information Project/Delivery Address Order Information
Jennifer Dibiase Dibiase,Jennifer,1713423 Quote Name: Dibiase,Jennifer,1713423
81 Hickory Hill Rd 81 Hickory Hill Rd
Order Number: 741TKO059
NORTH ANDOVER,MA 01845-1114 Lot# Quote Number: 7805029
Primary Phone: (978)9790182 North Andover, MA 01845-1114 Order Type: Installed Sales
Mobile Phone: County: Payment Terms:
Fax Number: Tax Code: MA TAX 6.25
E-Mail: jennifercuozzo@hotmail.com Quoted Date: 4/29/2016
Great Plains#:
Customer Number: 1007879226
Customer Account: 1003748032
Line# Location: Attributes
10 None Assigned Delivery/Setup- Delivery/Setup Qty
1
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com
Printed on 4/30/2016 Contract-Detailed Page 1 of 5
Customer: Jennifer Dibiase Project Name: Dibiase,Jennifer,1713423 Order Number: 741TKO059 Quote Number: 7805029
Line# Location: Attributes
20 None Assigned Pella Brand, 2-Wide Entry Door Sidelight, 51 X 81.75, Early American,4 9/16" Qty
1
1:1280 Fixed Entry Door Sidelight
PK# Frame Size: 13 1/2 X 81 3/4
784 Unit Type: Fixed Inswing,Standard Sill
Dimension Options: No Cut Down
I General Information: 5 7/8", 1 5/16",4 9/16"
l Panel Style: Full Light
Azr� Glass: Tempered Low-E Air Filled
Viewed From Exterior Grilles: No Grille
Frame Size:51"X 81.75" Panel Selection: Mahogany,Stained,Early American,Stained,Early American
Frame Selection: Clad,Pine,Oak Threshold,No Panel Reinforcement,Standard Enduraclad,White,Wood, Primed
Hardware Options: Bronze Finish Sill
Vertical Mull 1: FactoryMull,Standard Joining Mullion-Doors,Frame To Frame Width-0"
2:3680 Fixed Entry Door
Frame Size: 37 1/2 X 81 3/4
j Unit Type: Fixed Inswing,Standard Sill,No Fire Rating,No Fire Rating
Dimension Options: No Cut Down
General Information: 5 7/8", 1 5/16",4 9/16"
Panel Style: Craftsman Light
Glass: Tempered Low-E Air Filled
Grilles: Simulated Divided Light,7/8"Contour,Match Interior Panel Finish, Match Exterior Panel Finish,Traditional,Typical,3,2
Panel Selection: Mahogany,Stained,Early American,Stained,Early American
Frame Selection: Clad,Pine,Oak Threshold,No Panel Reinforcement,Standard Enduraclad,White,Wood,Primed
Hardware Options: No Bore,Oil Rubbed Bronze,Bronze Finish Sill
Unit Accessories: No Dentil Shelf,No Bang Panel
Vertical Mull 1: FactoryMull,Standard Joining Mullion-Doors,Frame To Frame Width-0"
Wrapping Information: Nail Fin,Factory Applied,No Exterior Trim,No Interior Trim,4 9/16",5 7/8",Factory Applied,Pella Recommended Clearance,
Perimeter Length=266".
Entry Trim Finish-Finish Paint/Stain Entry Interior Trim Only Qty 1
ES—Single with S/T-Install Single Entry Door with Sidelight and/or Transom Qty 1
PVC Upgrade>48-PVC Upgrade greater than 48 inches Qty 1
Line# Location: Attributes
25 None Assigned Entry Systems, Storm Door Fullview Interchangeable Unhanded, 36 X 80,White Qty
i . (91025) 1
1:3680 to 81 Unhanded Storm Door
PK# Frame Size: 36 X 80
9 " 784 General Information: Clad
Exterior Color/Finish: Standard Enduraclad,White
Sash/Panel: 1 5/8"Extruded
Glass: Clear
Hardware Options: Standard,Oil Rubbed Bronze
Viewed From Exterior Model: 4601
Frame Size:36"X 80" Wrapping Information: Perimeter Length=232".
ES Storm Door-Install Storm Door Qty 1
For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com
Printed on 4/30/2016 Contract-Detailed Page 2 of 5
i
Customer: Jennifer Dibiase Project Name: Dibiase,Jennifer,1713423 Order Number: 741TKO059 Quote Number: 7805029
I
Thank You For Purchasing Pella® Products
1 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)infonnation 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.NFRC 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.
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
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com
Printed on 4/30/2016 Contract-Detailed Page 3 of 5
Customer: Jennifer Dibiase Project Name: Dibiase,Jennifer,1713423 Order Number: 741TKO059 Quote Number: 7805029
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 aqrees 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
jad Project Checklist has been reviewed
Customer initial
Product Only Addendum has been reviewed
Customer initial
Credit Card Account#: Last 4 Digits
4 6 4 3
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com
Printed on 4/30/2016 Contract-Detailed Page 4 of 5
Customer:Jennifer Dibiase Project Name: Dibiase,Jennifer,1713423 Order Number: 741TKO059 Quote Number: 7805029
Expiration Date: 0 1 / 1 9
Charge final payment to same account jad
(Upon substantial completion) Customer initial
i
'I Project Checklist has been reviewed
Jennifer DiBiase Thomas Kelly
! Customer Name (Please print) Pella Sales Rep Name ( lease print) Order Totals
�eyj{-j f fed f�1�f1e Taxable Subtotal $3,225.30
Customer Signature Pella Sales Rep Signature Sales Tax @ 6.25% $201.58
4/30/2016 4/30/2016 Non-taxable Subtotal $1,573.20
Date Date Total $5,000.08
Jell;11f6- DirWe Deposit Received $2,500.00
Credit Card Approval Signature Amount Due $2,500.08
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com
Printed on 4/30/2016 Contract-Detailed Page 5 of 5
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 perforin 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. ]I. 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:
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, rovided ou notif
complete the Work is affected by conduct of the Owner,weather,labor p Y Y
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 re
financing paperwork must be completed upon signing of this Contract and the ,e��ifep D/W1'
requisite approvals and authorizations for the full amount of the requested
financing shall have been received from the financial institution. Customer signature
04/30/2016
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
jelliv fel- A$i4fe
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.
NOTICE OF CANCELLATION
Date of transaction: 04/30/2016
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 05/04/2016 (three business days from the date of
transaction above).
I hereby cancel this transaction.
(Date) (Buyer's signature)
The Commonwealth o��lWasscachusear,
N -
Department of Industrial Aecidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 021 14-2017
-
nwminass.govIdia
Workers' Compensation Insurance Affidavit: Buildelrs/Contt>ractors/Electricians/Plumbe>rs
Applicant Information Please Print Leeihly
Name(Business/Organitatiot>/Individual): ,C ' ,/a �;{1� .?7� Z_
Address: "
City/State/Zip: !: 1 Phone#: A - S_-72,
,;j,S'
Are you an employer?Check the appropriate box: Type of project(required):
1.[5,l am a employer with -S 4. ❑ I am a general contractor and 1.
have hired the sub-contractors 6. ❑New construction
employees(full and/orpart-time). •
*
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. rKRemodelina
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers'comp. insurance comp. insurance.=
❑
required.] . 5. ❑ We are a corporation and.its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbi..ng repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c. 52, §1(4),and we have no 13.❑Other
employees. [No workers'
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 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-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. i3elow is the policy and job site
information.
Insurance Company Name: 01,4 Lr� �
Policy#or Self-itis.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do herebp certify under the pains and penalties of pet jury tl:at the information provided above is true and correct
Sianattue:
Phone
Official use onlJ. Do not write in this area, to be completed by city or town offrcial.
City or Town: Permit/License#
Issuing Authority(circle one):
ll, board of Health 2. Building Department J.City/Town Clerk 4, Electrical inspector- 5. Plumbing Inspector
6. other
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TIFICA T E OF LIABILITY INSURANCE w2812015 on"
`PHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIRE CERTIFBCAIE HOI�9ER THIS
CERTIFICATE GOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
REPRESENTATIVE
THIS CERTIFICATE E AND
THE
ROES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{St AUTHORM
REPRESENTATIVE OR PRODUCER,AND THE GERTiFlCATE HOLDER.
IMPORTANT IP the certificate hDldea is an ADDITIONAL INSURER,thepolicypesp enDsthe endorsed IP
certificate balder In fi®RT®Esaach SUBROGATION IS NIAI{lEtD, subject to
the teens and conditions of the policy;certain pDGcles M.relgmlre an Ondayseimut. A slateyrlent on This R�rtiRI does not co
PRooucER nfer aigI�L,to the
endDysemen sj.
Fled C.Church bra 0 EACF l i ff I A CadeD G7C,RPLU
Al WeOrrren56es[
I.Owd.MAD1851 PHONE y�3a7261
(800)225.1865 IL Fi FAC Hal; I9711)454-1965
ADDRESS: 82dmhunir wm
OfiURER AFFORDING COVERAGE MAIC D
INSURED INS ERA-. C"llimRsurmmCanwnyoFAmedea 31534
N-rmorm OUrmlaw 6 OWLLC INSURER B• Noviompshlra Employers hrstaenra Company 13093
45 Fondl Road INSURER G:
NauedA MA DISI
INSURERD:
INSURER E:
COVERAGES CERT IFICA l lE NUMBER. INSURER F:
54457
THIS 15 TO CERTIFY i FIAT THE pOUC1ES OF INSURANCE LISTID BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEREVISION FOR THE POLICY PERIOD
INDICATED. NOTVNTHSTAMDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATT_MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
LINSR TYPE OF INSURANCE ADDL SUER
GENERAL LIAIBILITV PDLIpY EFf POUCp ENp
U4BILITV POUCYRUMBER MMIO
LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.006,000
D E
X AGft 100,000
CLAIMS MADE a OCCUR ISES a arcurrenae S
A 1( CGD001 MED EXP Any ane pawn) S WIC
ZBNB1fi140T 1/1/2015 11112016
PERSONALGADVIMLRY S 1ADD,000
GEM.AGGREGATE LIMB APPLIES PER: GENERAL AGGP.EGATE S ZOOD-000
POLICY X PRO- X LOC PRODUCTS-COMPIOPAGG S ZIMD.000
AUTOMOBILELUI6Rr1Y S
ANYAL(TO
COMBINED SINGLE UGIT
accident $
AN
UTOS �
USCHEDULED 6p01LYINJURY(Parpersan( S
HIREDAUTOS NO 005 SODILYIN.IURY(PQraufdenll $
PROS[14 BE S
UMBRELLA URB OCCUR $
EXCMSUAS CLAIMS-UADE EACHOCCURRENCE S
DEO RETE1nDNS AGGREGATE g
WORKERS COMPENSATION
AND EMPLOYERS'LIABRJTY S
B ANYPROPRIETORIPARTMUDIECUi1VE YIN H WCSTM„- ETH
OFFlCERIMEMBER EMLUDED7 ❑ NIA 40004D101
andatoryl500.000
[Mn NII) 7l11?O16 EL EACH ACCIDENT $
OESCRIPTIIONOFOPERATION5lrelase EL DISEASE-EA EMP $501).000
EL DISEASE-miry UMrT $500.000
DESCRIPTIONOFOPERA71ONSILOCATIMIVENICLES(AUacmACOR0101,AddiOormlltemarlrs5chedale,rTarmaspacemagrdced)
CIERT oFICAYE 0 80LDER
CANCELLSTION
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WILLI�4M R i�TICIOLS
7•PEARTREE RD"' a
HAVERMLL MA-'Q1830
Commissioner 16/2612016
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.V llP ((�a7T(717CJ72CCt<;CC�Jf!n ��ICYJJC(C�((JC tN•
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ie of Consumer Affairs&Business Regulation License or registration valid.for individul use only
E IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
y istration: 183279 Type: 10 Park Plaza-Suite 5170
Expiration:--9/24/201:7 Supplement C;.±rd Boston,MA 02116
NEW ENGLAND WINDOW`&'DOOR, LLC.
PELLA WINDOWS&-DOORS
William Nichols
45 FONDI ROAD
HAVERHILL,XAA 01832 .
Undersecretary Not valid.without signature