HomeMy WebLinkAboutBuilding Permit #187-2016 - 95 PHILLIPS COMMON 8/11/2015 ` "
Aa-i t yr r BUILDING PERMIT �� No DTH
Z ry�g4 646
TOWN OF NORTH ANDOVER -
APPLICATION FOR PLAN EXAMINATION 70
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Permit No#: oQ 0//, Date Received �gssgcIC
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Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION !'S 006� G�rn Ca �►,�
Print
PROPERTY OWNER RuO o L,0cL lwlt PLf'F_eL_
Print 100 Year Structure yes no
MAP PARCEL: �4 . ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building i<ne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial j
-5I.Repair, replacement ❑Assessory Bldg ❑ Others: i
❑ Demolition ❑ Other i
Septic 01Nelli ❑ Flo:otlplam Wetlands ❑ 1Natershedn D'stnct,
01Nater/Sewer;
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Cvt>OL_Pu+ INtuttaK Phone: 97&ft6`..Y7TS—
Address: � S (-A-4 A-4
Contractor Name:Pie u Iv k[ e � Phone: t,
Email:
Address: L4 F-bNrat-- Ko s6 4_&4G( Gw 046-2Z
Supervisor's Construction License'--a Exp. Date: lD ZG
-Home.Improve.ment License: t Ti-3 Exp: Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDIN(yPERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $`fes— FEE: $ ���
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ "
TYPEOF 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 e U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
a
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance Petition ti tion 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
Located at.1,N,���2{{4-- Main Street" `�`m� Du�mp� ir�ons�t.e "
� � r�,���'.�•:��$ t �m �#"
Fire Departmen signature%dateyd.':� j r � r{; ix . ,�� Z,
- ......'., _,a.-.�.:ir,.+.G'r....•�'- n ,y r ,,• ;g
� �Cn"'w�„":Arx4 [�-1� ��Q„+. err k tt H :" .a. 6 �bt a.rt�+Yay„ •, .a +t�},yrti 'r t r ori. y,. .r yr k¢� 4r��;;,�c,. ",,+� .• .
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c,.a,:f.:�.:ewr_ ^' „� c� trs wy...�' i• •.y�y,.,rb .a+. .y'!.�'Si#* t, �+�{` �'
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
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ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER
Z®IVE LITERATl1RE. Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department arse)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
M
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
6 Two Sets of Building Plans (One To Be,Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable).
Copy of Contract
2012 I ECC 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
r
Location -
No. �_ ' Date
• - - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
' Building/Frame Permit Fee $
Foundation Permit Fee $
�'4�(Pti446
P Permit
Other e Fee
TOTAL $
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Check'4t
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29194
Building Inspector
NORTH
Town of t ,. ndover
o-� ,,j -2bl
LAME h ver, Mass,
COC
MICMlWOC,[-4�'
"x,95 R�TEO 101�,`��
U BOARD OF HEALTH
Food/Kitchen
PER. MIT T D Septic System
THIS CERTIFIES THAT .........�. ... 7' .............................. BUILDING INSPECTOR
r........... ............................................
//�, �S p�7?�O-� Foundation
has permission to erect .................:.:...... buildings on .�,,�..�...... ............�.......................................
C, Rough
to be occupied as ......................1..........t--, .... �GG F........�..........1.�....i�!�!r�,P...�..�................................. 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
Service
....................... .....................
Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
` Contract - Detailed Q
Pella Window and Door Showroom of Haverhill _I
Sales Rep Name: Simpson, Jeffrey
® 45 Fondi Road Sales Rep Phone: 978-373-2500
Haverhill, MA 01832 Sales Rep Fax:
Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: SimpsonJS@Pellaboston.com
F s �
Customer Information Project/Del ivery,Address Order Information
Rudolph Mutter Mutter,Rudolph,North Andover,MA,1588418 Quote Name: Fiberglass Bathrooms
95 Phillips Cmn 95 Phillips Cmn
Order Number: 741JS0357
NORTH ANDOVER, MA 01845-4046 Lot# Quote Number: 6913165
Primary Phone: (978)7614775 NORTH ANDOVER, MA 018454046 Order Type: Installed Sales
Mobile Phone: County: ESSEX Payment Terms: Deposit/C.O.D.
Fax Number: Tax Code: MA TAX 6.25
E-Mail: rfmutter@comcast.net Quoted Date: 7/1/2015
Great Plains#: 9461131
Customer Number: 1007253122
Customer Account: 1002958361
Line# Location: _ Attributes
10 None Assigned Delivery/Setup- Delivery/Setup Item Price Qty Ext'd Price
$188.00 1 $188.00
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com
Printed on 7/2/2015 Contract-Detailed Page 1 of 5
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Customer: Rudolph Mutter Project Name: Mutter,Rudolph,North Andover,MA,1588418 Order Number: 741JS0357 Quote Number: 6913165
Line# Location: _ w Attributes
15 Down Bath Impervia, Double Hung, 27.5 X 53.5, White Item Price Qty Ext'd Price
$905.24 2 $1,810.48
1* 1:2854 Double Hung,Equal
PK# Frame Size: 27 1/2 X 53 1/2
General Information: Standard,Duracast®, Block, Foam Insulated,3",3"
716 Exterior Color/Finish: White
Interior Color/Finish: White
_. Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
m, Hardware Options: Cam-Action Lock,White
Viewed From Exterior Screen: Full Screen,InViewTM
Frame Size:27.5"X 53.5° Grille: GBG, No Custom Grille,3/4"Contour,Traditional(3W2H/OWOH),White,White
Wrapping Information: Replacement Precision Fit Kit, No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length= 162",
Glazing Pressure=205.
PI—Pocket Integrated Stop-Pocket Integrated Stop Qty 1
'Line# Location: _ ° , v . _ Attributes a
20 up Bath Impervia, Double Hung, 27.5 X 49.5, White Item Price Qty Ext'd Price
$753.92 2 $1,507.84
1:2850 Double Hung,Equal
PK# Frame Size: 27 1/2 X 49 1/2
ba
716 General Information: Standard,Duracast@,Block,Foam Insulated,3",3"
Exterior Color/Finish: White
Interior Color/Finish: White
Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude
Hardware Options: Cam-Action Lock,White
Viewed From Exterior Screen: Full Screen,InViewTM
Frame Size:27.5"X 49.5' Grille: GBG,No Custom Grille,3/4"Contour,Traditional(3W2H/OWOH),White,White
Wrapping Information: Replacement Precision Fit Kit, No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length= 154",
Glazing Pressure=130.
PI—Pocket Integrated Stop-Pocket Integrated Stop Qty 1
Thank You For Purchasing Pella® Products
PELLA WARRANTY:
Pella products are covered by Pella's limited warranties in effect at the time of sale.All applicable product warranties are incorporated into and become a part of this contract.
Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of 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.
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com
Printed on 7/2/2015 Contract-Detailed Page 2 of 5
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Customer: Rudolph Mutter Project Name: Mutter,Rudolph,North Andover,MA,1588418 Order Number: 741JS0357 Quote Number: 6913165
INSYNCTIVE PRODUCTS: In addition,Pella Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products
Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive
Software Agreement and Privacy Policy are part of the terms of sale.
Project Checklist Review (Installed Orders Only)
Before the Installation the Homeowner agrees to do the following:
Obtain Condo Association Approval
Obtain Historic Approval
Remove existing shutters and awnings
Remove air conditioners
Remove existing shades, drapes, window treatments, wall hangings, and personal belongings
Move furniture at least 3 feet away from work area
Tie or cut back trees, bushes and shrubs in the work area
Arrange to have alarm system and doorbells disconnected
Arrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor
Provide a door handle and lockset for entry door if Pella handle and lockset is not purchased.
s
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 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
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com
Printed on 7/2/2015 Contract-Detailed Page 3 of 5
Customer: Rudolph Mutter Project Name: M utter,Rudolph,North Andover,MA,1588418 Order Number: 741JS0357 Quote Number: 6913165
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
K(V\ Project Checklist has been reviewed
Custoiuei 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.pella.com
Printed on 7/2/2015 Contract-Detailed Page 4 of 5
Customer: Rudolph Mutter Project Name: Mutter,Rudolph,North Andover,MA,1588418 Order Number: 741JS0357 Quote Number: 6913165
[X Project Checklist has been reviewed
Rudy Mutter Jeff Simpson
Custo ame (Please print) Pella Sales Rep Name (Please print) Order Totals
-AJt "D� Taxable Subtotal $2,326.32
4Z 92--�'-��(Gust er Signature Rep SignatureSales Tax @ 6.25% $145.40
7/2/15 7/2/15 Non-taxable Subtotal $1,180.00
Date Date Total $3,651.72
Deposit Received $3,651.72
Credit Card Approval Signature Amount Due $0.00
For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pelia.com
Printed on 7/2/2015 Contract-Detailed Page 5 of 5
NOTICE OF CANCELLATION
Date of transaction: 7/2/15
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 forerformance of all obligations under the contract.
p g
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
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not later than midnight of 7/8/15 (three business days from the date of
transaction above).
I hereby cancel this transaction.
(Date) (Buyer's signature)
PELLA WINDOWS AND DOORS CONTRACT 7• PAYMENTS
Pella shall be entitled to stop the Work upon written notice to Owner for any
1. TERMS AND CONDITIONS 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 Pella shall correct installation Work not in conformance with the requirements of
Only purchases,a signed"Product Only Addendum"is a required part of the the Contract,if notified in writing by the Owner within two years after the
contract. 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
2. OWNER 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 all remedy for defective workmanship,and is provided in lieu of any and all other
shades;verticals,blinds,curtains,drapes or window mounted air conditioners, remedies.Pella's obligation to correct Work is conditioned on Pella's prior
prior to the installation of the Products.Pella's installers are not responsible for receipt of all payments then due.
the removal or installation of these types of items. Pella is not responsible for
pre-existing window coverings fitting on newly installed Pella windows. 9. LIMITED PRODUCT WARRANTY
The Owner shall provide complete access to the work site between the hours of Pella shall warrant all Pella products,but only in accordance with the Pella
7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to deliver Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL
the Products and perform the Work. BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND
PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES,
3. PELLA EXPRESS OR IMPLIED, WRITTEN OR ORAL(INCLUDING WITHOUT
LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS
Pella will be responsible for and have control over construction means,methods, FOR A PARTICULAR PURPOSE).
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 10. NO CONSEQUENTIAL DAMAGES UNDER NO
install the Products. CIRCUMSTANCES SHALL PELLA BE LIABLE FOR CONSEQUENTIAL,
Unless provided otherwise in the Work description,Pella will provide and pay for INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES,WHETHER
all labor,materials,equipment,tools and machinery,transportation,and other FORESEEN OR UNFORESEEN.
facilities and services necessary for the proper execution and completion of the
Work. 11. HOME IMPROVEMENT CONTRACTORS
All home improvement contractors and subcontractors shall be registered with
The materials and equipment furnished under the Contract will be good quality the director of the Home Improvement Contractor Registration Program
and new unless otherwise required or permitted,the Work will be free from administered by the Board of Building Regulations and Standards. Pella and any
defects not inherent in the quality required or permitted,and the Work conform of its subcontractors identified in this agreement have been registered. Any
with the requirements-of this Contract.Pella shall not be responsible for inquires about Pella or any of its subcontractors relating to registration should be
damages or defects caused by abuse,modifications not executed by Pella, directed to:Director,Home Improvement Contractor Registration,One
improper or insufficient maintenance,improper operation or normal wear and Ashburton Place,Boston,MA 02108,617-727-8598
tear. Pella will keep the premises and surrounding area free from accumulation
of waste materials or rubbish caused by performance of the Work. 12. PERMITS(MA customers only)
Pella is obligated to and will obtain the following permits for this project:
4. CHANGES BL1I1d Iq . 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 include chapter 142A.
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 In addition to the rights and warranties enumerated in this agreement,you may
and any such Change Order must be signed by both Owner and Pella to be have additional rights under Massachusetts General Laws,chapter 142A and 780
effective. 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 may
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, be his main office or branch thereof,provided you notify the
availability of subcontractors,acts of God,fire or other causes reasonably beyond seller in writing at his main office or branch by ordinary mail
Pella's control.If for any reason the Work is not fully completed by the posted,by telegram sent or by delivery,not later than midnight of
Substantial Completion Date(including any extensions contemplated above),but the third business day following the signing of this agreement.
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 See the attached Notice of Cancellation for an explanation of this
back proportionate to the cost of remaining parts or work to be completed is right.
acceptable.However,the holdback will not exceed the amount of the completion
costs or 10%of the remaining unpaid balance of the Price,whichever is less. Do not sign this contract if there are any blank spaces.
6. FINANCING
If payment of the Price is financed with a financial institution through Pella,all
financing paperwork must be completed upon signing 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. 7/2/15
Date
Customer ignature
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.
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The Commonwealth of Massachusetts t!�n�Fsorr�
Departinent of Industrial Accidents
Office of Investigations
.1 Congress Street, Suite 100
Boston, MA 02114-2017
><".mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Aal1 �6�,�,;�
Address: 45- 1--o t o r;_._
City/State/Zip: ,l 61U -2- Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.9,1 am a employer with '--7$ 4. ❑ I am a general contractor and.I
have hired the sub-contractors 6. ❑ New constriction
employees(full and/or part-time).*
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have g
❑ Demolition
working for me in any capacity. employees and have workers' 9. E]Building addition
[No workers' comp. insurance comp. insurance.
5. We are a corporation and its 10.E] .Electrical repairs or additions
required.] ❑ P
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself No workers' coun . right of exemption per MGL
y ' [ p 12.❑ Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also till 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 thein workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: j-� AA �.cg,,er�
Policy#or Self-ins.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.
1 do hereby certify under the pains and enalties of erjury that the information provided above is true and correct.
Signature: .._. _ '-- -__-_.__ _..___._.__ _. " _ Date:
Phone#: 7 Zl--,,5—7aYS—
Official use only. Do not write in this area,to be completed by eity or town official
City or Town: Permit/License#
issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACCOROFDATE
® F LIABILITY INSURANCE 0619/2015MMIODIYYYY)
CERTIFICATE
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 CONTA Fred C.Church,Inc. NAME: T Dorothy A Corlett,CIC,RPLU
41 Wellman Street PHONE 978 3227231 FAX (978)454-1665
Lowell,MA 01851 C o AXNo):
(800)225-1865 E-MAILSS: dcorlett@fredcchurch.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: Citizens Insurance Company of America 31534
INSURED INSURER B: New Hampshire Employers Insurance Company 13083
New England Window&Door LLC
45 Fondi Road
INSURER C:
Haverhill,MA 01832-1302 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:saas7 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MM/DDft`YYYl (MWDDNYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X DAMAGE TO RENTE
COMMERCIAL GENERAL LIABILITY 100,000
PREMISES Ea occurrence $
CLAIMS-MADE M OCCUR MED EXP(Any one person) $ 10,000
A X CG0001 ZBN8161407 7/112015 7/1/2016 1,000,000
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $ 2.000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2.000,000
POLICY X PRO- X LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
HIREDAUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
HEXCESS LIAR CLAIMS-MADE
AGGREGATE $
OED RETENTION$ $
WORKERS COMPENSATION X WC STA IU- OTH-
AND EMPLOYERS'LIABILITY YIN
I ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000
OFFICERIMEMBER EXCLUDED? N/A 400040101 7/1/2015 71112016
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below 500.000
E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
38497
client# Msl# Cert Holder# @ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
W
CS-089853
WILLIAM R NICHOLS
57 PEARTREE RID'
HAVERHILL MA;01830,
e �
10!26/2016
`� ' �
—\
Office-ofConsumerAffairs&$usiness Regulation License or reg9stration j.alid for indrvidul use only.
ME IMPROVEMENT CONTRACTOR before the expiration.date. If fo6ndreturn to:
egistration: 178383 Type: Office of Consumer Affairs andl3usiness.Regulation
xpiration: 4/tl7[21)16:.- Corporation 10 Park Plaza-Suite.5170
y = Boston,MA 02116
PELLA WINDOWS AND DOOR ,
;WILLIAM NICHOLS
. 45 FONDS RD
HAVERHILL,MA 01832 J al ^
Undersecretary Not valid without signature