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HomeMy WebLinkAboutMiscellaneous - 217 BEAR HILL ROAD 4/30/2018�� N V � W S D A tD = tP r r Oo O O D 0 v AMERICAN CLAIMS SERVICE MULTI -LINE ADJUSTERS BUILDING INSPECTOR/COMMISSIONER, BOARD OF HEALTH AND/OR BOARD OF SELECTMAN Building Inspector Town of North Andover 1600 Osgood St North Andover, MA 01845 Insured: James Address: 217 Bear Hill Road North Andover Policy: NPP8236563 Loss Date: July 18, 2015 Loss Type: Paint spray machine ACS File: 32148 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Tim McLaughlin Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 7/22/15 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 / FAX (781) 245-1077 E-MAIL — daims.acs@verizon.net --) I --N- Location (,'�L I -T- &M F - No. Date k 40ftTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ AC)M4USt' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t -�- �- Check # v 2330 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 11 IMPORTANT: Date Issued: Date Received must complete all items on this LOCATION at -7 46 4/Z A411 40 Print PROPERTY O�ER /'1.rlrr�� LZ A o..-4 MAP NO:PARCEL ZONING DISTRICT Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resi Non- Residential New Building One family Addition ily Industrial Alter No. of units: Commercial Rpair, re lac t Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: FIN a 5+vLtL r (., Identification Please Type or Print Clearly) OWNER: Name: f��4 c(�/ p �o L,eorL Phone: q -11 3 -633 Address: ;)- ( `I %9r=AA- �k G( kn CONTRACTOR Address: ` Fwa / at Supervisor's Construction License: Exp. Date: /8 Zc Home Improvement License: e3 -c "? `7 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. Total Project Cost: $� �, C) a e — FEE: $� ` J Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 6ignature of Agent/Owner Signature of contractorl' Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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: Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Blot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street .FIRE DEPARTMENT - Temp Dempster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: - Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc:.Building Permit Revised 2008 LAI W W O v JO ° L2 cn a cn O :j w° a�' v U G w A. o a: G w a �. U W o aG v� G w o U °�° w�' u. � rR ° cin Q o C/)— :.s o m c is O L O y QCJ a -o fl, c t s : y _ts :.. cD o c y *C-* + v os m c ' y R o Z' 3�p y � m m y O co a y m 4>3 O � oa ac.n m o � + v yZ cc m hc � a m c = O ''o O a.e12 W c ZS -62L o m.. c.' ~ 'VJ PCZ O c �'03LLI L3 •y C3 •m p m = = y a O.5 O :a Z /yp .0 c H _ C—L E d. MA L df Zoo H Occ CDc cm c m 0 cm c �c N m z 0 Z O 0 A4 z O U U) 2 W 1. I 0 I CO CCM CDCO2 CO) co m m -FE 1= O O = O f� 3 CD CD L env o Q CMQ C CD ca �� w -1 -v .FL O CD C Z CD CL V v� O C C c CLCO2 0 " uj uj U) W W 19 ujW to 1 ne C,ur[s.n.us.r�...... Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 i�M vv www.mass.gov/dia lumbers Workers' Compensation Insurance Affidavit: Builders/Contractors/El Ple se Print Lem Name (Business/Organization/Individual):&:-/—/ Address: 4S7 FoN n r S�, t( DttZPhone #: Zip City/State/ Type of project (required): Are you an employer? Check the.appropriate box: 4. E]I am a general contractor and I 6. ❑ New construction 1;m a employer with L� * have hired the sub -contractors 7. ❑Remodeling employees (full and/or part-time). listed on the attached sheet. 2. El These sub -contractors have I am a sole proprietor or partner- 8. ❑ Demolition ship and have no employees workers' comp. insurance. 9. ❑ Building addition. working for me in any capacity. 5 ❑ We are a corporation and its [No workers' comp. insurance 10.❑ Electrical repairs or additions officers have exercised their 1,1.❑_plumbing repairs or additions right of exemptionP er MGL ' 3. ❑ I am a homeowner doing all work c. 152, § 1(4), and we have no 12:❑ Roof repairs myself. [No workers' comp. employees. [No workers' 130 Other insurance required.] t. comp. insurance required.] # applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information: �Y aPP policy information• t Homeowners who submit this affidavit indicatinadditional shag showingthe ame of the. sub•contraciors and ide contrUctOM their wo kers' comp, p t y �hng sus tcontractors that check this box must attached an I am an employer that is.providing workers' compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: V-kF•J> Expiration Date: �� Policy # or Self -ins. Lic. #:�'7 A I A INJL'E;1 City/State/Zip: Job Site Address: Attach a copy -of the workers' compensation policy declaration page (showing the polis n of acriminal penalties of a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead _to the impositio fine u 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 P of this statement may be forwarded to the Office of of up to $250.00 a day against the violator. Be advised that a copy 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: nnrP• -5(— f ( me #: C4 19 " Ztvs —7;)S S official use only. Do not write in this area, to be completed by city.or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board. of Health 2. Building Department 3. City/Town Clerk 4. Electrical .Inspector 5. Plumbing Inspector 6.OthFr \ Phone #: Contact Person: DATE (MMIDDIYYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 07/02/201009:50 PRODUCER (800) 225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ERTIFICATE ONLY AN NO RIGHTS UPN T Fred Church, Inc. HOLDER. TH SOCERT CERTIFICATE DOES NOT AMEND, EXTEND OR 41 Wellman lman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell, MA 01851 800-225-1865 INSURERS AFFORDING COVERAGE NAIC # INSURED New England Window & Door LLC 45 Fondi Road Haverhill, MA 01832-1302 INSURER A: Citizens Insurance Company of America Wausau Underwriters Insurance Compal COVERAGES LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. MAY ISSUED WHICH THIS CERTIFICATE THE POLICIES OF INSURANCE SPECT RE O ANY REQUIREMENT, TERM OR CNDITION OF ANYOR BY HE OOLI) IES DESCRIBED HEREIN S SUB ETCT OR OTHER DOCUMENTICT O ALL THE TERMS, XCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN, THE INSURANCE AFFORDED LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICIES. AGGREGATE POLICYEFFECTIVE POLICY EXPIRATION D LIMITS INSR DD' POLICY NUMBER DTE D D T L EACH OCCURRENCE $ 1,000,000 GENERAL LIABILITY DAMAGE To RE TED 100,000 PREMISES Ea occurence $ X COMMERCIAL GENERAL LIABILITY10,000 FKOCCUR MED EXP (An one arson) $ 1,000,000 CLAIMS MADE ZBN8161407 7/1/2010 711/2011 PERSONAL gADV INJURY $ A GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY (Ee accident) X ANY AUTO BODILY INJURY $ ALL OWNED AUTOS (Per person) SCHEDULEDAUTOS ADN8162169 7/1/2010 7/1/2011 A X BODILY INJURY $ HIRED AUTOS (Per accident) X NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ GARAGE LIABILITY EA ACC $ OTHER THAN ANY AUTO AUTO ONLY: AGG $ EACH OCCURRENCE $ 9,000,000 EXCESSIUMBRELLA LIABILITY9,000,000 AGGREGATE $ X OCCUR CLAIMS MADE L(Hj.18167305 7/1/2010 711/2011 $ A DEDUCTIBLE $ X RETENTION $ X WC STATU- OTH- WORKERS COMPENSATION AND E.L. EACH ACCIDENT $ 500,000 EMPLOYERS'LIABILITY WCCZ11259957010 7/1/2010 7/1/2011 EA EMPLOYEE $ 500,000 B ANY PROPRIETORIPARTNERIEXECUTIVE E.L. DISEASE - OFFICERIMEMBER EXCLUDED? E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under SPECIAL PROVISIONS below OTHER I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS DESCRIPTION OF OPERATIONS Proof of Insurance _ CANCELLATION w England Window & Door LLC Fondi Road verhill. MA 01830 ACORD 25 (2001/08) Client # ?or;n SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE © ACORD CORPORATION 1988 Mst # 10-11 GL, UMB, WC, Cert # Auto J 1 Q Q 0 cc ;o 0- cot - oSD CQ a E o x 7 = LL U a CL 0- CL C- ir m W w 4 co X N Cn co U fl a` I Io 170 OCD E i cr- Cc >. �as a� V m� O c`> E U o I r ui o N o 1 Ql I O i c N C6 SII jx t.0 O av tYi �' ..L. 1 I li! 1 C7 P U' 67 m - N LC Q .. cc M O 'L O O O _R pC a z J- C5 o < N 7 a .� C, 1^ fD �W =_ W O c m g;y O` >rI W �t = m r c z = CoY'" c w t3; c O O Z U = = ?�Gu'l-'G N� a U 47 C [5 = C5 n= ��,� IL L LJ LL O fA d N LL i] O C Q1 ) o KD ppm = a' u� V N=U D N ��' tr Cl U � - '•� E� N "O e` �'' C 0. � � r Y � �[ �L-,0L.0m(p 7� - � G i Ln Q C� rcc CD O a Cl) CN N X C 7 ti in O C LL c C- O LU c a; r - C N O 0- - p N CD CL O > cu Q RST O x T Ci Q N --- ❑ s L LL C� J w m V E x s a w m o r i c7� � x ca W U p c =O O Ln U J - —= Q [ (n � v qN>> y v r .O E Q _--J {•L z a� o m L w es w V o� O A - 7. - - - G 3 � I U .r, � i c � Ln O 2 � � d Q G G N a L� p 21 � c T M S ?-D _ = o u n C. �i _ : c V oW"y y A tU hS r o ww`o r m �� m c W ti a J� m> r i o f o •y cM oUl=~-C xkc C c 0 Z d = N �'C d w 4> Q m cm ZE y W 1 co `) o ° c LC Q l y yA ru.C7rx cC7Y�Ci E x s v J m o r i � x ca U p c =O O Ln U J - —= Q [ (n � v v r O _ _--J {•L � J s v J i u - G o52 Ln U J - C v r _ J i 7. - - - u o o .r, i G •� J � O d G G 21 T z = o u n C. @ C r G O O lu OIL _'A o I O.— C J — Z C) aci J C.7 r , V cc �6 0 cd J sJ Qi :� �cciUr7 �J a� Hca J ' = Cl) m 3 M > y U C3 Q> co -a c o :E ` ' o M c a tn cn CU CO m > 9 � p N sup,a���'��tiu � J le C _ D- O p N U n V CG _ UCE czW puj 100 .p� > rr��sr� �.- ��: o n— E c I� Z Iti io N .fi •N � L I N ILL O . N U -O O t1] U N N U O •D 1 2 � d CL p O c' o UJ 2 O - C -- �3 CN z Y o X 1 �-a07. R O O r U C c O y a= ,O O y '5 c'u V _- c y 7 v ^� ch C atL N CO C ci v z, a �o.v �Z- Z .� -n— C G.— 1 cc -s co Q > to cn cry O E V _J U cc cl O N c6 = p i ti cn C - 3: 'a � EtC O o mN= a'' R o 0 X cn 0) = c O Q c � � c -C 'O N 'p �1 -in y„ ^• ^ U f N y cu N i._ L'yyG :v7OTCL ii cc D ti c g y O C-� y �- n L- cti s o — --T<U ^d Q cn •O �' I O -c O�r y NU U O OW c•nA , L O - i CO Q w y 0 . 0 'oc f CU pO Wo @pOi -0 0 N c^ L cz 0a i moC1 �'mB,Ln=33ETUAJ0_ -- CU cG N �- MO O A O C C O.:- U �� �_�_ a o OL L= d G 0 X 0 0 0 EG �o oC-Z C' O LL C_ CD O C T c9 O O X O Q O v= C co O �, v cc y — v ray r RS rI cz r cp • : cn cr � - E c I� z io •N � I ILL . N N -O O N U y CC •D i 2 d CL c' o O - C -- �3 z Y o X 1 i a 3 0 - C c cc C V _- ch C N CO C ci v z, c V C cyG J' 2 v. L 1 cc -s co C > ' cn cry O E V U i ti cn C - 3: 'a � > Z O y 0 O m = � � c -C 'O -in N •p in O r 4i J co i tL D ti c g y O C-� y �- n L- cti s o — I. Q cn •O �' I L Q y E p C N cz O p U c .-0 N LLL `m 0 a L C1 7 CL Q O si z O X N E cu z 0 a` OT m rn m 0 a Z5 a a 7 U r 1 z c rn O co O 0) co ;, d 'G N LV CtJ EA 1 a U1 W- c � ` L Q ' r tJJ NN fl > � IC ;co S. I- X y C N L Ca H U) Z F o Q `m 0 a L C1 7 CL Q O si z O X N E cu z 0 a` OT m rn m 0 a Z5 a a 7 U r 1 z c rn O PELLA WINDOWS AND DOORS CONTRACT I. rr-.RLNIS AND CONDITIONS These and Conditions arc an 1):111 of 111C COntmoi sel kirth on the PRILIUCL OIACC title beiwc(ni NcNv Wimiov, and Door U.C. Ciba PcIla Wic0cm-, & _)ants. Inc. i"11clk!"land Ill-.- Nr\on(sl idicilkiried on the Pr,XhlCI OIYI,!r C-OWIlff"I !0 Slippi.k [Ile IVIXIIIC(>. (Ale "P,0'dLM�"p.;jnd rerl'orm the work Ithe ­Wod,-, described or rel -erred to in such Con%r:tei. For Produel Only nurchamma signed ­Tlaiduu Only Addenti-rim' is ;I required limi of the Cott tr'ac't. 2. OWSIM ),61a i, not 'e.'Ilonsihle Cut any e%i,.ij1._- seCuril, ".Aril .:),,;!er Anilt remove all shades: verricuk, hlillds, ctirioin, dnaiies oi-xvindow nimm7c,_'l ;ii;' COIldid(NIC(S. 11601'(L) IIIc instal Ill till 11 01*!hL: Frildl.[CiS. PCII.1" inNizillers aft: not lexporl'i'le for flic vinmw:d or mstallatiOn offlit-,c t.vf,,,., or Items. Pella is not responsible lo: pre-esis6mg, '.vinjov. covelin> fiuhl� (in ncv,!�t installed pCilif windows. The O„nci',Ilall provide complete acres, the work si!.-- between the llours 7:00.1m). ;Slid 0.00 poll. 161%%;itki, thruue.h 'Frid.iyj for Vella c installer, to deliver the rook"1111,11le 3- PELTA Pella will k responsible -�spousble for end hive comm) ever construction inicaim inedi,ids. techniques. s;qucnce, mid procedures and Iii coordinatitiu, all porlions N the wmk_ Pella v. ill 1:+L: rospmisible for Clic NVirk,.ifits folia Cuomwtors whu will himnil the' Lhdc,< I)l'OVitild iSC ill Lljr W."k. de'c'iption. PcIla ;will pri" ide am C• pat) I'ov all !A'(m. material'. oklmpov.11. lo"I' ;1110 jvi:c list[c),v. and ,,the.- l'itizilizies ;till) i:i for ilic p—p_: ,nd conlpl,�.tivm lil, the Will*. The nwwriji, ;%nLI L\q Ifillmielil fnruisilec: under the C"ontract will ht: !fond quality and ii,v. unles' Otherwise required orivi'milled. the L%-(jrk- will hL fires.- fri)ni defecis not inherent M 01C (11WHlY rt?Ljlfirl!d Or lierniiiied- and the '*'m1k c0lil'unil with the rcyuirCmcnu ot*Ih:, C,xill-Lcl. Pella shall mil be responsible fordantaeC:.ui 041L'ed 1". M'vse. mi'difiwnfi"ll, not tiemied I" polls.. improper or in'tillicicill mtmllen:,nce. improrvi operuiinr, or normal L%e;a and tear- Min will keep :h- prerati&c, aril 11"rmli'lling, X.e;l I_r'x from of nmieriuls cw rullilish CUUMN! I),. 1xvit's-Illillicc 'A_;i1c Work. 4. CHANGES The Owner rn.m- ordti in wi-ii:11--i Ill the Cillisistwu of ❑Iddil.1011S, ;idcboil,. or modificutimiN AIIN ChLim--c Orcior 'Imli include all :tdjtism-,enl It' the Pries ;uld (h,' Sllbslalltjal (.70millolioll 0;11C. a, dotemlined by Peltas Pella lv"C;ve' the right in 4l.)IlTOVC Ol- dis31)jll'OVC :1111t CIlallL'_. Orderaild i'11v such Chnmizc Order mtiq he sianed It\ litith Owner and pell:. to he elTecti, e. 5. stuis j,AN'n.m. cami'umo\ Owner undermulds sillo agrees that ;he Sullstimliai C0111111elivii Date is Lill ,,ilnlaw Onl, and ibu; the ;wiL':Il Jille on IlliCh Ili' WIWI, PS -0111PICted 111:1% no CX101ILL'i U' :11101% for Cll;l1Iz%e Oilers. rcqtjcsled hl' Owner Or it' the time to Lmiiploic the Wmk is ti1 eonLluci of the Owner. vemiler. lithor disputes. avaikt-hility Ili 'oliconimmi'N. it.-*[, ref G,,J. lire or Lidicreause, reasomilliv heyond pcjI:(.s ccmtrtil. if fur aw, rcssm Ili,! Work I, not 1,01v C"Illplcml by the submantial Completion Dnic I inciLdil'y ally uxleilsitmis Conterlip1sils:d 'uhkl' el. but izzi 'Nul'sIanzizlilv C(xnjfleud i's Buell 'Jalc. i.e.. the pro.duct 11;s' ivell ill1IAICkL but lllin')r pitri., t,r con'.polivrits iu-e ;1---isAmu uT need to lie rephweJ or repaired. is hold bistik it, tile cost rr renlumm.2 part., or '(1.1 it) tv completed is acl:rputhle 1 tile will flul exceed :he amoutt! of ilic compiciion cos- l. -w 11) it tae iniimrinQ unpaid halzmcc of the Prkc. 'r 4, le". 6. FFNANCI NG if paymcrit of the Price i, Hmuwcd 'isidi a l'inancial in,imitim. thrsiuell PCLLI. all financing paperwork must he completed upon si'lihia of this Contrad and the requisite approvilk and aiitllciriznliilsi.. (OT the full ammuit ur'the requested financing iinill have Ilftil Wceked from the financial hlsillutit-n. PA N -MEN. -I'S Pella ,hall be entitled (u slop 11w Work upas 1,ziticil notice to Olvncr for an.% m,rerial Mault or f;iilanC I)%- 0-mici. inchiflim-, but not finiiied to, the Ovoicr*., )';1iItllv iii pay Pella the amount due within so,-,ni dzt.v, uficr the date payment is Li CORRI'l[TION OF NVORK Pella shall Ctirli-CI iaullalit'll nut Ill CL1nl'0ll',l,%I1LC %%hil illk: rLtIllil-eillenti Of tile ('0ntrlCi_ li'l101ffiC-LI in Wfiijne hk the 0m. tier within mo i curs aficr the Completion Dato tit. il'e-urlier. tile laic im which the Work N sillisuillialIN, "'011010E-t(I and VaIN-01411L of the F01-Cht1 Price llle;& Illbicel :;, n holdback it, p-ioNldLd aftvv. Con.-ection Of Nvnrl: os licn--io plovidoil sindi he Owim"s 'olc remedlc for dcierti,r wor'Kii'miship. ;tit([ i., :)I,L" iu,:(t ill Heil 01 ;Ill) and all ether rolledids' Pella', obloeatioli to correct W01 -k- is antdiconrtl on IffiOl' nx-ipt nr all payllivills Iticil (Ill,;. 9. LMITIED PRODUCT WARRANTY Pcll;t .hail WaIT.M.L iil! PCIIII J)lro(lilct', but mll\ it; :ZCCLl1d-.11ICc will' UIC Pella \Virdov. s & Doors Uinii,-d W'aieanty. Ti IIS LI-MITRD WARRANTY STIALL Biz- 1711-11: SOLL WARRANTY \VITH RFSPECT"I-0 TI IE PRODUCTS' AND SPLCIFICALLY DISC(_.AUMS AIJ. ')*I'] ILI, WARIZANTIL-S. I`XPIRESS OR IMPLIED. WIZFTTLN OR 01' A]. (INCLUDING WITHOU 1, LIMITATION VL'.ARRANTY OF Mj1-:RCH.*6NTA141jxrY OR FI'I'NFSS FOR A PARTICULAR PURIIOSFi. 11). NO CONSI%QUENTIA I . DANI.A(.F_S LNDF.R NO CWVXISTANCTS SHALL PI'LLA r1r. UAW F:1 -OR INCIT)KNITA"'.. INDIRECT. OR ',Pi:.(.'IAI- UAMAGF.S. W'WT HER FORFISL'S'N OR UNVORESFEN. 11. 00jvLE AilMoor.: Ullpik-CmelA alul 'uhC')Dtzi%k:t"T' shall Ile regis;ored with lite 6:revim- of the Home.. hnprw.Cjnmt (onu-acior Regimnitiou Program :10:11:11iSICI-ed ht- the %lard 0t'BWId;Il_-' KC_'1LJIa1.iUIlS and SUL11d;1rds. Pella and LInv oits 5:ubuomrucLor., iticritil'ied it; fli, aL"xmeta have b'ml rel--k(Cro.d. Any inquitc., about 11cila or an) ul'it. sviNconwacuirs tvlaun, in re ' a"nitluji shimitl he directed lo: Director. Ilona linpa%x.n%-nt Contrarcim- 011e Asll"'Un-m M., W'? -?2? -X'598 12. PERMITS IMA Cust(inlersolil\.1 ::ill Obtain Ill,' Totten ink PCflllitN AW this PilljW; V runt) urc Linicowner, who �.c-�tlre Meir o„ -n tvrtnits will no mLil isions l" NlJ1'S':1ChL1SQIt1 GC11CMI LZMx. chapter 14'-A. In addition to tile ridiis and Lill[ mel ale! I ill this agresninem. toll 11111)• lmve additional rh_,hi> under Cieamn-al I.aws, chupict, 141A and 7,K11 Of M1ln,sarhosems RCN;IZlfi,m, R6 NOTICE OF CANCELLATION YOU may cancel Ellis ziuvecmCnl il' it has been Juncd by I miriv LhL'TeL0 at a PlaCC 01-hel'than an ',liddl-U5� of the SCIleV- W-hidl njily be 1 -tis main of or branch thercof. prox.-i6ed You notify the seller in ,:exiting' LLL his mazIn office (.)I- bmich by ordinary mail -oosted- by telegom sent oi- by delivuv. not later than midnight ol'the vlm-d busiiicss dav foilowim, the sil:!ninf; of Ellis a'areemcm. SNC', 111C Mtacbd K'MiCe (11CaliCel IaLi Lill I'Ol- at-, eXI.711,U-IaLi011 Of this nalit. J)o not sigill, this contract if there are any blank spaces. " S / �-`Al C DuIL DISPUTES Job Nantc___ P I.3 Lcp_� Date 61 , l-3 • bb THE CONTRACTOR AND THE. I-IO.-MEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THA'F IN ,rHE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT, PELLA MAY" SUBMIT SC CH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF TI-lE EXECUTIVE OFFICE-; OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUiNlER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN I42A Contractor P — Homeowner NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNA"T"IVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPU'T'E RESOLUTION EVEN %VHERE- THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. NOTICE OF CANCELLATION Customer Name: V4 GL C1 (Please print) Date of transaction: 054-- G,.- U) 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 of 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 01 • t& • 117 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) Location a 1 -1 Y�eq A- ad - No. Date TOWN OF NORTH ANDOVER 0 jaillijj& Certificate of Occupancy $ Building/Frame Permit Fee $ CH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # (9-7�ry_ 19224 Building Inspector Rc F+ ••+ Cy . � i �SSgCHU Permit NO: --2 Date Issued: IMPORTANT: ,\ TOWN OF NORTH ANDOVER ,APPLICATION FOR PLAN EXAMINATION Date Received:a *V4 icant must complete all items on this e6 -T 1; d LOCA l JUN Print PROPERTY ONWNER P4 vi Print ti•1 AP NO.:_______ PARCEL: ZONING DISTRICT: — HISTORIC DISTRICT YES 0 TYPE AND USE OF BUILDING PROPOSED USE TYPE OF 1) New Non- Residential New Building °One family J Industrial --Two or more family Addition No. of units: Commercial Alteration ,_ 7 Assessory Bldg Repair, replacement F= Demolition i Other Others: Movin (relocation) Foundation onl V`FORK TO BE PREFORMED rnF.9C'RIPTION OF OV,'NER: Name Address: Z( Identification Please Type or Print Clearly) V)/'.,'A lkwe-r CONTRACTOR Marne Address: C4 S c V -L C "— - - 63 q Exp. Super -v isor's Construction License: 2�(�? Home Improvement License: l Esp. ,nk q73 o23S Date: G t q x Date: �' Z - D7 ARCHITECT. ENGfNEER tmc: Phc:ne:. Reg. . Wdress:. LE: BCLDLNG PER,i11T: SIo.00 PER Sp)oo.00 OF THE TOT. IL ESTputFEE � ST 5AS / S1=S°�i0 PER S. FEE' l Pr(L X23 x1o.0—4 Total Project Cost :$.___...._ � as • Cktc;ck P:r,te 10'4 J 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 A daAndlOr C.S.L. Licenses a Photo Copy Of H. Copy of Contract Floor Plan Or Proposed interior Work Addition Or Decks Building Permit Application Surveyed Plot Plan ❑ Workers Comp Affidavit :1 Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract 0 Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hy rau Calculations (If Applicable) (If Applicable) p o Mass check Energy Compliance Report ) New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan a 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) o Copy of Contract Mass check Energy Compliance Report sion from the d o In all cases if a variance or special permit was required i ast then gete Town thisrecorded d at the Registry e must stamp the of Deeds. one op)ran( %ppeals that the appeal period is over. The app proof of recording must be submitted with the building application !,,: I�.til'F.("1'to\,% tiF.R%A'l;'i UKII tR] )IF.`, VAPFOR` "-' I'.t"e 4 tl I TYPE OF SEWARGE DISPOSAL Public Sewer Well Private (septic tank etc Tanning'%lassage Body Art Tobacco Sales" Permanent Dumpster on Site _ SlAimming Pools _ Food Packaging Sales Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the arrtnly. ji d�- Signature of Agent OkNner Signature of Contr to Plans Submitted Plans Waived Certified Plot Plan ! Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ 1:1 ❑ Water Shed Special Permit CI Site Plan Special Permit J Other COMMENTS CONSERVATION COMMENTS HEALTH CO,'VI-NvTENTS DATE REJECTED DATE APPROVED ❑ ❑ DATE REJEC'T'ED DATE APPROVED Zoning Board of Appeals: k ariance,Petition,No: Zoning Decision; receipt submitted V es h!anning Board Decision: Conscr;&cn Dcci_ion:— —----�onunents__ WLtvr Fu: S.nl (-r ..onnection -i�naturc Jatc ;.,cmp Dumpster cn site yes_ - no x Fire Department sionatur: date — Building Pcrmit- \ppro%cd and (ssuc:d by r: 2(14 Building Setback( Front Yard Side Yard Rear Yard Required Provided Required Provides Re uired Provided rli\ rT\tcr�v ■/r.Tit G.\JIV.\ Number of Stories: __ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. It.: (. ,.. ,.,3 1 , , . The Commonwealth of Massachusetts Department of Industrial Accidents ff V Office of Investigations (TI a 600 Washington. Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ys FO✓t s City/State/Zip: )-Iage.rk i t , J14 OS 372 Phone #: q %9 72 6 S - -? 2 5�5 Are you an employer? Check the appropriate box: 1.� I am a employer with �� 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13,❑ Other *Tiny applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anal job site information. _ , r Insurance Company N NV -pp (vAs U -AACe- Policy # or Self -ins. Lic. #: d g4) IS IL 5 7L-/2- Expiration Date: -7/01 _ Job Site Address: �i 2 G ( V City/State/Zip: / d-�'! 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 o f 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 insuranSS-couert*e verification. I do hereby certi tide l e ins an enalties of perjury that the information provided above is true and correct Date: Phone#: -1 7�" Z65- "72 5C - Official use only. Do not write in this area, to be completed by city or town official Citv 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 #: , . r v.1. . 1 1. 1.. —U. 111r 1116. G–L–LUJJ J:L IPWI /I. L UI L �C�R� I-I:I I I I I 1111111.11.I I I I IYf.II lir . i. 018/ .... /..... . }}���� �r �/�w F MM/Domt 02/05 t THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER 978-458-1885 Fred C. Church, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 41 Wellman Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1865 COMPANIES AFFORDING COVERAGE Lowell, MA 01853-1.865 COMPANY A Hanover Insurance Company INSURED New England Window & Door, Inc COMPANY B Mass Bay Insurance Co dba Pella Windows & Doors, Inc 45 Fondi Road COMPANY C Hartford Insurance Company Haverhill MA 01830 COMPANY � D ph�q 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I COI TYPE OF INSURANCEPOLICY 1 NUMBER POLICY EFFECTIVE DATE IMI IDDMrI POLICY EXPIRATIORLTR DATE IMMIDD/YYI LINTS A GENERAL LIABILITY ZBN8161407 7/01!05 7/01/08 GENERAL AGGREGATE ! 2000000 PRODUCTS - COMP/OP AGG f 2000000 j COMMERCIAL GENERAL LIABILITY I ��I CLAIMS MADE CX I OCCUR I X OWNER'S 6 CONTRACTOR'S PROT I PERSONAL L ADV INJURY ! 1000000 EACH OCCURRENCE ! 1000000 FIRE DAMAGE (Any one lirel ! 500000 L MED EXP (Airy one pereonl ! 10000 B I AuTMAOBILE LIABILITY j X ANY AUTO ALL GW NED AUTOS ADN81 62169 7/01105 7/01106 COMBINED SINGLE LIMIT f 1000000 F__; i X SCHEDULED AUTOS BODILY INJURY f (Per Pereorf r; X I HIFED AUTOS —J XII NON -OWNED AUTOS I BODILY INJURY (Pere derdl f PROPERTY DAMAGE f IG RAGE LUIBRITY - ANY AUTO AUTO ONLY • EA ACCIDENT ! OTHER THAN AUTO ONLY: ; EACH ACCIDENT !�y AGGREGATE ! A 1 EXCESS LIABILrTY tx_I UMBRELLA FORM UHN8167305 7/01105 7/01106 EACH OCCURRENCE f 9000000 AGGREGATE f 90000M OTHER THAN UMBRELLA FORM f C WORKERS COMPENSATION AND EMPLOYEW LIABILITY 08WBNL5742 7/01105 7)01/06 X W c sTATu• arH• TORY UNITS ER EL EACH ACCIDENT f 500000 THE PROPRIETOR/ INCL PARTNERSRXECUTNE EL DISEASE- POLICY UNIT t 500000 EL D19EASE- EA EMPLOYEE f 500000 OFFICERS ARE EXCL. I I OTHER DESCRIPTION OF OPERATIONS/LOCATK/NSNBRCLESISPH:IAL ITEMS Town cf Needham is named Additional Insured as their Interests may appear. 10 days notice of cancellation for non-payment of premium. &7tlFiICA# !F! 1L I CMICEiLAT1ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE OU4 RATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAL 30 DAYS VOITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FALURE TO MAL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE nnMPANY,2 E24ADES OR REPRESENTATIVES. AUT}! RESENT TIVE ACfJi'D asl (�r9�$j I (� I Ai:pLI�iQRD CORPC1E3F1TOM =1888 AUG -02-2005 05:38PM FAX:508 454 1865 ID:PELLA� PAGE:002 R=�2% s. c� W o ` cc) C n'o a � s o 0 h CO E QCF Z CL E c 'r aim O o 0 s s c E ".O as N z � V /r Ca r! CD:m3 N � C m '(a cm Z = C h Go C U ti m E cm av m C!� CD co cm, N O 0 CD Z O � a _ m 3 N CL.- o t cc Co CW3 .`m tamva ~ V� a ID o � P 20 H •� O 40 -aim � rte, L O v co CLy c O CM C O C C93 m .0 3� co O L C. O O. cmQ c O .O O CO Z 4D C. COD C LU V/ uj Y/ W W 19 W U) v u .�i v vi O r-4 w° a°4 �. U w O Wooa 00 l p,y �. w w aG w U C7 n4 —co w W A w as ° 71 N cn O cn c� W o ` cc) C n'o a � s o 0 h CO E QCF Z CL E c 'r aim O o 0 s s c E ".O as N z � V /r Ca r! CD:m3 N � C m '(a cm Z = C h Go C U ti m E cm av m C!� CD co cm, N O 0 CD Z O � a _ m 3 N CL.- o t cc Co CW3 .`m tamva ~ V� a ID o � P 20 H •� O 40 -aim � rte, L O v co CLy c O CM C O C C93 m .0 3� co O L C. O O. cmQ c O .O O CO Z 4D C. COD C LU V/ uj Y/ W W 19 W U)