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HomeMy WebLinkAboutBuilding Permit # 7/21/2015 i BUILDING PERMIT 6G taoRrH Q`�t LED 6'14 O TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION s UR Permit No#: �`` Date Received ��SSACHusE��S Date Issued: Uzi k 1--) IMPORTANT: Applicant must complete all items on this page LOCATION l/_ ;Ifi ' Print PROPERTY OWNER' Print 100 Year Structure yes o MAP fflla PARCEL: 3 ZONING DISTRICT: Historic District yes Machine Shop Village yes no3 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other " Floo,pan 0 etla�s ®U11 ed 'i tsnct'� . Mat-Me a ,: � �Sewer "' DESCRIPTION OF WORK TO BE PERFORMED: C-in fAe Identification- Please Type or Print Clearly OWNER: Name: y Phone: 1,7f'A `- -e)3 Address: Yb Contractor Name tJ c4�kg Phone: Email: Address,: .46- Supervisor's Construction License: S-�3 Exp. Date: -tom Home Improvement License: / 3 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: 0 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaknty fund ' u r- r ttORT H uA 0' w n 0 lictover ® ® !"cam _ _ - �O '..46h h verbMass, 1 coc KIc Kl WtcK 'k. S u Nor— BOARD OF HEALTH Food/Kitchen PtRM1 _1 T Septic System THIS CERTIFIES THAT ...........Cr r.. .... ...., •. ,, , , ,, , ,,,,,,,,,, BUILDING INSPECTOR ... . ..... ...... . .............. .. Foundation has permission to erect .......................... buildings on .......... .. ..... I�1.. �........ . ... .................. ` Rough to be occupied as .... .... ► ..... ® �r ,1,. .. ...pokto.0.1.t?..................... Chimney provided that the person accepting this permit shall in every respect co'llfafm 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 PERMITIN OTHS ELECTRICAL INSPECTOR UNLESSTIOTA ff� Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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 Approvedy the Building Inspector. - Burner Street No. Smoke Det. MEOPO Contract - Detailed Pella Window and Door Showroom of Haverhill Sales Rep Name: Hanscom, Luke 45 Fondi Road Sales Rep Phone: 978-490-6934 Haverhill, MA 01832 Sales Rep Fax: Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: hanscomlf@pellaboston.com Customer lntormation Project/Delivery Address Order Information Craig Schumann Schumann,Craig,1581276 Quote Name: Schumann,Craig,1581276 40 Milk St 40 Milk St Order Number: 741 NORTH ANDOVE2,MA 01845-4518 Lot# Quote Number: 6855561 ° Primary Phone:(978)2250375 North Andover, MA 01845-4518 Order Type: Installed Sales Mobile Phone: County: Payment Terms: WF4091 -36 Month no Interest Fax Number: Tax Code: MA TAX 6.25 E-Mail: Quoted Date: 6/14/2015 Great Plains#: Customer Number: 1007238465 Customer Account: 1002936932 Line# Location: Attributes 10 None A-signed Delivery/Setup- Delivery/Setup Item Price Qty Exfd Price $222.99 1 $222.99 For more information regarding the finishing, maintenance,service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 6/15/2015 Contract-Detailed Page 1 of 6 Customer: Craig Schumann Project Name: Schumann,Craig,1581276 Order Number: 741 Quote Number: 6855561 Line# Location: Attributes 20 front door Designer, Double Inswing Door Active/Fixed, 66.25 X 79.5. Brick Red Item Price city Ext'd Price $7,610.13 1 $7,610.13 I'm — 1:6780 Active/Fixed Double Inswing Door PK# Frame Size: 661/4X791/2 714 General Information: Standard,Clad,5 7/8",4 9/16",No Certification,Standard Sill,Brown Finish Sill Exterior Color/Finish: Standard Enduraclad,Brick Red J Interior Color/Finish: Prefinished White Interior Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude S•z' Hinge Panel: Clear,Tempered Viewed From Exterior Hardware Options: Oil Rubbed Bronze,Order Handle Set,Multipoint Lock Frame Size:66.25"X 79.5" Screen: Sliding Screen,Brick Red,Brown,InViewTM Unit Accessories: Snap-In Between-The-Glass Fabric Shade Bottom-Up,Linen,Manual Grille: No Grille, Wrapping Information: Foldout Fins,Factory Applied,No Exterior Trim,No Interior Trim,4 9/16",5 7/8",Factory Applied,Pella Recommended Clearance, Perimeter Length=292",Glazing Pressure=205. PD-2 Wide Hinged-Install 2-Wide Hinged Patio Door Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 Comp Trim>48-Composite Trim Upgrade>Greater than 48 inches wide Qty 1 Line# Location: Attributes 30 living ro,)m Impervia, Single Sliding Door, Impervia, Double Sliding Dow, 104.312 X 79.5,White Item Price Qty Ext'd Price $4,918.43 1 $4,918.43 1:3280 Fixed Single Sliding Door PK# Frame Size: 31 5/16 X 79 1/2 714 General Information: Standard,Duracast(D,Block,Foam Insulated,4 3/4", 1 5/16",3 7/16" Exterior Color/Finish: White Interior Color/Finish: White •�:� �._�— t a' — Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Grille: No Grille, Viewed From Exterior Vertical Mull 1: FieldMull, V x 3"Tube Mullion,Frame To Frame Width: 1.5" Frame Size: 2:7280 Vent Right/Fixed Double Sliding Door Frame Size: 71 1/2 X 79 1/2 General Information: Standard,Duracast®,Block,Foam Insulated,4 3/4",1 5/16",3 7/16" Exterior Color/Finish: White Interior Color/Finish: White Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Footbolt Included,Oil Rubbed Bronze Screen: Sliding Screen,InViewTM Grille: No Grille, Wrapping Information: Standard Fin,No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length=368",Glazing Pressure =170. Comp Trim>48-Composite Trim Upgrade>Greater than 48 inches wide Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 PD-3-Wide-Install 3-wide Patio Door Qty 1 Bench Mull-Bench Mull 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 6/15/2015 Contract-Detailed Page 2 of 6 Customer: Craig Schumann Project Name: Schumann,Craig,1581276 Order Number: 741 Quote Number: 6855561 Line# Location: Attributes 35 back Impervia, Single Sliding Door, Impervia, Double Sliding Dwr, 104.312 X 79.5,White Item Price Qty Ext'd Price $4,918.43 1 $4,918.43 1:3280 Fixed Single Sliding Door PK# Frame Size: 31 5/16 X 79 1/2 ,` Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude a 714 General Information: Standard,Duracast®,Block,Foam Insulated,4 3/4", 1 5/16",3 7/16" Exterior Color/Finish: White Interior Color/Finish: White E' °12. -7. 9_ - ftl.J Grille: No Grille, Viewed From Exl>rior Vertical Mull 1: FieldMull, 1"x 3"Tube Mullion,Frame To Frame Width: 1.5" 2:7280 Vent Right/Fixed Double Sliding Door Frame Size: Frame Size: 71 1/2 X 79 1/2 General Information: Standard,Duracast®,Block,Foam Insulated,4 3/4",1 5/16",3 7/16" Exterior Color/Finish: White Interior Color/Finish: White Glass: Insulated Tempered Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Footbolt Included,Oil Rubbed Bronze Screen: Sliding Screen,InViewTM Grille: No Grille, Wrapping Information: Standard Fin,No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length=368",Glazing Pressure =170. Comp Trim>48-Composite Trim Upgrade>Greater than 48 inches wide Qty 1 Finish Patio Trim-Finish Paint/Stain Patio Door Interior Trim Only Qty 1 PD-3-Wide-Install 3-wide Patio Door Qty 1 Bench Mull-Bench Mull Qty 1 Thank You For Purchasing Pel�a® 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(ep—ess)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 manufactu-er'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 PLODUCTS: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 Agreemimt and Privacy Policy are part of the terms of sale. For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 6/15/2015 Contract-Detailed Page 3 of 6 Customer: Craig Schumann Project Name: Schumann,Craig,1581276 Order Number: 741 Quote Number: 6855561 o ect Checklist Review (Installed Orders Only) Before the Installation the Homeowner agrees to do the following: Obtain Condo Association Approval Obtain Historic Approval Remove existing shutters and awnings Remove air conditioners Remove existing shades, drapes, window treatments, wall hangings, and personal belongings Move furniture at least 3 feet away from work area Tie or cut back trees, bushes and shrubs in the work area Arrange to have alarm system and doorbells disconnected Arrange to have any plumbing and electrical repairs or changes made by appropriate licensed contractor Provide a door Handle and lockset for entry door if Pella handle and lockset is not purchased. Before the Installation Pella agrees to do the following: Obtain Building ?ermit(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 sefely away from work area Allow Pella Installer room to work safely within your home Durinq 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 produc:s 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„ompletion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings Re-install existir g shades, drapes, window treatments,wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners Remove stickerF 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 exteric.,casing issues due to storm window removal if full wrap or new exterior trim is not purchased For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 6/15/2015 Contract-Detailed Page 4 of 6 Customer: Craig Schumann Project Name: Schumann,Craig,1581276 Order Number: 741 Quote Number: 6855561 Project Checklist has been reviewed Customer initial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits b Expiration Date: 0 / 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 6/15.'2015 Contract-Detailed Page 5 of 6 Custom Craig Schumann Project Name: Schumann,Craig,1581276 Order Number: 741 Quote Number: 6855561 Project Checklist has been reviewed Craig Schumann Luk Hanscom Customer Name (Please print) PeZae Nam (Please rint) Order Totals Taxable Subtotal $13,461.65 stome Signs ture Signature Sales Tax @ 6.25% $841.35 6/15/15 6/15/15 Non-taxable Subtotal $4,208.33 Dat Date Total $18,511.33 Deposit Received $5,000.00 r 4roval Signature Amount Due $13,511.33 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pelia.com Printed on 6/15/2015 Contract-Detailed Page 6 of 6 NOTICE OF CANCELLATION Date of transaction: 6/15/15 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 yot, 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 6/18/15 (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 Tenns 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 ofthe 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 ofthe 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 ofthe 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 ofwaste materials or rubbish caused by performance ofthe Work. 12. PERMITS(NIA customers only) Pella is obligated to and will obtain the following permits for this project: 4. CHANGES 2'11Ir1ln 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 COINIPLETION 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 ofthe seller,which may extended to allow for Change Orders requested by Owner or if the time to be his main office or branch thereof,provided you notify the complete the Work is affected by conduct ofthe Owner,weather,labor disputes, availability of subcontractors,acts of God,fire or other causes reasonably beyond seller in writing at his main office or blanch by ordinary mail Pella's control.If for any reason the Work is not filly 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 ofthe completion costs or 10%ofthe remaining unpaid balance ofthe Price,whichever is less. Do not sign this contract if there are any blank spaces. 6. FINANCING If payment ofthe Price is financed with a financial institution through Pella,all imancing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the fill amount ofthe requested financing shall have been received from the financial institution. 6/15/15 Date Custom signature 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 Homeow er 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 DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. The Commonwealth ofll Massachusetts �r Fora _-- Department of Industrial Accidents Office of Investigations 1 Congress Street, ,utile 100 Boston, MA 02114-2017 n mv.mass.gov/ilia Workers' Compensation Insurance affidavit: Builders/Con>tr2etors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businessl0rganization/Indivi(Iual): �J,8, QLAU � LC Address: K(°N City/State/Zip: vz t! " l& Phone#: q 7B-Z63 --72: ,gam Are you an employer? Check the appropriate box: 'Type of project(required): 1.W1 am a employer with 4• ❑ 1 am a general contractor and I have hired the sub-contractors 6. E]New construction 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 wonting for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. instrance.+' 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 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] ' c. 152, §1(4),and we have no 13 ❑ Other employees. [No workers' comp. insurance required.] Anyapplicant,that checks box#1 must also Fill out the section below showing their workers'compensation policy information. ' Homeoxvners 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. Ian:an employer that isproviding workers'compensation irnsurarrce for rrry erxplopees. Below is the policy and job site information. Insurance Company Name: L C:,!M �•� ., _� 5 Policy#or Self-ins. Lie.#: 4000 L4 o.10 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 tine up to$1,500.00 and/or one-year i_mprisotniient, as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: -- - - - - - _ ._._: - -- -- - -.JDate:-- — `j` ------ ---- Phone#: 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 S. Plumbing inspector 6. Other Contact Person: Phone#: AC ® I I LIABILITY INSURANCE DATE(MWDD/YYYY) 06/29/2015 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 NTA T Dorothy A.Corlett,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman Street PHONE o 978 3227231 FAX No; (978)454-1865 Lowell,MA 01851 E-MAIL dcodeU@fredcchurch.com (800)225-1865 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 INSURER C: 45 Fondi Road Haverhill,MA 01832-1302 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:54457 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE JUa&WVD POLICY NUMBER MM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY 100,000 PREMISES Ea occurrence) $_ CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,000 A X CG0001 ZBN8161407 7/112015 7/1/2016 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY MPROJECT- X LOC $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY LI I E B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,OOD OFFICER/MEMBER EXCLUDED? ❑ N/A 400040101 7/112015 7/112016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE g 500,1700 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 Client# 29bu Mst# Cert Holder# 38487 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r 4 _ .....f,,it 5 J CS-089853 , WILLIAM R NICHOLS 57 PEARTREE RD HAVERHILL MA; 01830 10/26/2016 3 i �,� �fe�a�irn�a�uo�a l✓z a�'G%�!�c���aclrcae� _ _, � � Office-of Consumer Affairs&•,business Regulation License or registration k'alid for ind v'idul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 178383 Type: Office of Consumer Affairs and Business.Regulation xpiration: 4/10/2016 Corporation 10 Park Plaza-Suite 5170 PELLA WINDOWS AND DOOR Boston,MA 02116 _WILLIAM NICHOLS .45 FONDE RD MAVERHILL,MA 01832 Undersecretary Not valid without signature