HomeMy WebLinkAboutBuilding Permit # 8/6/2015 1 taosary
BUILDING PERMIT O�t.�LED 16.14'
TOWN OF NORTH ANDOVERsa y 46
APPLICATION FOR PLAN EXAMINATION o p
Permit No#: 9� Date Received -0 RArE"O PPR�cS
i SNCHUS�
Date Issued: i
IMPORTANT: Applicant must complete all items on this page
LOCATION / -SI e
' Ertl I- We—
Print
PROPERTY OWNER IVA -J A(2-
Print 100 Year Structure yesno
MAP 6 PARCEL:O/f ZONING DISTRICT: Historic District yes n
Machine Shop Village yeso
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
d,Sept�c ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
�p)Nater/Sewel-,, f t � ' ✓
DESCRIPTION OF WORK TO BE PERFORMED:
*Jot
Identification- Please Type or Print Clearly
OWNER: Name: 'b r 0 �i-J"I/"- Phone:
Address: ,2 e'7
4e'e°' S i elz- La4�-(D S 4.Ae-
Contractor Name: tAAti s6re, 0k"C,6J SIA hone: q-7 2b� 0
Email: da-dlrn is,, <F, r( 'D or M N/ f . e� ^�
Address: C13T ;f�irJ t md CImN anA 0I
Supervisor's Construction License: q 18'- Exp. Date: J 1 12,1 ZO1 L
Home Improvement License: d�� � Exp. Date: -1
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ y FEE: $ --,�L-f {(
Check No.: Receipt No.: q
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
tkORTH
Town of Andover
® - 161Y 4 Tk.
C, h ver, Mass
o LAKE a.
COC MtCHE WICK
PPO�.��
BOARD OF HEALTH
Food/Kitchen
PER ..MIT T LD Septic System
% a)o�� BUILDINGINSPECTOR
THIS CERTIFIES THAT " """""'.......................... ............. .......
Foundation
has permission to erect .......................... buildings on Rough
$o be occupied as .. !4lIV1. 1.�.V1.1!1�...... 1 4#Ro.�.. 1101.';�....... . . . .... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the applicatio Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
PLUMBING INSPECTOR
Construction of Buildings in the Town of North Andover.
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit. Final
PERMITI ESI 6 ® TS ELECTRICAL INSPECTOR
LESS CONSTRUCTION S RTSRough
Service
...... .. ........................... Final
B ILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Islay in a Conspicuous Place on the Premises — Do Not Remove Final
o Lathing or Dry Wall To Be Done FIRE DEPARTMENT
ntil Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Page 1 of 4
M_. _
RVIN North Shore Window Solutions, LLC (NSWS)
239 South Main Street, Middleton, MA 01949
Phone: 978-762-0007 FAX:866-809-3136
vn �cl v.9nclr anivr sf �n
Massachusetts HIC Registration#172585
INSTALLED PROJECTS PROPOSAL
DATE: 6/3/2015 6vy NSWS REP: Matt Tiffany PROPOSAL#: NAJJ-6315
Customer Name:Elie Najjar fAW,_M�
Project Address:287 Webster Woods Lane ,No. Andover,MA. 01845
Phone:978-682-5679 Mobile:508-523-4279 Email:dnajjar@nelgpc.com
WORK TO BE PERFORMED:
Funish and install Marvin Clad RT2 RO 69.x 72 1/2" Specificationsa as follows:
Exterior : stone white
Interior: Pre-finished White
Grills: GBG to match existing
r
Glass: Low E2 with Argon
Jambs: 6 9/16
Exterior Casing: BMC with A246 subsill
Interior casing : to be reused (due to custom detail)
****The Price includes a FIVE YEAR installation warranty****
TOTAL PRICE (Materials, Labor, and Sales Tax):.$6,195.00
TERMS: 1/3 total price deposit required, 1/3 total price required upon delivery, 1/3 total price payable
at completion of above mentioned work to be performed.
WORK INCLUDEDS THE INSTALLATION OF WINDOWS AND/OR DOORS;ALL NECESSARY FRAMING.MATERIALS, ROOFING
SUPPLIES WHERE APPLICABLE; NEW INTERIOR AND EXTERIOR CASING,SILLS, AND STOOLS AS NEEDED;THE REMOVAL
AND REINSTALLATION OF INTERIOR STOPS AS REQUIRED; CAULKING SUPPLIES, NECESSARY INSULATION, SHIMS,AND
FLASHING SUPPLIES;SUFFICIENT SIDING TO REPLACE THAT REMOVED DURING INSTALLATION AS REQUIRED;
SUFFICIENT DRYWALL SUPPLIES TO REPAIR THE INTERIOR WALLS FROM THE INSTALLATION,ALL NECESSARY
FASTENER AND ADHESIVES;REMOVAL OF CONSTRUCTION DEBRIS.
THANK YOU FOR THE OPPORTUNITY TO HELP YOU!
www.nswsformarvin.com
Page 2of4
Contract Installed r J t
North Shore Window Solutions LLC.dba Marvin Design Gallery by NSWS
239 South Main Street, Middleton, MA 01949
Phone:978-762-0007 FAX:866-809-3136 Contract#: NAJJ-6315
Massachusetts HIC Registration: 172585
CUSTOMER NAME: Elie Najjar
STREET ADDRESS:287 Webster Woods Lane ,No.Andover,MA. 01845
MOBILE PHONE:508-523-4279 EMAIL:
PHONE:978-682-5679
This contract appliessolely to the labor and materials required to install the exterior windows and doors specified on the attached proposal MAB Icing
included as part of this contract.If hidden conditions such as,but not limited ill rot,insect damage, uch situations substandard framing p
work
Code, interfere
with
determine the appropriate action. Sucllation of the h action may include tNSWS sop esubcont actor performing ryepairs at additional est,
representative
however any contractor of the homeowner's choosing may be employed to perform the additional work. NSWS also reserves the option o
decline supervision t such work at which time additional charges would be billed to the homeowner directly by the subcontractor.Any new
STOMER INITIALS
charges incurred through NSWS will be due upon completion of the additional work.Billable rate @$90.00 r our, us materials.
DEFINITIONS,INCLUSIONS,AND EXCLUSIONS home.The
®FULL FRAME REPLACEMENT:these wlnesofor bay usually be installed from and bow windows where tappl cable,new i interior and exterriilortcas ng,Isills,and stools,caulking
all necessary framing materials,roof hams,flashing
' Y
supplies,necessary insulation,shims,flashing supplies,sufficient siding to replace that removed during installation,sufficient drywall supplies to repair
the interior walls from the installation,and any necessary fasteners,and adhesives needed to complete the installation.
❑ INSERT OR SASH REPLACEMENT:these windows will usually be installed from the inside of the horne.The installation will include the windows,
caulking supplies,necessary insulation,shims,and fasteners.The interior stops will be removed and reinstalled.
EXCLUSIONS:NSWS will not be responsible for any existing items that are made unusable due to the installation new windows ne doors.
These items include,but are not limited to:blinds,shades,curtains,shutters,storm windi
ows,storm doers,wallpaper,
er,air conditioners,
d
awnings,window and door hardware,etc.Unless specifically listed in the
sills,or stools,or replacement of the existing window frame.A change order may be issued to cover extra charges to fix or replacproposal,the items not included will be:new interior and exterior casing,
e items not included.
ntered during installation.The homeowner will be responsible for contacting and
NSWS will not be responsible for alarm systems encou
scheduling the alarm service company to perform any necessary alterations to accommodate the new windows.
ocated or
minated in
er to
te
y new
Any required
and electrical
work
be is not included
d,this inln this ay result proposal.added cost Anyng iring ional cost for needs to be elect al will lbe handled as a Change Order and is the
responsibility of the customer and not included in this proposal
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
North Shore Window Solutions LLC.(NSWS)agrees to perform the work,furnish the material and labor specified above,clean the site and dispose of
waste for the sum of:$6,195.00
PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE:
$2,065.00 (33%OF TOTAL SALE PRICE UPON SIGNING CONTRACT)
$2,065 (33%OF TOTAL UPON COMMENCEMENT OF WORK)
$2,065 (BALANCE UPON COMPLETION OF THE CONTRACT)
ce with the Payment for this work is subject
too f dont contracted or deductions
kU i ions inmanufactuoerdan warranty sere ce s'r sions quired to corr ct any defect of this contract and any subsequent
ndowsidoors,
change orders.Upon completion
holdback will be
the homeowner may holdback
ant theoNSWS representat vei buof the contract totat in no event l such 'shall exceed 10%of the contract price for the for which is
determined by the horn�QQ ustomer Initials
the subject of the deuest of feoY�
te release of all
ens arising out of the con
At the time of the
final
agreem agreement payment
t has above,
een NSWS
by a party certify;
theretothe
req a place other an addreowner,a ss of NSWS, which'may be the main office ortract.
You may
branch thereof,provided you notify NSWS in writing at the main office or branch by ordinary mail posted,by telegram sent or by delivery,to be reviewed
by NSWS no later than midnight of the third business day following the signing of the agreement.
See attached notice of cancellation for an explanation of this right.Terms continued on pages 2& 3 are Integra!
parts of this contract.'Do not sign this contract if there are any blank spaces**
NSWS SIGNATURE
CUSTOMER SIGNATURE
LATE: DATE:
The following acts or occurrences shall not constitute default on the part of North Shore Window Solutions LLC.(NSWS)in connection with the date of
substantial completion and shall entitle NSWS to reasonable extensions of time to perform under the contract: acts of god,strikes,acts of war,
emergencies,failure of NSWS's suppliers or vendors to timely deliver materials to NSWS,failure of the owner or its agents to supply NSWS with job site
availability on a timely basis,or any other acts or conditions not within the direct exclusive control of NSWS.
1.INSURANCE:
A. NSWS'S LIABILITY INSURANCE.NSWS agrees to keep in force at it's own expense during the entire period of construction on the project
such liability insurance as will protect it from its claims, under workmen's_compensation and other employee benefit laws,for bodily injury and
death,and for property damage,that may arise out of work under this contract,whether directly or indirectly by NSWS,or directly or indirectly
by a subcontractor paid for or employed by NSWS for the above referenced project.The minimum liability limits of such insurance shall not be
less than the limits specified by law for that type of damage claim.
B. OWNER'S LIABILITY INSURANCE.Owner(s)agrees to maintain in force their own liability insurance during the construction on this project,
and reserves the right to purchase such additional insurance as in their opinion is necessary to protect them against claims arising out of
NSWS's operation,without diminishing NSWS's obligation to carry the insurance specified herein on his part to be carried.
C. PROPERTY DAMAGE INSURANCE ON WORK SITE.Owner grees to maintain at his expense during construction of the property,damage
insurance on the work at the site to its full insurable value,inclu Jing interest of owner,NSWS, and subcontractors,against fire,vandalism, and
other perils ordinarily included in extended coverage.Losses ui ider such insurance will be adjusted with and made payable to owner, NSWS,
and subcontractors,against fire,vandalism,and other perils or inarily included in extended coverage.Losses under such insurance will be
adjusted with and made payable to owner as trustee for the pa ies insured as their interests appear.Upon request,owner shall file a copy of
all such policies with NSWS within a reasonable time after con truction begins herein.
D. WAIVER OF WORK SITE DAMAGE CLAIM TO EXTENT OF I SURANCE COVERAGE.Owner and NSWS hereby waive all claims against
each other for fire damage or damages from other perils cover d by insurance provided in paragraph"C"of this section.
2.WORK CHANGES:Owner reserves the right to order changes in the nature of additions,deletions,or modifications,without invalidating the contract,
and agrees to corresponding adjustments in the contract price and time for completion.All changes.will be authorized only by a written change order
signed by owner or by his agent.The change order will include confirming changes in the contract and completion time.Work shall be changed, and the
contract price and completion time shall be modified only as set out in the written change order.Any adjustment in the contract price resulting in a credit
or a charge to owner shall be determined by mutual agreement of the parties,or by arbitration,before starting the work involved in the change.
3.TRASH AND CLEAN-UP:NSWS is responsible for interior and exterior clean-up in rooms and areas directly impacted by the construction,including
trash removal and vacuuming.Dumpster expenses,as needed,are included in the total price.
4.TERMINATION:If owner cancels this contract vvithout legal cause after any right to rescind period,he shall pay NSWS the amount of expenses
incurred to that date plus 15%of the contract price.If NSWS cancels this contract prior to commencement of construction,NSWS shall return to owner
any amounts paid to that date.That shall be the owner's sole remedy in law or equity.
5.COMPLETION CERTIFICATE BY OWNER:On completion of NSWS's work,owner shall execute and deliver to NSWS a completion certificate
confirming that the owner of his agent has inspected NSWS's work and that the work has been satisfactorily completed to the owner's satisfaction or
itemizing any deficiencies or the specific complaints in NSWS's work.
6. LIMITED WARRANTY: NSWS WARRANTS ITS INSTALLATION ONLY TO BE FREE FROM DEFECTS IN WORKMANSHIP FOR A
PERIOD OF FIVE(5)YEARS FROM COMPLETION.THE GOODS INSTALLED HEREUNDER ARE SUBJECT ONLY TO ANY
WARRANTIES OF THE MANUFACTURER,ANY WARRANTY HEREUNDER EXTENDS ONLY TO OWNER AND IS NOT
TRANSFERABLE TO SUBSEQUENT PURCHASERS OF THE REAL PROPERTY OR TO OWNER'S HEIRS, REPRESENTATIVES,
SUCCESSORS,OR ASSIGNS. IF A DEFECT IN WORKMANSHIP COVERED BY THIS WARRANTY OCCURS, NSWS WILL AT ITS
OPTION REPAIR, REPLACE, OR PAY OWNER THE COST OF REPAIRING THE DEFECTIVE WORK AT NO COST TO OWNER. TO
OBTAIN WARRANTY PERFORMANCE, NOTIFY NSWS OF ANY DEFECT OF CLAIMS FOR BREACH,AND THIS SHALL BE THE
OWNER'S SOLE REMEDY IN LAW OR EQUITY.THE PROVIDED SAID LIMITED WARRANTY IS SUBJECT TO THE FOLLOWING
EXCLUSIONS:
A. THE GOODS INSTALLED HEREUNDER ARE SOLD ON AN"AS IS"BASIS BY NSWS.THE ENTIRE RISK AS THE
QUALITY AND PERFORMANCE OF SUCH GOODS IS WITH OWNER.SHOULD SUCH GOODS PROVE DEFECTIVE,
OWNER, AND NOT NSWS ASSUMES THE ENTIRE COST OF ALL NECESSARY REPLACEMENT OR REPAIRS..THE
GOODS INSTALLED HEREUNDER CARRY THE MANUFACTURERS'WARRANTY ONLY AND NSWS WITHOUT IN ANY
WAY ASSUMING RESPONSIBILITY OR LIABILITY THEREFORE AGREES TO EXTEND OR PASS ON TO OWNER SO
FAR AS IS POSSIBLE MANUFACTURER'S WARRANTIES.
B. DEFECTS AND FAILURE FROM MISTREATMENT,NEGLECT,OR FROM OTHER CAUSES BEYOND NSWS'S DIRECT
CONTROL SUCH AS MOISTURE, EXPOSURE TO SUN, CRACKED, BUCKLED,WARPED, OR OTHERWISE DEFECTIVE
SURFACES AND SUBSURFACE,SETTLING,OR STRUCTURAL DEFECTS.
C. WORK PERFORMED BY,OR MATERIALS,APPLIANCES OR EQUIPMENT INSTALLED BY OTHERS NOT IN THIS
CONTRACT.
D. EXCLUSIONS AND'LIMITATIONS-OWNER'S RIGHT TO REPAIR AND REPLACEMENT ARE THE EXCLUSIVE
REMEDIES AND NSWS SHALL NOT BE LIABLE FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM
THE WORK PERFORMED BY NSWS OR FROM THE GOODS PROVIDED FOR IN THIS CONTRACT.
THIS LIMITED WARRANTY IS THE ONLY EXPRESSED WARRANTY NSWS GIVES. IMPLIED WARRANTIES, INCLUDING BUT
NOT LIMITED TO WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, ARE LIMITED TO A
DURATION OF 60 DAYS FROM THE DATE OF INSTALLATION.
THIS AGREEMENT SHALL BIND THE CUSTOMER'S HEIRS, BENEFICIARIES, EXECUTORS,ADMINISTRATORS,
SUCCESSORS, INQUIRERS,AND ASSIGNS OF THE PARTIES HERETO.
Page 4 of 4
REQUIRED PERMITS
THE FOLLOWING BUILDING PERMITS ARE REQUIRED.IT IS THE OBLIGATION OF THE CONTRACTOR TO SECURE SUCH PERMITS AS THE
HOMEOWNER'S AGENT:LIST ANY AND ALL NECESSARY CONSTRUCTION-RELATED PERMITS.
NOTE:OWNERS WHO SECURE THEIR OWN PERMITS OR DEAL WITH UNREGISTERED CONTRACTORS ARE EXCLUDED FROM THE
GUARANTY FUND.PROVISIONS OF MGL C.142A.
As required per town of
No Andover,MA
NOTE:ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE REGISTERED AND ANY INQUIRIES ABOUT A
CONTRACTOR OR SUBCONTRACTOR RELATING TO A REGISTRATION SHOULD BE DIRECTED TO:
DIRECTOR,HOME IMPROVEMENT CONTRACTOR REGISTRATION
ONE ASHBURTON PLACE,ROOM 1301
BOSTON,MA 02108
617-727-8598
UNLESS OTHERWISE NOTED WITHIN THIS DOCUMENT,THE CONTRACT SHALL NOT IMPLY THAT ANY LIEN OR OTHER SECURITY
INTEREST HAS BEEN PLACED ON THE RESIDENCE.
ARBITRATION
NSWS AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT THAT NSWS HAS A DISPUTE CONCERNING
THIS CONTRACT,NSWS 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.
NSWS: DATE:
CUSTOMER: r DATE: f S
NOTICE:THE SIGNATURES OF THE PART ROVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE
SETTLEMENT INITIATED BY NSWS.THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT
SEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
HOMEOWNER'S FINANCIAL INSECURITY-A CONTRACTOR MAY NOT DEMAND PAYMENTS IN ADVANCE OF THE DATES SPECIFIED ON THE
PAYMENT SCHEDULE IN CASES WHERE THE HOMEOWNER DEEMS HIM/HERSELF TO BE FINANCIALLY INSECURE.CONTRACTOR'S
FINANCIAL INSECURITY-IN INSTANCES WHERE A CONTRACTOR DEEMS HIM/HERSELF TO BE FINANCIALLY INSECURE,THE
CONTRACTOR MAY REQUIRE THAT THE BALANCE OF FUNDS NOT YET DUE BE PLACED IN A JOINT ESCROW ACCOUNT AS A
PREREQUISITE TO CONTINUING THE CONTRACTED WORK.WITHDRAWAL FROM SAID ACCOUNT WOULD REQUIRE THE SIGNATURES OF
BOTH PARTIES.
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE DATE THAT THE
CUSTOMER SIGNS THIS CONTRACT.
AFTER THREE BUSINESS DAYS,AN ORDER FOR NON-STOCK WINDOWS AND/OR DOORS MAY NOT BE CANCELLED.
IF YOU CANCEL WITHIN THREE BUSINESS DAYS,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE
CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS
FOLLOWING RECEIPT BYTHE 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 CONTRACT OR SALE;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 CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION.IF YOU FAIL
TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO
SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER
WRITTEN NOTICE,OR SEND A TELEGRAM TO NSWS INSTALLED SERVICES,AT 239 South Main Street,Middleton,MA 01949 NOT LATER THAN
MIDNIGHT OF (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
The Commonwealth of Massachusetts
Department of IndustrialACCidents
F 1 Congress Street,Suite 100
h r021142017
3 d Boston, MA
�t wwmass.gov/
w. dia
nsation Insurance Affidavit:Builders/Contractors/Electricians/�lumbexs.
G AUT fORITY.
yijorkers Compe TO BE FILED WITH THE PERNIIIN ..Please Print Le 'bl
A licant Informationr�
S �
Name(Business/Organ"ation/1ndividual):
Address: 13 �" 1tl,�, ��� l
Phone 4:
City/State/Zip: 'Type of project(Tecluired)
Leaemployer?Checic the appropriate box:
Ar yo 7, []New'oonstriiction
employees(full and/or part-time). ❑
I. a employer with__ ___ g, Remodeling
a sole proprietor or partnership and have no employees working for me in 9 El Demolition
capacity.[No workers'comp.insurance required.]
all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
a homeowner doing I will
be hiring contractors to conduct all work on my property. 11_❑Electrical repairs or additions
a homeowner and will bin repairs Or additions
ure that all contractors either have workers'compensation insurance or are sole 12_[]Plumbing
prietors with no employees. 13.gRoof repair a general contractor and I have hired the sub
ees and have o�kersetcompinsurance ached sheet. 14 r-/�Otherese sub-contractors have einp y �/1ees. o workerscomp.insurance required.]
are a corporation and its.officershave exercised their right o£exemption per MG o.
2,§1(4),and we have no employ
their workers'compensation must s information.
*Any applicant that checks box A must also fill outiltlhe sane d ing alllow showing the sub-contractors and state whether or not those entities,have
s affidavit indicating y all work and then hire outside contractors must submit anew affidavit indicating such.
1 Homeowners who submit this the name of
otic number.
$Contractors that checkthis box must attached an additional sheet showing enr l0 ees. Below is the policy and job site
employees. If the sub-contractors have employees,they must provide their workers'comp.policy
er that!SPY
compensation insurance for'my p Y
f am an employ
information.
Insurance Company Name: 'S
Expiration Date:_ �
policy#or Self-ins.Lic.
City/State/Zip:
tL'C1 showing the policy number and expiration date).
Job Site Address: compensation policy declaration page
a fine u to$1,500.00
Attach a copy of the workers' comp §25A is a criminal violation punishaband a fine Of UP to le by p
ER
Failure to secure coverage as required under MGL c.152, STOP
ent as well as civil penalties in the form of a e Office of Investigations of the DIA for insurance a
and/or one-year imprisonm be forwarded to the
day against the violator.A copy of this statement may
coverage verification. enalties of per jury tliat the information provided a ov' is t''u� d cor'r'ect.
I do Iter eby certify under the pains andp Date: n'J
Si nature:
�1
Phone#"
ial use only. teia.
offic
Do not write in this area,to be completed by city or town off
• Permit/License#
City or Town:
Authority(circle one): I Clerk Q.Electrical Inspector 5.Plumbing Inspector
Issuing a tment 3.City/Town
1.Board of Health 2.Building D par
6.other Phone#:
Contact Per son:
DATE(MMIDD/YYYY)
ACORD, CERTIFICATE OF LIABILITY INSURANCE 05/12/2015
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).
Patricia
PRODUCER NAME: Tedesco
Burns, Brooks & McNeil
PHONE
Burns, ,Ext: 860.482.5591 (A/C,No):860.496.9713
www.burnsbrooksmcneil.com ADDRESS: ptedesco@burnsbrooksmcneil.com
69 Water Street P.O. BOX 717 INSURER(S)AFFORDING COVERAGE NAIC#
Torrington, CT 06790 INSURERA: National Grange Mutual 14788
INSURED North Shore Window Solutions, LLC INSURERB: National Grange Mutual 14788
239 South Main Street INSURERC:
Middleton, MA 01949 INSURER D:
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: 15-16 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
POLICY EFF POLICY EXP LIMITS
rALTR TYPE OF INSURANCE INSR (M
WVD POLICY NUMBER MIDDIYYYY) (MM/DD/YYYY)
GENERAL LIABILITY BPT68$7 05/15/2015 05/15/2016 EACH OCCURRENCE 5 1,000,00
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S 500,00O
CLAIMS-MADE [X] OCCUR MED EXP(Any one person) S 10,000
X PERSONAL&ADV INJURY S 1,000,00
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000
POLICY X JE PRO LOCCOMBINED SINGLE $
AUTOMOBILE LIABILITY M2T68$7 05115/2015 05/15/2016 (Ea accident) S 1,000,000
BODILY INJURY(Per person) $
ANY AUTO
B ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS PR PER Y DA AGE
NON-OWNED (Per accident) S
HIRED AUTOS AUTOS
5
X UMBRELLA LIAB X OCCUR CUT68 57 05/1512015 05/15/2016 EACH OCCURRENCE $ 2,000,000
B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED X RETENTION$ 10,000
WORKERS COMPENSATION WCT685705/15/2015 05/15/2016 X WCTORSTATU- OTH-
Y LIMITS ER
AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVF�'� N/A
DED? N
A OFFICER/MEMBER EXCLUE.L.DISEASE-EA EMPLOYEE $ 500,000
(Mandatory in NH)
If yes,describe under E.L.DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
E: Evidence of Insurance
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
To Whom It May Concern Patricia Tedesco, CIC
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 172585
Type: LLC
Expiration: 7/10/2016 Tr# 253325
NORTH SHORE WINDOW SOLUTIONS-LL
BRIAN CONSOLAZIO
239 SOUTH MAIN ST
MIDDELTON, MA 01949
Update Address and return card.Mark reason for change.
SCA 1 C 20M-05/11 Address Renewal E] Employment Lost Card
CERTIFIED INSTALLER 9 71M Massachusetts ,Department of Public Safety
LEVEL: RLC-1
Board of Building Regulations 4-„d Standards
IIlt11.11 L1UL 3t1p C1 ti1JV1 J
License: CS-091857
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_ DENNIS E LASSEEL
571 West Street , ;
Leominster AIA 61453
#700005821
Expires: 09/01/1
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571 West street Architectural Testing,Inc. Expiration
Leominster,Massachusetts 01453 Commissioner 11/02/2016
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