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HomeMy WebLinkAboutBuilding Permit # 8/11/2015 %AORTH BUILDING PERMIT 0 16 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4t Permit No#: Date Received SSgC U5 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 5- - dpi/ Print PROPERTY OWNER SC-o-rt- it_=J/,S Z_� Print 100 Year Structure yes 4 no MAP PARCEL: ZONING DISTRICT: Historic District ye no I Machine Shop Village ye no 10) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building MzQne family El Addition 11 Two or more family 11 Industrial [I Alteration No. of units: 0 Commercial --CLRepair, replacement El Assessory Bldg El Others: [I Demolition El Other DESCRIPTIONF W OORK TO BE PERFORMED: i4 t L_J Identification- Please Type or Print Clearly OWNER: Name: SC,,fytf E16 S Phone: 9(bic Address: Contractor Name: hone: Email: Address: qS- Fzy,(ip C_ jz-) Supervisor's Construction License: Exp. Date: —1k 3 -Horne Improvement License: I Exp. Date: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund S 814natuii A�eiiifi/ tkORTH ' town of ..T 2 ..1,, Andover .. ...... - - 2.,b �, h ver, Mass, ® LAK. �. COC "Kot_KK S L) BOARD OF HEALTH PER Food/Kitchen Septic System THIS CERTIFIES THAT U1.7 BUILDING INSPECTOR Foundation has permission to erect .............. .:..:..... uildin son ... .. • .... ............... ....... ....................... Rough to be occupied as ....................... ......... .. ... . .. !l, .... � .. ........................ Chimney provided that the person accepting this permit hall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ..... ..... � - .............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Buildln_z Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Contract - Detailed Pella Window and Door Showroom of Haverhill Sales Rep Name: Gonya, Nathan ® 45 Fondi Road Sales Rep Phone: 978-360-1287 Haverhill, MA 01832 Sales Rep Fax: Phone: (978) 373-2500 Fax: (978) 373-7274 Sales Rep E-Mail: gonyanb@pellaboston.com Customer Information Project/Delivery Address Order Information Scott Ellis EIIis,Scott,1591050 Quote Name: EIIis,Scott,1591050 5 Green Hill Ave 5 Green Hill Ave Order Number: 741 NG0020 NORTH ANDOVER, MA 01845-4312 Lot# Quote Number: 6939347 Primary Phone:(401)9326739 North Andover, MA 01845-4312 Order Type: Installed Sales Mobile Phone: County: Payment Terms: Fax Number: Tax Code: MA TAX 6.25 E-Mail: Ellisl022@verzion.net Quoted Date: 7/10/2015 Great Plains#: Customer Number: 1007259409 Customer Account: 1002968809 Line# Location: Attributes 10 None Assigned Delivery/Setup-Delivery/Setup Item Price Qty Ext'd Price $188.00 1 $188.00 For more information regarding the finishing, maintenance, service and warranty of all Pella®products, visit the Pella®website at www.pella.com Printed on 7/11/2015 Contract-Detailed Page 1 of 4 Customer: Scott Ellis Project Name: EIIis,Scott,1591050 Order Number: 741 NG0020 Quote Number: 6939347 Line# Location: Attributes 15 Basement Vinyl Windows/Doors By Pella, Sliding Window Vent Right/Fixed, 32.25 X 21,White Item Price Qty Ext'd Price $453.55 4 $1,814.20 T 1:Non-Standard SizeNon-Standard Size Vent Right/Fixed Double Slider PK# Frame Size: 32 1/4 X 21 716 General Information: Standard,Vinyl,Block,2 11/16",2 11/16" Exterior Color/Finish: White Interior Color/Finish: White Glass: Insulated Low-E Advanced Low-E Insulating Glass Argon Non High Altitude Hardware Options: Cam-Action Lock Viewed From Exterior Screen: Half Screen Frame Size:32.25"X 21" Grille: No Grille, Wrapping Information: No Exterior Trim,No Interior Trim,Pella Recommended Clearance,Perimeter Length=107",Glazing Pressure=190. Venting Width: Equal PI_Hopper-Hopper Basement Window Qty 1 Thank You For Purchasing Pella® Products PELLA WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale.All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details,taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture within the wall system.Neither Pella Corporation nor Pella Windows&Doors will be bound by any other warranty unless specifically set out in this contract. However,Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening(egress)information does not take into consideration the addition of a Rolscreen[or any other accessory]to the product.You should consult your local building code to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty,unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually,thereafter. Variations in wood grain,color,texture or natural characteristics are not covered under the limited warranty. INSYNCTIVE PRODUCTS:In addition,Pella Insynctive Products are covered by the Pella Insynctive Products Software License Agreement and Pella Insynctive Products Privacy Policy in effect at the time of sale,which can be found at Insynctive.pella.com. By installing or using Your Insynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. Project Checklist Review (Installed Orders Only) Before the Installation the Homeowner agrees to do the following: Obtain Condo Association Approval Obtain Historic Approval Remove existing shutters and awnings Remove air conditioners Remove existing shades, drapes, window treatments, wall hangings, and personal belongings For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 7/11/2015 Contract-Detailed Page 2 of 4 Customer: Scott Ellis Project Name: Ellis,Scott,1591050 Order Number: 741NG0020 Quote Number: 6939347 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 Permit(When required) Prefinish products when purchased in contract During the Installation the Homeowner agrees to do the following: Keep pets safely away from work area Keep children safely away from work area Allow Pella Installer room to work safely within your home During the Installation Pella agrees to do the following: Deliver and unload products purchased per contract Place and remove drop cloths in work area then vacuum, and remove all debris at end of day Remove existing product, including storm windows, and dispose of it unless otherwise specified Install all products using method specified in contract per Pella Installation Instructions Replace interior and/or exterior trim only if purchased If Purchased, install exterior primed pine wood trim or Composite. Composite will be unfinished. If Purchased, install interior trim matching wood window finish or White trim for Impervia and Encompass Install non-Pella entry door lockset provided by you. Pella is not responsible for it's quality or performance After the Installation the Homeowner agrees to do the following: Be available for completion and sign off to verify all products purchased are in working order Reinstall existing shutters and awnings Re-install existing shades, drapes, window treatments,wall hangings, and reposition furniture Arrange to have alarm system and doorbells reinstalled Reinstall air conditioners Remove stickers from product and save for energy rebate and tax purposes Wash all interior& exterior glass surfaces Fill nail holes and joints on interior trim if windows are to be stained (after staining) Clean up ext r casing issues due to storm window removal if full wrap or new exterior trim is not purchased el kroject Checklist has been reviewed Customer initial Product Only Addendum has been reviewed Customer initial Credit Card Account#: Last 4 Digits For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella@ website at www.pella.com Printed on 7/11/2015 Contract-Detailed Page 3 of 4 Customer: Scott Ellis Project Name: EIIis,Scott,1591050 Order Number: 741 NG0020 Quote Number: 6939347 Expiration Date: / Charge final payment to same account (Upop substantial completion) Customer initial Project Checklist has been reviewed Scott Ellis Nathan Gonya Customer Name (Please print) Pell le ep Na (Please print) Order Totals Taxable Subtotal $694.20 A44101��o Custome gnature Pella Sales Rep Signature Sales Tax @ 6.25% $43.39 7/11/15 7/11/15 Non-taxable Subtotal $1,308.00 Date Date Total $2,045.59 Deposit Received $0.00 Credit Card Approval Signature Amount Due $2,045.59 For more information regarding the finishing, maintenance, service and warranty of all Pella®products,visit the Pella®website at www.pella.com Printed on 7/11/2015 Contract-Detailed Page 4 of 4 PELLA WINDOWS AND DOORS CONTRACT 7. PAYMENTS 1. TERMS AND CONDITIONS Pella shall be entitled to stop the Work upon written notice to Owner for any material default or failure by Owner,including but not limited to,the Owner's These Terms and Conditions are an integral part of the contract set forth on the failure to pay Pella the amount due within seven days after the date payment is Product Order(the"Contract")between New England Window and Door LLC due. dba Pella Windows&Doors,Inc.("Pella")and the person(s)identified on the Product Order("Owner")to supply the products(the"Products"),and perform 8, CORRECTION OF WORK the work(the"Work")described or referred to in such Contract. For Product Only purchases,a signed"Product Only Addendum"is a required part ofthe Pella shall correct installation Work not in conformance with the requirements contract. of the Contract,if notified in writing by the Owner within two years after the Completion Date or,if earlier,the date on which the Work is substantially completed and payment of the Purchase Price made subject to a holdback as 2. OWNER provided above.Correction of Work as herein provided shall be Owner's sole Pella is not responsible for any existing security systems.Owner shall remove remedy for defective workmanship,and is provided in lieu of any and all other all shades;verticals,blinds,curtains,drapes or window mounted air remedies.Pella's obligation to correct Work is conditioned on Pella's prior conditioners,prior to the installation of the Products.Pella's installers are not receipt of all payments then due. responsible for the removal or installation of these types of items. Pella is not responsible for pre-existing window coverings fitting on newly installed Pella 9. LIMITED PRODUCT WARRANTY windows. Pella shall warrant all Pella products,but only in accordance with the Pella The Owner shall provide complete access to the work site between the hours Windows&Doors Limited Warranty.THIS LIMITED WARRANTY SHALL of 7:00 a.m.and 6:00 p.m.(Monday through Friday)for Pella's installers to BE THE SOLE WARRANTY WITH RESPECT TO THE PRODUCTS AND deliver the Products and perform the Work. PELLA SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, WRITTEN OR ORAL(INCLUDING WITHOUT 3. PELLA LIMITATION ANY WARRANTY OF MERCHANTABILITY OR FITNESS Pella will be responsible For and have control over construction means, FOR A PARTICULAR PURPOSE). methods,techniques,sequences and procedures and for coordinating all portions of the Work.Pella will be responsible for the Work of its Pella 10. NO CONSEQUENTIAL DAMAGES Contractors who will install the Products. UNDER NO CIRCUMSTANCES SHALL PELLA BE LIABLE FOR CONSEQUENTIAL,INCIDENTAL,INDIRECT,OR SPECIAL DAMAGES, Unless provided otherwise in the Work description,Pella will provide and pay WHETHER FORESEEN OR UNFORESEEN. for all labor,materials,equipment,tools and machinery,transportation,and other 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 famished 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 defects not inherent in the quality required or permitted,and the Work conform any of its subcontractors identified in this agreement have been registered. with the requirements of this Contract.Pella shall not be responsible Any inquires about Pella or any of its subcontractors relating to registration for damages or defects caused by abuse,modifications not executed by Pella, should be directed to:Director,Home Improvement Contractor Registration, improper or insufficient maintenance,improper operation or normal wear and One Ashburton Place,Boston,MA 02108,617-727-8598 tear. Pella will keep the premises and surrounding area free from accumulation of waste materials or rubbish caused by performance of the 12. PERMITS(MA.customers only) Work. Pella is obligated to and will obtain the following permits for this project: . Homeowners who secure their own permits will be 4. CHANGES excluded from the guaranty fund provisions of Massachusetts General Laws, The Owner may order in writing changes in the Work consisting of additions, chapter 142A. deletions,or modifications("Change Order"). Any Change Order shall include an adjustment to the Price and the Substantial Completion Date,as In addition to the rights and warranties enumerated in this agreement,you may determined by Pella. Pella reserves the right to approve or disapprove any have additional rights under Massachusetts General Laws,chapter 142A and Change Order and any such Change Order must be signed by both Owner and 780 Code of Massachusetts Regulations R6. Pella to be effective. 13. NOTICE OF CANCELLATION 5. SUBSTANTIAL COMIPLETION You may cancel this agreement if it has been signed by a party Owner understands and agrees that the Substantial Completion Date is an thereto at a place other than an address of the seller,which estimate only and that the actual date on which the Work is completed may be may be his main office or branch thereof,provided you notify extended to allow for Change Orders requested by Owner or if the time to the seller in writing at his main office or branch by ordinary complete the Work is affected by conduct of the Owner,weather,labor disputes,availability of subcontractors,acts of God,fire or other causes mail posted,by telegram sent or by delivery,not later than reasonably beyond Pella's control.If for any reason the Work is not fully midnight of the third business day following the signing of this completed by the Substantial Completion Date(including any extensions agreement. contemplated above),but is substantially completed by such date,i.e.,the Product has been installed,but minor parts or components are missing or need See the attached Notice of Cancellation for an explanation of to be replaced or repaired,a hold back proportionate to the cost ofremaining this fight. parts or work to be completed is acceptable.However,the holdback will not exceed the amount of the completion costs or 10%of the remaining unpaid balance of the Price,whichever is less. Do not sign this contract if there are a nk spaces. 6. FINANCING If payment of the Price is financed with a financial institution through Pella,all financing paperwork must be completed upon signing of this Contract and the requisite approvals and authorizations for the full amount of the requested financing shall have been received from the financial institution. Customer signator 7/11/15 Date DISPUTES THE CONTRACTOR AND THE HOMEOWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT PELLA HAS A DISPUTE CONCERNING THIS CONTRACT,PELLA MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L.c. 142A Contractor Homeow NOTICE: THE SIGNATURE OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. NOTICE OF CANCELLATION Date of transaction: 7/11/15 You may cancel this transaction,without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable 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 7/15/15 (three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) The Commonwealth of Massachusetts -t'tt _Farm Department of Industrial Accidents Office of Ini,estigations I Congress Street, Suite 100 Boston,MA 021142017 www.inass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leery Name(Business/Organizatiott/Individual): IPEZIf) 4A 0;-u)S 4- b,;t;� �L _ Address: 4: EP.r� City/State/Zip: `ait.tI vvk 6632-2- Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.0&1 am a employer with -_-7,�, 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractot's 6. ❑New constriction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in an it employees and have workers' Y capacity.p Y 9. ❑Building addition [No workers' comp. insurance comp. insurance.. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box must attaclied 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. lain an employer that is providing work-ers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t_E_-',t4 ®C_CQ S 0 . Policy#or Self-ins. Lic. #: g000 14 C, tf Expiration Date: sj f 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-1 5A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,tinder the pains and penalties ofperjury that the information provided above is true and correct. Signature: --�"� `_ -'� " Date: _`/1-/s— --- Phone#: Of use only. Do not write in this area, to be completedby 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. Other Contact Person: Phone#: AC40RerDATE(MWDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 CONTACT Dorothy A.Corlett,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman StreetPHC N o 978 3227231 AX No; i978)454-1865 Lowell,MA01851 E-MAIL dcodeft@fredochurch.com (800)225-1865 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC ti 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 POLICY NUMBER MM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ CLAIMS-MADE M OCCUR MED EXP(Any one person) $ 10,000 A X CG0001 ZBN8161407 7/112015 7/1/2016 1,000,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2.000,000 POLICY rq PRO- X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS $ Per accident UMBRELLA LIAR [71�OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONX ACR STATU• 0TH- AND EMPLOYERS'LIABILITY YIN LI i' E ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? ❑ NIA 400040101 7/1/2015 7/112016 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 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 Cliental 2960 Mst# Cert Holder# 38487 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1 e. _,_'. CS-089853 w WILLIAM R NICHOLS 57 PEARTREE RD' HAVVERHILL MA„ 01830 10/261•2016 �< e Offce.of Consumer »Affairs&-$us inness Regulation � License or restration kalid for ind,vidul use only. ME IMPROVEMENT CONTRACTOR before the expiration date.'If foiind return to: egistration: 178383 Type: Office of Consumer Affairs and Business Regulation xpiration: 4/10%2016 Corporation 10 Park Plaza-Suite.5170 Boston,MA 02116 PELLA WINDOWS AND-DOOR--. :WILLIAM NICHOLS . 45 FONDE RD HAVERHILL,MA 01832 l" y •r Undersecretary Not valid without signature