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HomeMy WebLinkAboutBuilding Permit # 9/21/2015 V%ORTH BUILDING PERMIT °��=QED TOWN OF NORTHA VE ® ; APPLICATION FOR PLAN EXAMINATION _ �� z 01— w, " Permit No#: Date Received ®ADRATED YssAcwus� Date Issued: t I1VIPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER d Print 100 Year Structure yes no MAP 1 PARCEL: U)MG ZONING DISTRICT: es Historic District yno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition n Tynan or,mnrP family , [I Industrial El Alteration ❑ Repair, replacement ❑ Demolition "'NOW/0, i ocation mm i IP1Well1 ` \ gym / � Date DESCRI - TOWN OF NORTH A DOVER Certificate of Occupancy $ ' Building/Frame Permit Fee $ 3 Identifica OWNER: Name: Foundation Permit Fee $ Other Permit Fee $ Address: �� � TOTAL $ 1 Contractor Name: e { f Email e�,a '�a� �J � Check# Address: Supervisor's Construction Licen� Building inspector Home Improvement License: 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 EE: 'ect C st: $ �, F $ - Check No.. l/ Receipt N NOTE: Pe s ns cont actin itli u gist ed contractors do not have access to the guaranty fund ��.m �.a• FORTH Town of _ It T..." ndover 0 " 0% No. T' �O LAKE ver, Mass, Is COCNIC Nl WICK �1. ADRATE D / '�C S i] BOARD OF HEALTH Food/Kitchen rER* I T �t� D Septic System THIS CERTIFIES THATBUILDING INSPECTOR ........... ................ .......B.*........................ ....... ..... ..... ........ ' ® Foundation has permission to erect .......................... buildings on ... .. . . ........... ... ..^.. .......................... ..... ................................ Rough to be occupied as ....... �......��.. ...1, ...... .... . ...b!��.�. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Lavas 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 IT EXPIRES IN 6 MONTHELECTRICAL INSPECTOR UNLESSI Rough Service ................... ............................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Qccu,2y Buildin Rough Islay in a Conspicuous Place on the Premises — ® of Remove Final No Latin or Be® Wall To Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Page 2 of 4 Contract Installed Projects 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 Massachusetts HIC Registration: 172585 Contract#: BAKER-071815 CUSTOMER NAME: Kathy Baker STREET ADDRESS:257 Main Street, North Andover, MA 01845 PHONE:978-794-1888 MOBILE PHONE:978-987-6415 EMAIL: This contract applies solely to the labor and materials required to install the exterior windows and doors specified on the attached proposal which is included as part of this contract,if hidden conditions such as,but not limited to,rot,insect damage,or substandard framing per the MA Building Code, interfere with the proper installation of the products, the work will stop immediately. Such situations will be referred to NSWS's representative to determine the appropriate action. Such action may include NSWS's subcontractor performing repairs at additional cost, however any contractor of the homeowner's choosing may be employed to perform the additional work. NSWS also reserves the option to decline supervision of such work at which time additional charges would be billed to the homeowner directly by the subcontractor.Any new charges incurred through NSWS will be due upon completion of the additional work.Billable rate @$90.00 per man hour plus materials. CUSTOMER INITIALS DEFINITIONS,INCLUSIONS,AND EXCLUSIONS ❑FULL FRAME REPLACEMENT:these windows will usually be installed from the outside of the home.The installation will include windows or doors, all necessary framing materials,roofing supplies for bay and bow windows where applicable,new interior and exterior casing,sills,and stools,caulking 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 home.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 of new windows or doors. These items include,but are not limited to:blinds,shades,curtains,shutters,storm windows,storm doors,wallpaper,air conditioners, awnings,window and door hardware,etc.Unless specifically listed in the proposal,the items not included will be:new interior and exterior casing, sills,or stools,or replacement of the existing window frame.A change order may be issued to cover extra charges to fix or replace items not included. NSWS will not be responsible for alarm systems encountered during installation.The homeowner will be responsible for contacting and scheduling the alarm service company to perform any necessary alterations to accommodate the new windows. Any required electrical work is not included in this proposal. If existing wiring needs to be relocated or eliminated in order to accommodate any new windows and or doors to be installed,this may result in added cost. Any additional cost for electrical will be 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:$6,225.00 PAYMENTS WILL BE MADE ACCORDING TO THE FOLLOWING SCHEDULE: $2,075.00 (33%OF TOTAL SALE PRICE UPON SIGNING CONTRACT) $2,075 (33%OF TOTAL UPON COMMENCEMENT OF WORK) $2,075 (BALANCE UPON COMPLETION OF THE CONTRACT) Payment for this work is subject to additions or deductions in accordance with the provisions of this contract and any subsequent written change orders.Upon completion of contracted work,if manufacturer warranty service is required to correct any defect in the windows/doors, the homeowner may holdback up to 10%of the contract total until such service is performed.The actual amount of the holdback will be determined by the homeowner and the NSWS representative,but in no event shall exceed 10%of the contract price for the item(s)which is the subject of the defect. Customer Initials At the time of the final payment specified above,NSWS will certify,at the request of the owner,a complete release of all liens arising out of the contract. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of NSWS,which may be the main office or 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 integral parts of this contract.***Do not sign this contract if there are any blank spaces*** AA IV, CUSTOMER SIGNATURE NSW S NATURE DATE: I DATE: '? j c Page 3 of 4 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 v✓ill 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 agrees to maintain at his expense during construction of the property,damage insurance on the work at the site to its full insurable value,including interest of owner,NSWS,and subcontractors,against fire,vandalism;and other perils ordinarily included in extended coverage.Losses under such insurance will be adjusted with and made payable to owner,NSWS, and subcontractors,against fire,vandalism,and other perils ordinarily included in extended coverage.Losses under such insurance will be adjusted with and made payable to owner as trustee for the parties insured as their interests appear.Upon request,owner shall file a copy of all such policies with NSWS within a reasonable time after construction begins herein. D. WAIVER OF WORK SITE DAMAGE CLAIM TO EXTENT OF INSURANCE COVERAGE.Owner and NSWS hereby waive all claims against each other for fire damage or damages from other perils covered 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 without 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 North Andover Permit billed separately of this proposal based on total project cost,payable by customer to NSWS 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 SUWQT TO SUCF_ BITR TION AS PROVIDED IN M.G.L.C.142A. NSWS: DATE: CUSTOMER: DATE: _7// fS // S^ NOTICE:THE SIGNATURES OF THE PARTIES ABOVE 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 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 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: KORrN p4 rico�s'4bo b _� ���• �. Town of North Andover -f Machizie Shop Village Neighborhood Co-usenation District Commission, 1600 Osgood Street North Andover,NU 01$45 SSACHUS� Application For EXCLUSION From Certificate to Alter Certain alterations are excluded from review by the Machine Sliop'village Neighborhood Conservation District Convitission in accordance with the Bylaw, 11 pplicants for exempt projects must fill out the form below and submit to the Commission Chairperson(Contact info below). Date: (I -t ~261 Contact Name&Address: Denois LasSdl �Ao,4, gkal-f,'. W �'Alj �' bf"tA� MA 0.111q � - ProjectAddress: , Project Description(attach additional pages,if needed: IA&A t oto e.6gr,,A0 a . Exclusion From Review Requested For: ❑ 1.Interior Alterations existing conditions including materials, design and dimensions. El2.Storm windows and doors,screen windows and doors. 9.Replacement of existing substitute doors,substitute siding or substitute ❑ 3.Removal,replacement or installation of windo-vs with new materials that are gutters and downspouts, substantially similar to the existing condition. 4.Removal,replacement or installation of window and door shutters. ❑ 10.Replacement of original Fabric windows or doors with substitute D 5.Accessory buildings of less than 140 windows or doors that maintain the square feet of floor area. architectiltaI integrity with respect to fotm,fit and function of the original ❑ 6.Removal of substitute siding. windows or doors. ❑ 7.Alterations not visible from a public ❑ 11.Reconsttuction,substantially similar in way. mtedor design,of a building,damaged or desttoved by fire,stotin or other disaster, ❑ 8. Ordinary maintenance and repair of provided such reconstruction is begun architectural features that match the within one Year thereafter. MSV NCDC Page 1 Current Chair:Liz Fennessy,77 Elm Stteet,lizettefennessy@vahoo.com,978-688-2915 F�xoRrr�� Yawn o North Andover Machine Shop ViUage Neighborhood Conservation Distric'Commission 1600 Osgood Street Nord)_Andover,MA 01845 $Acm SE Apphcatzon For EXCLUSION From Cettxfieate to Alter Frot terns 9,10 or 11,protide the folio-inn docurnexitation; Photos/drawings of existing doors, windows or siding, as applicable DescriptionfCatalog Cuts of proposed materials to be ttsed for doors, windows or siding Plan and elevation of reconsttuction for Item 11 Determination: This project is determined to be e empt Q not exempt from revieiv by tlxe hfachine Sizop Village Neighbor hood Cotzsetvation District Commission. Projects that are not exempt must complete the Application.for Certificate to Alter,available from the Building Department and be reviewed by the Commission. Determination made by: Sign tire Neighborhood Corrser nation Distorrunission Date MSV NCQC Page 2 C anent Chair.Lir.Fennessy,77 Elm Street,lizettafennessvC@vahoo corn,978-688-2915 The Commonwealth of Massachusetts . Department oflndustrialAccidents f d 1 Congress Sheet,Suite 100 Boston,MA 02114-2017 www mass.gov/dia iV• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FMED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl NaMe (Business/Organization/Individual): o Ad(hess: , ,r8V) 01, City/State/Zip: s �M,fu 4 o l Phone#: 111v Are you an employer?Check the appropriate box: Type of project()required): 1. I am a employer with . employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3_F1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9 Demolition 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. • 12.[]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ t 13.[�Roof repairs • These sub-contractors have employees and have workers'comp.insivance. 6.F1 we are a corporation and its officers have exercised their right of exemption per MGL G. 14.[�OthBr Lo/N "-K, 152,§10),and we have nq employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. i Homeowners who subniif 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 sub-contractors and state whether or not those entities have employees. If the sub-conirac6s have employees,they must provide their workeis'comp.policy number. I am an employer that ispi dviding ivorkers'compensation insurance for my employees.'Below is thepolicy and job site information. Insurance Company Name: 0 51 Policy#or Self-ins,Lie.#: tD 0 ( Expiration Date: 1 Job Site Address: ��� city/State/Zip: 10 _ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(late). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.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 ofpetjuiy that the information provided above is true and correct. sign 0: Date: Phone# c9 112-, ( (j Official use only. Do not write in this area,to he 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.Other Contact Person: Phone#: DATE(MM/DD/YYYY) ACORD,, CERTIFICATE OF LIABILITY INSURANCE F05/12/2015 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). PRODUCER UUNIAUI NAME: Patricia Tedesco Burns, Brooks & McNeil AIC,NNo,Ext: 860.482.5591 (A/C,No ):860.496.9713 www.burnsbrooksmcneil.com AIL ADDRESS: ptedesco@burnsbrooksmcneil.com 69 Water Street P.O. BOX 717 INSURER(S)AFFORDING COVERAGE NAIC# Torrington, CT 06790 INSURER A: National Grange Mutual 14788 INSURED North Shore Window Solutions, LLC INSURER B: National Grange Mutual 14788 239 South Main Street INSURER C: 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 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY BPT6857 05/15/2015 05/15/2016 EACH OCCURRENCE $ 1,000,000 ',. X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 500,000 CLAIMS-MADE PC] OCCUR MED EXP(Any one person) $ 10,000 A X PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 17 POLICY X PRO- LOC S JECT AUTOMOBILE LIABILITY M2176857 05/15/2015 05/15/2016 (Ea accident) $ 1,0001000 ANY AUTO BODILY INJURY(Per person) $ '.. B ALL OWNED X (Per accident)AUTOS ( )SCHEDULED AUTOS BODILY INJURY Pidt $ HIRED AUTOS NON-OWNED PROPER DA A E $ '.. AUTOS (Per accident) S X UMBRELLA LIAB X OCCUR CUT68 57 05/15/2015 05/15/2016 EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 ',.. DED I X I RETENTION$ 10,000 $ '... WORKERS COMPENSATION WCT68 57 AND EMPLOYERS'LIABILITY Y/N 05/15/2015 05/15/2016 X TORY LIMITS R ANY PROPRIETOR/PARTNER/EXECUTIV� E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? 1 N I N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 _ v `Ge, Q��Qt%LZY%�2Q�'riLf�eC?iL�12 �^�C'LCL/L,lC�GI�iLL/.lG Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 172585 Type: Supplement Card NORTH SHORE WINDOW SOLUTIONS-LL Expiration: 7/10/2016 DENNIS LASSELL 239 SOUTH MAIN ST MIDDELTON, MA 01949 Update Address and return card.Mark reason for change. SCA 1 15 20rn-05/11 Address E] Renewal [-] Employment Lost Card ,� ��e'�o»rnra»raealf�af'�'il�m�J«c�7cte� ' ice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Office of Consumer Affairs and Business Regulation egistraUom 172585 Type: 10 Park Plaza-Suite 5170 Expiration; 7/10/2016 Supplement Card Boston,MA 02116 NORTH SHORE WINDOW SOLUTIONS LLC DENNIS LASSELL ANot�vfalr 239 SOUTH MAIN STMIDDELTON,MA 01949Undersecretary without signature SACHUSETTSr _ Massachusetts -Department of Public Safety' DRIVER — Board of 3 LI IN uildiny^ Regulations and Standards ,.. LICENS ---= y' r.__._-__. ._ c.__ �,i7 u.5u uunill auYei+"iSC�i s License: CS-091857 NUMBER1. S36245700 ati n N 3 Dou-- h DENNIS E LASSEA " ## ��-O 65 k 571 West Street - 1' Leominster MA 61455 ­ 9�J I 8 571 WEST ST � ��� � Expi ration LEOMINSTER,MA 07453 Commissioner 11/02/2016 �' 5 DD 10.242013 Rev 07.1¢2009 7FYETERAAI -.