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HomeMy WebLinkAboutBuilding Permit # 10/29/2015 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION r aaM Permit No#6 2r Date Received 0.- �'"ssvc usE ah Date Issued ZEEi IM ORTANT:Applicant must complete all items on this page //rl/r�/i;?!� /////%1%�i'f�✓//�/���/�/l/�i%'' �'%/`!//�//%%///r/,r//GPIi�D%%%///, 'oar�'!!��aoY e st ' / I�i P ✓,r�i��o'i/ RICTi%%%/% i/H �/n/j/��r,,,r/��/,M�chliie�3 rho/p U�(gej�y s�/jrno'! TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: ❑Commercial >zRepair,replacement ❑Assessory Bldg I I Others: ❑Demolition ❑Other q Sepho rF Well ' / /S l Floptlplam r O Wet lands ❑Watershed Dlstrict vw DESCRIPTION OF WORK TO BE PERFORMED: ' �- REQ U Identification-Please Type or Print Clearly OWNER: Name:aurt4­,. e tit-"s.. Phone: 70 `OY 7xOi Address: t¢Smln✓,.vnlCril`1=5.��.� � I,....., Contractor Name f'tlr1,G,��. �, Phone CiP' `I '17rs� /r/ /��i„„���/r�/���//�/!%/�/�/%%1���,�//r/�//�/,r/I /%r /✓/i rrr%%l/;r�//rr//!�/�l�/r/,r�/i, i Y%r�/., „ , ARCHITECT/ENGINEER Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASE'ON$125.00 PER S.F. Total Project Cost:$ k`'7.ocz, FEE:$ �' / C Check No.: / Receipt No.: C 7 . NOTE: Persons contracting with unregistered contractors do not have access to the guarantyJand Signature of Agent/Owner Co:e-(—,,,k:.a C�e Signature of contractor] __ Town of z "®R$" Andover o No. 99h^ * ver,Mass,_dD cZcl I I ERMIT T® S U ILD Septc Syst1e BOARD OF HEALTH THIS CERTIFIES THAT................. ...t,r.{... ,,.7.-9:`..-..L,.!?15 ................................................ BUILDING INSPECTOR 4S �,c(..kr ............................. o ndatlnn has permission to erect..........................buildings on... .. ............. Rough to be occupied as.. .(3.....fi.�.a.�l�.f!.W.� ...............L.......PaRP C7................................................. chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Fina[ 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 Fina[ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO� Rough ..................................................... semi e ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy PernTit Required to Occupy Building Rnngh Display in a Conspicuous Place on the Premises—Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Earner Street Nn. Smoke Det. Contract-Detailed Pella Window and Door Showroom of Haverhill ales Rep Name: Griseto, 45Fondi Rd HIC#183279/TaxID#2fi-1413183 1 iZ9S Sales Rep p Phone: 978-to,AnthonyAnth6 Haverhill.MA 01832 Sales Re Fax: Phone: (978)373-2500 Fax: (978)373-7274 Sales Rep E-Mail: GRISETOAC@pellaboston.com Quentere Cost. Costa,Quenmm,NorthAndmr,MA,1542565 quote Name. AS Full Frame Windows&Outswing Doors 45 Windldst Fan Rd 45 VVindkist Farm Rd Order Number. 741AGO527 NORTH ANDOVER MA 01845-6352 Lot# Quote Number: 7238542 Primary Phone:(781)4847203 NORTH ANDOVER,MA D1845-6352 Order Type: Installed Sales Mobile Phone: County: ESSEX PaymentTemrs: Depos111C.O.D. Fax Number: Tax Code: MA TAX 6.25 E-Mail:qd g5l@aol.ocm Quoted Date: 10/612015 Great Plains#: 9198736 Customer Number:1007158003 Customer Ae..unt: 1002846713 Customer Notes: MA North Andover $12/1000($30 MIN FEE). Customer a required to pay building permit fee with a seperate personal check made out to Pella Windows and Doors Pri must be paid in the form of personal Checks) 10 D.lidary Delivery/Setup-Delivery/Setup - Item Price Qty Ext d Price $14896 1 $148.96 For information regarding the fnishing, tenancrvi maine,sece and vrdnanty of all Pella®products,visit the Pella®website at www.pella.com Printed on 10/23/2015 re Contract-Detailed Page 1 el 18 3 jD a T ae T _ � P _ 3 - - - - - - - - - - aq { A ° z ti p a p 3 m � v i _ v A = $ n4.zg ¢Qag a a A AK mma= g aF o 54 N - - Z� Q n 4 PRO g � x MITr3 PH NOW=p °°-dr i a Zo`�oa,3 v ¶�m lull 51 � milli 6 a a`u LmW y m 11111 NO F D 3 2 a w� Customer:Quentara Costa Project Name:Costa,Quentara,NorthAndover,MA,1542565 Order Number:741AG0527 Quote Number.7238542 1� C 2 ."alt '@' 40 LR Beck Special Architect,Double Hung,Support Product,Direct Set White Item Price City E)Wd Pri- $3,447.21 2 $6,894,42 1.SuNon-Sta i Srze Double Hung,Equal PI(k General Col.,I Fi m Standard 1E —Ilad Phe 5"31III 6,NO CeMfcalion 731 Ifi.rr Colorll-lmsh Slantlard Enduraclad Wfi to Saahor Color l Flnah:Prefin shetl Waite lnreror Sash IPanel:Standard Glass:Insulatetl Dualplon- yle Look LU. .Limang Glass Amon Non High Alatude HardViewed From atedor S-1n:H.lf SaeenS�no�n li Lock,White,No Limited Opening Hartlware.Ortler Sazh Lia Grille:RMB,No Custom Grille,3/4",Traditional(—H/—H),Prefinrsh,d—le,—fte,Shipped!In Unit Horizontal Mu111:Fa-IMull,Slantlard Joining Mullion,Frame To Frame Wdth'.a" 2:Sire F—Freme Cycle Head Half Clrcle Generallinbumefion:Standard,Clad,Pine,6",311116",No Certification Exterior Color/Finish:Standard Endumclad,W hila Interior Cvlor/Finish:Prefinishad Whuandedor Glass Insulated Dual Law-E Ativanced Low-E Insulating Glass Argon Nan High Altitude Grille:RMB,NO Custom Grille,.1,Gothic(3W2H),Prefirmhed White,White,Shipped Sepamle Custom Product Instructions: Previously approved please mapprove grille pattern* FF>60 Height-Install Full Frame Wind.>60 inches Unil/Composae Height Cry 1 Comp Trim 148-Composite Upgrade-481nches or Less Wide Qty 1 CT FF�8-Clrcle Top FF<48 Qty 1 Finial,FF Trtm-Finish Paint/Slain FF Interior Tdm Only Qty 1 Trim Stool and Apron-Add Stool and Apron Tam to Picture Frame Cry 1 For more mformat'n regarding the finlshmo, ir aenanoe,serviw and vre ranty of all Pella®products,visit the Pella®websvowva. ite at pella.com Printed on 1012312015 Contract-Delailedr Page 5 of 18 \ / . iCI /\\ ! _ t; ! \//\/ k \g eeB , 2 : - z s gag. ! ` 9@ »! )\! 77 \ ; § ! �) • ° ! ) \ 9- - = i S - . } * ! # \ ° ! \ q \ \ i ( [ \ z \\ , z 4\ ~® ~® \ \ - tt tt Y1 RUN m P a CGU v P WIN%rye 1 A=no�.a d na Hui NAME .-s: ww" _ sul T y r and A E 2 g P 3 gna;�p y 3 P m m Hui p io ll 9 3 HIS, -� a g q �sg �o€� Aa .. "a 1. a =In n ll _ i a - i a � N 3 _ O � 3 Customer:Qdentere Ceara Project Name:Costa,Quentara,NorthAndover,MA,1542565 Order Number:741AGO527 Quote Number:7238542 Finish FF Tdm-Finish Paint/Stain FF Interior Trim Only Ory 1 FF a 60 Height-Install Full Frame Window>60 inches UniUComposite Height Qty 1 Trim_Stool and Apron-Atltl Stool and Apron Trim to Picture Frame Qty 1 65 cheat R.1 Architect,Double Hung,White Ism PI Qty Exfd Price $1,435.12 2 $2,870.24 1:SixeNon-Standard Srze Double None,equal PKC General lnfarnrat on'Slantlam Luxury Clatl Pre 5 311116',NOCedifcalion 731 Eater or ColorfFnsM1,Slandamenduraod Whrte Intenor Color-Fnsh,Prefnshetl Wntelntedor Sash fPanel:Sfantlard Glass:Insulated Di Low-E Ativanced Low-E Insulating Glass Argon Non High Allitutle Viewed Fmm Extelrior Screens GPPllf SdreenSPWnite,snveLoock.Brown,No United Opening Hantware,Order Sash Lift Gold:RMB,No Custom Grille—",Tratlltianal(3W Ia-H),Parity hetl White,While,Shipped In Unit Trim Stool and Apron-Atltl Stool and Apron Trim to Picture Frame Or, 1 FF<48witle-Inetali Full Frame Wintlow 48 inches or lea wide Qty 1 Finish FFTdm-Finish PainUStain FFlnterior Tdm Only Qty 1 FF>60Height-Install FullFrame Window>60inctres UnWComposite Height Qty 1 Comp Trim<48-Composite Upgrade-481nches or two Wide Oty 1 70 Bath Architect,Double Hung,White `ittem Pride Qty Ext'd Price $1,247.23 2 $2,494.46 1 S�teNanSbntlaN S-Double Hung Equal PKC General lnforma1—Slandard,Luxury Clad,Pne 5,311116",No Cadiroddi EMe 731 ror Color/mnreh Standard Entluraclad—te Intarlor Celorl Finsh Prefnrshed Mo Idteror Sash 1 Po 1:Slend- Glass:Insulated Dual Low-E A&dr—Low-E Insulating Glass Argon Non High Alt— Mewed From&tedm Hardware Options:Spoon-Style Lock,Brown,No Until tl Opening Hardware,Order Sash Lift Screen:Half Screen,While,In View'"" Grille:RMB,No Custom Grille,314",Traditional(3W2H f 3W2H),Prefinished White,White,Shipped In Unit Finish FF Trim-Finish Paint/Stain FF lntedor Trim Only Qty 1 Trim_Stool antl Apmn-Add Steel and Apron Trim to PicWre Frame Qty 1 FF<48 Acte-Install Full Frame Window 48 inches or less wide Qty 1 Comp Trind Composite Upgrade-48 Inches or Leas Wide City 1 For mare information regarding the finishing,maintenance,service and warranty of all Pella®products,visit the Pella®website atwww.pella.com Printed on 102312015 Cmdract-Detailed Page 8 of 18 33 3111 3 3 a 3 y 3� o� Do^�3mea"mso3c y i 3 g �ia— Jaz � yy°y oo zs g® a ry o! n 3 A «A 3 3 O o � � a a _ 3 _ � ll mdd3[��Im 5�'a o 3g _ F p?9=mo Q333� - oA�n�lrrYn K aRI m £ � D 8 _ _ 3 $ � 3 m 3 N D u 3 m � n 3 3 WHOM � _ T IA �e mgi .. v n �g o�nTy� s 3 N D HIM,T�QWill � a a - t n illgov- ami a.2 T p a °�' m3 z if 3 - 0 2 Customer.Quentars Costa Project Name: Costa,Quentara,NorfhAndover,MA,1542565 Order Number 741AG0527 quote Number.7238542 110 Femily Rm. Special Support Product,Direct Set Fixed Frame Arch Head,White aero Phil city exed Price ;a?"—._, $5,002.77 1 $5,00277 1:Fixed Frame Crtcle Hled Arch Head ir 2,1 . GolMorm.—5tandaM Clsd Pne,S",311/ie',No Certification T31erlvColorl Finish:Slantlard FiduradadVvhite Interior Cvlvr/Flnsh:Prefmished—nol—iaGlass:Insulated Dual Low£Advanced Lu—Insulating Gass Argon Non Hgh Alt tude Grille:RMB Yes(Acui Services droving reqs red)3/4,Custom Process Grlle,Predn shetl White,White,Shipped Separate Dewed From 2ttetiw Custom Product Instructions: *Bottom square grid should be 6 wide and 5 high reflected on top gothic grid above —Please note:No NFRC or Hallmark labels will be supplied for this unit*-1819/15 sh jch Trim Stool and Apron-Add Stool and Apron Trim to Picture Frame qty 1 Comp TH.>48-Composite Trim llpgrade>Greater than 48 inches wide Qty 1 FF>68 Heigh-Install Full Frame Window,>68 inches Un UComposite,Height Qty 1 GT_FF 4&96-Circle Top FF 48-96 Qty 1 Finish FF Trim-Finish Palnf/Stain FF Interior THm Only city 1 For more information regartling the fnishing.mamlenance,cervica and warranty of all Pella®products,—it the Pella®website at www.pella.com Printed on 10/2312015 Conrad-Detailed Page 12 of 18 a 2©ReR\9R\ # \\/QmRJR4w, , !;E( \ - [!\I;! / My 2 - _ / } ® . . , ° ( • . 2 §I\ � 3 '3 mv - h nF'Hd C 2, ..oTc33 Oa¢i�g O�L)3 day p m��m r � � a cEOD $.aa A6 a B A� a4Q� qaa fn m _ Haln 5 a5'N m p z ; I 5- ® u �1, a off, Q a 3 �A Customer:Quentara Costa Project Name: Costa,Quentam,Nor[hAndover,MA,1542565 Drier Number:741AGO527 Quote Number.7238542 Trim St—end Apron-Add Shill Md Apron Trim to Picture Frame Qty 1 FF<46 wide-Install Full Frame Window 48 inches a r leas wide Oty 1 Finish FF Trim-Finish Paint/Stain FF lyderiar Trim Only Qty 1 Comp Trim WB-Composite Upgrade-4s Inches or Less Wide Qty 1 135 Garage Architect,Double Hung,White It..Prue qty Exrd Price $1,247.23 2 $2,494.46 1:Sa rel IfI nn th"Size Double Hang,Equal 731 General Inform Frio Slandartl Luxury,Gred,—, a 5",311116",NO Gediflradon 731 Cxler,c—,r l F,ich: Standard-iraclatl Mae Interior Colorl Fm sh Prefri shetl VJM1[e lnteror BasM1/Panel,Standard Glass:Insulated Dual L-1--al Low-E Insuletmi,Glass Argon Nan High Alti— Hardw Viewed From&iedor Screen::1 Options:Spoon-Style Lock,Brown,No limited Opening Ha,dware,0—Sash Lift Half Screen,Mite.InV 1- Gdne:RMB,NO Custom Grille,3I4",Tredillonal(3W2H I—H),Prermished yc,,We Mite,Shipped In Unit Trim-Stool end Apron-Add Stunt and Apron Trim to Picture Frame Qty 1 Camp Trim <48-Composite Upgrade-48111hee or Less Wide Qty 1 Finish FF Trim-Finish Pe n.Stain FF Interior Trim Only Qty 1 FF<48 Ovide-Install Full Frame Wind—48 inches or less wide Qty 1 Thank You For Purchasing Pella®Products PELLA WARRANTY: Pella products are covered by Pellare limited wamatal.in card at the time of sale.Fill applicable product warranties us incorporated into and become a pan of this conhad. Please see the varrear ies for complete details,taking special note ofthe two important nofice sections regarding installation ofPella products and proper management ofmoisture within the wall system,Neither Pella Corporation nor Pella Windows&Deots 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 arc inconsistent with Pella written warranties. Clear opening(egress)information does not take into considernlion the addition of a Rolscreen[or y other accessory]m the product.You should consult your local building code to ensure your Pella products meet local egess 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 gain,color,texnne or natural characteristics are not covered under the limited wsm rdd y. INSYNCTTVB PRODUCTS:In addition,Pella Insynetive Products are covered by the Pella Insynctive Produ�Software License Agreement and Pella Insyr ive Products Privacy Policy in effect at the time of sale,which can be found at Insynctive.pellarcom.By installing or using Yourbssynctive Products you are acknowledging the Insynctive Software Agreement and Privacy Policy are part of the terms of sale. Farom'informationregardingthefinishing,maintenarue,service and—my ofall Pella®products,visilthe Pella®website at—s.pella.com Printed on 10=015 - Contract-Detailed Page 15 of 18 Customer:Quartan Costa Project Name: Costa,Quent—,NorlhAndover,MA,1542565 Order Number.741AGO627 Quote Number.7236542 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 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 Mrses to do the following- Obtain llo g- Obtain Building Permit(When required) Prefinish products when purchased in contrail During the Installation the Homeowner as 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 I tallat'nP 11 rest d the folio Deliver and unload products purchased per contrect 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 exteriortrim only if purchased If Purchased,install exterior primed pine mod trim or Composite.Composite will be unfinished. If Purchased,install interior trim matching wood window Finish or While trim for Impervia and Encompass Install non-Pella entry door lockset provided by you.Pella is not responsible for it's quality or performance Afterthe Installation the Homeown r agree t d th f 11 g' Be ovwlable for completion and sign oft to verify all products purchasetl 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 exterior casing issues due to storm window removal if full wrap or new exterior trim is not purchased For more information regarding the finishing,ma me-rim,service and weranty,of all Pella®products,visit the Pella®website at www.pella.com Printed on 1012312015 Contrad-Detailed Page 16 of 18 Customer Quentam Costa ProjeciName:Costa,Quentm,NorhAndove,MA,1542565 Order Number 741AGO527 Quote Number:7238542 Project Checklist bas been reviewed Product Only Addendum hu been reviewed cutmm�rr„n�1 Credit Card Account#:Last 4 Digits _ Expiration Date: _/ Charge final payment to same accolmt (Upon substantial completion) c-.—tin. For more information regarding the finishing,maintenance,service antl warranty of all Pella®products,visit the Pella®website a[w peils com Printed. 10122/2615 Connect-Detailed Page 17 of 18 Customer:Quentem Costa Projed Name:Costa,QuenWm,NmlhAndo r,MA,1542565 Order Number.741AGO527 Quote Number:7238542 [J Projeot Checklist has been reviewed Nama naml Pella sal Name mi c��n ��f3�r��otals I n,.�flt� � �I� H��tl A��[Q� Taxable Subtotal $56,737.85 Tomer slgnawre Peoa Sales Rep Sales Tax@ 6.25% $3,546.12 1012,7- Nontaxable Subtotal $27,547.89 Daly— Date Total $87,831.86 Deposit Received $0.00 Credit Coro Approval Signalure Amount Due $87,831.86 For more it donation regarding the finishing,maintenance,service and warranty of all Pella©pmduds,visit the Pella@ website st w peila.00m Pmdedop 10/2212015 Contract-Detailed Page 18 of 18 HanmH1111 U-11102 ME agml19 1 zu a a a 1 R191 !81 1RUN.- ..�.-—V Rwag"j WH . —1" ��'mfj tum Ql-f. -g,. , pFo- Em".: M - U P ERE all,-, PAIRK all,- M191 I MUM mi. MA ; IN ?Wl I * "mPE 181 1­11, RIM&. ISKI'muza I at E .2 1— - "a im 0 MR 1, SMI 9R." Haaall; 11; WE'S Hwu ul wo &ME > q M 1 up "Wirm- USF9 Uut M a .—P BMW. Z, WN; IMAIMIS Ry -no S. M 21"! t1k OPS �&%" "soon W jkm"M lim 1'.Ry K"LVE 10, -wg W.­ -.Al co a-, M a z Ea ,as m 17 HR C04IM > 6 z W gel— M 'jwV It 1 pass �Ho� �IUMM a p mg Z= gFujil gm, Q_ Vm- pj 0- -'s R Dug Mill a pug"I a 4 han -M .-.=o I isa VMS— FNI A H Rom 4 H."O Wazg g F=QzZRNF8 n; 11, ow-mr. o 1:12uj;ggg -H I. 51.41 1 a 1"AN I Rave"I U5 Q W0 4 MI= 9 "IN "Hot R 1,10 �a -,Eat to Okla 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 Herm owncr 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 TIES SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. / rNOME OF CANCELLATION Date of transaction: 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 most 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 eancellation,you may retain or dispose - ofthe good 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 ofthis cancellation notice or any other written notice,or send a telegram to Pella Windows and Doors, at7 �4i Fondi Rd..Haverhill NIA 01832 / not later than midnight of`01 7'!alf(three business days from the date of transaction above). I hereby cancel this transaction. (Date) (Buyer's signature) The Commonwealth ofMossachuseds IBefreutteorm offindrorMaaiAceldents Office of Investigations I Congress Street,Suite 100 1Bostoit,MA 02114-2012 eo' o"mass.gov/dia Workers'Compensation Insurance Affidaft Builders/Contractors/Elechicians/Plumbers Applicant Information /S Mrs.Prior L. ite Name(Easinesslorgaaizadordlaaividaaq: QE11A 1 to s -w- bac)rg a Lam, Address: 4�- Rn City/State/Zip: _ ( 7- Phone t '77 71-5—j)Sr Are you an employer?Check the appropriate box: Type of project(required): L@4 ama,employer with �15 4.❑I am a general contractor and I 6.f-1Newconstruction employees(full and/or part-time)-° have hired the sub-contraclm o 2.❑I am a sole proprietor or partner- fisted on the attached silent. 7.Vk$emodeling ship and have no employees These sub-contractors have g,❑Demolition worlds or me in say capacity. employees and have workers g r Y9.❑Building addition [No workers'camp.iasumnce camp.i.empee required.] 5.❑We are a coipomtion and in I0.❑Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their I L❑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 on - employees.[No workers' 13.❑Other comp.insurance required/ °Any applicant that cheek box#1 mast also CII cut the section lad—bowing Their workms'compensadunpoliey iafannatian. t Hoarens who unit this affidavit indicating they are doing all warkand at.hi—tside contractors sants.boatare-afflt,,il indicating welt. tCuotrectoss tha[chest thishox mon armched an addi[ioval sheet showing the name aEthe sub-wnhvclon end sivte whether yr vat those emi[ies have ', employees.ffthe sub-roans ess,haveemployees,they restprovido their svorlrers cowl policyaumher. [am an employer-(hat is prnyiding workers'compensatiou insumnee for nay eanployees.Belory is the policy need joh site irrforanation. Insurance Company Name: �{(� FM�J��z -1-n15 (°G Policy#or Self-ins.Lie.#: !4060 01,( Expiration Date: / j Job Site Address: City/StalclZip: Attach a copy of the workers'compensation policy declaration page(showing the policy amber and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 cart lead to the imposition of criminal penalties of a flue 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 5250.00 a day against the violator.Be advised that a copy of this smtetnent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereh ecr8 under the pains mul -Rias of erjuy that the iu/i, deo pravided above is true and correct. Siumature' — �-' -- n.,n. !71 L S�_ Phone It: ?13'2i-S 7 s-s ®ffrcial use only.Do nol write in this area,to he completed by city or town offrciaL City or Town: PeTraittLiceaese 9 housing Authority(circle one): 1.Board of Health 2.Rnildang Department 3.Cityfrowm Cleric 4.Rteddeal Impector o.Plumbing lmpeetor 6.Other t ® CERTIFICATE OF LIABILITY INSURANCE DATESN DD 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 en ADDITIONAL INSURED,the policylies)must be e,d,m,d,If SUBROGATION IS WAIVED,subject to the terms end 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 entlomement(s). <ad111,s N5 s] 'c",Icu,cic a111. c xo (9>9)n5°-lees 1e0-0)izusAieeS I RE mnell®woccnuren T--EC - INSU111A COVERAGES CERTIFICATE NUMBER:5°° 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 DOCUMENTWITH 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. GENINALLRCIALY a MIrsS1 INDEED $100000 OCCUR EXP(A"PREIIIER ymepe') 5 zaNB161°m ]/11]015 ]Itnpt6 S 1,0 AWAU70 10—INJURY(Perp I—) S ALLI-E0 IBjMCo RY(aeracuae"V$ U-11— UCUUR c ONE RAT— NCSTANT` S (Mn1VII NHl uctuoaov nvaO N aW01— TnlxmS ]nl2ata VI T51 H S OP OLC6CR T S 5� BCMPTI0NOP0"6 IONS/LOCApON51VEHICLES(A-1ACOR0101,Aau111"nal mmarb SCM1eEule,Irmo pe e,requ,real CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED]EFORETHEEXPIRATION GATE THEREOF,NOTICE WILL BE DELIVE ACCORDANCE WITH THE POLICY PROVISIONS. iHONZEO REPRESE'Tq�VY `' C'a" a Ced Holderk ©1988-20'10 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are regist,md marks of ACORD e of Consumer Affairs&Business Re9v1a60n I.iceuse or registration valid for ivdiva ut.: before the expiration date.If found return to: 1e EIMPROVEMENTGONTRACTOR Ofr_of Consumer Affairs and Business Regulation Type: 10V,Plaza-Suite 5176 egistratiov:,183279 Supplement Card Boston,MA 02116 Ste. Expiration:-.912412017. NEW ENGLAND WINDOW BDOOR,LLC. PELL4 WINDOWS 8 DOORS W!"'..Nlvhois 45FONDIROAD Not valid without menature HAVERHILL,MA 01832 ilveevsecremry N �_ CS-089853 n '(1r- IG IA'I LIAM R NIM9L-S 57 PE'ARTREE RIB 01830:'-� ggpy@RBY LMA'; ��••��� 10126/20$6