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Home My WebLink About10 REPLACEMENT WINDOWS 8k BUILDING PERMIT r►ORr tTtE TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * = o Permit No#: 4 }I_e � Date Received ��SsaCyuS��y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 61 Print PROPERTY OWNER ij. )I l ,') . e Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial E Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Vllatershed District lllaterlewer ... . F DESCRIPTIO�RKT?J14� ERFO-RMED- Ide, ficatio - lease Type or Print Clearly OWNER: Name: I Phone: Address: Contractor Name: Phone: Email: lcj44 r . Supervisor's Construction License: Exp. Date: P�; :L:� _ Home Improvement License: Exp. Date: ARCHITECTIENGINEER 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.: BNd Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ttORTil q oTown' _ :4T., b ndover O to No. * p «K, h ver, Mass 8,2b coc"�Cotw�. S U BOARD OF HEALTH PERM D Iti Food/Kitchen �j Septic System THIS CERTIFIES THAT ...., - A BUILDING INSPECTOR ... .... .. .... has permission to erect .............. .... buildings on .... ...,... ... ..1 � . . Foundation .': . a.M . ... . . Rough to be occupied as ..... ... .. .., .... i�. . ...................................... Chimney provided that the person accepting his permit shall in every respect conform to the terms of the application rind 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 16 MONTHS ELECTRICAL INSPECTOR LESS CONSVC 'ON Rough Service . BUILDING"14PECVOR Final GAS INSPECTOR Qccy2ancy Permit Required to Occupy Building Rough - Display in a Conspicuous Place onthePremises — 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. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, f=urnished and Installed by: THD AC-Home Services,Inc. Branch Name: New England Date: /' d/b/a The Home Depot At-Horne Services Branch Number: 31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#k C 02439;RI Cont.Lic# 16427 CT Lie#HIC.0565522;MA Home Improvement Contractor Ret;.#126893 Installation Address: 132 D City State Zip Purchaser(s): yy��ffWork phone: Home Phone: {F Cell Phone: Home Address: (If different from Installation Address) City State Zip E-snail Address(to receive project communications and Horne Depot updates): ❑I DO NOT wish to receive any marketing entails from The Home Depot Pro'ect Information: Undersigned("Customer"),the owners of the property located at the above installation address, agrees to buy, and THD At-Home Services, Inc. ("Thm e Hoe Depot") agrees to furnish, deliver and arrange for the installation ("Installation") of all materials described on the below and on the referenced Spee Slteet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): job#: (internal Reference) Products: Spec Sheet(s)#; Project Amount 1�� ooftna Siding Windows insulation �-�— Lt/ � 9- 0RuttersCovers / Etitry Doors ❑ 79 Roofing Siding ❑ Windows Insulation $ ❑Guttei:s/Covers ❑Entry Doors ❑ iZootina aiding, ❑ Windows Insiilatiort ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding ❑Windows ❑ insulation $ ❑Gutters/Covers ❑Entry Doors ❑ Minimum 25%IMposit of Contract Amount due upon execution of this contract. Total Contract Amount 1 $ (00577 Maine Purchasers may not deposit more than one-third of the Contract Amount. Customer agrees that, immediately upon completion of the work for each Product, Customer will execute it Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein, at its discretion, it'The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the jab was not included in the Contract. included as part of this Contract, sets forth the total Payment Summary—.' The Payment Summary Contract amount;and payments required for the deposits and final payments by product (as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spee Sheets)before work on that Product is complete. In the event of termination of this Contract, Castonier agrees to pay The Horne Depot the costs of materials, labor, expenses and services provided by The Horne Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE NOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR 07'11 GR PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance grid Authorization: Customer agrees and understands that this Agx•eement is the entire agreement between Customer and The Home Depot with regard to the Products and installation services and supersedes all prior discussions and agreements, either oral or written, relating to said Products and Installation_ This Agreement cannot be assianed or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Custosner has read, understands, voluntarily accepts the terms of and has received a copy of this Agreement. I Work area will be contained Pre-Renovation Form Date! jT- t NAT-19276 B. 7 rlt,r t hi. �y � Ff��SR✓ I This form is used to document compliance with the.requirements of the Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010. 5y ' ` Customer Address Job Numbers) 132 r-Xnr4S1VP yv&zz'IT ut �� be nlinilzed OCCUPANT CONFIRMATION Pamphlet j Receipt ZF 1 have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead _ hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began, Home Year Built Enter the year my home was built. r0 /k— If the year your ttome was bu'iA is Pre-1978,all work will be done following lead safe work practices. AltIr ilk Work area will a cleaned up Printed Name ofr ootupant ihff ignature of occupa t I Signa r f Person fing Lealamphlet Delivery SEE STATE SPECIFIC FORMS ON REVERSE SIDE THD At-Hoene Services, Inc.PRE-EXISTING CONDITIONS �yw._ f,��j,(,�/y}"'] rvf� tXV roan must be ctgneo by the customer �I7n Customer Name: E IMAM- Sob#. v 6 • 13 t. Sale Date; � Address: � y�rr* s The purpose of this form is to identify Lead Paint Status and any conditions or damage to the customer's home or property that was existing PRIOR to the.commencement of work e Pre-1978 structures are assumed to contain Lead Paint unless tested •If testing is allowed, each window must be tested or multiple locations vrith Siding,fascia or gutters(mul$ed windows are considered one window) •Record the results of the Lead Paint Tests in the space provided below(add additional sheets if needed) MOMEOVOTRE P?ESj tTfb t tfE LP Cert# FIRM Cert# INSPECTOR NAME(PRINT),(Personal EPA/State lead Paint Cert#-MANDATORY) COMPANY NAME(PRINT)(Firm Cert#-MANDATORY) It3EP7 TJPY�)AIUTAGE _ "tEAD:�PAihEf:TES F3PkG Yest Kit Manufacturer Test Kit Lot Test Date Test Site Test Kit Manufacturer Test Kit Lot Test Date Test Site At (Location#1-specific area of home) # (Location#1 Specific area of home) Test Results: [-.Lead Present? YES No PurchaselAssume Lead Paint Test Resutts: Is Lead Present? YES 0 NO PurchaselAssume Lead Paint cftck apprupnals box above check approprlalo box abclro Test Kit Manufacturer 'fest Kit Lot Test Date Test Site Test Kit Manufacturer Test Kit Lot Test Date Test Site # (Location#1 Specific area of home) # (Location#l Specific area of home) Test Results; Is Lead Present? YES ❑ NO ❑ PurchaselAssume Lead Paint Test Results: Is Lead Present? YES M NO PurchaselAssume Lead Paint chock appropdVa W.abom check hFRNarlafo boxabove Test Kit Manufacturer Test Kit Lot Test Date Test Site Test Kit Manufacturer Test Kit Lot Test Date Test Site # (Location#1 Specific area of home) # (Location#1 Specific area of home) Test Results: Is Lead Present? YES ❑ NO PurchaselAssume Lead Paint Test Results: Is Lead Present? YES ❑ NO PurchaselAssume Lead Paint chock approjem"a bsx above check approerlale Eax above Test Kit Manufacturer Test Kit Lot Test Date Test Site Test Kit Manufacturer Test Kit Lot 'test Date Test Site # (Location#1 Specific area of home) # (Location It i Specific area of home) Test Results: Is Lead Present? YES E] NO PurchaselAssume Lead Paint Test Results: Is lead present? YES ❑ NO PurchaselAssume Lead Paint ❑ check epprapka.'s Lax above check appmoriale box above Test Kit Manufacturer Test Kit Lot Test Date Test Site Test Kit Manufacturer Test Kit Lot Test Date Test Site # (Location#i Specific area of home) # (Location#I Specific area of home) Test Results: Is Lead Present? YES [:] NO PurchaselAssume Lead Paint Test Results: Is Lead Present? YES [] NO PurchaselAssume Lead Paint check eppruphV.bar nbavc aback epprcp'1 V box abeio I have reviewed andler discussed the fallowing with my Home Depot Representative during the Inspection AND I acknowledge that the conditions listed above existed prior to the commencement of my project. check all Met apply ontract(including final method of payment) Contract Amendment E]Pre-Exiist[iin�gjC{o�nditions Specification Sheet I Scope or Mork ElLead-Safe(if.positive result) "Iv L 4G CUSTOMER SIGNATURE DATE CUSTOMER SIGNATURE DATE 7-25-14 White-Home Depot Yellow-Customer THD-4008 .................................................................. ....... ........... CC WfNDOW [ONNSHEET - Spec.Sheett Sheet: of (SSPECMCAATL �//� y� Customer:_ v �" _ Job 9: +!�._"_ r� Consultant: &` ✓`�`n- ___ Date: New Vindow Existing Window Labor Hinge Locations Measurements Grids Product Options Options From outside, Leh to Right Bays,Sows, Location Color Rough Opening A of bars it of bars Csmnts,1 PH, use L.RorS m Glass Misc Items Hardware Code For doors use a Shktall s 'S"=stationary or Style Wraps d v c o "X"=operating Room Floor Code (YIN) SC vle Code Series Code 3 i E5 t; j W.- l IN z t� Y &to 1D w 3 112 73 3 [¢G&a P Z3 4 �- —Y p &tv0 -2— 00 &100 Q 142 73 a Z- + &coo w 0 31 q? 9 Z. &1010 W vQ 13 5- 47- 1 27 ,p Z_ - —Y NJ r t W V 35- Lf Z 7 ,z ---------------- 3 SPECIAL CONSIDERATIONS: Wrap color Interior Casing Type fj Bay or Bow window: Seatboard MaterfaE(vinylonly-Blrch or Oak) Bay Projection Angle (30'or 45 °) Say Flanker Type{DH,SH orCsmntl Top of window to soffit(inches) lftied to soffit color ofsoffit material 1 have reviewed and agree with all the job specifications above and the [instruct Roof(Yes or No) Spec€al Terms and Conditions on the back of the yellow(Customer)copy. Garden Window: Seatboard Material:(vinyl only-White P)Dnim Birch p.Oak) AA#//� C,15T0I1*r Signature WA Thickness.finch¢-s) Additional Shelf(Yes or Nol u,n��e a n°s�ue�a°tm uue o�,nms�,wu�mercx ew,.w,s iia. rwv:nv oxalo - While•The Home Depot Yelbw-Customer TND-163 VINYL WINDOW PRICING WORKSHEET BOSTON Customer: VJob#: q Consultant: -bm WINDOWS GRIDS TOTAL 1 x 2 "3" "4" 3 x 4 Windows Window Size Price I Window prical #Sashes Grid + Qty- Style Series Color (til) Window Price Sash w Grids Price Grids Uj 014 lot C 14. Ifl '7 ? -07 (A) TOTAL WINDOW PRICE (BEFORE OPTIONS): 1. t2Q7115 VINYL WINDOW PRICING WORKSHEET BOSTON "f" "2" i x 2 WINDOW& GLASS OPTIONS Unit Meas, Qty. Unit Price Sub-Total Fult Screen (Double Hung) Par Screen $20 Add1 Oper,Sash 1 deduct for Fixed Sash (Casements) Per sash $102 Mulling Charge (for DPD,etc.) Per Mullion $42 Tempered Glass(see below for Garden Window) $20 (W x H)1144=Sq,Ft. Per Sq,Ft. Obscure Glass $a N Energy Star ProSolar Sun,Supercept,Poly Rcinf Per Window $60 6500 W IN Energy Saver+ ProSolar Shade(2),Super Spacer, Per Window $140 Tri le Pane Metal Reinf N Sound&Security ProSo ar Sun,Lam[Glass, Per Wfndow $138 Su erre t Metal Reinf 6100 WIN N Energy Star ProSolar Sun,Supercept,Poly Reinf Per Window $54 N Energy Star ProSolar,Supercept,Poly Reinf Per neer $105 6500 PD Energy Saver+ ProSolar Shade Z,5uper Spacer, per Door $427 Trl le Pana Metal Reinf N Sound&Security ProSolar,Lam Glass,Supercept, Per Door $449 Metal Reinf 6100 PD N Energy Star ProSotar,Supercept,Poly Relnf Per[)car $99 WINDOW HARDWARE'OPTIONS (Premium Finishes Available With 6500 ONLY) Premium Finishes are:Polished Brass,Brushed Nickel Oil-Rubbed Bronze Note an 5 ec Sheet Premium Finish Lock&Keeper (DH,2/3 PNL Slider) Per tock $32 Premium Finish lift Handles Woodgrain only (DH,213 PNL Slider) Per Window $39 Premium Finish Crank HandlelHrdwr(Note"Folding"or"Non"on Spec Sheet) Per sash $160 Flush Mount Handle (casements,Awnings) Per Sash $11 Egress Hinge (Casements) Per Window $9 GARDEN WINDOW OPTIONS(see Price Book for Unit Price) Tempered Glass Per window Additional Glass Shelf(Tempered) Per window Jamb Depth 6"or Greater Per Windaw PATIO& GARDEN DOOR OPTIONS Premium Finishes are:Polished Brass,Brushed Nickel,Oil-Rubbed Bronze,Antique Brass Premium Finish Lock Handle-Sliding Patio Door(6500 Only) Each $143 Sliding Screen-Garden Door(Only with Center Hinge-Single Swing) Per screen $206 EXTERIOR COLOR UPCHARGF available only on 6500 Windows up to 120 til Per unit $193 Windows greater than 120 UI Per unit $230 Sliding Patio Door Per Door i q1813 Mulls Per Mullion (B) WINDOW OPTIONS SUBTOTAL: American Craftsman WINDOW&GLASS OPTIONS Unit Meas. qty. Unit Price sun-Tet l Tempered Glass $14 (1N x H)1 144=Sq.Ft. su•Ft Obscure Glass $5 FUII Screen (Double Flung) Screen $17 Add`t Oper.Sash I deduct for Fixed Sash (casements) Per sash $163 j P $63 9 Mulling Charge for DPD,etc. Mullion WINDOW HARDWARE OPTIONS j 121Egress Hinge (Casements) window $t9 I VINYL WINDOW PRICING WORKSHEET BOSTON PRS 5 OO WINDOW&GLASS OPTIONS Unit Was. Qty. Unit Price Sub-Total Tempered Glass (W x H)1 144=Sq.Ft, Sq.Fl, $18 Obscure Glass $6 Full Screen (DH and 2 PNL Slider) Screen $18 Add'I Oper.Sash!deduct for Fixed Sash (Casements) Per sash $89 Mulling Charge for DPD,etc. Mullion $59 N Energy Star 2 coats of Low E,Stainless Steel Per Window $54 PATIO DOOR OPTIONS Polished Brass Interior Handle Per Door $63 2 coats of Low E,Stainless Steel Per Door $99 N Energy Star Spacer C PRS5100 and AC 12 OPTIONS SUBTOTAL: ^2^ 1 x 2 LABOR OPTIONS Unit Was. Qty. r$t35 Sub-Total Lead Safe Renovation -Windows Per Opening Metal Window Replacement (exci.Bay,Bow,Garden Window&Patio or Garden Doors) Per window Additional Charge for Steel Pan Removal Each $199 Construct Roof over Eay?l3ow Window Each $657 Up to 120 UI Each $80 W 1ndow 1 Door Wraps:AC12,all additional wraps 121 -150 UI Each $95 (or Deduction for No Wrap) Over 160 UI Each $120 Custom Color Window/Door Wrap (only if<5 windows) Per Job $76 New Interior Wood Casing Per Lin.Ft. $10 Remove&Reinstall A1C Unit Each $58 Up to a' Each $35 Remove&Reinstall Awnings OVer g' Each Bid Remove&Reinstall Shutters Pair $23 Up to 120 UI Each Bid Simonton Nail Fin Over 121 Ul Each Bid Boston City Charge Per Joh $167 Misc.Labor (Call for Estimate of Hours) Per Hour $55 D LABOR OPTIONS SUBTOTAL: TOTAL PROJECT AMOUNT (A+ B + C + D). 69V51 ESTIMATED MONTHLY PAYMENT " Equal to Project Amount X.610 based on the assumption-Of 84 months and 13.99%APR). 12122115 I 3 HOME IMPROVEMENT CONTRACT For Massachusetts Residents Only Contractor Arbitration: The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. However, the same right is not afforded to a contractor. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the saine right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as pr ided in Massachusetts General Laws,chapter 142A Homeowner Sig, �r Contractor Signature NOTICE: The . gnnature of the parties above apply to the agreement of the parties to alternative dispute resolution initiated by the contractor. Th homeowner may initiate alternative dispute resolution even where this section is not separately signed by both parties. Homeowners Rights: A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from any Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described in a timely and workmanlike manner. Homeowners rnay be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry so implied warranty of merchantability and fitness for a particular purpose. An enumeration of these matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a honncowner's basic consumer's rights. Execution of Contract: The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all bhuik sections have been filled in or marked as void, deleted or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract. Accelerated Payments: A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hiaWherself to be financially insecure. However, in instances where a contractor deems hini/herself to be financially insecure, the contractor may require the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information: That all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consuauer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,MA 02116 Phone: (617)973-8700 l SUBMITTED BY: Date: '" ans ACCEPTED BY: Date: P` Purchaser Date: Purchaser 06-24-13 White—Branch File Yellow—Customer The Home Depot At-Home Services CUSTOMER MINE For ROOFING Projects: Horne as a Construction Site ❑ Your home will be a construction site during the installation of your roofing and it will be noisy. ❑ There may be a significant amount of job debris associated with roofing installations, most of which will be cleaned up and removed. However, some debris may fall between the roof decking boards and into the attic or an open garage. We are not responsible for cleaning up your attic or garage after the installation has been completed. ❑ We suggest you cover or remove any items that may need protection in order to avoid damage. Items such as grills, patio furniture, lawn and garden decorations, automobiles, items stored in the attic,etc. should be covered or moved. In addition, all windows should be closed during the installation. Trees, Bushes, Flowers & Shrubbery ❑ If you have low-hanging branches over your driveway or roof,trimming may be necessary. Our crews will only cut back branches that limit their ability to do a safe and efficient job. ❑ If any bushes,flowers or shrubbery need to be protected, please let us know. We will take proper precautions to keep your landscaping intact. Rotten or Deteriorated Wood ❑ The exact condition of your roof deck cannot be verified until we remove your existing shingles. ❑ If rotten or deteriorated wood is discovered AFTER removing your existing materials, additional charges will apply. Please review your Roofing Spec Sheet for details. ❑ Repairs to your roof deck may conflict with the original(estimated)completion date. Gutters, Satellite Dishes and Other Exterior Mountings ❑ Although we will make every effort to protect your existing gutters, some minor damage(scratches and/or dents)may occur.At our discretion and expense we will replace a section of gutter if we do more than minor damage, but we cannot be held responsible for small scratches and/or dents. LI "Gutter guard"or gutter helmet type materials attached to your roof that carry their own warranty need to be removed and replaced by an authorized service company so the warranty is not voided. ❑ Satellite dishes or solar panels mounted directly to the roof may need to be moved to allow us to properly install your new materials. You will have to contact your satellite or solar company to reinstall these items and/or realign your dish. ❑ Lightning rods, weather vanes,AC units or other mounted projections may require disassembly and reinstallation.You may have to contact your installation company to reinstall and/or realign.We are not responsible for the condition of these items during removal or reinstallation. Skylights Q Where necessary we can replace your skylight(s)with a stock skylight that is sized as close as possible to your existing skylight, however we do not create or modify openings. ❑ The skylight replacement will not require the installer to enter your home. Interior trim work or painting will usually need to be done after the installation of the skylight(s). You will be responsible for this work. Job Site Access ❑ Please let us know where you would like us to stage your materials(where to place the materials, dumpster, park vehicles, and where to store our equipment). ❑ Keep in mind that everything we use needs to be as close to the house as possible, and our workers need access to a grounded electrical source in order to run their equipment. Ei Please ensure all pets/animals are properly secured. ❑ We will attempt to protect the surface of your driveway, although minor scratches or cracks may occur. ❑ Please notify us prior to starting the job if you have a sprinkler system,septic field or well, and if so,the location(s). Wood, Slate or Muitiple Layer Removal 0 When we remove wood, slate, or multiple layers of composition shingles there may be a slight gap where the existing siding meets a roof Ane.This gap can be between 1"to 2"depending on the thickness of the shingles and number of layers being removed.Although we will install metal flashing to prevent leaks,we cannot be held responsible for the change in appearance_ Joh Completion ❑ Upon completion of your job, you will be asked to sign a Completion Certificate and pay the balance due on the job. Please note that our installers are authorized to receive the final payment. ❑ If you are paying by check, please make the check payable to"The Home Depot". ❑ Servlce issues found after job completion will be handled as part of the applicable Product or Craftsmanship Warranty. NOTE: Verbal promises cannot be honored. Please verify that everything you expect is detailed in the Home Improvement Contract or Spec Sheet that you signed. Customer Name: Customer Signature Date: Job#: AiD Rep Initials Q7.15.14 White—The Home Depot Yellow—Customer THD-509 — — - I lee Commonwealth of (Massachusetts Department`of l'ndustrial Aceidents Office of Investigations d 600 Washington Street .Boston, MA 02111 Qy www.rnass.gov/dia Workers' conipensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ill Na7f c (Business/(Drrganizatiordlndividual): ' City/State/Zip: ALk A Phone#: Are you an employer? Check the appropriatel Type of project(required): i.❑ I am a employer with 4. a general contractor and I 6. ❑New.construction employees full and/or part-time).* have hired the sub-contractors ( p 7. Remodeling 2.❑ I am a sale proprietor or partner- listed on the attached sheet. # ship and have no employees These sub-contractors have $. ED Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition o workers' comp.insurance 5• El We are a corporation and its [N p• 10.❑EIectrical repairs or additions required.] officers have exercised their ri ht of exemption er MGL 11.❑ Plumbing repairs or additions 3.F-1I am a homeowner doing all work g p p zmyseIf [No workers' comp. c. 152,§1{4),and we have no 12-E R frepairs insurance required.] t employees. [No workers' 13 Other t comp.insurance required.] Vny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing-all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. — surance Company Name: — )]icy# or Self-ins. Lic.#: IV Expiration Date: b Site Address: City/State/Zip: ' :tach a copy of the workers' compensation 01cy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of /estigations of the DIA for insurance coverage verification. o hereby cc i nd r th pains and penal£ies ofperjury that the information provided above is true and correct, nature: Date: ane M Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit[License [ssuing Authority (circle one): t. Board of Stealth 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector i. Other :30ntact Person: Phone P. ulad Re,cra s and Business Officeof Consumer Affair 10 Park Plaza Suitt,- 5170 2116 Boston, Massachusetts 0 140me improve �'- LContractOr Registration Registration: 126893 Type: Supplement card wration: 813/201 B INC, ,ME SERVICES, THD AT HOME RICHARD FALLONE 2455 PAGES FERRY ROAD, HSC ATLANTA, GA 30339 return card.Nfark reason for CLIanPr JjVdate-.kd&esg and retu Employment Lost Card Address Penewal i-vidual Use Ouly egjstmtion valid for ind License or lairs Rosiness Re0ation before the e%piradon date. If found return to' f nee 0 f Co nsumer Aff a -rRACTO" ()TIce of Consumer Affairs and Buftess Relation e i�omp ENTCON suit IMPROVEM'.'�. Type.. to park Plaza 5174 R3 -412 Z .jernent Card- -808to �V— v -M, 0 F Expire"of-11.0"11--� THD AT HC)mE SER LV ER; THE HOME DEPOiA� ' ;CES RICHARD �ALLON � HS / ture o valid with t s! 2455 PACES FERRY iLjudersecreUO g-rVANTA,GA 30339 AC R" CERTIFICATE OF LIABILITY INSURANCE DAT02401M-YY) 6 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONF=ERS 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 TETE 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 MARSH USA,INC. NAME: AX TWO ALLIANCE CENTER AIC N o FAA No): 3550 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC4 100492-HOmeD-GAW'-1[r17 INSURER A:Steadfast Insurance Company 26387 INSURED INSURrp a:Zud1Ch American insurance Co 16535 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW BUILDING C-20 INSURER D:(f11n415 Nafi4nSl([ISUfanCC Company 23817 - ATLANTA,GA 30339 INSURER ic: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-003741310-OB REVISION NUMBER:0 THIS IS TO CER-nFY THAT THE POLICIES OF INSURANCE LISTED BELLOW 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. 1LTR TYPE OF INSURANCE I=WVQ ARpL SUBR POLICY NUMBER MMroDY EFF NIMrop1YYYY L3#s71TS A X COMMERCIAL GENERAL LIABILITY CL04887714-06 0310112016 0310112017 EACH OCCURRENCE 5 9,000,000 CLAIMS-h7AOE M OCCUR DAMAGE S TOfRENTED PREMISE ;aoccur[ence $ _#,000,000 LIMITS OF POLICY XS MED EXP(Anyone person) $ EXCLUDED OF SIR..SIM PER OCC PERSONA€.&ADV INJURY S 9,000,000 GENLAGGREGATE LIMITAPPL€ES PER: GENERALAGGREGATE 5 9,000,000 X POLICY 0 JE7 r--J LOC PRODUCTS-COMPIOPAGG 5 9,000,000 OTHER: 1 5 B AUTOMOBILE LIABILITY BAP 2936663-13 0310112016 03/0112017 COMBINED SINGLE LIMIT 5 Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per perenn) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS 80DILYINdURY(Pesaccldent) S HIREDAUTOS NON-OWNED PROPERTY DAMAGE 5 AUTOS Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LWB CLAIMS•MADE AGGREGATE S DEC) RETENTIONS 5 C WORKERS COMPENSATION WC015519215(AOS) - 0310112016 03101120€7 )( PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPR€ETOW6'ARTNER/1 XECUTIV E YIN WC015519217(AK,KYE.L.EACH ACCIDENT,NH,NJ,VT) 03101/2016 03/01/2017 1,000,000 OFRCERIMEMBER EXCLUDED? NIA $ D (irMandato[y In NH) WC015519216(FL) 03101/2016 0310112017 E.L.DISEASE-EA EMPLOYEE S 1,000,000 iryes,describe under C4n6nued on Additional Pa E.L.DISEASE-POLICY LIMIT g DESCRIPTION OF OPERATIONS below Rage 1,000,000 DESCRIPTION OF OPERATIONS r LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 OSGOOD ST. THE EXPIRATION DATE THEREOF, NOTICE VOLL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISION'S. AUTHORIZED REPRESENTATIVE of Marsh USA Inc_ Mana5lli Mukhedee _3A-CLu�s.% , O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 6/21/2016 Custom CSL.png i�pl,i i ill I �* . terd f U " Ity gg x i � r '-'... -.-. .. .�',• '3's^10.x' '^" bJ .. Ex ' https:llrnail.google.com/maiilLdO/ inbox/15573e4l29c8f270?projector=l 111