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7 PATRIOT LN - BUILDING INSPECTION (2) 4��k � rile Commonwealth of Massachusetts CITY OF Bo.1t�(j�ppf����u��lIdingg R��,gg,uI bons and Standards SALEM S l IVlas jll f�6l4s StAte bTfild�ng�t de, 730 CMR Revised liar 2011 oBuilding Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling ® This Section For Official Use Only Building Permit Number: Date.A ed: Building 0111cial(Print Name). Signature - Date SECTION 1:SITE INFORtNIATIO! I L I Property Add a 1.2 Assessors Nlap&Parcel Numbers 1.to Is this an accepted street?yes no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: "Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required P_:: ovided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ P P y S CT[ONZ: PR OPERTYOWNERSHIPl' 2.1 Ownert of Rc rd: �hme Print IN City,State,ZI No.and Street Telephone' Lmail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check al t apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Altemtian(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 1 SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I, Building S 1. Building Permit Fee:S n icate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: S it. Mechanical (HVAC) S List: i. iMechanicaI (Fire S Total All Fees:S Su ression) Check No._Check Amount: Cash Amount:_ 6.Tut:d Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: I ( Ip V(lAltrb '�O (>��tvcJ0�9 (1�OfL SECTION 5: CONSTRUCTION SERVICES , 5.1 Cmtstruction Supervisor License(CSL) //� 7A Qe`v License Number Ex ' a. n Date N:mteofC�"SL/I�ul ear /At ListCSLType(see below) -74 I->Y�y1/ !'Ir�/� Type Description . No.;urd Strect A� U Unrestricted I 1DuiWin s u -to 35,000 cu. tt. N�71f•/' R Restricted I&2 F;unil Dwellin Chyfrown, Late,ZIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone - Emad address D Demolition 5.2 Registered I ome Improvement C atrac or(HI HIC Wgistratir sp' on Dnte HIC Cum any pm or 11 + istrant .Ian o.all t Email address City/Town ate ZIP Tel hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2$C(Q) Workers Compensation Insurance affidavit must be cogipleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Istuanc the building permit. Signed Affidavit Attached? Yee.......... No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN. " OWNEWS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Nano(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my nme belo hereby attest under the pains and penalties of perjury that all of the information contained in IN applic is and accurat sI9 n knowledge understanding. Pr' a kill r Name(Electronic Signature) ate NOTES: 1. A Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will Trot have access to the arbitration program or guaranty tund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www mass eov:'oca Information on the Construction Supervisor License can be found at ww�:'dns 2. When substantial work is planned,provide the information below: 'total fluor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Cross lNing area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "I'utal Project Square Footage"may be substituted for"Coral Project Cost" The Commonwealth ofkfassachusetts ' Department oflndustriaZAccidenis f Office of Investigatons 600 pvashingfon Street Boston, MA 0211I www.m¢ss.gav/din davit: Builders/Conte'actors/Electricians/Plumbers Workers, Compensztion Insu an e Affi Please Print Lezibly A licant Information p/� �f �) � L�OS'fc�/i Name(Business/Orgaam /g �ation Ind rtdual): t nl/C VA2LlJ Address: A,'4 s /0/L 80 hone : g�" ✓�� — y0 S ILt/�. o �P 7 City/State/Zip. W Are you an employer? Check the appropriate bog: Type of project(required): a. ❑ 1 am a general contractor and I 6 ❑New construction 1.[�I am a employer with ' have hired the sub-contractors employees(full and/or part-time).' listed on the attached sheet 7. ❑Remodeling 2.❑ I am a sole pi oprietor or partner- These sub-contractors have g. ❑Demolition slip and have no employees employees and have workers' 9 .❑Building addition working for me in any capacity. comp.insurance.$ [No workers' comp.insurance 5 � We area corporation and its 10.❑Electrical repairs or additions required] officers have exercised thei 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work -ight of e emption per MGL 12.❑Roof repairs myself{No workers' comp. c. 152, §1(4),and Ere have no sauce required.]t o workers' 13.�her ,LZH ins employe e_, F s comp.insurance required_] w showing their *Any applitant that checks box#1 must also fill cut a are dome all wo.- and rhea hire outside conhactor must submits new ai-chn t indiczting such. t Homeowners who submit this a.9davit indicating Y t .. - 3Contrectors that check this box must attached m additional sheet shpwingthe name,of sub-contrectos and state whethe.or aotthose entities have employees. L the sub-contacton have employees,they must provide their workers'co policy number- j am an employer that is prorzding workers'compensadon insurance foo/r my�employees. Below is the pokey and job site information. f Ijee '/?` 72 sr R_ -!�/v✓� co ' Insurance Company Name: f 1 C 77 / .J a� W r, ('i L_ ��' 6 3 J Expiration Date: / Policy r or Self=ins.Lic.n if City/stateaip: Job Site Address Attach to secure£ov e agekas requiredtsation Seetion 25A of MGL aration c. 52olicy ded (canQead to the g the p oimposition of e imnal penalties of a Failu e der Section as well as civil penalties in the form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one-year imp of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ertify and the ains and es of that the information provided above is true and correct I do hereby c Date: Si�aa Phone� a D �✓ official ase only. Do not write in this area to be completed by city or town o5xial Permit/License City or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone f Contact Person: Ch YOFSALEA MAS$AQ3G n Bu>ZMnerumervr �Wvsnr�r,�lso�s lh 7454M. $11�BiRiBY O�L FAX 740- MO MAYM 7troiresS7'.P�s€ Dotcrptwxjnmt 7Y/auffzm Construction Debris Disposa/Affidovit (required fora►► demolition andrenovation worki In aac dwm with the sbA edition of the Stall MOW Code, 7W Sestlon 111.5 Debris; and the p Mi0ons of MGL cm S-Up ti ift Permit it is issued WM the corm that the debris resuMW from this work slog be disposed of in a grope*licensed waste deposit fadgty as deftneci by MGL c 111,S 15K The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address o fadgity) S gnature of applicant Me vvinupw wunu uI Offices & Showrooms Number: ❑ 15A Cummings Park ❑295 Old Oak Street 166025 Woburn, MA 01801 Pembroke, MA 02359 Federal ID# (781) 932-4805 (781) 826-6281 27-1481665 "Simply the Best for Less" www.WindowWorldofBoston.com Customer: ,` mjdL `` -- Y� a1a Phone (h) Ou Install Address: Pt6yc i o Y LM Phone (w) City: )6 L State: MA Zip Q q' E-mail WINDOW WORLD GLASS OPTIONS _1000 Series Single-hung All-Weld $189 --6—SolarZone Elite $99 6"?4 _2000 Series DH Mech/Welded Sash $195 Triple Glazed TG2* $175 4000 Series DH All-Weld $205_M-3-0 (*Series 6000 Only) 6000 Series DH All-Weld $240 WINDOW OPTIONS _2 Lite Slider $334 Glass Breakage Warranty $15 INCLUDED 3 Lite Slider hs,,ia,,n> (1i4,1i2,114) $525 1/2Screens $91NCLUDED _Picture/Fixed Lite $334 / Foam Insulation on Jambs and Head $11 INCLUDED _Awning $260 Double Strength Glass $15 INCLUDED _Casement $290 Double Locks (> 26") $5.INCLUDED 2 Lite Casement $575 _Full Screens $22 3 Lite Casement (vs,va,11s) w4,1rz,rm) $860 Colonial Grids (Contoured/Flat) $45 _Basement Hopper $334 Prairie Grids $51 BayWindow-Soffit Mount/INS Seat $2660 —Diamond Grids $69—_ _Simulated Divided Lite $182 Bow Window-Soffit Mount/INS Seat$2785 Tempered DH Sash, (BSO) (TSO) $65 _Garden Window $1880 __Obscure Glass (BSO) (TSO) $35 _Specialty Window $ _Oriel Style (40/60 or 60/40) $30 —Beige/Almond $40 _Foam Enhanced Frame $35 _Wood Grain Interior(Series 400016000 only) $100 PRE 1978 BUILT HOMES(Federal Lead Containment Law) (Light Oak/Dark Oak/Cherry/ Fox Wood Lead Safe Practices Required $25 Rich Maple) MY HOME WAS BUILT IN THE YEAR Initial" Brown Exterior(Arch.Bronze/American Terra)$100 Designer Color Exterior $155 MISCELLANEOUS Custom ExterlorAlu�ynum Cladding Window Color/ w�. . K ❑Textured$75 fd Smooth G-8 $75 $ Inside outside Facing Color Metal Window Removal $50 NON CUSTOM DOORS New Construction Vinyl Removal $175 _Vinyl Rolling Patio Door 51t.or Eft. $995 _Specialty Window Exterior Trim $ _Vinyl Rolling Patio Door Bit. $1095 Mull to Form Multi Unit $30 _Add to base price for Custom Rolling Patio Door $1150 Install Interior/Exterior Stops $50 CaO _French Rail Sliding Patio Door 51t,or Eft. $1295 Install Interior Casing Starts At $95 _French Rail Sliding Patio Door 8fL $1395 _Insulate Weight Boxes $20 French Rail Sliding Patio Door 9ft. $1495 Roof for Bay/Bow Windows $500 _Custom Exterior Cladding $150 Existing New Const. Ext. Retro Fit $150 SolarZone Elite or ETC Glass $175 Removal of Existing Bay/Bow $250 _Grids Patio Door $129 _Repair Sill,Jamb or replace sill nosing $50 Woodgraln Interiors $295 Full Sub-Sill (Single) replacement $150 _Exterior Designer Colors $395 _Mullion Removal $30 _Interior Casing 21/2 31i2 $175 Bay/Bow Conversion Ext. Retro Fit $350 _Handleset Options $ (New Siding Will Not Match) $ Building Permit $150 /Sd Door Color / RQU D•UP F`C1R WINpQIS1 WORLD Inside Outside -�-^ �Y -� " a St.Judc Clld(atan's Reearcn Hospital $ Customer declines exterior wrap and understands naintinn and/nr renair may ha renuireri Initial DISCLAIMER:Customer is responsible fort following in connection with this contract:Painting,Staining,Alarm System disconnect/reconnect Building Permit tees in excess of$25,00,Homeowner and or Condo Association Approval,Historic District Approval.City of Boston parking&sidewalk Permit fees in connection with installation. NO EXTRA WORK IF NOT IN WRITING! Customer agrees to the terms of payment as follows: Extra Labor&Materials $ 5f..cu q Site Set Up, Disposal&Delivery Fee $ $195.00 Total Amount $ 3C2 117 Custom Order Deposit 50% $ Ck# Balance Paid to Installer upon Completion $ Amount Financed $ .�?(� Window World of Boston anticipates starting this work on: - f©eN and being substantially completed in fL days.Security Interest:Yes No equipment Any deposit required in advance of the start of the work SHALL NOTexceed 331/3%of the total contract price or the actual cost of any material or of a ' spe cial order or custom made nature which most be ordered in advance of the start of the work to,assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of both parties. All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to registration should be a directed to:Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170 Boston,MA 02116.Phone:(617)973.8700 No work shall begin prior to the signing o1 the contract and transmittal to the owner of a copy of such contract. Window World of Boston under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.Window World of Boston shalloot.be deemed responsible for delays in the work described in t'nis agreement caused by regulatory,permit granting agencies,authorities or individuals. Notice:If the PURCHASER(S)obtains his own construction related permits for the work described under this agreement or deals with unregistered contractors, the PURCHASER(S)is hereby advised that in the event of a dispute,judgement and nonpayment,the PURCHASER(S)will not be entaled to make a claim or collection from the guaranty fund established by chapter 142A,M.G.L. You the buyer:may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Notice of cancellation must be in writing postmarked no later than midnight of the following third business day. I t This Window World®Franchise is independently owned and operated by Window World of Boston,I.I.C.under license from Window Word,Inc. net Do not sign if there are any blank spaces. Date Salesman:Do not sign if there are any blank spaces. Date Owner:Do not sign if there are any blank spaces. Date Boston 07-15 White Copy-Original Yellow Copy-File Pink Copy-Customer Hayes Pr1ntlng88&687-1116 II Massachusetts Department of Pv011C Safet7 Board of Building Regulations and Standards License: CS-072772 Cans"'iction Sdoernsor a JEFF C STEELE 24 SHERWOOD AVE ; DANVERS MA 01920 .Se;, s, I — I^^�� ✓`�- =xpiration: Commissioner 04/07/2018 a Office of Consumer Affairs&Business Regulation HOMEIMPROVEMENT CONTRACTOR I Registration: 166025 Type: Expiration:. 411212018 LLC WINDOW WORLD OF BOSTON,LLC. JEFF STEELE 24 CUMMINGS PARK SUITE 15-A WOBURN,MA 01801 Undersecretary License or registration valid for individual use only before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 1, i t*ot valid without signature • �, WINDO-2 OP ID: HI DATE IMMIDDfIYY1'1 `�- CERTIFICATE OF LIABILITY INSURANCE o7118no16 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). CONTACT PRODUCER NAME: C. Timothy Ward, CPCU, CIC Senn Dunn -GSO PRONE 336-272-7161 uc.No: 336-346-1397 3625 N.Elm St. aNI IL Exl: Greensboro,NC 27455 ADDRESS:tward@senndunn.com C.Timothy Ward,CPCU,CIC INSURERS AFFORDING COVERAGE NAIC# INSURER A:Citizens Ins CoofAmerica 31534 INSURED Window World of Boston,LLC INSURER B:Allmerica Financial Benefit 118 Shaver Street INSURER C:Hartford Fire Insurance Co. 19682 North Wilkesboro,NC 28659 INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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 1ADDL SUBR POLICY EFF I POLICY EXP LIMITS LTR TYPE OF INSURANCE .INSD MD POLICY NUMBER ! MWDDIYYYY . MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1'000+00 DAMAGE OR N CLAIMSMADE T OCCUR !0B6790252707 04/01/2016 04101/2017 PREMISES Ea occurrence I S 50O'000 Business Owners 1 MED EXP(Anyone person) IS 0,000 PERSONAL A ADV INJURY is 1'00 ,00 GENERAL AGGREGATE i5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. � PRODUCTS-COMPIOP AGG IS 2,000,000 I POLICY[]JECTT C'' LOC S OTHER: COM DINED SINGLE LIMIT S 1,000,000 AUTOMOBILE LIABILITY I Ea accident) B X ANYAUTO !AW68757615 06/16/2016 06M612017 BODILY INJURY(Par person) S r—ALL OWNED �SCTOSULED NON-OWNED I I I BODILYINJURY(Peraccitlengl5 AUTOS PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident S I ! ! 5 UMBRELLA LIAB X OCCUR EACH OCCURRENCE s 1,000'O00 A I EXCESS UAB CLAIM6MADE iOB6790252707 I04I01/2016 0410V2017 AGGREGATE s DED RETENTIONS _ S WORKERS COMPENSATION I I x I3TPTUTE ERH AND EMPLOYERS'LIABILITY C ANY PROPRIETORJPARTNER(EXECUTIVE YIN !22WECLJ2635 01/27/2016 0112712017 E.L.EACH ACCIDENT S 500'000 OFFICERIMEMBER EXCLUDED? ❑INIA 500,000 fMandmory In NH) I EL.DISEASE-EA EMPLOYIT IS If yes.describe under i 1 E.L.OISE45E-POLICY LIMIT IS 500,000 DESCRIPTION OF OPERATIONS below I II I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is raculred) 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. Town Of North Andover 1600 Osgood St.Ste 2043 AUTHORIZED REPRESENTATIVE North Andover, MA 018415 �— fit.,u_V/W* ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD