6 VICTORY RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
^ ( Building Permit Number: ied•
Building Official(Print Name) Signature
SECTION 1:SITE INFORMATION
1.1 Prope•ty Address: 1.2 Assessors Map&Parcel Numbers
i l o J,I 'ROM d S01EM, NA-
(� Lin Is this an accept d street?yesZ no O I'170 Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
L Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yardcn
2
Required Provided Required Provided Required Provide
L
a
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: ra
Zone: _ Outside Flood Zone? t n
Public❑ Private Cl Check if yes0 Municipal❑ On site disposal systdadi ❑ ,<
SECTION 2: PROPERTY OWNERSHIP' "' O
2.1 Owner'of Record: (`_Ism 'AI A- CITY)
y
Name( nnt) City,State,ZIP „p GO
to Jl60 Road �P� �yy-)��[P
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition - ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
_ Brief Description of Proposed Work-:
,t7rxrl I�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ 3 pOo, ❑Paid in Full ❑Outstanding Balance Due:
I ($
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /os.911 a ,/&.�
1 QbVA+- �aUMt License Number Expiration Date
Name of CSL Holder
Ia6 I W/1`Fi l h�.�U List CSL Type(see below)
No.and Street Type Description
�, •L t I 1 i A '� Otp 3-� U Unrestricted(Buildings s u el ing cu.ft.
yV111 "'1 'O c7�. R Restricted 1&2 Family Dwelling
Cityrrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
�5.2 Registered Home Improvement Contractor(HIC) / 7 03 y 9 A�.la .�5
"lJl ZL 1 'e fft- `PQ,yslanfi-1 M I n� . HIC Registration Number Expiration Date
HIC Comp y Ny�e m HIC tstr Name
I..D > II C�
and Street
QI�ya3 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize 194 L/0C 1
to act on my behalf,in all matters relative to work authorized by this building permit application.
i
Print Owner's Name(Elec[r nic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained inI-this application is true and accurate to the best of my knowledge and understanding.
4 [�lT 1�/I I err I c2 ct�5/ � _
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
NOTES:
1. An 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.niass.eoy/ocs Information on the Construction Supervisor License can be found at www.nras$.g—oWems
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living 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. ` total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
i Department oflndustrialAccidents
Office oflnvestigations
UT 600 ,Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Le 'bl
AQxL—,e((oL 1PL6pef anacjemei t-r ►nQ--o.
Name(Business/Organization/Ittdividual): �@ } ��D(/y1 tfgd', }�G(1 S'tG�J2 (1(p9P?
Address: I I D t9b 60K LAcg) r
City/State/Zip:_ ? ye(S, ►``'�Pr 0 Iqd b Phone#: 000 7�7- 55toc�,
Are you an employer?Check the appropriate box: Type of project(required):
I Al I am a employer with, 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I'am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for mein any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required,] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we,have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.KOtherS-o4P_ Itu-Isrllcl:L,cz
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they one doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracton that check this box must attached an additional sheet showing the name ofthe subcontractors and their workers'comp.policy information.
I am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and job site
Information.
Insurance Company Name: l/1SL%-an C —
Policy#orSelf-ins.Lic.#: i,.t.)CA' Expiration Date: Lt
Job Site Address: J City/State/Zip:&EM, Hft- 01970
Attach a copy of the workers'compen ation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 0.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce under the ar and penalties of perjury that the information provided above is trite and correct.
®Signature VD!/ r ate' ��/a�VV
Phone#: -
official use only. Do not write In this area,to be completed by city or town official.
City or Town:
Permit/License#
Issuing Authority(circle one):
i.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chap
ter
Pursuant p 152 requires all employers to provide t to this statute P se workers compensation an em .. ensa'!o e P ton for e is de thew P y fine employees.d as ,...every person m the service of another under any contract ofhire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter the
self-insurance license number on the a-----riate line. ir
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been tY Officially
e provided to te
applicant as proof that a valid affidavit is on file for future permits or licenses. A newed by the cityoaffidavitt musmayt befilled out each
year.More a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts '
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
evised 5-26-05 Fax#617-727-7749
Department of Code Enforcement
Debris Disposal Affidavit
In accordance with the provisions of GL,c. 40, sec. 564,a condition of permit N_ _is that the debris
resulting from this work shall be disposed of in a properly licensed solid waste disposal facility a.;defined by
GL,c. I I, sec. 150A.
The debes will,orhes been disposeO orat:
.I Rnl i,r.10st r`fat q�mpn}L0°atior�ofFeciuty
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o�lDS tpwb�-ry S-}- ' 'c�tlxxle.l fLl►�- 41�i(cC
Location of action/lobsne (Street Address)
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Signature of npplicanUcontractor Date'
/"tVVRL.�„ vruaou ava-a � �. �,r� Cori�Foomu �o nwv�v-�e�.r rm '-' I 11/11/2014
PRODJCER 978.887.4900 FAX 978,887.2404 THIS CERTIFICATE IS ISSUED AS A NATTER OF INFO NATION
Edward F. Senrott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND EX.TENDOR
_I 16 South plain Street ALTER THECOVERAGEAFFORDED BY THE POLICIESBELOW.
P. 0. Box 457 --ri------
Topsfield, MA 01983 INSURERSUnionRDlnsuranceACo. - - - ' N31325
INaUREO A ua Terra Pro ert Mann"emenf,Inca
C DBA Warn Traditions Stove ShoPpe
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A P Y 9 uI L: � Acadia Insurance I I
Box d081
L aln1 vets, VA 01923
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COVERAGES -- -'----iY� -----�
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSLEDTO THE INSURED NAMED ABOVE FOR T'HE POLICY PERIOD INFCAI'ED.NOTWITHSTANDING
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEENRECUC R8Y PAID Ci ATUOOYFFCfCrtT RESPECT TO WHICH T4 S CER IriCATE MAY BE ISSUE[)OR
ANY REQUIREMENT, rERM OR CONOL ION OF ANY CONTRACTOR OTHER DOCUMENT NTH
ED
MAY PERTAIN,THE II SURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCL IS'ONS AND CONDII IONS OF SUCH
LT�R Y1Ir ... TYPE OF INSURANCE
DATE{MM_. IOM`MT_OATE(MMttIDM^rn LWTB
c 11 C0RREn E p 1 OQO, 000
• %/ ! 04/14/20151, mr-�rrvErT LT -rt--- ----
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AUTOMOBILE UASILRY MAA0335589-14 04/14/2014 IU4/14/2015 a LrmT
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!EXCESS I UMBFELLALAeILIr CUA0335764-51i0�4/21E 0�4%14/2015 Enrn IRREnc s 1,000,00
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WORKERS" Sornv`ensa Ion ry—� WCA033 5 5 90-14, 04/14/204/14/L.O15 X X !
ANDEMPLOYER$LINIILT' Y1t1 ICI L_� '1 LI ? R
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DE90RIPfIONOFOPERATOq8ILOCATgN31VEHIC_E91E%i.L'J91pN9 ADDED BY EN5OR9eAENT19PECIAL PROVlLONB
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CERTIFICATE HOLDER CANCELLATION ! _
�— SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRA.TION
DATE THEREOF'HE ISSUING INSURER WILL ENDEAVOR TO MAIL 101 DAYSWRirreN
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BU-FAIL.URE TO,DO SO SHAL_
Tom Cunn'''.ngham IMPOSE NO OBLIGATION OR LIABIL?hDF ANY HINC UPON THE INSURER,Its AGENTS OR
6 Victory Road REPRE9ENTATNES
Salem, Wi 01970 AUTHORIZED REPRESENTATIVE "-"---- '-1
Peter Sennott AAM
ACORD 25(2009101) 01988-2009 ACORD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD !
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J IMPORTANT
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If the certifi„ate holder is ar ADDfrIONAL INSURED,the policy(ies) must be endorsed A statement
cn this certificate does not confer rights to the certificate holder in ieu of such endorsement(s).
If<;JBROGATION IS WAIVED, subject to the terms and conditions cf the policy, certain policies may ICI
rec wire an endorsement.A statement on this certificate does not confer;fights to the certificate
holder in Geu of such endorsement(s). li
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DISCLAIMER
This Geaificate of Insurance does not constitute a contract between the issuing insurer(s),authorized -
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.
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ACORD 25(2009101)
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WARM TRADITIONS
STOVE SHOPPE
A Division of
AQUA TERRA PROPERTYMANAGEMENT,INC.
Construction Supervisor Contractors License #CSFA-105711
Robert Raucci
10 Massachusetts Gepar r a.i, o` , c Hafer,
Board of 3.1!.;:ng Reg,a .'w ,,,ls :,.,.. ..,a
Cunsti uctinn Supu.i.ni inuh "
'..cer se CSFA-105711
ROBERT G RAUCCI R
123 NORTH BROADWAY _
HAVERHILLMA 01832
02/13/2016
Home Improvement Contractors License #170349
Aqua Terra Property Management, Inc.
�.
a..-`-. Office of Consumer Affairs&Business Regulation
SOME IMPROVEMENT CONTRACTOR
k egistration: 170349 Type:
�_--,y expiration: 10/12/2015 Corporation
cz, _-
AQUA TERRA PROPERTY MANAGEMENT INC.
ROBERT RAUCCI
110 NEWBURY ST 11C g �
DANVERS,MA 01923 Undersecretary
110 Newbury Street 911C P.O.Box 2081 Danvers,MA 01923 978-777-5562
c6'{ao ceeflet.insert l l iCQ� ct77Co�ao�D/(�� 4
Listing=and CodeAppirove([
A. Appliance Certification E. BTU & Efficien.cy Specifications . ...
IyIODEL: 12P0-I'Pellet Insert Emissions Rating- .9 grams/hr
LABORATORY: OMNI Test Laboratories, Inc fBTU'Output: 14,000-40,000/hr
REPORT NO. 061-S-13-2 Heating Capacity: up to 2,500 sq.ft. depending
ion climate zone
TYPE: Solid Fuel Room:Heater/Pdllet Fuel
Burning Type Insert Hopper Capacity 60-75 Ibis
STANDARD: ASTM:E1509 95;'ULC.S628-93,ULC Fuel: Wood Pellets or Shelled Corn
S610-M87, ULC S628-'W3 and ULC/ Shipping Weight: 243 fbs
ORD-C1482-M1990 Room Heater Pellet
Fuel Burning Type'and (UM)84-HUD, •BTU output will vary, depending on the brand of fuel you
Mobile Home Approved use in your appliance. Consult your Quadra fire-dealer
for best results'.,
B. Mobile Home Approved
This appliance is approved for mobile home installations . WARN►NGI Risk of Firel Hearth &Home Technologies dis-
when not installed in.a sleeping room and when an outside claims.any responsibility for, and the warranty and agency
combustion air inlet is provided. The structural Integrity of the listing will be voided by the above actions.
mobile home floor, ceiling,oridmalls;rnustbe maintained.:. DO NOT.•
The appliance must be properly grounded to the Iframe of • Install or operate damagad appliance
the mobile home and use only libted:peiiet'vent,:Class"L".,or . Modify appliance
"PL"connector pipe. A Quadra-Flre Quf de,Air kit must be Install other than as instructed by Hearth & Home
installed in a mobile home installation. Technoldgie
Note: This appliance Is also approved for installation Operate the appliance without fully assembling all
into a shop, components
• bverfire
j Install any component not approved by Hearth &
'Home Technologies
C. Glass Specifications
• Install parts or components hot'Listed or approved.
Improper installation,,adjustment, alteration, service or
This appliance is equipped with 5mm ceramic glass. Replace maintenance can cause`injury or property damage.
glass only with 5mm ceramic glass. Please contact your For assistance or additional information, consult a qualified
dealer for replacement glass. installer, service agency or yourdeales
NOTE: This installation must conform with:local codes.In
the absence of local codes you must=mply with the ASTM ::; NOTE: Hearth & Home Technologies, manufacturer of
E1509.95, ULC S628-93, ULC $,6111-M87,ULC/ORD-C• this appliance, reserves the right alter its products,
1482-M1990, (UM) 84�HUD. their specifications and/or price without notice.
D. Electrical Rating Qtiadra-Fire is asreglsteredtrademark
115 VAC,60 Hz, Start 4.1 Amps, Run 1.1 Amps of Hearth &Home Technologies.
7014-188 September 16, 2009
IRE
th
Outside Width
Outside Insidet Depth Depth Weight BTU/Hr Heating Burn Rate Hopper Particulate
nrevleee Fireplace Fireplace fireplace Fireptare on to Hearth pbzl Input' Capacity' Imslbourl Capacity' Emissions Efficiency
tbsl igliourl
lCa
ernon AE 36-5/8" 32" 29-3/4" 23-7/8" 15" 13-1/8" 425 14,620 to 1,300-
sert 52,460 2,900 sq.ft. . -6.1 47 .9 86.5%ernon E2 36-5/8' 32' 29-3/4" 23-7/8" 15" 13-1/8" 425 14.620 to 1,300-
sert 52,460 2,900 sq.ft. 1.7-6.1 47 2.7 87.0%stile 32-1/4" 27-7/8" 24-3/4" 19" 13" 9-3/4" 260 12.900 to 700-
i Insert - 34,400 1,800 sq.fL 1.5-4 45 .7 81.7re
Classic Bay 281/ " 17.200 to 1,000-
l 1200i - 2" 29-1/4 25-i/2" 22" 13" 12" 243 2 0-5.5 75 .9 85.2%
47,300 2,600 sq.ft. '
Santa Fe 21-1/2" 28.7/8 25-3/8' 23' 12-3/4 12,900 to , 700-
. .Insert 8-5/e" 21G 4 7 %
,34400 1111 18sq.ft.
CLEARANCES
I.Vernon AE - ,„.,--,F, JA
cInsert \\1 8 '0 B p. C
mminnm .
ai n <me $dim
MASONRY&ZERO CLEARANCE BUILT-IN INSTALLATION
TION
INSTALLATIONS
mpvem rear vem F Masonr 24" 15" 23J/8' 34"
6' 12' 0" 0" 6" 6" 3. 2.. 7-1/2" 2-3/4" 3.. 6" ZC 2L" 15" 23-7/8" 34..
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MASONRY&ZERO IONS NCE BUILT-IN INSTALLATION
INSTALLATIONS E
Masonr 24- 15" 23-7/8" 34"
,op list I F :<m PAPEN
ZC 2G" 15" 23-7/B" 34"
6' 12" 1 0' 0' b" b" 3 2' 7-1/2"12-3/4-1 3 1 6-
Castile
Insert
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MASONRY&ZERO CLEARANCE
INSTALLATIONS BUILT-IN INSTALLATION a,av aowe w:nm<aan e
me„m
• : ° F Masonr 23-5/8" 14' 19-1/4" 21-1/4" 28-1/4"
16" 12` 1-3/41 10 1 6 16" 3" 3" ZC 23-5/8" 18' 19-1/4 1 21-1 4" 28-1/4'
ssic Bay 1200i ® A s„<ottme. ,e pr t«roe
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elm<ozlomu�.mq
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MASONRY&ZERO CLEARANCE BUILT-IN INSTALLATION[using rearsnroml
INSTALLATIONS
: p r<ervem mpv<er
:
r<ar vem tap ye�i k:rv<m tovv<m Masonr 22" 13 1 29-1/4"
6; 12" 3- 6" 8- 0- 3" 0- 0' 2-1/2' 3" 0" ZC 22" 15-1/2" 25-1/2" 22-1/2' 29-1/4"
nta Fe -a..mame Dewn:t2m. —�
Insert _ A
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MASONRY&ZERO CLEARANCE BUILT-IN INSTALLATION
INSTALLATIONS
:
tov eem
rear.em
: Masonr 24" 16' 23-1/4" 29-1/4"
• '
2-1/2' 2 2-1/2" 3" ZC 24 1 6" 23-1/4" 29-1/4"
.......... ........................ ......... . . ........... . .. ........ ...... . .. ............. ..............,
'BTU/Hour Input calculated using premium wood pellets at 8,600 BTU/Ib. BTU output wilt vary depending on type of fuel used.Fuel density and pellet shape wit[affect
hopper capacity;2 See your local Ouadra-Fire dealer for help in determining the product that best suits your heating needs based on climate and home efficiency.
vvtiluvi TRADITIONS STOVE SHOPPE
110 Newbul'y`Street P O Box 2081 Danvers, MA 01923 978.777.5562
This form satisfies all basic requirements of the states home improvement Contractor Law(MGL chapter 142A),but does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person phuminghome improvements should first Obtaia8 copy o""
Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the
Office of Consumer Affair's and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3157 or on our website.
Homeowner Information Contractor information
_Name Company Name AAA-)'IYtzeil 1UY1d
1 a Cl`t�S:r/rl DF -AQLb _T oVAAA '01/) r i ril - �. 0ty .
Street Add�rIqss(do not me aPost Office Box ddress) Contractor/Salesperson/Owner Name '
tP V '1C r *oLvA+ Paoa-i
Cbw7own Zip Code Bpsiuess Add ass(must include a street address)
m M State e?W)o A)bv S-+. lbipw.1,� M4 019,4.3
Daytime Phone Evening Phone City/1'own State Zip Code
Mailing Address(It different from above) Business Phone I Federal Employ IDor S.S.Number
name Impm oeoos contmeternc&Number 'Expintioadaa
A+w mgnlres that most home
Impruvomann volts ration resole avc
The Contractor agrees to do the following work for the Homeowner:
(Describe in deWithe workto completed,specifying the typo,brand,
used,,and grade of materials to be use additional sheets 1fnecessmy.)
n g-kI lath k C n t�Ctz `"e I1'e-T �.11'1+
7Permitsts-Thefollowingbuildingpermitsarerequired Proposed start and CompletionSchedule-Thefollowingschedulewill
ed by the contractor as•th,homeowner's agent: be adhered to unless circumstances beyond the contractor's coatt'ol arise
secure their own permits will be
m t]i a Guaranty)Fund provisions of / d1 Date when contractorwill begin contracted workr 142A.)
Date when contracted work will be substantially,completed.
Total Contract Price and Payment Schedule t
The Contractor agrees to perfomzthe,work,furnish the material and labor specified above for the total sum of: (')
Payments will be made according to the following schedule:
$ AG2 �upon signing contract(not to exceed 1/3 of the,total contract pprice or the cost of special order items,whichever is greater)
S 3,2 03. f/O by l 1 or upon completion of U 9122Y !!�
$ by _/_/ or upon completion of
g _upon completion of the contract (Law forbidsdemtmdingfallpaymentuntilcontractiscompletedtobothparty'ssatisfaction) .
The following material/equipmentmust be special $._to be paid for
ordered before the contracted work begins in order
to meet ate completion schedule.("') $ to be paid for
NOTES;(*)Including all fmaace charges(oc')Law requims that any deposit or down-payment required by the contractor before worlcbegtas may
not exceed the greater of(a)one-third of are total contract price or(b)the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
ire s Warranty XS an express warranty beinz provided by the contractor? ❑Ne❑'Yes(rill terms ofibc warranty must be attached io the contract)
Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless a the actions all
sub of tractors
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
ate ials and labor gn I
dm-thisaFre t
Contract Acceptance-Upon signing,this document becomes a chiding contract under law. Unless otherwise noted within this document,the
contract shell not implythat any lien or other security interest has been placed onthe residence. Review the following cautions and notices
carefully before signing this contract.
e Don't be pressured into signing the contract.Take time to read and fully understand it Ask questions if something is unclear..
a t as a vaiid Ilom elm nrovement Contractor Reastration. The law requires most home improvement com actors and
Home Improvement Contractor Registration. You may inquire about contractor
subcontractors to be registered with the Detector of
registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02inf m , calling 61 c,L,ca 8 ,.m or 88o overage,
7 r a
e Does the contractor have insurance? AsktheContractorforhisinsurancecompanyinforma'.tea"=X, Iy"L'°m°''ismcoverage,oraslcto
soc a copy cf a"proof of insurance"document• gel.acopy of the Consumer
a I(nowyour rights and responsibilities. Read the Important?nformationmithereversesidec:` l .
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor inwrit rig at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later ation than midnight ofthe
tlrird business day followiagthe signing oftbis agreement See the attached notice of cancellation formm�fur SPACES his right.
DO NOT'SIGN DUS CONTRACT IN TIIER>;ARE ANS'
Two identical copies ofthe contract mist be Completed and signed. one copy should go totheliomeowner. The otlier copy sshouldbekeptbythecontractor.
v " Contractor's Signature
Homeowner's ignlatnto v/ �2
pat < 7
Date
Contractor Arbitrition
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. The same right is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner i a court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
EL���
actor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
g this contract;the contractor may submit the dispute to a private arbitration firm which has been approved by
tary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be requiredt to such arbitration as provided In Massachusetts General Laws, chapter 142A.Contractor's Signaturener's Signature P PP Y YE,:The signatures of the arties above a 1 onl •to the a eement of the parties to alternative pu e
on initiated by the contractor: Thehomeownermay initiate alternative dispute resolution even where thusis not separately sigaedby the parties.
Homeowner's Rights GL chapter 142 A) and other consumer
A homeowner's rights under the Home Improvement Contractor Law(h1 P Bement. However,homeowners
protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agr
may be excluded from certain rights if tl?e contractor they choose is not properly registered as prescribed by law.
its are automatically excluded from all Guaranty Fuld provisions of
Homeowners who secure their own building perm
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and wor1manlike manner. Homeowners may be entitled to other specific legal rights if the contractor
antees or warranties
of merchantability and fitness for
guarantees or provides an express warranty for workmanship or materials. In addition to g� agree may be
provided by the contractor, all goods sold inMassachusotts carry an implied
andy
a particular,puxp consumer rights' If youti have
ore. An enumeration of other matters on which the homeowner and contractor lawfully �•
added to the terms of the contract as long as they do not restrict a homeowner s basic consum
questions e ter s of the contract
ct owner rights,contact the Consumer Information Hotline(listed below).
out
�Our
cOnsume
Execution of Contract
enced
The contract must
he executed in attached parties c. to also e and av red not
bc sign thewc��n om�all f all b�t��sections
have been
documents have signed co• of the contract with attachments is to
filled in or marked as void,deleted, or not applicable. One original sign PY contract must be in writing
Parties- Contracted work may notbegm untilboth parties have received a fully executed copy of
be given to the owner and the other kept by the contractor• Any modification to the.origin
and agreed to by both P period has expired.
the contract,and
the three day rescission p
e payment schedule in cases where the
payments dates specified on th .p Ym erself
ntract5 m ce of the P contractor deems hiuu/h
Acceleratedeats in advance A contractor may not demand p o b
,, �;„ ,,;a � ;,,Sectxe. However;in rpstances where a
l,. ,cov er deems;u n/herself to be_ an "ul require that the balance of funds not yet due be placed w a j d re escrow
to be financially inseclre,the contractor may
account n iPrerequisite to continuing the contractedwork- Withdrawal of funds from said account would require the
signatures of both parties.
additional Information Improvement
Contractor Law or other
of "A Maout h the
Consumer Guide to Home Improvement"
ff you have general questions or need additional information about the Home Imp
inner rights,or if you wish to obtain a free copy
. ,as
contact:
Consumer Information Hotline'Regulation
Office of Consumer Affairs and Business Re0g 6
10 Park Plaza,Room 5 17 0,Boston,MA
617-973 8787, 888-283-3757 or visit
the 0CABR web site at 1i //�2--v-'rlass a°v/ocabr/
tional
If on want to verify the registration of Component tr tc1tor i'lave questions or need he Home Imp Improvo'Lement C ntractor Law, contact:
ontaet information specifically
about the contractor registration compo
Director of Home Improvement Contractor Registration
O'fdice of Consumer Affairs and Business Regulation0
16 Parl0laza,Room 5170,Boston,MA mass aov/ocabr/
617-973-8787, S88-283-3757 or visit the 13ICwebsite atbtt a/wvnv
rovement Contractor's Registration:Go online to view the status of a Home Imp
hits://ab.state.ma.ns/hoeneim rovemenlJlicenseelist.asL mat con taints against abusiness,cad
• P'or assistance with informal mediation of disputes or to regisier for P
Consumer Complaint Section
Office of the Attorney General
Offi
617-727-8400
AND/OR
Better Buuiness Bureau
' 508-652-4800, 508-755-2548 or 413-734-311
Version 2.1-11/22/2010