7 GREEN ST - BUILDING INSPECTION (2) V1Rttt is 1M aurm t use of the SUM AV?
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COOVucgm&+pv�License d O r7 953 HiC Regislratlon i 7
EsMrnsMd Coat of Projad Perri Fee Cala+ldlon
Pamdt FM i EslbAted Cost X$7161000 Residential
-- . -- — Esdmaled Coat X:41/i1000 Comrnsrda�---- —
An Additional ff!-00 W added as an
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L48M aura that as fields an properly and sa*wMan to avoid delays in processinil.
The undersigned doss honey apply for a Buudnp Permit to bold to the above staled
specyaptione. Signed under Density of p
Date 1�' a' a ` a7
F
• �I'fY-OFgXLEn
17/7 PUBLIC PROPERTY
DEPARTME,�tT
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A>rPI1CATI IN FORTH! IMPAIR. BI wd%%?A ION_ C9NrrQ>rtrrrnta
DILMOLTTIO&OR CHANG9 Of USZ OR OC(.'Mn_rcw_ >Pn>Q Arry >I'xtrsrrxr�
TRUCTURA OR MIMM did
1.0 SITE INFORMATION
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2 O ONME:RSW INFORMATION
11 Owrw d Land X14Qe)Aaci Keyes
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Addrua. -7 &kECF S-t" SA� c�.r� rya o/9zzs
TMephorw. 97,�-.46 J -
sA C.OMPLM THIS SECTION FOR WORK IN MU SMUG Mm nu LM"S ONLY
Addidon
Renovation Number a storlea Raravated
Change In Use ( Now
DemoGtlon usting
Approximate you of Area par flow(at) Ranonrated
conatrucbon or ranovabon
a existing building New
gad Descrtpbon of Proposed Work:
---—- ---Mail Permit to -
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ?ek W1✓ A_0615 CL-A t' -Ors I Ac .
Address: qS F-Dw\4% RA .
City/State/Zip: 4&yP,rk'ill MA 011?31 i''PhbtAi4f, '97b's26� 7255
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 2 S 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 me in 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 L[I Plumbing repairs.or additions
myself [No workers' comp. ct 152, §1(4), and we have no 12.[3 Roof repairs
insurance required.] t employees.[No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing th4W&lfeist compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire,outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. r
Insurance Company Name: C . C h yr a yt
Policy#or Self-ins. Lic. #: D$ W 4 N l-• 51 H 2. Expiration Date: 2 00
Job Site Address: City/State/Zip: .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c.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 copyofthis-statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify underthe pains and penalties of perjury that,the information provided above is true and correct
Signatures �✓�i ^^ /�� Date:
q
Phone#• ( 79' 2�75 7Z S5
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):
1.Board of Health 2.Building Department 3. City/Towu Clerk 4. Electrical Inspector 5.Plumbing Inspector
li. Other ,.., .. .•,,::,,
Contact Person: Phone#:
DATE(MMIDD/YYV!)
ACORD. CERTIFICATE OF LIABILITY INSURANCE 07/112007" 1
PaolwcER (800)225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS TE
UPON THE CERTIfID IT
0
Fred-C.--Church--- -- _-- _ - - HOLDER THIS--CERTIFICATE DOES NOT AMEND,_EXTEND OR
41 Wellman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lowell,MA 01851
900-225-1865 INSURERS AFFORDING COVERAGE NAIC 8
INSURED INSURERA Hanover lDSUtenee Compaey
Pella Windows&Doors,Inc. - INSURER a: Twin CitY Fire durance Co'
45 Fondi Road INSURER C:
Haverhill,MA 01832-1302
INSUREROI
INSURER E
COVERAGES
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 DESCRI13EO HEREIN IS SUBJECT TO ALL THE TERMS,D(CIUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICYNUMBER POLICY EFFECTIVE POLICY E3PIRATION LIMITS
EACH OCWPRENCE $1.000•000
GENERAL LUBIIm a 500,000
X COMMERCIAL GENERA.LIABILITY
CLAIMS MADE r OCCURMED EXP, w $10 000
A ZBN8161407 7/l2007 7/1/1008 PERSONAL a ADY INJURY S 1,000,000
GENERAL AGGREGATE $2,000,D00
PROOUCTS.COMP/OPAGG $ 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER.
POLICY PRtO' X LOC
AUTOMOBILE LIABILITY CCOMBINE�DI SINGLE LIMIT =1000(�
ANY AUTO
X ALL OWNED AUTOS ro�aINJURY =
A SCHEDULED AUTOS ADN8162169 7/112007 7112008
X HIREOAUTOS mod"tt) =
X NON-OWNED AUTOS
PROPERTY DAMAGE _
(Par gihM)
AUTO ONLY-EAACCIDENT 4
GARAGE LIABILITY
CA ACC $
ANY AUTO - - - OTHER THAN. .,
AUTO DOILY, AGO
i 9,000,000
EKCESSRIMBRELLAUABnm EACH OCCIRUtENCE. .
AGGREGATE 19,000,000
X OCCUR - CLAIMS WOE
A - LTHN8167305 7/1/2007 7/12008 =
i
DEDUCTIBLE
s
X RETENTION S WC STATV- H-
WORNERS COMPENSATION AND
EMPLOYERS-L"Urf E.L EACH ACCIDENT 5 500,000.00
B ANYPRDPRIETORNARTNER/E%ECUTIVE , 09WBNL5742 7/12007 - 7/1/2009 EL DISEASE-EAEMPLOY S 500.0m•A
OFfICERIM FD EMBERE%CCLLUDT 500-000.00
SGUILPROVISIONS WIow , - E.L pISEASE-POLICY LIMB {
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
ella Windows&Doors,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POL LIES BE CANCELLED BEFORE THE EXPIRATION
FOndl Road DATE THEREOF;THE ISSUING INSURER WILL ENDEAVOR TO MAX. 10 DAYS WRITTEN
S l,MA OIH3O NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 So SHALL
aFondi
IMPOSE NO OBLIGATION OR LMURUTY OF ANY Me UPON THE W SURER.M AGENTS OR
. REPRESENTATNES. ..........
AV TIORILEG gEP11E SENTATNE
®ACORD CORPORATION 1988
ACORD 25(2001108) Clieut# 2960 Mgt# 07.09 OL.Auto,WC& Cast#
C . �oanenoouceall� o`./�f!aosaa/satelD -
Board of Building ReQnlations and Standards
HOME IMEMENT CONTRACTOR
.
Re9ist 129774 '
E /2I2009 Trp 260785
PELLA WINDO 'e
KENNETH PAQU
45 FONDI RD.
HAVERHILL,MA 01832 Administratorinommomw '
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IlIllpipi
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'ss; 09ti:1
£99690 '
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,
Contract
Paul Finnegan-Sales Consultant
45 FONDI ROAD
® HA 01832 L
MA 1832 1
Phone: 978-361-6922 Fax: 978-373-7274
Customer Project/Ship-To Order
Keyes,Margaret Keyes,Salem,WME Date 00/00/00
Quote No. KEYES
7 Green St. 7 Green St. Order No. 7ql6io(0`2�
Need Date 00/00/00
SALEM,MA 01970 SALEM,MA 01970 Sales Rep.Name Finnegan,Paul/WME
ESSEX ESSEX Prepared by
Payment Terms Deposit/C.O.D.
Owner: Margaret Keyes Architect
Bus.Phone:( ) - Bus.Phone: Jamb Depth
Bus.Fax:( - Home Phone:�)—_ P.O.No.
Cellular: ( ) - Branch Order No.
Home Phone:( - Order Type Installed Sales Order
Glazing Design 20.00 psf.
Pressure
Branch Name Paul Finnegan-Sales Consultant Branch Address 45 FONDI ROAD
Phone 978-361-6922 City HAVERHILL
Fax 978-373-7274 State MA 01832
Comments: Cient agreed to provided a deposit in the amount of$705.70.
Client agrees to pay the difference of$705.00 at completion of the project.
Client agreed to pay a separate check in the amount of$25.00 for Pella to secure a building permit from the Town of Salem.
For information regarding the fmishing,maintenance,service,and warranty for all Pella products,visit the Pella Website at
Nvww.nella.com.
Printed 10/24/07 Contract-Page I of 3
Contract for Customer Keyes,Margaret Project: Keyes,Salem,WME Order No.:
Outside View Item No. Otv. Summary Descrinion Unit Price Extended Price
Item#20 Qty: 1 Vent Double-Hung,Frame:31-1/2 X 45:Pella Impervia,Alternative
Location: Impervia Bathroom Material,Model 1 ,Half Vent/match Half Vent,White, I1/16"
R.O:2'8" X 3'9-1/2" InsulShld Temp IG Glazing,Half Screen,White Hardware,Precision
wn va
-— ,,.""„ Wa1lCopd: 1 11/16"(Fin to Roomside) Fit Frame-3 1/4"
Value Added Items:Impervia DH P-Fit-Qty 1
Disposal per Unit-Qty 1
Notes:
Outside View Item No. Otv. Summary Description Unit Price Extended Price
Item#25 Qty: 1 Vent Double-Hung,Frame:31-1/2 X 45:Pella Impervia,Alternative
Location: Impervia kitchen Material,Model 1 ,Half Vent/match Half Vent,White, 11/16"
R.O: 2'8" X 3'9-1/2" InsulShld Temp IG Glazing,Half Screen,White Hardware,Precision
w"�NVW WallCond: 1 I1/16"(Fin to Roomside) Fit Frame-3 1/4"
--
Value Added Items:Disposal per Unit-Qty 1
Impervia DH P-Fit-Qty 1
Notes:
Thank You r Purchasing Pella Products
QYq Qni& Taxable Subtotal $ 1,343.52
Custome ignature Pella Sales Representative Signature Sales Tax at 5.0000% 67.18
Non-taxable Subtotal 0.00
l J C _ YC �J_•' Total $ 1,410.70
Date Date Deposit Received $ 0.00
For information regarding the finishing, maintenance,service,and warranty for all Pella products,visit the Pella Website at
www.pella.com.
Contract-Page 2 of 3
Contract for Customer Keyes Margaret Project: Keyes,Salem,WME Order No.:
WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are
incorporated into and become a part of this contract. Please see the warranties for complete details,taking special note of the two important notice
sections regarding installation of Pella products and proper management of moisture within the wall system.Neither Pella Corporation nor Paul
Finnegan-Sales Consultant 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 are inconsistent with Pella written warranties.
Clear opening(egress) information does not take into consideration the addition of a Rolscreen [or any other accessory)to the product. You should
consult your local building code to ensure your Pella products meet local egress 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 grain, color, texture or natural characteristics are not covered under the limited warranty.
Contract-Page 3 of 3