8 HERSEY ST - BUILDING INSPECTION (2) vvNa� tlra aurM t use at the auild6417
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Arditc a Name I 1
Addrs"and PNOM
Madw ies Name
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CooNa+�S &vW=Lkwnaa• O�9�S'3 HICRap�albna
Est>rrralad Coat i $ (o Par*FM Caindadon
Permit FN i Estlmaesd Cost X i71111000 Resider"
Esenaled Coat X i'l i1i100A Canrnsn�aL
M Addeanal i6Ao Is added as an
AdmOnlatrativs duwggL
Make sure that aq flelds am property and WO*written to avoid delays In prodsslna
The undsrsipnad doee hereby a"W a&'pdkV ParrrA to trued to the above stated
spediadom 8lpned ur4w peruUy of pw*m
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APPLICATION FOR 33M RZFAIIL R>i WATIM rnNQT UCrW
DMOLI71M OR CHANGR OF USZ OR QCCIMANCV, FnR.Ny ZXL4n qG
1.a an INFORMATION
Locm*m Name: Bu&*W
i
Properly In kxaled in a;Consmsson Ares YA f =- Hlftft DkWot YIII( 2-4
2.0 ONMERMF INFORMATION
11 OwaN d Land _
Address:
Telephone: 01 -3 6 0 -q> z s
&&COMPLETE THIS SECTION FOR WORK IN E><IiI1dG BUILDINGS ONLY
Additlon Eid"
Renovadon Numbs of Stories lisnovabd
Change h UN New
DemoUdon dreg
Approximate year of Area per floor(of) Renovated
construcdon or renovation
of existing buildup New
add Descripddon of Proposed Work:
--- - - ---Mail Permit to:w,I I„ Al rc A),c 14 I s PEi/� w.�,�w vs FouSp- R-6 /14vee 141, �
0/Jts d--
r Vr I OF Sa'fa.Fm
PUBLIC PROPRERTY -
- DEPARTMENT
�.ysat of•"�i.►`I►.
a4aa tiGraea :oa+i7t[T iAt:)1.]Lwl�t»a�tt1s::9
fit:te7fiJa�99M�t.�91N961iN
Construcdos Debris Dtspossf Affidavit
(required lbr an demolition"A renovadom wet)
in=ordancc with the sixth ed dm of dw State Hu WWg Code.7W CMR sation 111.S
oebri&sad dw prwrisiom of M. GL a 4%S St
gwId(ng Pon f _ is iswwd with the condWm chat the debris rcmdtins does
this wait shall be disposed of in a properly lieatio d waste disposal facility as defined by MOO e
1 t I.S lSOA.
The debris will be transported by:
auomtt oY 1+otJd)
rho&-bds will be disposed of in :
was �et^ A-.
tauneuYfa.tluy) �`y ��
�+Jrtta.. aY Cxa.ty)
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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
`� I�OrS .
Name (Business/Organizatiotu/Individual): t��y--�e l'CC w ����1..1 S A✓ld '\C
Address: qS IFaha P-A '
City/State/Zip: .r-leai��
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with Z S 4. ❑ I am a general contractor and I
... • • 6. ❑New construction
employees (full and/or part-time).* have hired S.sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. �• ❑ Remodeling,
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. ' q. ❑ Building addition
o workers' comp. insurance 5. ❑ We are a corporation and its
� P• 10.Q Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all.work right of exemption per MGL It.0 Plumbing repairs or additions
myself. [No workers' comp. ci 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.[No workers' 13.Q Other
comp. insurance required.]
•My applicant that checks box#1 must also fill out the section below showing thei��nlidikersr:comens pat[on po m licy in in 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 subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance formy employees. Below is the policy and job site
information T r Insurance Company Name: r f q C k V r a ►'I_
1
Policy#or Self-ins. Lic. #: 019 W SAIL. S 7 H 2 Expiration Date:
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 copypf this'statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi& under the pains and penalties of perjury that,the information provided above is true and correct
Signature: q—L1 V,1/1 � �_.. Date- 11 —u 7 —o l
Phone# 1 /O ' 265 �ZSS
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/Town Clerk 4.Electrical In
5.Plumbing Inspector
6. Other
Contact Person: .... Phone#:
r
,per 71-w >°iommmian uea�c _��/�iraaar/iaee!!d
�\ Board of Building Regulation and Standards
HOME IMPROVEMENT CONTRACTOR
Registr4(1� 129774
-4=1/212009 Tr# 260785
PELLA WINDOWS
SCOTT HOUSE`i'� '� (}` -
45 FONDI RD.
HAVERHILL, C.
MA 01832
Administrator -
�BOA�,tD,OR BgILflINOrREGU
Licence COI TRUCTIt h SUPS St3R�
NurFtl� S = �089853 t
"' 7s 157 PEARTREE R ; S
ATE
A-CO&D,N CERTIFICATE OF LIABILITY INSURANCE D1/200709:56YY)
ovunoo7 o9s6
PRODUCER (800)225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
RO
Fred C.Church ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
41 Wellman Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lowell,MA 01851
800-225-1865
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA' Han0Ver11LSUrallne COMPany
Pella Windows&Doors,Inc. INSURERS: Twin Ci4r FKe Insurance Co.
45 Fondi Road
Haverhill,1AA 01832-1302 INSURER C'.
INSURER D:
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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS0. POLICYNUMBER POUCYEFFECmm TYPE OF INSURANCE DATE As D TIVE POLICY E%PIRATION LIMITS
EACMOCCVRRENCE $1,
GENERAL LIABILITY �.�
X COMMERCIAL GENERAL LIABILITY M S ° n a f 500,000
CLAIMS MADE 1 7X OCCUR MED EXP are arson f 10,000
A ZBN8161407 7/VY2007 7/1/2008 PERSONAL6ADVINJURY $1,000,000
GENERALAGGREGATE f 2,000,000
PRODUCTS.COMP/OPAGG $ 2.000•000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO- X LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
(Es acddenl)
ANY AUTO
X ALL OWNED AUTOS BODILY INJURY =
SCHEOULED AUTOS (Far� )
A ADN8162169 7/1/2007 7/1/2008
X HIRED AUTOS BODILY INJURY f
(Per arsAdent) _
X NON-OWNED AUTOS
PROPERTY DAMAGE f
(Par acclderd)
AUTO ONLY-EAACCIDENT $
GARAGE LIABILITY EA ACC $
ANY AUTO OTHER THAN
AUTOONLY: - AGO f
EXCESSAIMBRELLALIABILITY EACH OCCURRENCE f 9,000,000
X OCCUR Q CLAIMS MADE AGGREGATE f 9.000,000
/ 007
7/1/2008 f
p
UHN6167305 71R
S
DEDUCTIBLE
f
X RETENTION S We STATU- OTH-
tiTHER
RNERS COMPENSATION AND -
PLOYERS'LIABILITY EL.EACH ACCIDENT $500,000.00
PROPRIETORIPARWERrEXECUTIVE -OBWBNL5742 7/1/2007 7/IROOS E.L.DISEASE-EA EMPLOYEE f 500,000,00
;ERIMEMSER EXCLUDED? _ 540rOC4 00
IIAL PROVISIONS EeIow EL DISEASE-POLICY LIMIT f
DESCRIPnO OFOPERATlNSILOCATIONS/VEHICLESIEXCLUSIONSADDEDBYENOMSEMENTISPECALPROVISNNIS -
CERTIFICATE HOLDER CANCELLATION
Pella Windows&Doors,Inc. SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
S FOndi Road DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRRTEN
Haverhill,NIA 01830 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES ..
AUTNORREDREPRESENTATNE .'.,
2001lOB O ACORD CORPORATION 1988
ACORD 25
( � Client# 2960 Mst# 07-08 GL-Auto,WC& Cert#
Umb
Contract y� �°Mvo 7/yso
Pella Windows&Doors,Inc.45 FONDI ROAD f
HAVERHILL I�
MA 01832 \
Phone: 978-373-2500 Fax: 978-373-7274
Customer Project/Ship-To Order
Prieto,Ana Prieto WME Salem Date 00/00/00
Quote No. PRIETO
5 mayflower lane 5 mayflower lane Order No.
Need Date 00/00/00
Salem,MA 01970 Salem,MA 01970 Sales Rep.Name Donvan, James/WME
ESSEX ESSEX Prepared by
Payment Terms Deposit/C.O.D.
Owner: Ana Prieto Architect
Bus. Phone: ( ) - Bus. Phone: Jamb Depth
Bus. Fax: ( ) - Home Phone: 978 745-6684 P.O.No.
Cellular: (617)784-1988 Branch Order No.
Home Phone: ( ) - Order Type Installed Sales Order
Glazing Design 20.00 psf.
Pressure
Branch Name Pella Windows&Doors,Inc. Branch Address 45 FONDI ROAD
Phone 978-373-2500 City HAVERHILL
Fax 978-373-7274 State MA 01832
Comments: Customer has paid$3014.13deposit(50%of contract Total)
Customer has paid using a(Credit Card)
The Remaining$3014.29(Final 50%)will be paid upon Substantial Completion of Installation.
Customer will be paying remaining balance using(Credit Card)
For information regarding the finishing, maintenance, service, and warranty for all Pella products, visit the Pella Website at
www.i)eila.com.
Printed 09/29/07 Contract-Page I of 3
I
1
Contract for Customer Prieto, Ana Project: Prieto WME Salem Order No.:
Outside View Item No. Oty, Summary Description Unite Extended Price
Item#10 Qty: 2 Vent/Fixed XO Sliding Window,Frame:58-1/4 X 55:Pella
Location: Impervia,Alternative Material,Model 1 ,White, 11/16"InsulShld IG
RO: 4' 10-3/4" X 4'7-1/2" Glazing,Half Screen,White Hardware,Block Frame
° WallCond: 1 11/16" (Fin to Roomside) Value Added Items:Disposal per Unit-Qty 1
Full Frame P-Fit or Exterior P-fit install-Qty 1
Notes:
Outside View Item No. Otv, Summary Descrintinn Unit Pri a Extended Price
Item#15 Qty: 1 Vent/Fixed XO Sliding Window,Frame:58-1/4 X 32:Pella
Location: Impervia,Alternative Material,Model 1 ,White, 11/16"InsulShld IG
RO: 4' 10-3/4" X 2'8-1/2" Glazing,Half Screen,White Hardware,Block Frame
° WallCond: 1 I1/16" (Fin to Roomside) Value Added Items: Disposal per Unit-Qty 1
Full Frame P-Fit or Exterior P-fit install-Qty 1
Notes:
Outside View Item No. Otv. Summary Descrintinn Unit Price Extended Price
Item#25 Qty: 4 Vent/Fixed XO Sliding Window,Frame:58-1/4 X 44-1/2:Pella
Location: Impervia,Alternative Material,Model 1 ,White, I1/16"InsulShld IG
RO: 4' 10-3/4" X TV Glazing,Half Screen,White Hardware,Block Frame
° WallCond: 1 11/16" (Fin to Roomside) Value Added Items:Disposal per Unit-Qty I
Full Frame P-Fit or Exterior P-fit install-Qty 1
Notes:
Thank You For Purchasing Pella Products
For information regarding the finishing, maintenance, service, and warranty for all Pella products,visit the Pella Website at
www_,peila.com.
Contract-Page 2 of 3
� v
Contract for Customer Prieto,Ana Project: Prieto WME Salem Order No.:
t
Taxable Subtotal $ 5,742.43
Custot r Signature Pella Sales Representative i afore Sales Tax at 5.0000% 287.12
Non-taxable Subtotal 0.00
4�,L4�07 a��k 1 a Total $6,029.55
Date Date T Deposit Received $ 3014.13.
Remaining Balance $ 3014.13.
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 Pella
Windows&Doors,Inc. 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.
For information regarding the finishing, maintenance, service, and warranty for all Pella products, visit the Pella Website at
www.yelia.com.
Contract-Page 3 of 3
. _
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