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HomeMy WebLinkAboutBuilding Permit #500-14 - 136 OLD VILLAGE LANE 12/13/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit-!40,56z)/ Date Received Date Issued: 1,-�J, rLIOITANT:Applicant must complete all items on this page �.. .._... ...,, � ..}y�� .... .. fM._�..•7.•P.�..>,..,._'ty y/')Yt,,'/f��ts�t+F"f�'w{ a.-- y�♦ys�i"Sr""""r."'��9!'°`�'""""",y".......�[S \ -�,+�--r { w Jar t ... ., ,'PR©PERT;YtiOWNERt z / f9G�PrLQrI _.� - MY- On .., �- y �Pt -. ea- Old Stru yes no �, MAP�NO .x,10 .PARC < Z© ,INGWlSip -''- .__� Hi ric Dis rict� a yes) +no'�� tur 1 ; .� :S.Y� {Mach`'ne=`StopViJla9e� :YeS�, >°no5a TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial ❑ Iteration No. of units: ❑Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other —1-1V44-Septipl Niw".ell : '' < ° '❑`Floodplain ` i0lWetlands, '' t ®I V1/atershed,Distnci 60ater/Sewer: i' r 1 t t ♦ _ » .� r ' DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: "�' GcJDo I`7 Phone: 417— Address: Z04 6/D C�®NTRACTtO;Rt`Nam_ er; t m Q/?Plq x Phone (29, til 7 .4 +rY-':. .` Yl•r+'7""':.r Arv..-+.e .,-....w. -.�.�... .-+-F-.ti+ "C ar- +t+..�++r w- s�,"' i*, f �� ♦ a ess4 q Tt 7 ,t�� t♦. �� {� - < 1' C t ♦,., _ , / 1 �C.�.,r,r-�i!rr�e����, t . � Y .Supervisors Construction-�Llcense �Exti!.Bate :3; HomeAMPT9veme'nt;Llcense ARCHITECT/ENGINEER Phone: \ Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �� /�02�D(' FEE: $ Check No.:, 0R a 69 q Receipt No.: a NOTE: Persons contracting with unregistered contractors do not have access th guaranty fund !Signature of:AgenVOwner..;. :. :'.: :`. Sig atta:re of.contra:ct' F. - ---- - ri1--_ r+..t-__ai_-3 n ni - �n►�:., J n /+.,a:F;,,,-0 r]L.+ 01.,., C�nmrar�rl Dlnnc+ F-1 Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ -TYFE OF-SEWERAGEDISPOSAL 1 Public Sewer ❑ Tanning/Massage/BodyArt ❑. . Swimming Pools ❑ Well ❑ Tobacco Sales ❑ FoodP acka ' Sales 11 Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY i INTERDEPARTMENTAL SIGN OFF - U FORM i DATE REJECTED DATE APPROVED r PLANNING & DEVELOPMENT ❑ .❑ I COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on _ Signature COMMENTS t' `N4 Zoning Board of Appeals:Variance, Petition No: Zoning Decisionfreceipt submitted yes_.. Planning Board Decision: Comments -Conservation Decision: Comments ''Water& Sewer Connection ermit DPW Toiv ]Engineer: Signature: Located 384 Osgood Street FIRE•®EP�;p7MiE T -Temp Dumpster on site yes no D •Located at•124 Maih`Strdet Fire Deparineet signature/elate COMMENTS Dimension Vumber of Stories: Total square feet of floor area, based on Exterior dimensions. _ rotal land area, sq. ft.: :LECTRICAL: Movement of Dieter location, mast or service drop requires approval of :Iectrical Inspector Yes No )ANGER ZONE LITERATURE: Yes No AGL Chapter 166 Section 21A�F and G min.$100-$9000 fine 40TES and DATA-- For department use B Notified for pickup - Date oc.Building Permit Revised 2010 Building Department 'rhe foliowing is a-list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o- Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L.- Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products TOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Aiiidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application P Certified Proposed Plot Plan - o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract a Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products DTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit lin all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apni al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording trmst be subm;tted with the building application i Doc: Doc.Buil;iing permit Revised 2012 Location �--!� '0� o j � ��� c._ l�r J No. X>U �`-4 Date (Z 131(3 ti . - TOWN OF NORTH ANDOVER ow . Certificate of Occupancy $ Building/Frame Permit Fee $J-�� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Check 029 j i� L Building Inspector I NORTH own of t 1/ Andover O - 1 0% No. . - �` Z Ke ver, Mass , 2 / 12 COCMICHI WICK A- 7,e A�QgTEO S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. P�ID .� ........... BUILDING INSPECTOR ............... .... .... ......................... . ............ .............. . i 1 r has permission to erect buildings on 13fa. told, V�l.� l�/...,... Foundation .... .................. ..... .. .... ..... � .... Rough 11to be occupied as ......... ....... ....1�1J ............. .. ......,p�.�.��....�............................. Chimney provided that the person acpiing this permit shall in every res ect conform to the terms of the application Final 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 IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION FART Rough Service ....................... .. .................................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — 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. SEE REVERSE SIDE Me-* n,eWai MA Home Improvement Contractor byA Idersen« �• License#170810(Expires 12/23/2013 -wINOOW aEPUCEMENT vo iwknraCiwm Renewal by Andersen Corporation Federal Tax ID#41-191841311 104 Otis St. Northborough,MA 01532 1 (508)351-2200 Fax(508)-986-7072 CUSTOMER VO NDOW AND DOOR REMODELING AGREEMENT IBu er s Name Date: GARY WOOD - PAMELA WOOD SEPTEMBER 28, 2013 IJI Buyer(s)Street Address,City,State and Zip Code. I 136 OLD VILLAGE LN NORTH ANDOVER MA 01845 II IEmail Address Home Telephone Number Work/Cell Telephone Number Gwoodfamil comcast.net Buyer(s)hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("Contractor"),in accordance 'with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this PAgreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount$ 21,682.00 Amount Financed$ 21,682.00 Est.Start Date Method of Payment j Deposit Received(33%)$ 0.00 8-11 weeks L Check/Cash Balance Start of Job(33%)$ 0.00 Front Deposit(50%)$ 10,841.00 I Est.Install Time U Credit Card Balance on Substantial Substantial Completion of Job(33%)$ 0.00 Completion (50%)$ 10,841.00 3-4 days K credit is selected,please see Credd Card Pa ent Form. i Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the (signed,written consent of both Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed and dated copy of this Agreement,Including the two attached Notices of Cancellation, on the date first written above and 2)was orally informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. 1Renewal by Andersen CorrpoorratiioonQ Buyer(s) Buye(rr s) ',` OOL Signature of Project Manager Stature Signature 1 TOM WILSON GARY WOOD PAMELA WOOD I Printed Name of Project Manager Printed Name Printed Name i YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE 1( DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTCIE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. ----------------------------- --------- NOTICE OF CANCELLATION I NOTICE OF CANCELLATION 1 Date of Transaction 9/28/13 You may cancel this I Date of Transaction 9/28/13 You may cancel this `transaction,without any penalty or obligation,within three I transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any property I business days from the above date.If you cancel,any property traded in,any payments made by you—der the Contract of Sale, I traded in,any payments made by you under the Contract of Sale, (and any negotiable instrument executed by you will be returned I and any negotiable instrument executed by you will be returned within 10 days following receipt by the Contractor("Seller") of I within 10 days following receipt by the Contractor("Seller") of +your canceltation notice,and any security interest arising out of I your cancellation notice,and any security interest arising ont of the the transaction will be canceled. If you cancel,you must make I transaction will be canceled. If you cancel,you most make 1avarlable to the Seller at your residence,in substantially as good I available to the Seller at your residence,in substantially as good (condition as when received,any goods delivered to you—der 1 condition as when received,any goods delivered to you under this 'this Contract or Bale;or you may,if you wish,comply with the I Contract or Sale; or you may,if you wish,comply with the iinstructions of the Seller regarding the return shipment of the I instructions of the Seller regarding the return shipment of the 'goods at the Seller's expense and risk. If you do make the goods I goods at the Seller's expense and risk. If you do make the goods lavailable to the Seller and the Seger does not pick them up within a—Bable to the Seller and the Seller does not pick them up within 120 days of the date of your Notice of Cancellation,you may I 20 days of the date of your Notice of Cancellation,you may retain Iretain or dispose of the goods without any further obligation. If I or dispose of the goods without any further obligation. If you fall ,you fail to make the goods available to the Seller,or if you agree I to make the goods available to the Seber,or if you agree to return ito return the goods to the Seller and fail to do so,then you remain I the goods to the Seller and fail to do so,then you remain liable for ,liable for performance of all obligations—der the Contract.To I performance of all obligations under the Contract.To cancel this cancel this transaction,mail or deliver a signed and dated copy I transaction,marl or deliver a signed and dated copy of this hof this cancellation notice or any other written notice,or send a I cancellation notice or any other written notice,or send a telegram {telegram to Contractor. Renewal by Andersen,104 Otis St. I to Contractor. Renewal by Andersen,104 Otis St.Northborough, I iNorthboreueh,MA 01532,BY NOT LATER THAN MIDNIGHT I MA 01532,BY NOT LATER THAN MIDNIGHT 1 1 OF 10/1/13 .(Date) I HEREBY CANCEL THIS TRANSACTION. I OF 10/1/13 .(Date) I HEREBY CANCEL THIS TRANSACTION. Ii I I I I iBuyers SlgraNre Prim Name Date Buyer's slgnstuee PAm Nana Date I� 1 ...........-----...--- --..._.....-_......-- ---._...._-..........---- - --- enewa a Renewal by Andersen Corporation MA Home Improvement Contractor yAndersen. 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2013) Ewsnoow REPLACEMENT :na4n.krncnt.lmyw.ny (508)351-2200 Fax:(508)-986-7072 Federal ID#41-1918413 I Window Specification Sheet EBu er s Name Date of Agreement GARY WOOD PAMELA WOOD Se tember28,2013 i The buyer(s)listed above herebyjointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which the Specification Sheet is part. WDdDOW DETAILS Style Full/ Approx. Exterior Interior Hardware Hardware LoWE4/ Grille Grille Glass Room # style Detail Insert U.I. Casings Ob Sills Color Color Color Style Screens Smartsun Grilles Sash 1/3 Sash 2 Lifts Options Wood 's 1 DOORS Equal Full 156 xt.MF Flat WH PN White Tribeca FFG Low-E4 None Temper Woo 's 2 DB:S uare Equal Full 95 .M Sloped WH WH White stanclarc FTS Low-E4 Gso 4/2 4/2 No No Wood 's 1 Storm FV Full 116 No None WH WH White Stanclarr FFG Low-E4 None No Living 1 DOORS Equal Full 176 ixt.MF Flat WH PN White Tribeca FFG Low-E4 None ---- ----- ---- Temper Total 6 BAY&BOW DETAILS *See Ba /Bow Measure Sheet Style Detail/ Appm Approx. Number Exterior Interior End Center LowE/ Roof/ Hardware Room Count Style Flankers U.I. Casin s An le I Lites I Color Color Grilles sashes sashes Screens Smartsun Soffit Color Living 1 Ba 1:2:1 OB.PW.DB 160 lExt.MFI 35 1 3 1 WH WH GBG 3/2 FTS I Low-E4 Soffit White 0 Full/ Approx. LowE/ Exterior Interior ADDITIONAL WORK DETAIL.NOTES Room Count Style Insert U.I. Smartsun Grilles Grille'Style Calor Color Cut in Eft Nanoline door,customer aware 0 We don't do electrical work 0 0 UR Narroline Door 0 rovia full View storm door ADD]TIONAL WORK DETAILS P7ovia 1 No Qty of 0 Sills 0 Sill noses to be replaced by Contractor. ( 2 No Contractor will remove metal frames of windows. € 3 No Contractor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior casings in 0 Pine 0 Maintenance-free material i 4 No Contractor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior stops in 0 Pine 0 Maintenance-free material fE 5 No Contractor will wrap exterior casings with coil stock of color. 6 Owner is aware that Contractor does not do any painting/staining or removal/installation of alarm system/hardware.It is the responsibility of the homeowner to have the alarm system/hardware removed prior to installation. Customer is aware in some cases there will be glass loss. If there is,the mount will be dependent on the type of existing windows,type of installation,insert or lull frame and window style.We make no guarantee as to the amount of glass loss.Customer is aware and understands any and all unseen rot is not included in this contract.Should any rot be found there will be an additional cher a for time and materials unless so stated in this contract. 7 Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris windows,doors,stone windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 6 Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract Price and a separate check is required at the time of sale for this fee. Check# 1425 $ 264 s Yes All discounts have been applied to this agreement. 10 9 Yes Q No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). 'It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire 'understanding between the parties,and then are no verbal understandings changing or modifying any of the terms.This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are N writing and signed by both the Buyer(s)and Contractor.Buyer(s)hereby acknowledge that Buyer(s)has teal this Specification Sheet. �Reaewal by Andersen Corporation Buyers) Buyer(s) � err �/t1/G I�VL[60tiG IN� �rmp�n_ � j Signature of Project Manager qignature Signature ( TOM WILSON GARY WOOD PAMELA WOOD € Print Name of Project Manager Print Name Print Name IDN'tenewalRenewal by Andersen Corporation D4 Sit-*1!�tarxhhurxstigt:'%fz s Aust t.� 01531 � sd4a tic`sna tens+c mp nr r" rmcivr AMersem ffitme(SM)351-2200•Fax &7 d3N)98972. tfer�l°t'zoa IC3,� 31-191i4t3 COMMACUAMENEfiGHT Title AWefthticni ("AariPualitiJntl')is:is the CUSTOM WM-DOAXD DOOR B:E.A'tD!DrUX'G AGREUU- "T("Aptx6vantj by acid tVtWefl ienL* A by Aikkrr M C orp.%tt"t at�d 0"V cadtractar led''Bu)w(s) twr&y�% la a ftd ArA,ttoffifg tite. art as tiultcafed ham_ tither Lha-a as 4veii're-0)?ieAcAWJ't+L"c ,A the ti+>r7iits ind LvmfiLlatis of the ASmeldent will.m,=t n in fuu font And, A dfoct. i tis:+ r st xit is suet to the ttnm��i recittiutis due�:+ ,estx�it The fatiowtax Mite ,a[ti wsti�t ct,otdd h= to dw t u ardd.:� � . yYed atm kdk* fludL- Only doing �Y t nIL IRGI ,In all dtnbs,ands 2!PftMa stil i doom Model 397 FW View FI€tit m a quit a them dunrns the(a"W s ter=of its Avacatew aye alw dutm* of there is iso efraw ani,lfem will te GA F or Mukkim 4 N/A'y imfic-IfIxis tint no 4chaj%e rYppl6m tcLwTWA]job AbuAwe St JX5.00 Phi bleehard; New DevaW Pmvhhrxt:$55 IZ 50 Green Sky Fimnce. Xrw tt2uw-V td sud of Job t New Hihnx onGreen Skyy'R1 wce 5ial Cam�atetiun cai'Jeb_�3x.' i I wfo-Your *will be delay id lun[D awombnent,is seted and at .: brew tiro Pmtk0%al w oiewam domwtt>frd�t�x�i t�+��+ �"a�iiia trth�is cif tltii�� ham, iial� rn*it d w arprM harm!thb Wit.arrtLl u:ra�aeitaed tiroaiN��, Renu sal b9 And6nm.Corpwallcm SIg"turc&vmhwt.Nww6gr Si etatur WWI TOM,Viumn E-Mgrred t IDILV2913 0711C FNt'r;nt Named Bw At31it a Gary Wood CST [?she mdl�w m�a�r,nec Solt 3�:3„?B,13,1.D Dur M,.30131W9113:59161 s ; SUM smbftle SkjAcaum ' •. '. - _ ." Do�at ���ryP�O°•i�reUWlori�i�lrs.- . ' Agm . VVajdfvvo Q.10 Ufictor edw.Hot Gob 0'.29 1.65 0.28 •. AOOITICNN ver MTMO� ' ybble Tlirnll>�° _. • . . � � ' , '' OAB Thank You for choosing ProVia Door products. This product has been specifically designed to improve energy efficiency and the appearance of your home. tsttu! To register this product,go to our website and dick the Does this door meet the criteria warranty registration tab.Fill for its glazing level?(Check only one box) out the requested information including the product For: factor SHGC Yes identification number listed below. Opaque AO-21 Any Product lD Nor 14 Lite s 0.27 s 0.30 -V.* 2160587.001 'A or Full Lite s 0.32 s 0.30 ProVia Door NFRC Heritage Fiberglass Entry Door in Wood Ire Frame Qualifies 230DLA 1/2 Lite For Tax National Fenestration Credit! Rating Council® Double Glaze Low-E Glass w/Argon =1111-11111 311111 ProVia certifies this product PRD-K-2-00299 qualifies for the 2011 Energy Tax Credit.(As determined in ENERGY PERFORMANCE RATINGS accordance with The Tax Relief,unemployment U-Factor(U.S/1-P) Solar Heat Gain Coefficient(SHGC) Insurance Reauthorization and 0.19 0 .1 Job Creation Act of 2010.) ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0.18 — ProVia Door 2150 State Route 39 Manufacture'stipulates that these ratings conform to applicable NFRC procedures for determining Sugarcreek,01-144681 whole product performance.NFRC ratings are determined for a fixed sat of environmental conditions and a specific product size.NFRC does not recommend any product and does not www•Proviadoor.com warrant the suitability of any product for any specific use.consult manufacturers literature for other product performance information.-www.nfrc.org rprO�IDoor THE PROFESSIONAL WAY r r i Massachusetts-Department of Public Safety Board of Building Regulations and Stattaardtti' Construction Supervisor License:CS4$0125 '' ` F JAIME L MORIN 36 GARDINXR ST is ' LYNN MA 0190 ' i Expiration . Commissioner 10/06/2014 j C-fie�pamnea�u.�ea�o�C�aaoac�uQe�d , frree of Consumer Affairs&Business Regulation OME IMPROV 5 MENT CONTRACTOR Registration:: Oil' : Type: E)(PIr*!*-.;1223)2015 Supplement r RENEWAL BY ANDERPORATION ' JAIME MORIN 104 OTIS STREET d..s.. , NORTHBOROUGH,MA 01532 Undersecretary - i ' i CERTIFICATE OF LIABILITY INSURA,NCE eA,E io/ol/2o1a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN SNE ISSUING INSU REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER, �Sh AUTNORIMD IMPORTANT: If the eertmats holder Is en ADDITIONAL INSURED.arc poligr(les)must be sndorsed. N SUBROGATgN IS WAIVED. to ars tonna end condllbns of are panty,artsln polk:iss may rpulrs en endorsement. A statement On this atflACcts Catlfktb holder In Ibu of such endorse s does not Confer s IIro01iCFJJt 2-622-333-33 soya 0ampanies PRONE .612-333-3323 Ax so soeth fth street :612-373-7270 suite 700 stinnsepolis, 1011 55402 81SURERA:OLD R 111 IC 1m m471Ce IIno 1ATI01" IDr1Oa ir"M ZKO CO Of PITte 19447 ReneMel sY ladertso Corporctioa srilRlHts: 194!5 304 Otis Street s+slsisrlC: eifum R 0: Irortbborough, Iia ois32 11rsLIltEitEe CO RAG CERTIFICATE NUMBER aca224fo F- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED REVISN�M NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDfitON OF ANY ISSUED TO THE INSURED sI���FDR TtfE��,PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE CONTRACT OR OTHER DOCUMENT WITH RESpW, AfFORpED BY THE POLICIES DESCRIBED HEWN IS Ute{-M�INHICH THIS SSS ECCLUSIONS AEE CONDf$ONS OF SUCH POLICIES.LIIIfTS SHOWN MAY HAVE BEEN REDUCED BY PAID.CLABIS, slstt TMOFOSURAMCE JP GDM%IUARLrIY MOST 300361 to/ol/ 10/01/1! EACirOCCI &4mx �m"PAaawmaLpmn 11.000.000 CIAW64 ME Q OCCUR !Sao.000 30.000 pE7I5CNALiAOVe1,IVRy 2,000,000 GB1i AGGREGATE uma mpum pm. A REanTE 4.000,000 t pOUCY PRO' LOC pRODlICTS-OOMP/OPA6G 14.000.000 a ANTGAM*U U ANAM p i = AWAM 1 5.000.000 "OwmA�m® eOOLY f✓aIURY ftp" 1 _ HR _ ri p sooareuLiar�r.c,rc„q t 6 s z UMIRKLAUAS OCCUR 20961239 30/01/1 10/01/24 EAplpp 1 cxAers4LAOE 25.000.086 IS 2$,000 E /25.000,000 AAM W ujI"m 11NC 300359 0o ANYrCR to/ox/ 10/01/14 OOCLUOEDr dA ��r kiwi) EACH f 1,000.000 K lffr PrWNOFOPERAT10NSbebw E"a� -��P 11.000,000 ELO11SEASE-FOLrCYLNT 1,000,000 0ESCRWTOW OF OPERATO t/LOCATONS I VE"H3"Y AGW l0l.Add0@ i Rm syy:yylA rl �eD k � CERTIFICATE HOLDER CANCELLATH>wl To Ilhm it slay ConcerSHOULD ANY OF THE ABOVE n OESCIIMED POLtCEt BE CANCELLED @EFDRE For Iosurenos purposes Only THE EXPIRATION CMN DATE THE THEREOF, NOTICE WILL BE DELIVEREDPOLICY/ROVISN". AUIIIOR?t•D REPIIE16dTATIWE ACORD 2801IM2010 ACORD CORPORATION. Ail rfhts FWWVo—d iberord•.(201010 The ACORD Home and loco sn teBld*md marks of ACORD 39222490 The Conww.nwealth ofMUSWAnsetls Depay"t of lndas&W,4 cMe# Office of Invesdigadons 600 Washington Street Boston;MA 02111 www.mas�gav/dia Workers' Compensationlnstta'tnee AMdsivit: Buflders/Conttmctors/Elec'4iciRMS/Pltmbers Applicant b ormation Please Pru4t 'b Name(BusinesslOrgawation/ludividu y Ren eW c,, c /address.: b 14 i S City/State/Zip: Ar �2 D>hone Are you&a employer?Check the appropriate box: 1 J2rI am a employer with 3J 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time). have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or pgrtner- listed on the attached sheet. 7. construction ship and have no employees TMese sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance? 9- ❑Building addition required.) 5• ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ 1 ata a homeowner doing ell work officers have exercised their 11.❑plumbing rept or additions myself. [No workers'comp. right of exemption per MGL insurance required.]t c. 152, §1(4);and we have no 12.❑Roofrepairs employees. [No workers' 13.(]Other comp. I stuauuce required.) "Any awlicant that cbecb box 81 must also fill out the section below t Homeowners who submit ibis affidavit indi 61MRand their workers'�puM mEotaoation =Confnadors that check this box must �e ffiey nal shed all work and thaw ofthim qst const sn fit a neve affidavit attached as additional sheet employees. Iftht sub-connactpra have employees,they.conal PwM w�-cow m��be on a.' soft qb�a or not those�>� gip;Po>�'number. r an_, L t pro Wing wy eau rs vragig worKeis'comtpe�rsa&n rnsurence r ° my corloyem Below is the policy X101}site Insurance Company Name: ` lt- Policy#or Self-ins.Lie.#: 0 C� Expiration Date: Job Site Address:L�tP City/State �o Attach a copy of the workers'coal �� �N.�ye�1 b elpxr pensoation policyeclmration page(showing the porky number and expiration date Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the fine up to$1,500.00 and/or one-year imprisonment,as well as civil m1p°srtton of criminal penalties of a of to x250.00 a da Peres in the form of a STOP WORK b1tDElt and a fine up y against the violator. Be advised that a copy of this statement may be forwarded to the Odea a Investigations of the DIA for insurance coverage verification. Ido.aereay under tae pains and peneftki ofperpay that the infomsadoa P�'�d oboee is d'rtt arrd coma S' ate: Phone F cial rose only. Do not write is this eree,to be Completed by city'or town ORWAL or Town: Permit/l icense# ng Authority(circle one): ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector heract Person: Phone M