HomeMy WebLinkAboutBuilding Permit #631-2016 - 175 GREAT POND ROAD 11/19/2015BUILDING PERMIT �? e�`.•+• . _"�"'
TOWN OF NORTH ANDOVER
°1 APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: i 1 9ss�c"us�c
IMPORTANT: Applicant must complete all items on this page
t_OCI�#ON
!' 1 2 R►T ` I NA RD MIRTH 14,DOVE 2 MA U`t 5 ,
,y
PROPERT1i�O1"W&tERi)OWGIALL{
I0/4374-W-1.6-tiiflt304 Priint
MAR 1wt,`37�iiO�:, ZOtNiN. G31STA+I� j''yyyy �y
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
One family
❑ Addition
0 Two or more family
0 Industrial
Alteration
No. of units:
0 Commercial
Repair, replacement
0 Assessory Bldg
Others:
0 Demolition
❑ Other
❑ Septic D.Well
❑ Floodplain o Wevarids
Cl. Wit t i
0 Watet/;ewer
REPLACEMENT OF 5 WINDOWS AND ONE DOOR - NO STRUCTURAL CHANGES
Identification Please Type or Print Clearly)
OWNER: Name: WALTER DOWGIALLO Phone: 978-975-4334
Address: 175 GREAT POND RD NORTH ANDOVER MA 01845
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED
ON $125.00 PER S.F.
Total Project Cost: $ 12,547.00 FEE: $ � V'. 0-�
Check No.: Receipt No.: �,cAll Ort
NOTE: Persons contracting wyk unregistfled contractors do not have access to the guarantyfund
Ile
d
It
J
n
L 1. --
Plans Submitted ❑ x Flans Waived.[] Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageBody Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF ® U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature_
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition
Planning Board Decision:
Conservation Decision:
Comments
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384. Osgood Street
FIRE EDED PARgTMENTernDumpsterjon site4yest
t etD nartmpnt4_-nnatiirp%itatau
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
I ® Notified for pickup Call Email I
Date Time Contact Name
Doc.Building Pennit Revised 2014
The following is a list of the required forms to be filled out for the appropriate permit to be obtained,
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ 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)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerics office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
Location 15 RPYIX le- CD -
No. (,*3\- 2o\� Date
Check 4tV),5),];L
2 7 0 9
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee sh�--
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
k
y
a
CD
0- Z
CD O
�r
CL
c.
0v
CD
C 5
CD O
CD
CL 0O
S• .=
CO CD
y
.�-40L
O
tx
H .
c
z
z
ch
700
0
Z
m
U)
0
N
0
1
m
X
a
58
cn
Z
O
N
0 "o a -4
v=_. CD �N
, G �CD�a -N
N
m
0 O = 0 _3 m
o _3 -0 CA �_
O y
at CD T
CD O. N
�� H O
CD (D 2
Q O y CD
O O O rt
(O Q O
_U) o O
r+ CD
CD
� n
CD 'a �
� 0 ;(D o < c0-+ yOO
O
n N Q.
Q O O:9
1
�. _
G y o O
Q
W �
CD
N
CD
f/1 C')
� Cl)
O O
rt C
co
�D O
O O
cD �
o 0, .rho
nCD
CD
sun
0 SU •
sv o
M
(n
Vl
W
T�o
T
(n
7o
T
:;a
T
n
:T7
T
V1
T
o
(D
rr
(D
''t
O
C
rD
T
m
'm0
m
-ZI
5.
O
s
H
N
n
O
:3
(D
p
S
m
m
f1
>
H
m
=3
p
S
c
W
�n
M
p
S
3
=3
O
opo
=r
O
D
Q
p'
=
C
_p
Z
m
0
(D
n
3
O
Q
\
n
3
W
O
T
m
_
a
O
C
Renewal MR Noma lmorovement Contractor
License #170810 (E:xpires 12=12015):
F /Andersen 4 v - Renewal by Andersen Corporation Federal Tax ID #41-1918413
30 Forbes Rd. Northborough, AAA 01532
(508) 351.2200 Fax (508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s) Name Date:
WALTER DOWGIALLO - TONI DOWGIALLO OCTOBER 18, 2015
Buyer(s) Street Address Cit State ZipCode�
175 GREAT POND ROAD NORTH ANJ70VER MA 01845
�^ TOOWOSC_REENPRINTOOW.COM 1 9178-436-0324 1 378-975-4334 f
Buyer(s) hereby jointly and severally agrees to purchase the go. -Ids 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 "Agreement").
Buyers) hereby agrees to sign a eomple8on oeriificate after Contractor has completed all work under this Agreement.
Est. ;start Date f k4g) � Paymlent
Total Job Amount S 12547 kmoont Financed 5 0
Deposit Received {33°b) $ 4.182.33 oe;,t,w at silnt,:q 5 0.00 1 U-72we9ks ChecklCash
Balance Start of Jab (33%l $ _ 4,182.33 l Check
j Balance on Substantial At sutr,tantia i ( ' II01e ✓ Credit Card
ComplPnon of Job (3.4%) -S 4,182.33 00'nr)*lian 5 0.00
j 1-2 daYS; =Cm czrci Is seteoteti please"
_ No I.." all! yaY"nr_ snlu x de—oath U"V isee Credit Card. Payment!
Buyers) agrees and understands that this Agreement constitutes this 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 Buyers) 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 Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation Buyer(s)
_ lr � % $ grnaiure t
N-A.13uy
o(sre)
Signature of Consultant
xGREG ARSENAULT WALTER DOWGIALLO
DOWGIALLO
Printed of Comuitsm Prated Name Printed Name
YOU, THE eUYER(S), MAY CANCEL THIS TRANSACTIM AT ANY TIAW PRIOR TO WDIOGHT OFTHE THIRD SUSMESs DAY AFTER THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED "Once OF cANCELLAnow FORKS FOR AN EXPLANATlt7r1 OF THIS RIGHT.
NO'ne.E OF C&WAUATION NOTICE OF CANCEMAMON
Darr. of "ii-aan:u ti�n 1b. unr r—el d&
Dnto of Fraaancd an ;tri1h1;15 . You may cancel thin
_
trnwiv.d..,—ith ut any penalty or;1-. gatiou, witbiu three hruiaer.. d— from the f
trcaasction, without ny praaky or obtigafioa, tritaita the 6wvu.- days fee- the
above drun'If you e-4 say Prep—" traded la, any paymeum made by yon under 1
ibos t dare. It yrru cancel, my p roperty traded in, say paymrat. m". by you udder
the Coeir—cr of Sair, cad any negutiahle, inmennrnt ea<taated by you grill be
the Coati ar! af' $die, cad say-axgodabie ivatrrraseat ercnuclf by yoo r ill be
returned within 10 zl o following mo_ipt by the Contrutor ("Seiler') of year I
returned within 10 day* failmving rho .ipt by the Contractor {"Seager") of your
c a lhrti..n aoricr.. ,vat any t+rcutfty lot,, xt:ri.irw.on, of theo tramca.ti..a will he I
caacetlation dotke, and any secarity interer tarf.iag out of the trxu elan will be
c o,Aed, if yW a caarxl, you am" make ararLible to the Seller m your-*Meare, to
can Aed. tf gala cnntrl, yew tanat maitr madlaMe Ro tM timer ntyaar msidenrr, in
.abatantiaily it: good corulitiYla as when reeth.d, tory gods deli—red td yaw haslet• �
ani.tnnilally— good CnddYtion as wbCn recetred, ttLy xOt1dP deliVTrezl RO yMl ande.T
this Contra" or Sae; or you arty; if you . i h. comply with are i—trenticado of the
tbia Contract or Safe, or)aon +nay, if you wiA4 cmapiy with tae ibsirur doax of the
Seller reit r6ag doe retnra nWomeat of the pseud* at the Seller'. eapen",, and rink.
SWIer regarding thr reaora abipmeat of the good. at the Selk e`. exptar.e. o od rick.
It you do mak. the go.&, avaiialde m thio Seller and the Seller does or pinkthrm or, i
If you do make. the good• a ailabie to the Seller and the Seller down our pick them up
within 20 A y of dw .A.td of your Naticx of {Cuseellation, you may retain or divpti I
within 20 days of the date of your Noticeof Camellatim, yaw soar retain or dhrpor r.
of the ;ior,d. without guy further oidiyxtiou. IC yiw! it to snake tae. goads availsdde I
n€ the good. "hoot say further ohligatiow >t you full m make the. gouda orA:Balde
to the Seller, — if you agreeto return the good. to dr Seller and fail w d. eo, drop ,
to the Setter, or if you orgrre to oerarn the good. to the Beller and fail to do so, then
y ut Damm. liabir for PerformaaCr of all obligation.. under the Goan o. To c:x . f
you -main fiahl.. for prefioren me of all ahiigneora. ander the Ceatract. U cal
thic trw.w:w'tioo, arab or deliver a aipand cad dated ropy of this i;aatreltation boti— t
thin tranxattion, mail or delfrer a signed —d datrd copy of this. caner 16don notice
or any other write.- under, or .Cud a.trlcgram to Contmetoa liege, A by Andres—, I
or any other written not!", or send A. telegrxm to Conera,.tov Reaewai by Audetsea,
30 Forbes pd. %ord,hdrough, MA 01532. a
30 F—be. Rd. N—thboroaph, MA 01$32.
i IYERLBY CANCEL Ting TRANSACTION. ?
I IIER£BY tiNCELT1315 TPANSACTION.
@sfta's Sq'u«.m !int Nord Data I &"q i9sgar a ;irn N_ DASH
Renewal
byAndersen LAX
x,Mnow wt r1 ACXmtNT . :' — "'..
Renewal by Andersen Corporation
10 Forbes rd Not thtK)rough, MA 01532
(508)351-2200 Fa)c:(508)-986-7072
Window Specification Sheet
MA Nome Improverrivit Contractor
Lioense#170810 (Expires 1023/2015)
Federal ID #41-1918413
Name
i3 aft W1, At;rvemcyn
WALTER DOWGIALLO
TONI DOWGIALLO t SUN, OCT 18. 2015
-The. hu4•erii;3 and sevcra.11%, agree to purclifite the, 6ted I*lo%'V, in accondance with ihvjirk&mid terms iescribcd
.()n ifit- Specilicatim) Sheet anti tht: Front and the. i-m-crc.
of the accornpulying CUSMOINI NVINDOV( AND DOOR RI -MODELING AGREFAILNI: of which
tht; specification sheet is part.
'WINDOW h DOOR DMULS
z Nv Am hziv Color I fiardwe i LCA:A
Style Cetai t:asst Ert tm terve St, tic 8--r`aa"unn Gri! Sasr ti9 CM2 lift i optiti�_
Acarn ( s ; ..K+r 'i'""3° u -•---J 4Yi xfaw Ocw .._ I .a.... i&xeens k
f ?T
'SatMidj
Kitchen vi 1 63 101 GS1 full frame
Estate F tow Es
"PP r
IntSy.1 MF Flat CV!PN
)Z. 36 63 101
intT- Xt MF Fiat I Tenlie
Kzftchfiri
t;airk-
InVExt MF Flat 1 FFG F Urw-Eat lv.w
A
k'at , t4 5:6b 8' 1-tf
R0,3A. VI Game
r
InVEAMF FlatimP'—, Set_Lk�! f—vme_
il_aW-
W.S.. Bath t 201 Yu 1 35 83 AN f-00'ra1.e
1 hil/Exi MFFIP mit FFG 114 4- No i
CvfP?q W
-T—
C
------ ----
MY, HOW & MIRM OUT AF IMS
style MWI I
I Awdrm.. 1 Ni�� 1 frsi* I VA-XLw I Fact l Cvmer owF HA"Wart
C&".1
BAY113OW ADDITIOX&L WORK NOTTS
f`U3 i iApormj I
-,4- w!d, 2
Intek1—ut ismvls� GWIf"
T
ADDS? TONAI. WORK DETAi1S: .......... .
0
-Cowmrjs aware that Contractor VO&Snot trivirrh7valfinsk1jaVon ofalermsyssm orvorrdow treatmentsittardware. Itis the responsibility of
e is xurr rrra;r :r. aur rhea + y ,ern ti 1 aTndcn ±rt+� mrents.+ha dwa a re no.ed price to ns±a£aftn :. tSE; n aFr no g a!antae as 7o whether aiamm or window
Gurmajiv is also- awa,& h 6ome -.ases rhem will be gals lomm II there n, the amountmvill Im dependent an the tkTA
v irl evsfing Wir;dows. y tr orkistaffation and windowstyk. AJ6 amhe W!7,_4#antae as to the smouni a1 p ass lass Customer is aware and understands any and ail
Ijunseer; tot is not inchh'Ied in this any tot tee ft-turt?d there williv an by tima and fmteniais vnie.-,s so stated in, "his comrart
Yes Contractor will intilala, caulk aridsea) v0ndows; with 3 -point system to premr.t water and Ali infilhation, Removal and disposal of all job related deb)*i,
Upon completion of the job and paymet;t in full, a limited warranty shall be Issued.
Build" Pe. rent--Gontractorwllf secure any anti all necessary pernIts. Ihe fee for the p*wrnit(i) Is Included in the total contrart. price.
All discounts have been applied I u this agreement.
No Owner agrees to be present or.. the final day of installation for final inspecim and to deliver fins! P8y!TIeqI r finance fonts).
1*, ,!%,I 1.^:,011 -fit JN!4t<e, inA, J6'Issl..lif:",0,11 „�nIi Ow CUSP)M IVIN(x(AVANJ) lY AA RF1401)1I.lN;G w;lkfrmENI"
If tile, lerms. lo, 11,
;iv
sheep.
Renewal Ander,-en Corporation Jim"n"
r
gnalure of ConsultantOure Sign re
GREG ARSENAULI WALTER DOWGIALLJ) To 0%IklALLQ
Print Name of ConT_ftan, Print Name Print Name
Canada
`"- r
&
M. q-sprdrAdff"bie
Mn
wiwadn�' AL►rweladawi WAslswnGr�i�r+r
Kim
AND-W37
vinyod Composilm M�risl
dualMoArgon Low-E4 SmertSun
Product Type: Prclvrm
ENERGY PERFORMANCE RATINGS
r
U-Facto11.53
Solar Hest Gain C MMOient
0.27
0.2
U.S.A-P McLicJSI
ADDITIONAL PERFOAMAHOE RAnNC-S
visible Transmittance
0-51
a�
rra.aarrL�arwpummOMa+uanmwecomaimmsommme►macwow owasMQ—sw Y* niwe—
paaonanm wPAC ravtQs are aemr mtraAaaa ataf wM�wr��dem� f maw:Pmt �.
WRC Wes nalaW wwo ww wwftd .na sey NamatAi arM aPec�a.re.
QyrladtosiibeWnrNt ahffela rnr eawr pt�prlomrnm atommtlort .
. YAhWfala.arY •
♦ �.r r
ori aWindow
an ar
Standeird Rating
RAFI-M a A4MA OAA09A 1111A.S,UAaas DP psf F-050
Omen Sean
4t araArmaaarrwl 99wdrrd
tiff abwa(ilea -Aft*
tru- aid oM•mammk
PROMW L Y54arm4n
&Maaomwauumom t
100-�51 i006-00�
A
Do code insped0n. Saye libel triuWm reference,
Cra
cc
+;
c
Renewal
bxAndersen,
�ripboM RCPLACENCpT
samc'3t+sR AHD -N-103
Cxmscz . WoodMnyl Compotes
Dual Argon Low -E4
ProduotType: Awning
r;RW pMFFOAMANCE RATINGS
Solar Heat Galn Coefficient
. - • U -Factor ,
0.29 1 1.65 0.28 j
u4ji-P ebicf5l
ADDITIONAL PI AFORMANCE PATINGs
Vlslble Transrnrttan0e
0.48
. cy,�„�q,,,�,e„ev.�enanwop„pm,nPR.erRPRCvoaau..ive,ox,m,r�rmneo�
�ac,mw.. eame.e mr. R.e xsveµamnm mn�ay.pp+� ��
� mmaac.po
eryen a an n
cop � mn ng
Slehdard Ra6na
paamQAvAk W=A MAS204M QPpsfOP40
I
'rsE46 ' rm mut
. � 4be� am •
qbc. ma
Cgt 100 00618940.016
M MYneKm9evpn .
E
A
Da not femme mrtll final code InspedUsn. Save label for Up iekrenm
c r■w
h 0.1 mED
7.
< P. m . fi
.m a�s1Ex
• � tea
Rehewal
byAndersenWINDOW 1"LAOMMIT
!
AND -N-102
: `., Woodrviq Composite
Dual Argon • Low -E4,
Product Type, Casement
i
ENERGY PERFORMANCE RATINGS j
U -Factor solar. Heat Galn Ccefficlent
0'. 2 9.1 1.65 0..28.
' • - .S.A-P etrirJe�
AMMONAL •PERFORMANCE RAMNGS
Vlslble Tmnsmfttence
0.48
•...
�,gmpWmfwclsnO,P mmm�nb�6Ptab M9lOPoorwnOrddOdOlaMleM Pesc
POe1111��. IIF71C a. ddgti,�kflO.tl Ketalda,O,Oa mldOCl. wnll RldIC pedl�da
11Cd aO*IM- it 0"tln011et�ll.Rtdl
Qs1�d,RQMItMKM—Or 11R0' P
. •II.OJdv11
1 =11,21111M �Ivffi r
eraen on
60IP�IIII�Im
' o1m lid fwry
�� muss,w�aAe DP pe DP36
�n■.I�e.we..el
' 100-bb613872-0�1
If F
►s.e e.me. -'-.► .rlrMu.mnlegd>As nrl�.dmawan
i
a
The CommmmWe4uh Of Marackmeft
Deparftmt of IndabW Accidents
office q(1Jlvesti dkfis
600 WashingWa Street
Axon, MA 0,2111
wwwjxMgev1ft
Workers' Compenudon Insu=rance Affidavit: Builder&/ContractomfElectrkianaML lnmben
Annlicant �tufor_i don ... p da Im-bi<_v
Name (BusineslOrganizedwIndividualy RENEWAL. BY ANDERSEN
Address: 30 FORBES ROAD
City/State/Zip: NORTHBORO_MA 01532 Phone A': 508-351-2200
An1 an employer? Cbeck Hie appropriate bor.Type of project (required):4fjjt a eanployer with ___LO_ * 4. [11 am a sennid have hired the rector and 1 h. ❑ New duction.
employees (full and/or part-time). alto-conbuton
2. ❑ I am a sole proprietor or partner- li3ted cut the attached 5ltert t 7. �exttodoling
ship and have no employees These sub -contractors have S. ❑ DoxneUtion
working fbr me inany workers' comp. inatn um. g•
[No workers' comp. imu ce 5. ❑ Weare a cora ration and its ❑ 13niWir►g addition
reA*W•)
officars leave exorcised their 1013 Slech ica despairs or additions
3. ❑ I am a homeoumer doing all work right of ixnptim pet MOL I i.[] Plumbing repairs or additions
myself (No ww rrkkers' comp. c. I S2, 41(41, and wt have no 12.❑ Roof reptiirs
insurance requiral t employees. [No workers' 1313 CWw
comp. insunincerequired.]
"=4rry appLcant tt�et decks box # I mast ais ? SII out the sedion'b ow sbm* dwir w+xkw ` ooatpmution po* bftmadom
t Haaeovvr�ars who suW1 ddb affidavit irn&Alas dray'aro doing W work mid then hire outside 00MIisars mm t s0mit a neo aS&"-WMA* such
°K:ot�traatats that deck this box must atta6bw an additional ahep -Ovahsg the mon oithe xk eottlttucoorn and +,icon• s►ettcets` 00" policy inaxmattoa.
lain an ea9eyar that is pnovN* woAm I cou>f mad m iatsamme fur eq+ eralrliym below 1s 1he poAW and job she
infornro"
Insurance Company Name: OLD REPUBLIC INS. CO. r
Policv # or Self -ins. Lic. #P:�MWC 30543.700_ _ __ _ 1:xphd0n DM:_10-01-16
Job Site Address: 175 GREAT POND RD -� Ohy/dip: NORTH ANDOVER, MA 01845
Attach a copy of the workers' compensation policy declaration page (showing the poley number sad 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 epe-year imprisonment, as well as civil penalties in the firm of a STOP WORK OkMR 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 va iftcmtion.
Ido he C�*z r paha and pew of prdx7 dW the h� poo Wed above h true crud c ry
508-351-2200
Qffi%iul ase on6k Do not write in this arca, to be cofirWed by C*,Or town offlelaL
City or Town: PermitdAcense #
Issuing Authority (circle ane):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Pim ableg Inspector
6.Otber
Contact Person: Phone
ANDECOR-01 YADAWO
CERTIFICATE OF LIABILITY INSURANCE°" °5
10111�1
Hl
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 13Y 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 certMcate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subp :t to
the terns and cond)Uons of the policy, certain policies may require an endorsemeft A statenlertt on this certificate does not confer rights to tits
certificate holder in lleu of such endorsement(s).
PRODUCER
Willis of Minnesota Inc.
CIO 26 Century Blvd=A
COOMACY
NAME: Willis Certificate Center
PWME Na. 888 457-2378
. (877) 945-7378
P.O. Box 305191
Nashville, TN 37230-5191
5MAIL : CertlP Ilis.com
ARRNgg
AFFORDING COVERAGE NMC!
POLICY NUMBLSRY
INWRERA.Old R ublic Insurance Company 24147
INSURED
INSIIREn s
INSURER C :
Renewal by Andersen LLC
30 Forbes Road
Northborough, MA 01532
INSURER D:
INSURER E:
INSURER F:
a.vVCt[AV W UCK I IrILvA I C NUIMBFK: 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 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
SR
�
TYPE OF INSURANCE
Ulm
POLICY NUMBLSRY
POLICY EFF
UMTS
A
X COMMERCIAL GENERAL LIASIUTY
EACH OCCURRENCE b
1,000,
CLAMMS-MADE Pq OCCUR
MvM 305440
10/0112015
10/01/2016
PRFauSEs ocaiarenoe b
600.00
MED EXP ampmwn) b
1Q,Q
PERSONAL& ADV INJURY b
1,000
NL AGGREGATE LMITAPPLIES PER:
F1
GENEWLL b
00AGGREGATE
4,0,POLICY
PRODUCTS - COIdPIDP AGG b
4,000
11 JECT LOC
OTHER
i
�MSI(M N19 b
5,000,00
AUTOMOBILE
LIA81Lm
A
X
ANY AM
MWTB 305439
10/01/2015
10/01/2016
BODILY INJURY (per pemon) b
ALL OWNED SCHEDULED
BODILY INJURY (Per mddent) b
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
Per aerJderd =
b
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE b
EXCESS LIAS
CLAIMS -MADE
AGGREGATE b
DED I I RETENTION:
b
WORKERS COMPEMSATION
X STATUTE
AND EMMPLOYERG LIAELrTY YIN
R
A ANFICER/IdEM ORIPARLUDE�D7��� I NMA MWC30543700 10/01/2015 10101/2016
EL EACH ACCIDENT
i
(MwMeeory Ih NH)
H yes, dozarbe indw
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - EA EWLOYFEb
1,000
EL DISEASE -POLICY LMR =
1,000,
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD lot. Addl ioval Remade SeMdift maybe aftched Iimom apace is requksd)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVlS10NS.
AUTIIORMED REPRESEMTATTVE
m, .avo-&v w wRM'vK A I JUN. All rlghts reserved.
ACORD 26 (2014101) The ACORD name and logo are registered malice of ACORD
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS -090125
JAM L MOIIW. `�
86 GARDWIM S'$-
LYNN
"�LYNN MA 019K
'.r
jy.D►.'���a Expiration
Commissioner 1111081!Q 18
at ter ARiiQs is � .
WAM
Cts1R ,
40
+ • +mem r
�� 0Y I�iT�ht
101 OTIS a Et—
'WORTHBOROUOHUAW532 ,