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Home My WebLink AboutBuilding Permit #343 - 18 EQUESTRIAN DRIVE 11/1/2007 �� ✓ 3 `NUn M q L BUILDING PERMIT ° ""to �o I TOWN OF NORTH ANDOVER o i p APPLICATION FOR PLAN EXAMINATION Permit NO: %� Date Received Sys R,TEo�P��y SACHU`' Date Issued: IMPORTANT:Applicant must complete all items on this page c17 �A L`0CATIO`I i r T Ptw : "PR . 0 � ) z�` t� a MAF' NO4 �str�c PAZEgLONfiJG C31TR1 a istorlcl3t yep no g : . /lachne Sh`°rap Village :fires no . TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition ❑ Two or more family 11 Industrial ❑ Alteration No. of uriits: [I Commercial Vj;�epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other T: xi Fl + tarn Wtln�ts 1Ilatshed Distr�ot " ❑�tE fl V11�7t p x x Wdter!SeW{3l _.. ,s; DESCRIPTION OF WORK TO BE PREFORMED: t�Jin�atui 5" ons 'J100�'�? a� c�an�-gS Identification Please Type or Print Clearly) 6�7 0OD// - OWNER: Name: a Phone: 1 Address: Cc-e3fr+an -b►' 0r4AAAV--rr- M 0 > ai CG}N 'MAC C?R Narrie Phor e a Address: Epp Slip+ rv�sor'svnstrtatic� icse v Hr�rne:fr»prover�ierltLrcense -� �� . x �� x� �F �E tt Date: g, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7 FEE: $ %?% Receipt No.: 75 Check No.: P NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund St nature cf contractor Signaltare of Agent/Owner�... g, ., i t t n Location 1,c-,�-� No. L/� Date oma40RTot TOWN OF NORTH ANDOVER 1 9 Certificate of Occupancy $ t i i }�'sC'•• E<�• Building/Frame Permit Fee $ AC Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r 20756 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body 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 DATE REJECTED DATE APPROVED PLANNING &-DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/S9nature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Loca#eel at 12 Magi Street, FNre Department signature/dafie n, M; s CO MIVfENTS 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date ........................._......................................................_...... ......................................... ............................................ Doc.Building Permit Revised 2007 Building Department 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 o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 Clerks 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 NORTH&4 TO" Of Andover No. 0 L A 0 . dover, Mass., COCHICHEWICK 11 ORATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ............. ............. ............................................................................................................ Foundation has permission to erect........................................ buildings on ...Z��. ..17 ....Al. ........................... Rough tobe occupied as...... ................................................................................................................. Chimney thisthat the person accep Ing it permit shall in every respect conform to the terms of the application on file in Final 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 CONSTRUCTIO STARTS Rough ............................... Service ................... ................... ................... ' ...................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. K) C' lozva 0q l s h � 17 7,33 37 a renewal ® EY ANDERSEN' wid—replar<menc Customer Service 800-573-7606 104 Otis St.-Northborough,MA 01532•Main:(508)919-0900•Fax:(508)919-0903 J&L Windows,Inc.dba Renewal by Andersen-Contractor License#149601•Expiration Date 09/23/2008 S.I / / WI DOW AGREEMENT SOLD TO: / vl7 G ! 1 11 DATE: �6 2 G _G ADDRESS: 1Y - A Z2.-, PHONE-Home:( L(r)-`OGS I R CITY: �Gj '�h rd cy�'�` STATE�ZIP: �� ,? PHONE-Work: (�JY JOB SITE ADDRESS(if different): E-mail: Approximate Start Date: Approximate-�� 'Ute Approximate Completion Date: SPECIFICATIONS Renewal by Andersen roved materials will be furnished and installed to these specifications: 1. Install total of windows. 2 .quantity of windows: Double Hung(DB) ❑Equal sash ❑Cottage sash(1/3 top,2/3 bottom) ❑Oriel sash(2/3 top,1/3 bottom) _Casement(CW) ❑Hinge right ❑Hinge left(as viewed from exterior):❑Standard handle ❑Metro handle _Double Casement(CDW) ❑Standard handle ❑Metro handle _Casement/Picture/Casement(CPW) 111:1 A or ❑1:2:1❑Standard handle ❑Metro handle _2 Lite Gliding Window(GW) _Glider/Picture/Glider(GPW) ❑1:1:1 or ❑1:2:1 Awning Window(AW) 0-1.T-Picture Window(PW) _BlA�y or Bow Window: �/ 3. 9 Yes ❑No #Windows to be Custom Fit Replacement: �a 4. ❑Yes ❑alio #of sills to be replaced: 5. ❑Yes filo #Windows to be New Construction Full frame(includes new interior&exterior casings): Exterior casings: ❑Pine ❑Maintenance-free material ❑Factory applied 908 Fibrex brickmold 6. Glazing to be: li- gh Performance ❑Other If other,please specify: / ,= [Y 7. Exterior color to be: rohite ❑Sand ❑Canvas ❑Terratone I 8. Interior color to be: LJ White ❑Sand ❑Canvas ❑Terratone ❑Wood Note:Interior c or can only be white,wood or same color as exterior. Wood interiors nobd to be finished by Gust. 9. Hardware: U'White ❑Stone ❑Canvas❑Brass Double Hung: Install lifts? &Yes ❑No 10. ❑Yes EYN Removal of metal frames or grilles #of Units: 11. ❑Yes L7"No Install new paint-ready or stain read cast Inside or outside stops#of openings:_ Interior casing#of openings: Exterior casing ings: ❑Pine ❑Maintenance free material 12. Customer awe that RbA does not do any painting. ust.initials 13. ❑Yes V foo Wrap exterior casings with aluminum it tock: color. Note:Required with storm window removal.Removal o windoo sill leave screw holes in casing. 14. New windows to have: ❑Half or�ID9 1 screens Screens to be: L�Fiberglass ❑Aluminum 15.Windows to have grilles: El Yes qd No if Yes: ❑Grille Between Glass(GBG) ❑Removable Interior Wood(INTW) ❑Full Divided Light(FDL) Grille patterns: DH DH DH DH CW/Picture Glider CPW GP�N 'use ,ftonal sheet if needed Customer approved(initial 16. 45s ❑No Insulate,caulk and seal windows with three-point system to prevent water and ai infi anon yJ 17. €S ❑No Remove and dispose of existing windows and storm / 18. s ❑No Clean Up. All job related debris removed.Vacuum nightly. 19. Y,es ❑No Insurance. All workers compensation and liability insurance maintained. 20. 0"Yes ❑No Warranty.Given to custoer upon completion and r ceipt o full payme t. 21.Additional information: G'Z•. v t�. r C 22. Regular Retail Price:$ 23.Total Project Amount:$ zr' f �,2 All available discounts have been applied:❑Yes ❑No 24. Is Project to be paid in❑Cash ❑Financed ❑Combination of Cash and Finance 25,Cash Deposit(1/3):$ 1/3 of balance due at start of job and final 1/3 due at completion of job. If remaining payment is made by credit card,an additional fee of 3%will be added to cover fee charged by Credit Card 26. ❑Y S o Financed. If Yes,Amount Financed: (Account#: ) 27. ��s ❑No Customer agrees to be present on the final day of installation for final inspection and to deliver final payment. 28. QY�es ❑No Homeowner gives RBA approval to place a yard sign on their lawn at the time of measure. 29, as ❑No Building Permit-As a convenience the company will secure the building permit.The fee for the permit is not included in the agreement price and a separate check is required at the time of sale for this fee. 'RENEWAL BY ANDERSEW IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS OR CONDITIONS THAT COULD NOT HAVE BEEN SEEN PRIOR TO OPENING THE WALLS. PLEASE REMOVE ALL SHADES,VERTICALS,BLINDS,CURTAINS,DRAPES OR WINDOW MOUNTED AIR CONDITIONERS,AND ANY FURNITURE AT LEAST SIX FEET AWAY FROM WINDOWS AND DOORS PRIOR TO THE INSTALLATION OF YOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS.'SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMENT AND"OWNER"REPRESENTS THAT NONE HAVE BEEN MADE TO,OR RELIED UPON BY"OWNER.'YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT,*CONTRACT SUBJECT TO FINAL INSPECTION BY RENEWAL BY ANDERSEN CONSTRUCTION DEPARTMENT.*TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract Is a legal document.Your Renewal by Andersen products will be especially made-to-order for you.UNDER NO CIRCUM¢TANCES WILL REVISIONS OR CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRAT HAS BE N SIGNED AND D POSIT PAI BY SIGNING BELO YOU ARE ACKNOWLED ING THAT THE ABOVE SPECIFICATIONS F R T R PR TS YOU ARE ORDERING ARE CORRECT RbA Rep.Signature: IruT Z�✓ Date: J C if Customer Signature: "r"'—�-Customer Signature: it –Renewal by Andersen Yellow–Installation Pink-Homeowner 02-02.07 C 1Q 1 1 7 33 T)1 renerval By ANDERSEN*I id— Customer Service 800-573-7606 104 Otis St.-Northborough,MA 01532•Main:(508)919-0900•Fax:(508)919-0903 JBL Windows,Inc.the Renewal by Andersen•Contractor License#149601•Expiration Date 09/23/2008 /DOOR AGREEMENT ., SOLD TO: Y L� Z�G �i), d C4 DATE: �G Z� Ll✓ ADDRESS: /7 / -li-l4 r . PHONE-Home:&7SS,,k?7 CITY:,Al" Ado,,e✓ STATE/"JIP: �� /� PHONE-Work: (2N) �3� ^ 23 eI JOB SITE ADDRESS(if different): Approximate Start Date: /% ' (U liCY'% Approximate Completion Date: Ty 4.4'S SPECIFICATIONS Renewal by Andersen approved materials will be furnished and installed to these specifications: Patio Doors 0�j 1. InstM1 total of: tP�L Permashield Gliding Patio Door(s) 2. 95'10"x 6'8" ❑Other: (not avail in 8068) Op.panel is Zleft ❑right(as viewed from exterior) Interior and Exterior CoT, be: ite ❑Canvas ❑Sandtone ❑Terratone(Color is same inside and out on PS) Hardware:: Metro: I hite ❑Stone ❑Canvas ❑Bright Brass ❑Other-Specify ❑Yes [a W Gliding Patio door to have sidelight ❑Yes 044o Grilles ❑GBG ❑Intw ❑FDL(pattern is standard as viewed in book for all doors) 3. Install total of: Narrowline Gliding Patio Door:(s) ❑6'0"x 6'8" ❑Other: Op.panel is❑left ❑right(as viewed from exterior) Exterior Color: ❑White❑Canvas ❑Sandtone❑Terratone (Interior is WOOD and Gust.must paint or stain) Hardware: Metro: ❑White❑Canvas ❑Stone ❑Bright Brass ❑Other-Specify ❑Yes ❑No Gliding Patio door to have sidelight ❑Yes ❑No Grilles ❑GBG ❑Removable Intw ❑FDL 4. Install total of: Frenchwood Gliding Patio Door(s) 1160"x 6'8" ❑Other: Op.panel is❑left ❑right(as viewed from exterior) Exterior Color: ❑White❑Canvas ❑Sandtone❑Terratone Interior wood:❑Pine ❑Oak ❑Maple Interior finish:❑Prefinished White (Available only with white exterior)❑Unfinished(Paint/stain done by customer) Hardware: Metro: ❑White❑Canvas ❑Stone ❑Bright Brass ❑Satin Nickel ❑Yes ❑No Gliding Patio door to have sidelight ❑Yes ❑No Grilles ❑GBG ❑Removable Intw ❑FDL-Full Divided Light 5. ❑Yes ❑No Frenchwood Hinted Patio Door(s) ❑60"x 6'8" ❑Other: Active/Passive Panel: ❑left ❑right(viewed from ext.which is active)or Active/Stationary ❑left ❑right Exterior Color: ❑White❑Canvas ❑Sandtone❑Terratone Interior wood:❑Pine ❑Oak ❑Maple Interior finish:❑Prefinished white ❑Unfinished(Painting or staining to be done by customer) Hardware: Metro: ❑White ❑Stone❑Canvas ❑Bright Brass ❑Satin Nickel "canvas hinged screen frame NIA-must choose white or stone if exterior is canvas' ❑Yes ❑No Hinged Patio door to have sidelight ❑Yes ❑No Grilles ❑GBG ❑Removable Interior Wood Grilles ❑FDL-Full Divided Light Entry Doors f+ 6. ❑Yes ❑No Install Therrna Tru Entry Door: ❑6'0"x 68" [1 Other Model# ❑Yes ❑No Entry door to have sidelight: Model# Storm Doors 7. ❑Yes ❑No Install Storm Door. 8. ❑ Full View ❑Mid View 9. Color to be:❑White ❑Canvas ❑Sandtone ❑Bronze ❑Forest Green 10. Size to be: ❑32" ❑34"(white only) ❑36" ❑ Custom (10 week lead time. Size_) 11. Hardware to be: ❑Bright yasa �❑Nickel Regular Retail Price:$ / f 12. Total Project Amount:$ � All available discounts have been applied:❑Yes ❑No 13, Is Project to be paid in❑Cash ❑Financed ❑Combination of Cash and Finance 14, Cash Deposit(1/3):$ rOO-� 1/3 of balance due at start of job and final 1/3 due at completion of job. 15. ❑Yes CfD190 Financed. If Yes,Amount Financed: (Account#: ) 16. ❑Yes EVNo Customer agrees to be present on the final day of installation for final inspection and to deliver final payment. 'RENEWAL BY ANDERSEN"IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS OR CONDITIONS THAT COULD NOT HAVE BEEN SEEN PRIOR TO OPENING THE WALLS. 'SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMENT AND-OWNER"REPRESENTS THAT NONE HAVE BEEN MADE TO,OR RELIED UPON BY'OWNER."YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT.*CONTRACT SUBJECT TO FINAL INSPECTION BY RENEWAL BY ANDERSEN CONSTRUCTION DEPARTMENT.*TERMS AND CONDITIONS THAT GOVERN THIS • CONTRACT ARE PRINTED ON THE REVERSE SIDE.This contract Is a legal document.Your Renewal by Andersen products will be especially made-to-order for you.UNDER NO CIRCUMSTANCES WILL REVISIONS OR CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESSDAY AFT R THE CONTRACT HAS BEEN SIGNED AND DEPOSIT PAID.BY SIGNING BELOW YOU ARE ACKNOWLEDGING THAT THE ABOVE SPECI IgATIONSFO R THE R03 PR I)UCTa YOW4RE,ORQERIN AFRMIJ CORRET. / RbA Rep.Signature: f�Date: L�f�G 7 YV Customer Signature: Customer Signature: White–Renewal by Andersen Yellow–Installation Pink-Homeowner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Wr� Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual)- Ec- ��S o') Address: 10 `' — OILS STA C ET City/State/Zip: 1N)p&W6040 01532 Phone-(,v)y) C) 9 • 09q Are you an employer?Check the appropriate box: Type of project(required): 1. I am a Y emP to er with 3 U - 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am.a sole proprietor nr Par ner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors.have g. Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. E]Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E]Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C'4<C U 1j i� Policy#or Self-ins.Lic.#: 35 LJ134#JC—w gco I Expiration Date: Job Site Address: I (� pa-'es ^ISG h 1— City/State/Zip: A�O(d✓P� .Q/c� 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 copy of this statement may be forwarded to the Office of Investi ations of Afor 'nsurance coverage verification. I do hereby ce ' under t p Wndpenalties of perjury that the information provided above is true and+correct. Signature: Date: d 31 d Phone#: SOS g/9 U 9 QO 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 Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, 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 of public 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-contractors)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 their self-insurance license number on the appropriate line. 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 officially stamped or marked by the city or town may be provided to the applicant as proof-that a valid affidavit is on file for future permits or licenses. A new affidavit must be fiiied-out each year.Where 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 Revised 11-22-06 Fax# 617-727-7749 www.mass.gov/dia r C. 0�/�jczaaczc�iuQe�6— _ _ Board of Building Regulations and Standards Constructiok3upervisor License Liceniec=CS 74251 Biihte 31911.63 lPra%on 3191209 Tr# 11065 41�- JOHN K ESLER 104 OTIS ST \ NORTHBORO,MA 01532 Commissioner ✓lie i�omvrizovuuect�i o�✓�xaaae/iteP,I�a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrabo!� 149601 r E014/2008 t1=jib@ Sp�lement Card RENEWAL BY A + ry =e 1J1 KATHLEEN BLAN�F{ 2p;?� 1y == 104 OTIS STREET;;; NORTHBOROUGH, MA bT532 Administrator DATE(14*001YYY} ACt?Rd CERT FIOAT` � . ABi�.t`T`YINSURANCE 0910.1/2007 PRODUCER ' THIS CERTIFICATE IS ISSUED AS A MATTER OP.INFORMATION Joseph MCKeone ONLY AND :CONFERS NO RIGHTS UPON THE CERTIFICATE JP MCKeone it stirai ce A enc , Inc; HOLDER; THIS .CERTIFICATE DOES OT NAMEND, EXTEND OR 9 Y ALTER THE COVERAGE AFFORDED BY THE POLICIES:BELOW PA Box 333: ... ... At1n Afbclt;'Ml. 48106-4333 INSURERS AFFORDING COVERAGE INSutEa Renewal.by Anderson IN$tIHERA` I i }ird lnstararrrmtC>k .:w.. .. ..w. w_:: _M... J&L Wndows,Inc: IN uRERe 104OtIS.St 1 INSURERC, Nbrthborotio,'MA 01532 ,: IN8';IRER E: COVERAGES .:: .. . THE POLICIES;OF iNSURANCE.LISTED BELOW HAKE BEEN IMEO:T0„1HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY:REGUIREMENI'.TERM OR CONDITION OF ANY OONT'RACT OR:.OTHER:DOCUMENT WITH RESPECT TO,WHICH THIS CERTIFICATE MAY:BE ISSUED OR: MAY OERTAIN;TI4E INSURANCE AFFORDEQ BY.THE POLICIES DESCRIBED HEREIN 1S`.SUBdECT:TO ALL THE TERMS,•EXCLUSlON3 ANp CONt7I31ONS OF:SVCH POI.IC0,A0.01EGATE;LIMITS'SHOWN.t,MAY HAVEBEEN RE0UCEDlY:PAIDCL4JMS.. MBEPOLICY fizFFEETIVE liOUCY EXPIRATION. POLICYNUR I. LIMITS g CyEli ftA�L1A1lILITY HER885$850: 917/07 917/48 EACHpCGURRENCE 3 t-,t70¢�OQCI MGD l7CP tanY neo cn 13 10 000,: 8✓LAIrAS irSAOE :F pGCUBq M• \. �:. _ PERSONAL:3AbV INJ4IRY S.:..:.�.\ „ 1iU44�13U.. _ I GGNFRA!AGuR£GATE s' 2,0Q0�(I00 GEhLA,GsREGs0 POICY.. U {010/10 .LS.>L: f .. s:. A auraluoar ►u►e rid 35 MCC X0 6388 10/1106 tw m Ccs:,m"tDrim .uwr � 1,00 000 - ANY AUTO' AI,L ONNER AUTOSGORILY INJURY I SGHEOULED kt�TC}5 /Far persosi}, 1 • H4fi£EI}ALIT&SS ! �CkLY 8 d,SL�RY �� {Pct 6006M d4C7rIC74'�TFEOhrJ OS: '•, 1, .____ ...._..._-.»_ [,nOlpeRTY DAMAGE S. _ (Pett'. tern} 3. . ..... ..... ... ... 1': UTOONLY-EAAPXIOENT S: DABIAOk LIAAIUT`t � ~�ANY AUTO OT11644 AN. ACC 1 AU Y: AGG 11 meswumbRiLLA{�UA ILItY: : EACHOCGUR�Fi4£R iS ClGGLIR t••......t CLAIMS MADE- : I+GGR>t3AT1 $ ... q WORKERS COA1pEH8ATIDN AND 1 `35 WBGNC8861 1.11107 I 01/01/08 .O�RY a�lzs i '°��.� _ EIPI DYERS°UABBUT Y ! El,EACs ACCIDENT. ^l sem. . .. ...UOO o Fie R'waPI a civa a Ecvtlu i tt RSEAS£ I:ASI}LEAOYEE I S 500,000 �.y:b84 descistss�8ndar :SPECU61F'ROV15i0N5beI6w E.L,i�lSEAS.-POLICY LIMIT ..1 0 . .... OE3.00jp; NOFOAC'RATIONStLOCATIONStVEHICLE&IUCLUSIONSADDEDBYENDORSEMENTISpamPRDYiSONs CERTIFICATE'HOLDER CANCELLATION :. SHOULD ANY OF THE ABOVE DESCRIBED POVICIES BE CANCELLED BEFORE THE.EXPIRATION DATE THEREOF,THE ISSUING INSURER wu ENDEAVOR to MARL 301 oAYS_viRITTEH : NOTICE TO THE:CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TAILURO TO 00 SO$HALL IMPOSE NO OBUDATION OR I tABILrrY OF ANY K1ND UPON'RHE IN$UPtER,ITS A I S O t: RE &SENT TIMES, AU..p#iifEO PItEffiENTA;7" ACORD 2.3{280,1/.bit) ACOR CCIR'ORATICIN 1088 P1CHC WoodNinyl Composite Frame FFDual'.' Argon' Low E Double Hung ENERGY PERFORMANCE RATINGS U-Factor(U,S)/I-P Solar Heat Gain Coefficient ` 0832 . 1 • 33* ADDITIONAL PERFORMANCE RATINGS = .Visible Transrimittan .e O's 54'. . M•nyl�clu(•t•tltwl•f.1 Jrt Masi-p6.p.eoMurm le•pplk•tll.NERC poe•dw..f•r h1.mJ.iq.'neM yreducr p:rtum•ne•.NFRC MWq• ier d P••da•r.[•m�hr•n.nMl cenad.�.Md•.pel(<p•Iwl�h• . KnC de•.Mt nc•minW4•ny prod,ict•nd d••.—t*WM II#•2415b bf•1•hr Predwt9•req rpcfBe•.•. - ' C•nrWf Inep■t�ckir.r`•Nr•nlv,•[er•M.rpredwt peN•m■ne.'rtfdnn•tleq,. • �••'ti 7m. OFSIGN PSESSURE-(PSF) H L C 2 5 ^ 100-0027023M12 • - 't.a•d Y.AN7[' M.�. M'Ib Ult[ Ai 'IStll M.i[M1Y ■ atm•.b, fo J• .. - .. MeA•m•ie••d.•M_6.C..'C.E-C,•LE,C.F,AW InMHnWp ngdtMNnk WOfdA H+[trek C«dNwtl.e lryr•rn, .' S re al . ►rpyeryinK W!or>rFfir Hron 'WoodNlpyl Composite Frimc Dual• •, Wtfi►p Car>c1A P tau e �. low E . - . • . ENERGY PERFORMANCE:flAT1N6S t" U4actor(.U,S)%t.-P • Solar Meat Gain Coefficient . 0 -' -32- ' *. ADDITIONAL PERFORMANCE RATINGS Visible Transmittance ' :53.,... '.. M+n+►elJnr•�uVIu M�M•.••PWM••nhRnNy1F.M!MIIO�we•IvwrMh�MfrMl�n�fl�fV�r♦,Hwt • �.rwwAw;:•-NM�rArP.til.�.ne1••II•..A�.��.iw.•wtnn•�us:niM.rw.M..►..MMM`!!!.tih., . . . - H��c�•:•n.lr,fwr.n•01Ny'h•IwlA11«�p.Iwvwgi!M�N��/'1Pi1rVM!Iw'b'•n/'L.M..vi.. - . ... -o,q•uM T.nuw.awn�•1•tYp NrfM•r�nlVrt j�q••n•r:L-i•k!rM1•n• r � .. . 7;&SIGN P.RESSURE'IPSFI . • _ • • F --x:50 . 100 06,229�• -,,• • • � . . • . - .• . W%Ar Moo" k( .•�.kit.e.,o.Eo,•�t_e.a_Irl•MM.«•er.ww►.nawow�N.hn.r�o•wldtm►n�.n. •- .. _ - . 400 Frenchwood® Gliding Page 1 of Andersen@ 400 Series Frenchwood®Gliding Patio Door Performance Center of Glass Performance Data .................................................. C�atttettafArttlueg, 7f�IRas>k �w. 1fb+�d Nano Tran4.92 191 �� X496 4196 Feud idure 0.90 187 646 419 aw"be�"f$Nd L�Path Door 0.�9y7 0,82 e x e CMWUK ftft Tftwwl, low"K �...� 6D Casment P{ ue. AmkVIloubie�N�trl�.._Plmm _.. __...... 0.4 . ... ............. _ iNfiC�rdor {4oc) s).... .......-..... CI Sf}_... _...1fld_.._ 3496 ..... ._.. ._._ ._.,, Owd 0,54 "; 104 3496 60% CST T C � . Pwma~3hkM Patb Elam Efano�'"RWho Palb kar 0 49 109 . .-.... FNM*WQNI H@".OuW"ON 0.49 11.11 32% 6040 fbdltae he.Arch0.47 W� no 3146 ' G194 .Rot Whion/StkylVo_t pp o....... D 49......_ 1 3396 1i0 a _... __. _ Eaali Eftated 0.49 101 25% 601YO . C.nwwv�Aw trag,TEN.VEii Mbed"M7 Traun 0.36 762496 5 �° _ _ �if� �`b 89a PLIUM 111101 : N RHP 035 74 23% 579'0 OWN Wfmlowte 4.38 75 24% 57% Climb To � chick oaf ,k 0.36 75 24% 57Oa «: Perna-Shfeld' Falb Owr 0.34 73 22% 58% Finacbmiod•NbIA 6Nd1 0.35 73 2246 5 Fbdk meAtch Wtdwa W 033 '� 71 21% � 59% Ralf MISlryliRltb lb a 0.34 73 2296 5 Laatlaalr�d (alt toduels 0.35 73 1696 589'0 "High-Performance"(HP Low-E)and"High-Performance Sun"(HP Sun)are Andersen trademarks for Low-E glass.