HomeMy WebLinkAboutBuilding Permit #340-13 - 193 LACY STREET 10/24/2012 ft
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BUILDING:-PERMIT 35. d�:r. •_•.:• °o
TOWN OF NORTH ANDOVER
(� APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: v
cHus
IMPORTANT: Applicant must complete all items on this pMe
LOCATION _M Li
PROPERTY OWNER, c ,cl)�O t"��.� - ft r
Print
MAP NO: PARCEL:0 06 y ZONING DISTRICT: L—Histoft Dwict yesno
Machine V es no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
0 Septic 0 Well 0 Floodplain 0 Wetlands 0 Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
43 W t A (I"
�T(`iyr C
Identificat`i/o�n Please Type or Print Clearly)
OWNER: Name: ���� �"1a tee(' Phone: ,Db-4 LIL (-c�6�
Address:
CONTRACTOR Name: V_)��t, to C� it A �
Address: 1 k 5 JT 1) Vx A't Ck G ( S -31-11
Supervisor's Construction License: �f S Exp. Date:
Home Improvement License: Exp. Date:
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: $ ,��a FEE: $ TFOu,s
Check No.: a b Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
ignature__ of ent/Owner Si n"ature of contractor
Plans Submitted ❑ Plans Waived ❑F 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 ❑ ❑
C(MMLONTS
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/Signature&Date Driveway Permit
Located at 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes � no '
Located at 924 Main Street
Fire Department signatureldate
COMMENTS
i
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must com Tete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Old Structure yes no
MAP NO: PARCEL: ZONING DISTRICT: Historic District. yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition 0 Two or more family El Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement 0 Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
0 Septic ❑Well 0 Floodplain El Wetlands
❑ Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
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 ti
DATE REJECTED DATE APPROVED I
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
_s
DPW TowL Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department-signature/tlate
COMMENTS
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.$10041000 fine
NOTES and DATA— For department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
i
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
a Building Permit Application
❑ Workers Comp Affidavit
a 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
NOTE: 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
E3 Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
a Copy Of Contract
Li Floor/Crossectlon/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
NOTE: 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
a Workers Comp Affidavit
o 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
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 submi4ted with the building application
Doc: Doc.Building Permit Revised 2012
X
Location
No.
�' �� Date 'b 2w
• ' TOWN OF NORTH ANDOVER
• '1'LED',T46` f
O
• � �, Certificate of Occupancy $
Building/Frame Permit Fee $ ��
`� Foundation Permit Fee $
Other Permit Fee $
TOTAL $ `
Check#7w Cl �P
25874 Building Inspector
r � NORT1� .
_ WL . ? _E , �\A ic . . ve. .
No. 34b .
-
h ti ver, Mass, I �� kwo
COCNIc Nl WIcK y1•
�•9 A°RATeo �Pa�,�S
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT LD Septic System
THIS CERTIFIES THATBUILDING INSPECTOR
...............qlWb...... ..w. .6 ..:...............................................
has permission to erect ........................... buildings on . Foundation
................ ....�. �........���..... ...�................... Rough
to be occupied as ..........F.4........ ....... .. ........ .................................... Chimney
provided that the person accepting this permit shall in every respect 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 CONSTRU4;E:;w00 Rough
Service
.......... ................................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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
Renewal MA Home Improvement Contractor
�� �� License#170810(Expires 12/23/2013)
byAndersen. Renewal b Andersen Cor oration Federal Tax 1D#41-1918413
WINDOW REPLACEMENT an Andersen Company
104 Otis St.,Northborough,MA 01532
(508)351-2200•Fax:(651)351-4810
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)NameDate of Agreement
Buyer(s)Street Address,City,State,and Zip Code
TEnta3 L_g G S7-
Wail
il Address me Tel hone Number Work Telephone Number
Buyer(s)hereby jointly and severally agrees to purchase the products 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 sheets) (collectively,this"Agreement').Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
Estimated Starting Date: Method of Payment:
Total lob Amount: 31-- Amount financed UCheck ❑Cash
oviso/MC ❑Discover
Deposit Received(33%):�0,i `1`T l V W l
Balance at Start of Job(33%):1 ,,5 y y D ❑Financed " 81�EX
Estimated Completion Date: If credit card is selected,please
Balance on Substantial / 2 3 see Credit Card Payment Form.
Completion of Job(33%):LO- �^ q
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 Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation yer(s Buyer(s)
By:
Signature of Product Manager 6ignaturc Signature
Print Name of Product Manager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
— — — — — — — — — — — — — — —:,<- — — — — — — — — — — — — — — -a<— — — — — — — — — — — — — — —�c
NOTICE LANCE ON X NOTICE OF CANCELLATION
Date of Transaction - t- — . You may cancel Date of Transaction You may cancel
this transaction,without any penalty or obligation,within I this transaction,without any penahy or obligation,within
three business days from the above .If you cancel,any I three business days from the above date.If you cancel,any
property traded in,any payments made by you under the I property traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrument executed
by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice, I by the Contractor.("Seller") of your cancellation notice,
and any security interest arising out of the transaction will I and any securityinterest arising out of the hnnsaction will
be canceled.If you cancel,you must make available to the be canceled.if you cancel,you must make available to the
Seller at your residence,in substantially as good condition I Seller at your residence,in substantially as good condition
as when received, any goods delivered to you under I as when received,any goods delivered to you under this
this Contract or Sale; or you may, if you wish, comply I Contract or Sale;or you may,if you wish,comply with the
with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of
shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.if you do make
If you do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not
Seller does not pick them up within 20 days of the date I pick them uP within 20 days of the date ofyour Notice
of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods
of the goods without any further obligation.If you fail to without any further obligation. If you fail to make the
make the goods available to the Seller, or iflou agree I goods available to the Seller,or if you agree to return the
to return the goods to the Seller and fail to do so, then I moods to the Seller and fail to do so,then You remain liable
you remain liable for performance of all obligations under I for performance of all obligations under the Contract.
the Contract.To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and
signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written
other written notice, or send a telegram to Contractor: I notice,or send a telegram to Contractor.
Renewal by Andersen Corporation, 104 Otis I Renewal by Andersen Corporation, 104 Otis Street,
Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OF .(Date) OF .(Date)
1 HEREBY CANCEL THIS TRANSACTION. i I HEREBY CANCEL THIS TRANSACTION.
I
Buyer's Signature Print Name Data I Buyer's Signofuro Print Name Date
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink 0JBUP2OO9.RBA4h.MANH
Renewal -.... _mewal by Andersen Corporatic MA Home Improvement Contractor
bYAI'1CIeCSeil. .��� 104 Otis St.,Northborough,MA 01532 License#170810(Expires 12/23/2013)
b Federal Tax ID#41-1918413
WINDOW REPLACEMENT an Andersen Company (508)351-2200'Fax:(651)351-4810
WINDOW SPECIFICATION SHEET
Buyer(s)Name Date of Agre ent
VZV 1Z
The Buyer(s)listed above hereby jointly 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 this Specification Sheet is a part.
WINDOW DETAILS
1. Contractor will Install a total of windows in Owner's home,using the following individual quantities:
Double Hung(DB) Equal sash_Cottage sash(1/3 top,2/3 bottom)_Oriel sash(2/3 top.1/3 bottom)_Flat sill aw ra esto class ions)
Casement(CS)_Hinge right_Hinge left(as viewed from exterior)
Double Casement(CD)
2 Lite Gliding Window(GW)
Casement/Picture/Casement(CT)_1:1:1 or_1:2:1
Glider/Picture/Glider(GPM_1:1:1 or_1:2:1
Picture Window Bay or Bow
Awning Window _#Lights Soffit/Roof Shingle/Copper
Specialty Window Patio Doors(see separate door spec sheet) Seat to be Primed/Oak/Pine
DE10 1 11 11
I
i
2. d3 Qty of Windows to be Custom Fit Replacement:
3. 6 Qty of Windows to be Custom Fit Full frame(INCLUDES NEW INTERIOR&EXTERIOR CASINGS)
Exterior casings:_Pine_Maintenance-free material_Factory applied 908 Fibrex brickmold
4.Glazing to be:23 HP Low-E-4 TM _Tempered _Other If other,please specify:
5.Exterior color to be:��Atte_Sand_Canvas_Terratone_Cocoa Bean_Dark Bronze_Forest Green_Black
6.Interior color to be:�' White_Sand_Canvas_Pine_Maple_Oak_Same as Exterior Note:Wood interiors need to finished by Owner.
7.Hardware:ZWhite_Stone_Canvas_Estate Hardware: Style:
8.NZ)_Install Lifts with Double Hung Win s
9. Screens:windows to have:_Half or II screens Screens to be:_Fiberglass_Aluminum 23T-Scene
GRRM DETAILS
10 ndows have grilles:_Grille Between Glass(GBG)'3RemovW)able Interior Wood(INT _Full Divided Light(FDL)
_ Owner approv, (initials) Draw grille patterns below "Use additional sheet if needed
Qty: -3 Qty: QtyQty: Qty: Qty: Qty:
ADDITIONAL.WORK DEFAIIS
11. Qty of_Sills_Sill noses to be replaced by Contractor
12. Contractor will remove metal frames of windows.
13. Contractor will install new_paint-ready or_stain-ready_Interior_Exterior casings in_Pine_Maintenance-free material
14. /(/ actor will install new_paint-ready or_stain-ready_Interior_Exterior stops in_fine_Maintenance-free material
15. Intls Owner is aware that Contractor does not do any painting.
16. Contractor will wrap exterior casings with coil stock of color.
Note:Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17. e 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,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued.
18. Yes❑No 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. Ck# $
19. Yes❑No All discounts have en applied to this a reement price.
20.Additional job details: � e�1 67n► e_.'
Z'
21. Yes❑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 there 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 in writing and signed by both
the Buyer(s)and Contractor.Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet.
Renewal by Anderseq Corporation Buyer( Buyer(s)
By:
Signature of Product Manager Signature Signature
Print Name of Product Manager Print Name Print Name
: The Coricrha We Eu of Hassacltuaeft
Deptc�iceact.of Ir1:�ustriul�4ccide:rta .
Offwe ce of b"kS ffa loris
600 Waih*gton Sfreei
'Boston,MA 0111
wrt W- asS:gv'v/did
Workers t✓oensstion Insgrance Affidavit B ulders/Contrmctars/Meetridans/Plumbers
Please Print Leyl
_A want Inferi>a�fian ( .
2�eme(Bns�ras/Org�izafiaollndvi�neil: t�'e 11 P la G. u1 t�f�Cd'Ce r�
Address: bLA
CitylSt$te/Tag: �� ,�a�o��ni� -11S 3 Phan#: S-d�'
Are u sn s Check the bar~ Type of project(req dredj:
Po employer? aPProP�.
fh _ 4. ❑ I em a gene¢al coa�racbr sad I
1,'q I am a C=PIoyW wi6. ❑New camsfzvati In
CUPloyees(full MWVorpMt-time),* hm bnrd the soh-contzactois
2.D I am a sole propcietnr arpsrtnar- listed on the sttarhed sheet t L�
ship end hFW no eMployees I Thexe snb-ca-cmc!)lave s• D
Dcmmolition
wa 3dng for me in any cepach-y works=' w�.mmminca g• QBuIrFmaddition .
[No wars' warp..:^^� a 5. ❑ We acs a ompam ion and its 10. Eketical��or adrlitious
officers hum ezercisexi theme -• .
3.❑ I am a homeowner doing ell woric right of s =VtirM per MGL 11.D Pludhin repairs CT additiaas
myself [No wodar"-MMP. c. 152, ¢1(4),and'we himo no 12,D Roof repairs
insnraace requicad_]t ermployM& [No work= 13.0 offim
camp..insncancs izquirt4.)
`Any that cheers has#1 meat elan fill cot the awfian below&migg t ci�WMAMCe WR=Mdm F oba
• t thin davit fb its d�e11 wart aa8 ihm hire outride camtae�tm�aa6omdt.t new ett;ttavit iti3iaatlag aar� ,
Homeownea who ccbmit mdu�mg ey
is�eaom.
ICov�arma'that ahect thit Ix.mrst etn>ohed an addrtiemml�thow6ag the Hama ofitte' and fbeir wawa aomP Prey
r mn an.employer ate is prvvidbT workaa''compa wafion irrswwwe for my mpLoyeaA Below it flee po&cy and fob site
InMMM=e Campaay Name:_ a
Polior Self-in. T�pirsiiaa
cy# .
?�? cxy
lob Site A�ress: 3 LA L
AtNA s copy of time workrza' mmpens8tiwn Policy l„lar ,.cm page(s ow*g the policy number and ezptrsbon*late)•
Peitmre'ta pew co#m mgt'as required m,dw Soodon 25A ofMGL e• 152 can lead to the impOd icm•of Q+niaal pmaltim of s
fine•uP to;1,500.00 mxVar ame-peer hnprisaiemt as v eaZ as civil penalties in the fig of a STOP WORK ORDER and a fine
of up to$250.00 a day ayd1 st the VlolatoL Be advised-dW a a:vpy a�thiS sterane nt M'ry-be faQ M%kd.t D the Office of
kerions of the:DIA for insurance coverage vsdacabM
n _
.I do ireneby-cerfifi� r 'fate p' penalfi�a ofpc*7,tbas the irtfWw arfihn prvvided/-above is ruse ttnd correct
Phaae
D 'sczal use onlj+. Do not writs in aneq to be completed by crty or tows*vaL .
Chy Peramrt/Lace�e#
ar Taws: .
' �@ag A1od�torfty{cFrcie.oaej: •. . •
1. Board of HMI& 2,lgi mg Dgmr6nent a, aty1r-oorn Clerk 4;MecEdcal bopeedw S.Pkmbbq bapxhnr '.
Coatre
.em= P
II
coRv'° CERTIFICATE OF LIABILITY INSURANCE DATE 2`5/20 2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON ' 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 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 1-612-333-3323 NAME CONCT Jonelle Hargrove or Eric Johnson
Hays Companies PHONE 612-333-3323 FAXC No: 612-373-7270
A/
B0 South 8th Street MAIL
ADDRESS:
Suite 700 PRODUCER
Minneapolis, NN 55402 CUSTOMER ID 0,
INSURERS)AFFORDING COVERAGE NAIC A
INSURED INSURER A: OLD REPUBLIC INS CO 24147
Renewal By Andersen Corporation
INSURERS: NATIONAL IINION FIRE INS CO OF P 19445
104 Otis Street INSURER C:
Northborough, MA 01532 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 29229436 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 IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTR TYPE OF INSURANCE ADDL SU R POLICY EFF POLICY EXP
WVD POLICY NUMBER MIDD MIDD LIMITS
A GENERAL LIABILITY MNZY 59828 10/01/1 10/01/13 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO R
PREMISES(Es occurrence $ 500,000
CLAIMS-MADE OCCUR
MED EXP(Any one person) E 3.0,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE $ 4,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG S 3,000,000
—XI POLICY PRO LOC $
A AUTOMOBILE LIABILITY KW1% 21700 10101114 10/01/13 COMBINED SINGLE LIMB $ 3,000,000
X ANY AUTO (Ea accident)
BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Per accident) $
X NON-OWNED AUTOS $
S
B X UMBRELLA UABX OCCUR 13273355 10/01/1 10/01/13 EACH OCCURRENCE $ 25,000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE' S 25,000,000
DEDUCTIBLE
$
X RETENTION s 25,000
i
A WORKERS COMPENSATION IANC 117948 0010/01/2, 10/02/13 OTH-
ANDEMPLOYERS'LIABILITY Y/N 10/O1/1 10/01/13 X
ANY PROPRIETOR/PARTNERMXECUTIVEE.L.EACH ACCIDENT $ 2,000,000
OFFICER/MEMBER EXCLUDED? N❑ N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 11000,000
K s,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,K mon spaced reouhed)
Evidence of Insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORED REPRESENTATIVE
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License: CS-095707
BRIAN D DENNISON
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Charlton MA 01507
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Registration: _2:170810
Expiration: fi/2$/2013
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