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HomeMy WebLinkAboutBuilding Permit #339-13 - 20 STAGE COACH ROAD 10/24/2012 µoft BUILDING P-' MIT ,?� 6•.`;r. •_•.:a °o TOWN OF NORTH ANDOVER 1 0 APPLICATION FOR PLAN EXAMINATION Permit NO:_5_1211. Date Received 10 24 (( �,ss�c►+us�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION .''U S Paint PROPERTY OWNER <;` stn .�.� -► Print, MAP NO:CLs PARCEL:O/1 ZONING DISTRICT: L Historic District yes /noo Machine Shop Village yes 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 ❑Septic ❑Well D Floodplain 0 Wetlands ❑ Watershed District _ ❑Water/Sewer DESCRIPTION OF WORK TO BE PREFORM D: Identification Please Type or Print Clearly) OWNER: Name: 1 ('-ey)' L vv\Iu Phone: Address: *o S-u t. Lo,-U. ONAO: CONTRACTOR Name: v"\_&v\ `J„ ��✓�� Phone: `1'3 - 3- � -X00 Supervisor's Construction License: S Earp. Date: c� g--j Home improvement License: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ .:� 9-�6 ,°L' FEE: $ qK vn Check No.: a tp'9-- �e Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund __ gnature oent/Owner Signa a of contractor I �I L 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 ❑ ❑ CWMENTS 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 124 Main Street Fire Deparftnent signature/date COMMENTS TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page 11 i LOCATIO,N1: .PROP.ERTiYf OWNER -- —.-- y ". .. T.� '_Pant;. OQYear�QfdStructure yes no>* ' " MAPN'.NO' _Y _PARCEL -__ _ .ZONING�DISTRIC�T? -Hi or yes, l - -_ �. Machine Shop'Villagea , yes nod TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑'S_eptic ❑�We-Ili ❑ Floo plairil ❑Wetland's, ❑ WatershetllDistnct� DESCRIPTION OF WORK TO BE PERFORMED. Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: 77 Phone -CONTRACTOR Name - - Y _ — j Su emsor,' Construction License;: : - _ �Ekp Date ,P # - . . - h x f r. Exp Date:;--- Nomeslmprovernent License: - -_ T ARCHITECT/ENGINEER Phone: Address: Reg. No. 9 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 :>r.. 7 ""`:.�"�S'?-, ,y°"+ s+g-vq'^"' �".%s .C"` 9,90-0-74=urof gent/Orwner �_ Si,gnatur �of contractor L __ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ a, 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 ❑ h THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ I COMMENTS CONSERVATION Reviewed on Signature i COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments G Conservation Decision: Comments Water & Severer Connection/Signature& Date Driveway Permit DPW Tow Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on site yes no Located at 124,Matn Street= Fire Department-sigh' Wrb/date COMMENTS `; I ` I 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 I i I i I ® Notified for pickup - Date I Doc.Building Permit Revised 2010 I Building Department The fohowin is a list of the required forms to be filled out for the appropriate permit to be obtained. _ 9 q 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 o Copy of Contract o 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 o Building Permit Application o 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) o 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) La Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And i 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 submitted with the building application Doc: Doc.Building Permit Revised 2012 i . 3 Location � � No.3,3q- 13 Date ` a ® ' : TOWN OF NORTH ANDOVER . \/ a I \ . CeCf! @meofOcupny . $ \ . y/ Building/FramePermit F e $ . : ± ©\ 2\a • = w} \ . +:• . © . � ` � Foundation P Em|! F e . � \ § \ Other Permit Fee $ ~ TOTAL $ Check* 7(0�4� \\ . . . .\ 25573 Building h9eto \\ \ / NH ORT Town of t E ,, RAndover No. -t _ o �A�, h ver, Mass, �� a� &one coc NlC„l WS K y1• A0OATED IPP5 S U BOARD OF HEALTH Food/Kitchen PERMIT. LD Septic System K&O40kow `V�� BUILDING INSPECTOR THIS CERTIFIES THAT ................... ........ ....................................................................... has permission to erect .......................... buildings on ...ca.0................ ... ...... ..................... Foundation Rough to be occupied as ................. .............. ......... ..".or..... �......................... Chimney provided that the person accepting this permit sha I 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUARTS Rough Service ........ . .... ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place onthePremises — 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 RenewalMA Home Improvement Contractor bYAndersen. License#1708 10(Expires 12/23/2013) WINDOW REPLACEMENT an Andersen Company Renewal by Andersen Corporation - Federal Tax ID#41-1918413 104 Otis St.,Northborough,MA 01532 (508)351-2200•Fax:(651)351-4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name - Date of Agreement 2- Buyer(s)Street Address,City,State,and Zip Code "- - - E-Mail Address Home Telephone Number Work Telephone umber " 7 - /2 S 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 sheet(s)"(collectively,this"Agreement').Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: 7 Estimated Starting Date: Method of Payment: Deposit Received(33%):- '�� 9- Z ❑Check ❑Cash ❑Financed Balance at Start of Job(33%):-11, ❑Visa/MC ❑Discover AMEX Estimated Completion Date: If credit card is selected, please see Credit Card Completion of Job(33%): Balance on Substantial 25-q v Payment Form. x_ 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 Buyer(s) Buyer(s) By: / K t Signature of Product Manager Signature U Signature fes. // �e <ajt r, Lui-1 l Yl t.j 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. — — — — — — — — — — — — — — —�<- — — — — — - — - - — — — — — — — — — — — — � NOTICE OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction 9- 9- (� . You may cancelI Date of Transaction 9-i 9-/Z . You may cancel a this transaction,without any penalty or obligation,within this transaction,without any penalty or obligation,within three business clays from the above date.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 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, by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction 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 Seller at your residence,in substantially as good condition as when received, any goods delivered to you under 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 Ifyou do make the goods available to the Seller and the 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 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 ifyou 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 goods to the Seller and fail to do so,then You remain liable you remain liable for performance of all obligations under for performance of all obligations under the Contract. the Contract.To cancel this transaction,mail or deliver a 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 Renewal by Andersen Corporation, 104 Otis Street, Street, Northboro gh, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF -r 2- .(Date) OF 9-2 y-1-Z .(Date) I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Date I Buyer's Signature -Print Name Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink ®JBLLP2009.RBAPh.MANH Renewal ` -newal by Andersen Corporatit MA Home Improvement Contractor bYAndersen. g _ License#170810(Expires 12/23/2013) p♦ 104 Otis St.,Northborough,MA 01532 WINDOW REPLACEMENT =Andens ncompany (508)351-2200•Fax:(651)351-4810 Federal Tax ID#41-1918413 WINDOW SPECIFICATION SHEET Buyer(s)Name Date of Agreement 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 DETAIIS 1. Cgntractor will Install a total of windows in Owner's home,using the following individual quantities: 6 Double Hung(DB)E4-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) ❑ 1:1:1 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) Picture Window(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. -E-Yes ❑ No Qty of Windows to be Custom Fit Replacement: 4�> 3. 'Yes ❑ No Qty of Sills to be replaced by Contractor: ro s;/t 4. ❑ Yes JNo Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)and actual Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: 2HP Low-E-4 TM ❑ Other If other,please specify: 6. Exterior color to be: ®'White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: White ❑ Stone p Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ Yes ,. Nc Install Lifts with Double Hung Windows 10. Screens:: dows to have: ❑ Half or�tixll screens Screens to be:L'fiberglass ❑ Aluminum ❑ Tr Scene GRUIX DETAILS 11.Windows have grilles: 5�`Yes ❑ No If yes:�RGrille Between Glass(GBG)❑ Removable Interior Wood(iNTM❑ Full Divided Light(FDI,) Qty: Qty:�- Qty: Qty: Qty Qty: Qty: H DH DH CW/Picture Glider CPW or Draw grille patterns above 'Use additional sheet if needed Owner approved(initials. ADDITIONAL WORK DETAILS 12.❑ Yes ®"No Contractor will remove metal frames of windows. Qty of Units: 13,-Yes ❑ No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: lc> Exterior casings qty of openings: ❑ Pine PR,-Maintenance-free material 14.❑ Yes Je No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior sap o openm ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any pain' r Initials 16.❑ Yes [ No Contractor will wrap exterior casings with alut ock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17._�R-Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18.15�es ❑No Clean up all job related debris including old windows will be removed.Vacuum nightly. 19. es E] No A limited warranty shall be issued to Owner upon completion of the job and payment in full. e 20. s ❑ No Rg9ding BuildingPermit—Contractor will secure any and all necessary permits. The fee for theP ermit(s)is not included in the Contract Price and a separate check is required at the time of sale for this fee. 21. Yes ❑No All discounts have been applied to this agreement price. 22. Additional job details: 23. Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. 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 er Co ration Buyer(s) Buyer(s) By: ' Signature of Product Manager Signature S' - -- — Lit mom -- tgxtature Print Name of Product Manager Print Name i Print Name The Car?wxwe zu of�asa�ac�tr r UT1}ep¢rrrcet�t.of Iraiius�rial Accidetrtt' Of five of brvk igt 6bAr 600 Washington Sire& Boston;MA 0111 w w.mas M,,1dia Workers' Compensation fnsnrance Affidavit BxWers/Contractors/Fieetriciatu/Plgmbers AQ Ii ant Information Presse Print Lepb� LA Gtp/S�ta/Zig: �Jn��- ,�dd�IMLs. 1S 3 Ph.one#: -d`�' - Are yon an employer.? Check the&ppropaatz'box: T`pe of project(requredj; and I I am a t:mployra with — 4. ❑ I am a zd the mib.-o n:t 6. ❑New coastzvct�na emploY� (�and/orpatt-timc),a have hind the sa�coatractio=s �-,�,, 2.EDI am a sole pzopmaar etm orpart - listed an the attached sheet t 7..,��' ° ship and have no employees Thes&snb-cam m==bave S, ❑Demolstum v working fm IDs in aay-capaczfy, wori=' camp.7nsIIx = 9. ❑$fig addition [No worlt=' comp,hUMr aoe 5, ❑ We ars a=porafim and its 10.❑F cal repairs or additions '?d) offLUM hm=M-c sed thea - aQ addi 3.❑ I am a homeowner doing eIl wo=k �of==13ptiffi Per MGL Pl�iag repairs tiaas 1(4), mwc vno Rfeai 12- oorepairs myself [?3o workers -camp• c• 152� � d' lae ❑ . insmance requirbd.]t employees. [No wozkz rs 13,0 Other camp.insaranx itrgaired,) °Any e�pfiraat tient shacks box#1 mast also 571 and the aeiti=below showing fiWjrWDdmU'=Up=G86M PafiYOII t Ha=M=who submit this affidavit iadir�iag the}'art doing all wad;sad then hat Evs sm�su6mdt.a aeov e�davh indiamag sock ZC that chemo fire box const attached an ad"aael dmd showing the nsmc of tbt'sob-cam and thea w=Imw'c=,p pofiey dao, I aw an zmplrryer that irproviding war*ffla'cotaperravlion bz=v we.for my wPIvP=• Below is tic policy rend job adz InsaMace Company Name:_ Policy#F s •z ic,# Ac w ti --qL�. �; na>c: 1 c� - '1 = 3 I. Iob Ritz Ad&rss Aa copy of the workmT' compensation policy decla_rafa gage(dwwimg the pow number snd expiration dLte)• Faihae to pacts covexagr,sr rupini malar•section 25A of MGL c, 152'can lamrl to the anpositiaa of ct-irtal proal ias of a fine-up to S 1,500.00 and/or one-year=pmso�ntmt,as well as civsl panalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a dap-against the violstnL Be advised fiat a copy a'this obdrancat may-be fnrwwdod.tn ft O$ce of Imv=ftgatk=of the DIA frs insurance coveasge vrr caliaa .I do by. ' WaG;.the proms of per, 7,drat the information provided above rs true=artd estreat Daft: Phone - SLL 3s t?(zciirl usr only. Do not write in t3Ftb'.m-ea, m be.coaraletrd by city or tnwrt Vffxc w Chy PermiSlLieense# or Tovea: .' • • �oingArd`horftp-(t�rrcie.onej: . L Bard of SexkI 2.B ndir•,g Dgmr•fmaw .3. atw Tvwm Cierk 4: baps 5.PSL uPedur 6.•Other. - - ' - .. - • •Coact Persoa: phone#: . CERTIFICATE OF LIABILITY INSURANCEA-5*FDD/Y /2012 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 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(iss)must be endorsed. H SUBROGATION IS WAIVED,subject to the terms 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 CONTACT-1-612-333-3323 Joaelle Hargrove or Eric Johnson Hays Colapaaiea NAME: PHONE , 612-333-3323 FAX 80 South 8th Street E-MAIL AIC No: 612-373-7270 Suite 700 ADDRESS: PRODUCER Minneapolis, MN 55402 ID Ne INSURED INSURER(S) AFFORDING COVERAGE NAIC N Renewal By Andersen Corporation INSURER A: OLD REPUBLIC INS CO 24147 INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 104 OtiB 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. INSR AD L SUER LTR TYPE OF INSURANCEINSR V"DPOLICY NUMBER POLICY EFF P CY EXP LIMITS A GENERAL LIABILITY MINZY 59828 10/01/1 10/01/13 EACHOCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY 15AMAGE TO 9 9 9 fE PREMISES Me occurrence $ 500,000 CLAIMS MADErTl OCCUR MED EXP(Any one person) E 10,000 PERSONAL BADV INJURY E 1,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY r PRO- LOC $ A AUTOMOBILE LIABILITY MHTB 21700 10/01 14 10/01 13 COMBINED SINGLE LIMB X ANY AUTO (Ea accident) E 3,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per aoddeni) $ XHIRED AUTOS PROPERTY DAMAGE $ (Per accident) X NON-OWNED AUTOS $ B X UMBRELLA U" X OCCUR 1327335510/02/1, 10/01/13 EACH OCCURRENCE $ 25,000,000 EXCESS LIAR CLAIMS-AZIDE AGGREGATE' $ 25,000,000 DEDUCTIBLE X RETENTION 25,000 S WORKERS COMPENSATION s A AND EMPLOYERS,LIABILITY YIN MINC 117948 00 10/0l/1 10/01/13 X WCSTATU- or PROPRIETORIPARTNER/FXECUTIVE OFFICERIMEMBEREXCLUDED7 K NIA E.L.EACH ACCIDENT : 1,000,000 (Mandatory M NH) 0Ues E.L.DISEASE-EA EMPLOYE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Atlaeh ACOR 11111,Additional Remarks Schedule,N more space Is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE lrici ,a Tee even �Awww wwwwww.�.wu .......... Massachusetts -Department of Public Safety { Board of Building Regulations and Standards Construction Supenisor License: CS-095707 BRIAN D DENNL40N 7 LAMBS POND CIRC Charlton MA 01507 Expiration ; Commissioner 09/08/2014 i i i ✓lee timersin aactivaeda I Office of Consumer Affairs&B smess Regulation r HOME IMPROVEMENT CONTRACTOR Registration:;x70810 Expiration: I i/2013 Type: ! Corporation i. + R WAL BY ANDE#ZSEi\j CORpORATIONa. ! tera. R BRIAN DENNISOb� / I 104 OTIS ST. 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