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Home My WebLink AboutBuilding Permit #122-16 - 281 MIDDLESEX STREET 7/29/2016 BUILDING PERMIT "O RT b�ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . l/ 7 4 Permit No#• Date Received p�R�reo�PP �5 Date Issued: l IMPORTANT: /Applicant must complete all items on this page LOCATION gf r�' , Print PROPERTY OWNER f'�� / 1144 Dd 'l Print 100 Year Structure yes no MAP v PARCEL: ZONING DISTRICT: Historic District yes no WL/7 Machine Shop Village yes no 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 ❑ Septic ❑W611 D Floodplain 11 Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identi f�iicatio�Please Tye r Print Clearly OWNER: Name: Yt�/Q Phone: 971' 6d9-?-1Z)3) Address: Contractor Name: TA1kK0 /'6&JA� Phone: 7 4&,(e Dif Email: Address: TO ffe,. tO5 AQ eY ;a 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: $ O a. 475' FEE: $ Check J U ! O Z, Receipt No.: � t NOTE: Persons contracting with unregistered contractors do not have access a guaranty fund . . J 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 4 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 OTE: 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 ik Photo Copy of H.I.C. And C.S.L. Licenses 4. 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) • Building Permit Application • 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 2012 IECC Energy code 4, 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 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:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming P111s ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ f j THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS ,toning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 6 Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ;FIRE DEP .� EF :TrnpDumpst ronsi � = - _ � } r0 acac ted at 124 Main St er et Fii`re De -AM partm-e�nt s gnatur,e/d_, rate - > 4 Y ' .)..:1 3u +r, $ is"w e "i -ov 'a• t Fi 1;. ` ; N # + II 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 LJ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 1 4 Location liolae rr No. 7 '•' Date . • TOWN OF NORTH ANDOVER ., Certificate of Occupancyodll $ Building/Frame Permit Fee $ e - Foundation Permit Fee $ Other Permit Fee ' ` TOTAL $ Check W,72-, 292 1 0 uilding Inspector NOKf/i Town of S EAndover ;L61h ," ver, Mass, A q//,!g [OC MIC Nl WIC.I 11. ADRgTED r'PP,`,�5 S u BOARD OF HEALTH P. ERR IT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ....... " 14( �� BUILDING INSPECTOR ........................................................ ... .......................................... has permission to erect buildings on ..... Foundation Rough to be occupied as Chimney .. .... ��L....... !!�4..............-�:......:, .......1..?.f1.d.. .......................... ..�. a-c ... .... ey 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 TRUCTI RTS UNLESS CONS 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. Rn � eal i�,f ftp 5 byAnde"sena ♦�p� w1NDOW- REPLACEMENT mAndeotIRC.oatpa014„ WoodArinyl Composite IF Dual Argon Low E4 SmarlSun w�ii :l xs'g Double Hung 100-00473518-010 ERERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient i at 011v u' ADDITIONAL PERFORMANCE WINGS Visible Transmittance U v 411�. 2- Manufacturer stipulates lhal these mfmgs conform to appf�ala NFRC pracedurae for determining wlwk prod"I performance.NFRC ratings are detern(med for a faed set of environmental condhions and a specific plod-sae. NFRC does not recommend any product and does not warrant the svdand'ey 61 any product Wany specific use. Co..manufacturer's fseraturs for other product peAomrattee information. 7C www.nitcAfg ' f"�IC♦r ThisProduct meets Green Sears envvonmental sMees "->w••.'- r standards governina ene(gy :. .'e" '.h ,>.�.....,.j..i'^'•t r„ r r y. �. aMiciarlcY.hes metals in f� yr ,.:tM lmme and ssh .material Packagieg.and :ft,{{y �I :`t';,F,�'y'• its consumer educational r;;i:;c��>tN.J•r�F� materials. as.rt.aii DESIGN PRESSURE(PSF) WiteOa sIw roa �WwW�.wd-.H�.•. -h H- 25 RbA DB Sloped Sill DH IN yarW 10111f5-02a aA)VVOW)CSA IOtAMWM" Marty elurar sl- nes conk mer"to we a fimata slnMaros. rfeets or exceeds M.E.C.,C.E.C.61.E.C.C.Air IntAration requveenants WOMA NaRmark CengLation Program. .. t W Do not remove until final code inspection. Save label for future reference. i 13 > 5 j energystarmrcan- tT rncan.go.ca fV C CM /`r cc WAvg 00 No al nergystar.gov \y , e � ®-Qualified/Admissible L— — Renewal An ,h? WINDOW REPLACEMENT nnArulersefCorupany tF dsu� s AND-N-35 . �T.t`;; ;�;, WoodNinyl Composite FF ••--•............••• Dual Argon Low-E4 SmartSun i Product Type: Glider I ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0.29 1o65 .21 U.S./I-P (Metric 1) • ADDITIONAL PERFORMANCE RATINGS GS Visible Transmittance 0*49 Manufacturer stipulates that these ratings conform to applicaole NFRC procedures for oetenriining whole product performance.NFRC ratings are tier rif inea for a ftc!set of environmental conditions anti a specific proautt size. NFRC goes not recommend any proautt and aces not warrant the suitability of any proautt for any specific use. Consult manufacturers literature for other proautt performance information. wwa.nfrc.org Window ana Door igloo m-nufaCturers �ssocistian CCL Andersen Co oration:RBA Glidin Window Manufacturer_pu a as conrormence o a tollovong standar-05 Standard Rating w;ncS'J2�t;'1Fd1sMrB,^A�FG&A-4FitA:S.2JP.J.^0 gS..... .. vP pst—i-&-C3,5. . t�1 SE4,f This praauctmeets Green Seel'e environmental stanaaros {p ;,governing energy 4.efficiency heavy metals in the frame ana sash r material•packaging.ana •y '{� consumer eaucational 100-00512036-015 Meets or exceeds M.E.C.,C.E.C,&I.E.C.C.Fir Intarration requirements WOMA Hallmark caratication Program. Idm r i �c L& eit�, *' Vin �/yy ANO-N-:37 Duel oovd Gompogra Material - Prod uotArgon LOW-E4 Srllr Sun ENERGY PERPORiyIMC�a RATINGS , U-Feator S+Dlar Hest Gain Coemolent 0.27 1 - 53 U.3J1-P Me3rlcfal 0 . 22 '. ADDITIONAL'p RMANC� RATINGS Vielble Tranemittanoe 0 , 51 no=,g +b a en,«�wi'�sn� "�eft1r'rnt aa �. 0 �rPb6etYq �OOma . +�+rYoaiy i 0�6- a h on: tyre c�alow ftkndsM R�1Vng m°rte,au s�4u�o os OP psf F-050 I , N* 3iEr � .eca.wun neq„+mromnrvrti �� r � a PRODUCT PERFORMANCE A Andersen° NRC Certified Total Unit Performance (continued) Andersen'Product Glass Type U-Factor' SHGC' VF' 200 Series. .. :. Clear Dual Pane 0.45 0.60 0.63 - Clear Dual Pane with Grilles 0.45 054 0.56 - nL•wa5n Law-E 0.30 032 0.55 y Double-HungWindow Lmv-E wnh Grilles 0.30 029 0.49 .. - HP lmv{4 SmartSun 0.30 021 0.49 14 HP Low-E4 SmantSun w/Grilles 0.31 0.19 0.43 F_- Clear Dual Pane 0.45 0.61 0.64 - Narroline: Clear Dual Pane with Gdlles 0.45 0.54 0.57 - Double-Hung Window Low-E 0.30 032 0.56 Low-E.,bGrilles 0.31 029 0.50 - Clear Dual Pane 0.44 0.63 0.66 - Narroline; Clear Dual Pane with Grilles 0.44 057 0.59 - Transom Window Laty{ 0.27 034 0.58 Lmv-E with Grilles 0.27 0.30 0.52 i Clear Dual Pane 0.45 0.60 0.63 - - Clear Dual Pane with Grilles 0.45 154 0.56 - Low-E 0.30 0.32 0.55 - Gilding Window Low-E with Grilles 030 029 0.49 �u Lmv-E SmartSun 0.30 021 0.49 .. Lnw-E SmartSun with Grilles 0.31 0.19 0.43 Clear Dual Pane 0.43 0.61 0.65 - Clear Dual Pane with Grilles 0.43 0.55 ' 0.58 - Fixed,Transom;. Low-E 028 033 0.56 x3 -Circle Top'Wmdbw Lmv-E with Grilles 028 0.30 0.50 %�i -- Lmv-E SmartSun 027 022 0.51 Low-E SmartSun with Grilles 0.27 020 0.45 Clear Dual Pane 0A4 0.61 0.64 - Clear Dual Pane with Grilles OA5 0.53 0.56 - Lmv-E 029 032 0.56 - .Narroline7 Low-E with Grilles 0.30 029 0.49 - Gliding Patio Doors Lmv-E Sun 029 020 0.31 Low-E Sun with Grilles 0.31 0.18 027' Lmv-E SmartSun 028 021 0.50 3 3 LmrE SmartSun with Grilles - 0.30 0.19 0.44 - Clear Dual Pane 0.43 0.61 0.64 - Clear Dual Pane with Grilles 0.43 0.54 0.56 - Low-E 028 0.32 0.56 - -Penna-Shield'. Low-E with Grilles 0.30 029 0.49 m7 Gliding Patio Doors Law{Sun 0.29 0.19 030 _. Law{Sun with Grilles 0.30 0.17 027 E Lmv-ESmartSun0.27 022 0.50 Lmv-E SmartSun with Grilles 029 0.19 0.44 Clear Dual Pane 0.43 0.45 0.47 - Clear Dual Pane with Grilles 0.43 039 0.40 - Lmv-E 032 024 0.41 u Hinged.].nswing. Low-E with Grilles 0.33 021 0.35 - Pado Doors Law{Sun 0.32 0.15 023 Lmv-E Sun with Grilles 034 0.13 0.19 - - - Law-E SmartSun 0.32 0.16 0.37 - -. Low-E SmartSun with Grilles - 033 0.14 0.31 - ill ` w i4iWINDOWS•DOORS !Andersen NFRC Certified Total Unit Performance (eonlinued) Product Glass Type ; U-Factor' SHGC' �" Andersen* Andersen"Product Glasslype U-Factor' ! SHGC2 ! VVVrr Architectural 400 Series IIP Low E4 0.32 028 0.47 f _ HP Lour-E4. 0.27 0"35 0 60 - Hp Low-E4 with Gilles 0.28 0.31 0.54 - HP Imo-E4 with Grilles 0.32 025 .42 0tri HP Low-E4 Sun 0.32 0.17 0.26 Circle Tap' HP Low-E4 Sun 0.27 0.21 0.33 i Casement Window HP Imv-E4 Sun with Grilles 0.32 0.16 0.23 f Casement Window HP Low-E4 Sun with Grilles 0.29 0.19 0.30 Eq' Hp tow-E4 SmanSun 0.31 0-18 0.42 E4 HP Lox- SmanSun 0.26 023 0.54 F.I --- 0.31 0-17 038 _ HP Lmw-E4 SmartSun vi/Grilles j HP Lox-E4 SmartSun vi/Grilles 0.28 021 0.49 ) HP Low-E4 0.32 028 0.47 1 HP Law-E4 0.27 0.35 0.60 T HP Lour-E4 with Grilles 0.32 025 0.42 lip Low-E4 with Grilles 0.28 031 0.54 _ HP Low-E4 Sun 0.32 0-17 0.26 HP Low___-E4 Sun 027 021 0.33 `' French Casement Circle&Oval Window'---- window fIP Law-E4 Sun with Grilles 0.32 0.16 0.23 ' 1 HP Law-E4 Sun with Grilles 0.29 0.19 0.30 f Hp Low-E4 SmarlSun 0.31 0-18 0,42 HP Law- ma E4 SmanSun 0.26 023 0.54 .,•� ;� HP Lmx-E4 SmanSun w/Grilles 0.31 0.17 0.38 HP low-E4 SmanSun w/Grilles 0.28 0.21 0.49 HP Low-E4 0.32 028 0.47 ({ HP Low-E4 0.28 0.33 0.58 F -___ 1-i HP Low-E4 with Grilles 0.32 025 0"42 _ ftp low-E4 with Grilles 0.29 0.30 0.52 ir' lip Low-E4 Sun 0.32 0-17 0.26 1 NP Law-E4 Sun 0.28 0.20 0.31 ° r Awning Window - HP Low-E4 Sun with Grilles 0.32 0.16 0.23 Arch Window \ HP Low-E4 Sun with Grilles 0.29 0.18 b.28 r{ HP Law-E4 SmartSun 0.31 0.18 0.42 HP Low- .IIS-- 0 E4 Sm27 023 0.52 ' '_ HP Lmv-E4 SmartSun w/Grilles 031 0.17 0.38 ..€:? n , __HP_ SmartSun w/Grilles 0"28 021 0.46 " HP law E4 0.31 032 0.55 r, HP Low-E4 0.27 0.33 0.58 � _ lip law-E4 with Grilles 0.31 029 0.49 HP low-E4 with Grilles 0.28 0.30 0.52 l.'1 -- lip Lmv_E4 Sun 0.31 020 0.31 NP Low-E4 Sun 0.27 020 0.31 y Casement/Awning y Flexiflame•Wihidaiv HP Low-E4 Sun with Gilles 0.29 0.18 0.28 _ 1 iicture Window HP Low-E4 Sun with Grilles 0.31 0.18 028 , HP law-E4 SmanSun 0.31 021 0.50 _71113 HP Low-E4 SmartSun 0.26 023 0.52 F'i _ Hp Imo-E4 SmanSun w/Grilles 0.31 0.19 0.44 *" HP Low-E4 SmanSun w/Grilles 0.28 0.21 0.46 t I HP Lav+-E4 0.30 037 0.64 HP Imo-E4 0.31 0.33 0.58 _ HP law-E4 with Grilles 0.30 033 0.57 t"'! HP Low-Ell with Grilles 0.32 030 0.52 HP Low-E4 Sun 0.31 022 0.36 1{p Low-E4 Sun 0.31 020 0.31 Specialty Window - 4 Spdngllne Window - 018 0 2g t - HP Law-E4 Sun with Grilles 0.31 020 0.32 + I, IiP low-E4 Sun with Grilles 0.33 _ HP lour-E4 SmartSun 0.30 024 0.58 .. HP Law-E4 SmanSun 0.30 0.23 0.52 t _ - HP law-E4 SmanSun w/Gilles 0.30 022 0.52 i44' IIP Lox-E4 SmartSun vi/Grilles 0.32 021 0.461 HP Imr-E4 0.32 022 0.37 ! �` HP Law-E4 0.30 0.27 0.45 HP Lmv{q Mth Grilles 0.33 0-20 0.33 - HP tatv-E4 with Grilles 0.32 0.23 0.39 Hp Low-E4 Sun 0.33 0-14 0.21 - Frenchwood' HP Low-E4 Sun 0.31 0-16 0.25 1 Hinged Inswing _ French Door Hp low-E4 Sun with Grilles 0.34 0.13 0.18 ',• Gliding Patio Doo HP Low-E4 Sun with Grilles 0.32 0.14 0.22 r'%% lip Low-E4 SmartSun 0.32 0.15 0.33 HP lino-E4 SmanSun 030 0.18 0.41 - tip Low-E4 SmanSun yr/Grilles 0.33 0-14 0.30 ! HP law-E4 SmanSun w/Grilles 0.31 0-16 0.35 '-i HP Low-E4 0.33 025 0.41 HP Low-E4 0.31 024 0.41 17 !FR iz HP Low-E4 with Grilles 0.34 022 0.36 m 1 HP Lour-E4 wNh Grilles 0.32 021 0.35 HP Low-E4 Sun 0.33 0.16 0.23 174 Hinged Outswing Frenchwood'Hinged HP Low-E4 Sun 0.31 0.15 0.23 - o o0 French Door HP law-E4 Sun with Grilles 0.35 0.14 0.20 n. Inswing Patio Door ? HP lave-E4 Sun viith Grilles 0.32 0-13 0.19- j Vii.. lip Lmx-E4 SmartSun 032 0.17 0.37 SmanSun 0.30 0-16 0.37 HP Low-E4 - _ HP Low-E4 SmartSun w/Gdlles 0.34 0.15 0.32 E o HP Law-E4 SmanSun w/Grilles 0.31 0.14 0.31 F HP taw-E4 0.33 023 0.38 HP Low-E4 0.31 025 0.411. HP lux-E4 with Grilles 0.33 021 0.34 - HP Imo-E4 with Grilles 0.32 021 0.35 - - Hp{ux-E4 Sun 0.33 0.14 0.21 - Frenehwood'Hinged'; HP law-E4 Sun 0.31 0.15 0.23 Fixed French Door- _ Sidelight' HP law-E4 Sun with Grilles 0.34 0.13 0.19 Outswing Patio Door tip low-E4 Sun with Grilles 0.32 0.13 0.19 lip Iger-E4 Smartsun 0.32 0.15 0.34 - HP tow-E4 SmartSun 0.30 0.17 0.37 i?i _ HP Lux-E4 SmanSun w/Grilles 0.33 0.14 0.30 - HP love-E4 SmartSun w/Gdlles 0.31 0-15 0.31 m� - HPLaw-E4 0.32 025 0.41 HP Low-E4 0.31 022 0.37 7,,, ' 022 0.37 - HP Low-E4 with Grilles 0.33 HP Law-E4 with Grilles 0.32 020 0.33 HP Lmv-E4 Sun 032 0.15 0.23 - _ HP Lour-E4 Sun 0.32 0.14 0.21 ,r",:r ' Fixed Transom _ Frenchwood•` French Door HP LOW-E4 Sun with Grilles 0.33 0.14 0.20 Patio Door SidefrghIt HP Low-4 Sun with Grilles 0.32 0.13 0.18 ?) - HP lux-E4 SmanSun 032 0.16 0.37 - HP Low-E4 SmartSun 0.31 0-15 0.33 7171 %"�'' - ' � I,,Fill HP tow-E4 SmanSun w/Grilles 0.32 0.15 0.33 - Hp Inw-E4 SmartSun w/Grilles 0.32 0-14 0.29HP low-E4 0.35 026 0.44 - HPLow-E4 0.30 0.24 0.40 " - HPLaw-E4 with Grilles 0.36 023 0.38 HP Law-E4 with Grilles 0.30 02_i _ 035 1{P Law-E4 Sun 0.35 0.16 0.24 - i,:vv Frenchwood' HP Low-E4 Sun 0.30 0.15 022 '" Folding Door Hp lux-E4 Sun vriih Grilles 0.36 0-14 0.21 - c'. Patio Door Transom I IP low-E4 Sun with Gdlles 0.31 0.13 0.20_ •'9 Sma "; 0.16 0.36 -1 '91 Hp lin HP Low- o-E4 SmartSun 0.34 0.17 0.39 - E4 nSun 0.29 __ -- - HP Lwr E4 SmanSun w/Grilles 0.30 0.14 0.32 1;1! 1 HP Low-E4 SmartSun w/Grilles 0.36 0.15 0.34 cantlnued on next page • For NFRC certified total unit performance on units with capillary breather tubes for high altitudes,please vis it andersenvrindows.com- •"high-Performance"Law-E4'"(NP Low-E4),'High-Performance"Lave-E4'SmarlSun'(HP Low-E4 SmartSun)and"High-Performance"Law-E4'Sun'(lip Law-E4 Sun)ate Andersen trademarks for•Low-E'glass- ' U-Factor defines the amount of heat loss through the total unit in BTU/hr sq.fL•F-The lower the value,the less heat peris ed glass- the entire product Window values represent non-tempered glass.Use of tempered glass can r values re at is transmitted performance P value tihelesshe rr erfo werte , r specific D ward.The to increase U-Factor ratings.See andersemrindaws.com fo p both direct transmitted and absorbed and subsequently released inward.h the lass o Y 'Solar Heat Gain Coefficient(SHGC)defines the fraction of solar radiation admitted throng g through the praducL g the more da lihtthe product lets in aver the product's total unit area.Visible Transmittance comes through a product(glass and frame).The hi her the value,from 0 to 1, yg w much light g 'Visible Transmittance(VT)measures ho g is measured over the 380 to 760 nanometer portion of the solat spectrum. agency as validated by an independent test lab in compliance with NFRC program and procedural requirements. a over time.Ratings are for sizes specified by NFRC far •NFRC ratings are based an modeling by a third party g y •This data is accurate as of December 2010.Due to ongoing productry standards or requirements.this data may Chang t changes,updated lest results or new indus testing and certification-Ratings may vary depending on use of tempered glass,different grille Options,glass for high altitudes,etc. •PassiveSun"glass values are available online at andersenwindows-com. 277 The Commonwealth of Massachusetts 62 Department of Industrial Accidents Office oflnvestigadons IV 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers Applicant Information • Please Print Legibly Name (Business/Organization/lndividual): RENEWAL BY ANDERSEN Address:30 FORBES ROAD City/State/Zip:NORTHBORO, MA 01532 Phone#:508-351-2200 Are you an employer?Check the appropriate box: Type of project(required): 1.11 1 am a employer with 30 4. 1 am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6• ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. K Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity, employees and have workers' 9 El Building addition [No workers' comp.insurance comp.insurance.: required.] S. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their l l.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] 'Any applicant that cheeks box ill most 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 hive outside c ktractors must submit a new affidavit indicating such. =Contractors 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. lam an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name:OLD REPUBLIC INS.CO. Policy#or Self-ins. Lic. #:MWC 30293800 Expiration Date:10/01/15 Job Site Address: 281 Middlesex RD City/State/Zip:North Andover, MA 01845 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 Investigations of the DIA for insurance coverage verification. I do hereby 9wffy u der the pains and penalties of perjury that the i iformation provided above is true and correct Dat 71 -351-2200 use only. Do not write in this area,to be completed by city or town oJjsciW. City or Town: PermitUcense# 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#• 11 ANDECOR-01 YADAVYO ACORU' CERTIFICATE OF LIABILITY INSURANCE �` 0111° '"'x"' +••..�� 1a1�z0la 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(les)must be endorsed. If 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 REACT certlflcates@wlllis.com Willis of Minnesota,Inc. PHo'' :(877)945_7378 F c/o 26 Century Blvd Nor(888)467-2378 P.O.Box 305191 EA per; AL Nashville,TN 37230-5191 INSu 8 AFFORMNG COVERAGE NAIC N INSURERA:Old Republic Insurance Company 24147 INSURED INSURER 0: Renewal by Andersen Corporation INSURERC: 30 Forbes Road INSURER D: Northborough,MA 01532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF WWRANCE JIM wVDPOLICY NUMBER MSI POLICY EFF POLICY EXP Lam A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0 CLAIMS-MADE TOCCUR MWZY302940 1010112014 1010112015 PREMISES jEa occurtence S 500,004 MED EXP(Any one person) S 10,0 PERSONAL&ADV INJURY $ 1,000,00 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,00 X POLICY El SM F LOC PRODUCTS-COMNOPAGG $ 4,000,00 OTHER; S AUTOMOBILE LIABILITY COMBINEDa $ 5,000,00 A X ANY AUTO NIWTB302575 10101/2014 10/0112015 BODILY INJURY(Per person) $ AALED SCHEDULED BODILY INJURY(Par acadwM $ AUT NON-OWNED PRWEUY DA A E $ HIREDAUTOS AUTOS (per accident) $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAa HCLAIMS-MADE AGGREGATE $ DED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS LIABI'LITYX I STATUTE I I ER A ANY PROPRIETORIPARTNERiEXECUTIVE YIN MWC30293800 1010112014 10101/2015 E.L EACH ACCIDENT $ 110001 OFFICERIMEMBEREXCLUDED? N❑ NIA (Mandatory In NM E.L.DISEASE-EA EMPLOYE $ 11000100 If Yes,describe u Kim DESMIFTION OF OPERATIONS below E.L DISEASE-POLICY OMIT $ 1100010 DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Sdwdule,may be attsohad U morn spaes to required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE YPLL BE DELIVERED IN ACCORDANCE YYITH THE POLICY PROVISIONS. AUTHORIMD REPRESP.NTATNE Evidence of Insurance ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD k . 4 a� Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License;CS-080125 " ,\\ JAIME L MORIN 86 GARDINER ST -M4.$KA`, LYNN MA 0190rr '��. �' Expiration Commissioner 10/08/2018 ... � C-�il'e�anr.�oouc o�Q!uaaoaalitioells Rice of Consamer Affairs&Business Replallon I. IMPROVEMENT CONTRACTOR i Registration: 1.70810TYPe.`1 Eacplration: 92123x21315 Supplement+ * RENEWAL BY ANbE'RSOWCORPORATION l It JAIME MORIN 104 OTIS STREET NORTHBOROUGH,MA 01532 Undersecretary j( t