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HomeMy WebLinkAboutBuilding Permit #101-13 - 472 MASSACHUSETTS AVENUE 8/6/2012 B-UILDING PERMIT tA0RT#j TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION -JK % Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page Print JRPPE P 14 _k_TTYMWIN=E81,1A „titer ; ­ _fhhtl 7S _MA'P)N(D".'Opp < PAkC .'ZO' N"ING -i is rct, ,- yes ) Wn 0�bhihei�sob' agi�,V yes$ ...4 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building e fa�miy . Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic A _ e. . ain, wetlands;,, Waterslied_District z,, �7 Water/8'e we-r!,* ' DESCRIPTION OF WORK TO BE PREFORMED: Ive Identification Please Type or Print Clearly) OWNER: Name: T e FA 10VZ Av Phone: Address t-M V*A65 A11Z "N7 A) 4 e 250 "Rh6ri )00 N'Tir RA`qv�T'0 R "N afm'e'- !'A'dd 1.9 " -ssu yisor-'§,11._ nstir ujctibh�Libdoso 67-76Q E per 'oMp mpToygiT�en12:., 'Ei P. , S qqR 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. O Total Project Cost: $ 6,e5col FEE: $ C-3 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signaturef Adent/Owner Signature of.cantrac7to 7� 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 ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks i ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 I New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 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 2.2008 i J Plans Submitted Plans Waived Certified Plot Plan Stamped Plans i 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 CONSERVATION Reviewed on Signature S COMMENTS HEALTH. Reviewed on Signature COMMENTS I 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 DPW Town Engineer:FSignature: Located 384 Osgood Street FIRE.DEPARTMENT- Temp Dumpster on site yes no. Located:at 124.Main Street Fire DepaitMent-,signature/date 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use) I I I Y I i ® Notified for pickup - Date Doc.Building Permit Revised 2008 ti 1� Location No. Date - �— t • ' TOWN OF NORTH ANDOVER . e a e Certificate of Occupancy $ • Building/Frame Permit Fee; ° � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# T 25583 Building Inspector f NORT1y Town of _ Andover No. ro h ver, Mass, g • I 'Q COC NICNl W/CN S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ............�.�.. U110 1............................................... BUILDING INSPECTOR has permission to erect buildings on ,. ..J..;r!'.— Foundation .. :............... T.. . ........................ Rough tobe occupied as ........... ....... ......... ...................... ......................................... 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 CONSTRUC N DRTS Rough Service ................ ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 NORTH Town -o- � .. ? . :....�,.� ndover No. — - h h ver, Mass, � • I r�- COCMICNlWICK �� CRATED P �y S V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT L ...... .�.. �'^^ 1............................................... BUILDING INSPECTOR has permission to erect VV g . .. �S' Foundation .......................... buildings ..... .... .. . ........... �...... —................. Rough tobe occupied as ........... �........ ......... ......... ............................................. 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 31� — UNLESS CONSTRUC N DRTS Rough Service ................ ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT 1 Until Insoected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE From Our Home to Yours... MA Reg#146589 t Federal ID#20-2625129 CT Reg d",Ia, �- RI Reg ', .463 Windows,Siding and More k Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com THIS CONTRACT MADE THE it day of ;., ` 20 between V { 4:. t i d (Home Owners) (Home Phone) (Bus/Cell Phone) of A� - 14� i A tC Itt�f '� lr cy� i` .� i� !� �E ` (Address) (City) (state) (zip) the"Owner"and NEWPRO Operating, LLC, "NEWPRO". F-1 The job address is a condominium. NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install the following described work at the premises located at r r,, (Job Address) * (E-Mail) for proprietary use only TOTAL Additional Model TOTAL Windows Purchased INEWPRO7�- _ Work Number Q!y CASH r Window Color In: Whk J,J;` ut: Sliding Glass Door PRICE r Capping Color Steel Security Door Door Color In: Out: DEPOSIT ! Model Name Model Number(s) Qty Sidelites -° WITH 1� Double Hung New Construction Unit ^"^- ORDER t Picture Window f. Storm Door BALANCE Casement ? :' Obscure Glass TOP BOTTOM DUE AT 2 Lite/3 Lite Slider Screens "LF FULL INSTALL Bay/Bow Frame Please Initial: m- Roof: ❑ Soffit: ❑ Customer understands that NEWPRO®does not CASH Garden Window do any painting or staining. (ie:when removing Balance paid to installer at installation Awning or replacing interior stops or trim) Hopper -w NEWPRO®is not responsible for conditions or Shaped circumstances beyond its control including con- FINANCE Other densation resulting from or due to pre-existing Bank completion form signed at installation GRIDS �4 Colonial SDL Euro conditions. DESCRIBE WORK: r`_ uAk Of�' . z. it`,� . - 1-4r I t zC r ,sem �/ v r i II 1 Est. Start Date: t Customer understands this is an"estimated date" Est. Comp. Date: Unt, Initials Customer understands all steel security doors will have a 3/4"aluminum threshold installed over existing threshold. It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent. The Owners who secure their own construction-related permits,or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. All Home Improvement Contractors and Subcontractors shall be registered by the Director and any inquiries about a Contractor or Subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration,One Ashburton PI,Room 1301,Boston,MA 02108,(617)727-8598. If the Owner is obtaining financing by way of a Retail Installment Sales Agreement,such Agreement shall include a time schedule of payments to be made under said contract and the amount of each payment stated in dollars,including all finance charges. The Retail Installment Sales Agreement shall be incorporated herein by reference. If the Owner is obtaining a revolving credit line to pay,in whole or in part,for the contract amount herein,the terms of the revolving line of credit including interest rate and payment terms,shall be clearly set out on the credit application. The portion of the credit application referencing a time schedule of payment,to be made under this contract,and the amount of each payment stated in dollars,including all finance charges,shall be incorporated herein by reference. NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of$100,000-$300,000. If the Owner refuses to permit NEWPRO to proceed with the work herein,or in the event of any breach of the Owner of this agreement,for any reason whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid,as fixed, liquidated and ascertained damages,and not as a penalty,without further proof of loss or damage. NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control. j Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners to enter i into this agreement. This contract represents the entire agreement between Owner and NEWPRO and cannot be changed except in writing signed by both the Owner and NEWPRO. You are entitled to a copy of the Contract at the time you sign. Keep it to protect your legal rights. We,the aforesaid owners, certify that immediately after the signing of the aforesaid agreement, a copy was furnished to us. I, You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the f seller,which may be his main office, or branch'thereof, provi1ded you notify seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. (Saturday is a legal business day). See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. OThe owner has seen"sample"warranties that will be provided by NEWPRO upon installation. Sample warranties provided to Owner. IN WITNESS WHEREOF,the parties have hereunto signed their names this 1 i day of 1 f il\> 20� t � 1 EIN# Signed 1*_� _".74 ? I �FL�ts Marketing Representative Printed Name l Owner ,l Accepted: NEWPRO Operating,LLC - By— Signed Owner CORPORATE OFFICE / WARWICK BRANCH OFFICE 26 Cedar St 24 Minnesota Ave Woburn,MA 01801 Warwick,RI 02888 (P)800-242-9974(From NE) (P)800-356-3312(From NE) (F)781-933-0717 (F)401-732-1371 i WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy i US-15 R0508 I V Frorr OtarNometo Yours... JOB#: LEAD PAINT STATUS I Yr Built: 1M LSWP: )C ONE MUST - ; Widdoin,Siding and More Pa of1 XEM E PT. BE SELECTS —F— �' ari E-MAIL CUSTOMER s i DATE t' HOME PHONE 7 ADDRESS MASS V SR S VCS WORK/ ELL HONE — CITY,STATE Nuri h An( t�e�,f It1 T_ZIP BEST DAY TO INSTALL: M T W TH F (circle one) ? PRODUCT SPECIALIST ho " nsonESTIMATED START DATE TOTAL#OF #OF BOWISAY/ "EXTERIOR GRID COLOR WINDOWS GARDEN CLADDING #OF DOORS (insidef0utaide) CAP COLOR g�' eew•- White rm F SDL 1^/ MFG: MAPCO/ Norandex iGarden_S Stee S ontoU VV h\�[? Other _ or Soffit Painted to X prafae (circle one) Diamond / Smooth Locks$Kea Pers(c/rcle one): h mo Bronze Brass (circle one) (circle one) Handles&Night Latches(circle all that apply): (1Qe � Imo d Bronze No Bottom Handles Night Latches(Night catches are N T/a�sttanda d0aru�m)) Inside Color (circle one) hit �aiural London Walnut Colonial Cherry Muskoka Oak Barrister Oak Outside Color(circle one): /Whitd Univ.Brown Wicker Forest Green Wedge Blue Sandstone Burgandy Bronze Custom 1OPENING SIZE STOPS i NO. STYLE W x H U.I. LOCATION GRI SCR IN I OUT CONV ADDITIONS OPENING CUT U X ►V ti 12 � x Jqy4,JW,1 x qlf A 2 2151 2'x L'l v 1 x`Jb x b x 13 - �x �5 , ,v � 2 14x c x V /� '12 ��, �cn x tj� 3$t x C & ,00J,3xVqJx x ,� �a�. 35 -. x x� C. Denl� � x x L x (A x Ix G 3�X e 2 3� x c x 2 ��"x x . A 5/s U ,D3 I'xx 3 37�V x 3 ��� ✓✓� X ' b z sx j r x L Yv 2 35yrx 3 l x NSI . . X -BA j R 112 �5qr x 3�Oxy� g 2 x , x V 2 :s x x V L Measureman: _�Z Initials Date Crew Size Needed Time Frame to complete job Capping Type fir✓Special installation Instructions: �1r1� () !C , �(V.ry-\,e ,,� __ J e�►�le A Revised 111111A a t From Our Nome to Yours... JOB#: LEAD PAINT STATUS Yr Built: - LSWP: �_ ONE MUST Windows,Siding and More Paof /, EXEMPT: BE SELECTED I CUSTOMER - 1 ge Sdn) . E-MAIL { DATE ��I "_IHOME PHONE t {� ADDRESS y1�( ` _ WORK/CELL PHONE CITY,STATE NoA` l` n (�ye(� I A ZIPy. V �� BEST DAY TO INSTALL: M T W TH F (circle one) PRODUCT SPECIALIST t 1D1Y7�SUT�/ LJer S ESTIMATED START DATE _ TOTAL#OF #OF BOW/3AY1 *EXTERIOR GRID COLOR i WINDOWS GARDEN CLADDING #OF DOORS (tnsidefCuteide) CAP COLOR I Bey' BovA White Storm SDL MFG: NAPCO t Norandex 1 i Garden__.;—Shetr_,� Steel Contour � � Other 14 Roof or Sofif Painted Patio Prairie (circle one) (circle mooth Locks&Keepers circle one: 67e � Bronze Brass Diamond / P ) ((CIM/0 one) (circle one)one) Handles&Night Latches(circle all that apply): it mon Bronze No Bottom Handles Night Latches(Night Latches are NOT standard feature) 1 Inside Color(circle one): N63N63k London Walnut Colonial Cherry Muskoka Oak Barrister Oak Outside Color(circle one); hit Univ.Brown Wicker Forest Green Wedge Blue Sandstone Burgandy Bronze Custom I OPENING SIZE STOPS NO. STYLE W x H U.I. LOCATION GRID SCR IN OUT CONV ADDITIONS OPENING CUT 20. 2155 X 13 3 �z ��-x 35' x y t1 x LI'Ll U x x x x x x x x x x x x x x x x x x x x x x xx x x ' - x x Measureman: Initials Date Crew Size Needed Time Frame to complete job Capping Type - Special Installation Instructions: Revised 11/11 PRE-INSTALLATION INSPECTION MATERIAL CHECK LIST CUSTOMER NAME ADDRESS -------- --------_ _ -------- --- NE PHONE: DATE: Please Circle TYPE OF HOUSE EXTERIOR OUTS.DE-GAS.MG� CASINGS _ 2 Story Aluminum Siding 8 Hrr % 2 1/2 Clam. 3 Story Asbestos 4 Bend 1 2 1/2 Colo Camponelli's Brick Blind Stop 3 Clam Cape-_ Clap Board Crown Headers 3 1/2 Colonial Raised Ranch Stucco Flat Belly T1-11 Narrow Metal Fin Flat Split Entry Vinyl Siding Permashield Tri Level ,/ oo 16 CONSTRUCTION TYPE OF INSTALL STOOL STOPS Barn Sash Aluminum Track 2 1/2 1 5/8 nia'�. Bay Removal Anderson 3.1/2 2 Bow Removal Outside Install 41/4 1 5/8 Ranch Enlarge Opening Plastic Track 5 Bull Nose Garden Removal Replacement 6 7/8 Colonial Mullion Removal Steel Frame Clear Silicone Scotia Reduce Opening Thumb Latch Latex Weight Pockets White Silicone Wood Conversion tom : ~j List all othein mation and Stock Needed s AC4Rl�� CERTIFICATE OF LIABILITY INSURANCE DOAT5 0M/D2012 05/02/2012 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(ies)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 NTACT NAME: Mackintire Insurance Agency, Inc. PHONE Ext, 508.366.6161 aCNo:508.366.5202 11 West Main Street E-MAIL ADDRESS: _- Westborough, MA 01581-1931 PRODUCERCUSTOMER 00013793 ID INSURER(S)AFFORDING COVERAGE NAIC# _ INSURED INSURER A; Peerless Insurance Co. 24198 Newpro Operating LLC INSURER 8: 26 Cedar St. INSURER C: Woburn, MA 01801 INSURER D: INSURER E: COYERAGES� CERTIFICATE N!!G`RER: 1.1-12 Revises! Master` 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 INSURANCE ADDL SUBR POLICY EFF POUCY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY CBP 858957 12/31/2011 12/31/2012 EACH OCCURRENCE $ 1,000,000 DAMAGE TO X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE ri] OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PROECT El LOC $ J AUTOMOBILE LIABILITY BA 858417 12/31/2011 12/31/2012 COMBINED SINGLE LIMIT $ .. (Ea accident) 1,000,00_0 ANY AUTO BODILY'INJURY(Per person) $ ALL OWNED AUTOS --------- BODILYJNJURY(Per accident)'$ A X SCHEDULED AUTOS PROFERTYDAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR CU 858257 12/31/2011 12/31/2012 EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR HCLAIMS-MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION WC864507 05/01/2012 05/01/2013 X ORYLAMITS ER AND EMPLOYERS'LIABILITY Y/N ANY 4 OFFICERIMEMBER EXCLUDED?ECU 11VEa N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S00,000 . ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ERTIFICATE HOLDER CANCELLATION 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 To Whom It May Concern Timothy Mo na h ©1988-2009 ACORD CORPORATION. All rights reserved. ;ORD 25(2009/09) The ACORD name and logo are registered marks of ACORD � ✓he. �anv�rwazusealC� n�..l�aaeae�uaeC�`s ' Of:ce of Consumer Affairs&Business Regulation �, License or registration valid for individul use only OME 1111IPROVcMENT CONTRACTOR i before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration 1,x16589 �`Ti 10 Park Plaza-Suite 5170 < .x% Exp�r2fton, �5 ;zp3'3 Supplement :ard Boston,MA 02116 NEWPRO OPERA'rlffl- CL THOMAS FOXO!`—t'-: 20 CEDAR ST 4 vt � V`JOBURN, IviA 0180Yi;_,:-.,•r.,.' � — — Uadersecretary Not valid without signature Massachusetts -Department of public Safety Board of Building Regulations and Standards Construction Su er%isur License: CS-029090 ; �r�.• 40, r1 THOMAS P FON r HI 230 WALNUt-ST i `' 1'' r READING* 0t$Itk y {, Expiration Commissioner 11/19/2013 'v a - The Comm nwealth-v,f Massack-mse,#s Departmer�-of Indusifriail Accideltts A . p,}�tce:�►f�ia�e�sfigat�ss SOD WashiiWOn Street Bosm4 MA 0M1 www n ms govAUa - a Workers' Compensation xasnrance Affidavit:gtgders/Contractors/ElectridaiadPl mbers � Agolicantlnfolrmatio Please print I,et=ibl f: Name(Business/Organization/Individual): eUJ_ _c� D e.� i At I .Adiiress: a h C' �Y a r C�fl 01 g co v- Phone.#: :Are you an employer?Cheek the approprsate bog: Type of project(required)': r t 4:. ❑ I am:a general contmctar and.I I am a employer with , Jr—C) 6, New construction employees.-.(Mand/or art time:* Have hired the sub-contractors p ), 7. Remoc3elin-,. 2 ❑ I;atn a sole proprietor or partner listed on the attached sheet. . ship and have no employees These sub-contractors have $ ❑Demolitrnp . Buil ding adcttiion worldna for me m an capacity. comp insurance•, 9 i _ b y aacity. ❑ ding" [No wor1.kers'camp.insurance 5. ❑ We area oarporatian and ids 2Q.❑Blectrneal repairs or additions required:} officers have.:ezercised their 3.❑ Imam a homeowner doing:all ovoik right of exemption per MGL T.1.❑Plumbing:, airs.,&additions c.15' 1 myself[No workers comp, {4?;and we have no i2.❑Roof.repa rs insurance required:]t employees [Np%N prkers' 110 Other. .eamp msuz'anaerequirecL�; _ "AYapplicantthatchec3cs:boxfilmustalsofit[pathe8=000belowsliowing W,work«':a6mp-satioapoIICYrhtntma6on t I3omeovr _who submit this affidavit indicating they are doing sil;wod and'the�hire outside confrsctors must sultmiti avew'a davit indicating such. ZCanua tors thatci,eclthuboxmistattiachedsnadditionalsheetshOwingthe:nameofthe:sgbconnectorsendthe¢wodoors'COMP.policy'iohrmation-. I azmdn employer that is providing workers'.compensation imarmice for my mV19yees. Below is!h_e policy andjob site a jorrea�iiorr. ,liisurance Company Name: ),gG K i n 't r) U>'" oCc, Co f hnoa r y Policy#or Self-:ins.I.ic.tt: E iration Date;. S Job Site Address: '�a. �"� -�� ,. Cityrstate/zip: i , f�Uc� f� OJ��� A106of the workers''_eom nsation polley declaration ae(Aimmg the palicy:Wmber and expiration date). Faihire-,Wservm.cowerage as required tinder Sed-400SA;:.ofMG ,e .1.51-,.can lead to the:imposition of cr uaal p tialties of s fide up to S1;500'.00�and/br one year irmrison�meutt as weII as civil penalties in:the form'of a STOP WORK ORDER and a fineof np to, 250 A arlay ams#the violator. Be advised:tT at a:copy-ort]is'stateixaeat may be oroeartiied to the Di ce of Iftyest ptions of the DIA for ins n-ance-covemp vetriication. Ida hereiij�cerizfy unJler ihe,p°ns'andP 0fPre?"lzUvhdt 4 e infortnution prate de-a ove-ts true arad Tree : Signature;. Date: O f acial else only. Do:not write in this':area,•m be tornpteted by city or town of jciaj Issuing Authority(circle one} l Board of Health 2.--Duildi ft Depaz•tmeut 3.;Q. ty/Town Clerk 4.Llectrietil Inspector 5 Plumbing Inspector . 6.Other Contact Person; . _._ phone#: in Highlighted RegiOils ® =Qualified In all zones NEWPRO MANUFACTURING SERIES G NEWPRO 2000 LANPRC DOUBLE HUNG Cellular PVC frame,Triple glazed, Nallonal Fenestration Low E coating(e=0.027,S2&5), Raling 0oundle Kryptonlair filled DEV-K-27-00030.00007 ENERGY PERFORMANCE RATINGS U-Factor(U.S.A-P) Solar Heat Gain Coefficient 0.17 0.24 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air leakage(U.S./I-P) 0.40 0111 Condensation Resistance 70 -- Man**ret pmduetpe*mance.NFRG radags am determined for afbtedadof wdmmenrtd condt0anaand a epeoMc pproduct else.NFflGdses hat It manufacWrecommend anyproduetand doeenotwauerdMeaultahglHaf enN product ror am epeclfic uN.0oneuwwwr�.nfro,ofor other product performance bdcrmegon, r