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HomeMy WebLinkAboutBuilding Permit #414-2011 - 5 PERRY STREET 11/15/2010 BUILDING PEKMI I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION b yyT 7 abf� Date Received Permit N0: °�q�reo►� c� �SSACHU Date Issued: �f fS' �0 MPORTANT Applicant must complete all items on this page WEr TYPE OF IMPROVEMENT PROPOSED USE Residential, Non- Residential ❑ New Building A One family ❑ Addition 0 Two or more family 0 Industrial ❑ Alteration No. of units: o Commercial Repair, replacement ❑ Assessory Bldg 0 Others: 0 Demolition 0 Other DESCRIPTION_ t( OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address ��e 1� �� ACAQl�? b§ � r rmrr •+k:sa,.zzs» ..u.�--.aa.",m t. <:...� 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. 00Total Project Cost: $ 1(o e 52(a -uv _FEE: $ Check No.: !/-26� Receipt No.: 2J NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund : .: h. 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract - Li 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 ❑ Workers Comp Affidavit El . 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) o 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 o 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) o Copy of Contract ❑ Mass check Energy Compliance Report D Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 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 ❑ j I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF U FORM DATE REJECTED DATE APPROVED PLANNING &-DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION N F1 ❑ 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 �r '"e„ c' ��r,► ..: ' -a.«:<<:a�sy n�r�raz�.�i?,]> tl���'�$,��,���� "���'r� k�,�s„'�.R':�� ` �c '�'s �" ,� �.' Y� �j'' ;,�,a'.l�sar'r. '( 6♦ Q g ,3 Dimension i 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 MGL Chapter l% Section 21A—F and G min.$100-$1000 fine NO NOTES and DATA— (For department use I 0 Notified for pickup - Date Doc-Building Permit Revised 2007 Location - K No. y/��-��// Date / "i Of AORTA TOWN OF NORTH ANDOVER O � a a y, + ; ; Certificate of Occupancy $ Building/Frame Permit Fee $ Z Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 6 '� Building Inspector ORTH TONM of Andover . No. 6 t"f- L A K_ O lover, Mass., COCMICMEWICK V %p ADRATED P' C 1 S J BOARD OF HEALTH Food/Kitchen PER IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................:................................................................. . ........................................................................... Foundation has permission to erect...............:...................... . buildings on ...XY_r?.° tr.................................................................. Rough (Ol/ Chimney to be occupied as "... d ............................. .....................................................:.......... . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations'Voids this Permit. Rough Final PERMIT EXPIRES IN r_6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I(1}Ori:SL.N Irthhnnnt h,I11A 61,5:31 J&1.i INOOM,INC.,O/1S/A MA Herne Improvement Contractor �;108)4119-0900 FAtx:t774i 987-3013 Renewal #149O')I (f:xpires '1/24/2411) byAndmen. Federal Tax 11)#,33.040420 CUSTOM WINDQW AND DOOR REMODELING AGREEMENT Bu ertsl Nome _ Date of Agreement ij2i-1-X)/ C,-Z a Buyerlsl Street Address,Cry,Stole,and Zip Cods E-Moll Address home Tele hone Nom ., C-"–'/ Mirk}elephone Number 8Uyer(s) herebyjoinlly fund sSOVCrally agrees to purchase the products and/or services of)&L Windows,Inc.d/b/a Renewal by Andersen ("C ntraotar"),in accordance with the terms and corlditionS described on the front and the reverse of this agreement and on the attached specification shect(s) (Collectively,this"Agreement").Buyer(s) hereby agrees to sign a completion Certificate after Contractor has completed all work order this A„rs;emcnt. // Method of Pymr.t:0 Cash U Check J Mastercard U V15A Total Job Amount Gf Disrover U Financed,App#: Deposit Received(33%):/S 7` F� l�! ,........ 1 ' ,fV-0'0 Name on Credit Card: Balance at Start of Job(33%(: S`1J v 0.. Estimated Completion Dote: Credit Card#: Balance on Substantial Completion of Job(33%1:�Do �. (f/,9,f, CC Exp.Date: CC Security Code: By iaitialirig here,you acknotvlerluc chat the Balance at Start of j'oh and the balance on Sul.sstantial C.omplct.ion Buyer Initials of Joh cannot he mad('by credit ca,rJ and must be.madr.by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitute&the entire understanding between the partied,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)her4hy 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. J&L Wind* ,Inc.d/b/a Renewal by Andersen Buyer(s) Buver(g) Si,Ytat re of p educt N1anaRcr Signature 5i.gnaturc w Cli'y/ Print Name•of ProduCt�na>er Print Name Print Name. YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT Or 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- NOTICE Q CANCELLATION Date of Transaction - You may cancel Date of Transaction . You may cancel this transaction,without any penalty or obligation,within I this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three busit+ira days from the above date.If you cancel,any property traded in,any payments made by you under the 1 property traded in,any payments made by you under the Contract of Sale,and any ne4otiable instrument executed I Contract of Sale,and any neqoKoble instrurrrenf executed byyou 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 gsactionwill and any security interest arising out of the transaction will be canceled.If you cancel,you must make alable to the be canceled.if you cancel,you must make available to the Seller at your residence,in substantially as gcondition 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 Wier'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 Seiler and the Seller does not Seller does not pick them up within 20 days of the date pick them up within 20 days of the dare of your 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 an further abli8alion. If you fail to make the make the goods available to the Seller, or if you agree goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do gar then goods to the Seller and fal ro do so,then you remain liable you remain liable for performance of all obligations under Tor 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 oe any other written other written notice, or send a Wegrom to Contractor:J notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT.OF (Data) OF_ .(Dale) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION, Buyer S Signature Noe Buyers Signature Date RbA Copy- White Buyer Copv-fellow Buyer Copy.-fink V0 39vd -:TBL; 2T:60' 0T07/E0/60 J&L Windows,Inc,4/b/a 104 011k Strcct,Northborough,MA 01 y32 MA H1C LiCenke 0 14;)6,01(expires 1/24/12) Phone 508,9 19,0900•Fax 11 774 987.3013' � Renewal� �� �� � � Foderal Tax IDN 83-0404 20 1 byAnderseh.: WINDOW REPLACEMENT as Andtme C Pm y - OF Gumw MrssAcHusrers AND NEw HAmrsHm WINDOW SPECMCA71ON SHEEP_ Buyer(s)Name Date of Agreement The Buycr(s)listed above hcfcby jointiy and severally agree to purchaw 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 DETAU 1. Contractor well Install a total of windows in Owner's home,using the following individual quantities: Double 1iur4g(DB) Equal sash Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑HEl right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle. [)cubic Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:I or ❑ I:2:1 Q Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPAA� ❑ 1:1:1 or Q 1:2:1 Awning Window(AW) Picture Window(PW) [lay or Clow Window Patio Doors(see separate Door Specification Sheet) 2. �U Yes Q No Qty of Windows to be Custom Fit Replacement: 3, ❑ Yes No Qty of Sills to be replaced by Contractor: 4. ❑ Yes B No (Zty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 F'ibrex brickmold 5. Glazing to be:k HP Low-Ex?;)SmartSun"A (Tax t-tadr'tEZ&jblc) ❑ Other If other,please specify: G. Exterior color to be;,] White ❑,S,and ❑iCari�as ❑ l erratone E],Cacoa Bean ; 7. hitr.rior color to lx: tRWhitc ❑ Sand ❑ Canvas n tl.cqatone ❑ Pinc.[] Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. S. Hardware:�K White [❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style:, D. F Yes 2�>No Install Lifts with Double Hung Windows 10. Screens; windows to have: ❑ Half or)DA�ull screens Screens to be:'Y Eberglass ❑ Aluminum ❑ TruScene GRXI,E DETARS 11.Windows have grilles: ❑ Yes XNo if yes:❑ Grille Between Glass(enc)❑ Removable Interior Wood m7w)❑ Full[)h2ded Light(m1J Qty: Qty= Qty: Qty: Qty: Qty: —�-- DH 0H DH DH CW/Piotum 4goer CPW orG Draw grille patterns above `Lase additional sheet if needed Owner approved(initials): ADDI'T'IONAL WORK DETAIM 12.❑ Yes jg No Contractor will remove metal frames of windows, Qty of Units: 13,Q Yes I No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine [ Maintenance-free material 14.❑ Ycs�R No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine [J Maintenance-free material 15. Owner is aware that Contractor does not do any painting. ( )Owner initials 16- Yes E] No Contractor will wrap exterior casings with aluminum coil stock of Gam_color."Ur '0 Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.X Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18. Yes Q No A limited warranty shall be issued to Owner upon completion of the job and payment in.full. 19.�Yes ❑ Ne Buil irtg T'ermt— Contractdr,will secure any and;all necessary pctitiits:The fee for'the permiti(s),is not included in the Contract Price and a separate check 1s required at the time of sale for this fee. 20. Additional job details: 21. Yes El No Owner agrees to be present on the final day of installation for final inspection Axid to deliver final payment. p finalluywrent shall be demanded until the contract is completed to the satisfw6on ofali parties. it is agreed and understood by and between the panics that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there arc no verbal understandings changing or modifying any of the terms. This Specification Sheet xray not be,ch"6d or its terms modified or varied in any way unless such chartges are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specificafim Sheet. Rtncw y7Ande sen of Greater MA and NH Buyer(s Buyer(s) Bv: F-- --• �gnature o oduvi Manxgct / Signat=e Signature Print Name of Product Manager Print Name Print Name E0 3�dd S3�dtilS E89b9LZZ8L 8L�6© OT.9c'/E©;'69 1041)lis Street,NOtthbOrullY,kL MA 01532 L Windows,Inc,d/b/a Renewal MA H1C Ucen$e N 149601(expires 1/2.1/12) Phone 50$,919.0900•Fax 77;087.3013 federal Tax IDN 81-0404201 byAndersen. WINDOW REPLACEMENT ao Andeme Company OF GREATER MAssAcHusms Arra NEw HA.rtvst= WINDOW SPECIFICATION SHEET Buyy-err((s))Name Date of Agreement The 6uycr(s)listed above hereby jointly and severally agree to put-chase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sllecl and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMINT, of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install it total of-2 Y__windows in Owner's home,using the following individual quantities: Double Bung(DE) 0 Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) [] Oriel sas11(2/3 top,1/3 bottom) Casement(CW) ❑'Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle. Doublc Casement(CDW) ❑ Standard handle 7,-Metro handle Casement/Picture/Casement(CPWV ❑`1:1:1 or, 1,2.i_❑ Stazrdardit.cidle"❑ fvtetro,handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(PW) Clay or Bow Window Patio Doors($ee scparata Door Specification Sheet) 2. Yes ❑ No Qty of Windows to be Custorn Fit Replacement: 3, ❑ Yes No Qty of Sills to be replaced by Contractor: 4. ❑ Yes No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ElPine E] Maintenance-free material ❑ Factory applied 908 Plbrex brickmold 5. Glazing to be:k HP Low-E40 SmartSunr'M (Tax Cse+ditEZLgifble) ❑ Other If other,please specify:_ G. Exterior color to bc::,X White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. interior color to be: �R White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine [] Maple ❑ Oak Note: Interior color can only be white,wood or sane color as exterior. Wood interiors need to finished by Owner. S. Hardware;,3.White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ Yes �No Install Lifts with Double Hung Windows 10. Screens. windows to have: ❑ Half oi-3a:; tll screens Screens to be:Pf Fiberglass ❑ Aluminum ❑ TruScene GRILLE DETAIIS 1 i.Windows have grilles: ❑ Yes No if yes;❑ Grille Between Glass(GAC)❑ Removable Interior Wood(i w)❑ Hill Divided Light(tnU Qty:__ __ Qty: Qty: Qty: Qty: Qty: Qty: I DH DN - OH OH CWrPictua pIICBr CPVJ ofG Draw grille patterns above "Use additie:i.dl'sheet if needed Owner approved(iniiials):( ) ADDI'T'IONAL WORK DETAILS 12.❑ Yes No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes g No Contractor will install new paint-ready or stain-ready casings. Interior,casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14,❑ Ycs No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any painting. ( . )Owner Initials 16.( Yes E] No Contractor will wrap exterior casings with aluminum coil stock of�color:�I�r TA Note: Wrapping may be required with storm window removali removal of storm windows will leave screw holes in casing. 17.�Yes ❑ No Contractor'Mil insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. i 9.K 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. 20, Additional job details: 21. Yes p No Owner,agrees to be present on the final day of installation for final inspection and to deliver final payment. /No finallmyment shall Iv,demanded until the contract is completed to the shtisfaetion ofall palates: 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 tcrnts. This Specification Sheet may not be cha=rged or'Pts terms modifted or varied in any way artless such charges are in writing and signed by both the Buycr(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewof Greater MA and NH Buyers Buyer(a) Bv 5ignature o odtut ManuZct Signature Signature j Print.Name of Product Manager Print Nairne M Print Name EO 39ttd S3-livis 68eb9L T.8L 8T.:60 OTOVEO/60 . The CommaxweaYJi of Massachusetts Department of Industrial Accidents Office of Investigations 600 FdOdngton Street Boston,MA 02111 www.mus govldia Workers Compensation Insurance Af$dsvitt Builders/CoatractorsXlectridazslPlumbers Applicant Information' Please.Print Lenbly NaMe(Business/Organindon/lndivid'ad): J)en I�1 G.l Ny H1'i el-S e Y1 Address: CitotstelZip: 'rte d �� Phone Are you an emplayer?Check the appropriate bay Type of project (rt:gtiired); 1.f�-i=a employer with•L3 D 4. []'1 am a gmmal contraatar Rad I fi, ❑New construction employees(fn f M' /or part-time),*' Im hired tdm sub-contractors 7s dating 2.❑ I Rm a sole proprietor or perkier- .listed m the attached sheat t ship and have no•amplorm .7msr--mb-contractors have R, Demolition - working form.in any capacity, wml-xn' comp.ironmoe. g, ❑Building addif m [No w.orkms' comp:inmrarioa 5. ❑ Wean a corporation end its 10.0 Eloctrical repairs or addifiom. roqL�rad.) . offers have=raised their 3:❑ I am a homeowaes doing an work 'lift of czeniption per MGL 11.❑Rhrmbing repairs or additions myself[No workers'comp: a 152,j1(4),and we have nti 12.[]Roof repairs insu ante required,] 13.[]employees.-[No WorLtss' 13,❑Offer comp.insurance rggnimd.] *Any appHmit tbet 6mih boz#1 must also fll ora the seatioe belmr showing their wod�e'oompeasa6oa policy info�atioa t H'omeownen who submit ft efyi jne hr=&g they are doing znwet end dam hire outside coatractaa nuut mobmk n new etndevft iadieating such . toanaotors th.9 chwk 6b bn mast atfarhed ea additional sheetshoring the aa»u of the sub-eoat:nntaa end dui wool as'comp.policy iafnnaatiaa I am an empla��er that isproyidiV workers'cowp=l don insarant:e far my employees 33elaw.ia the policy and job site ' ircforrrtatwn. f �,/� (( Insurance Company Name; - Policy#or Self-ins.Lic,M. 3�� GU,���� ��`� Fzgiratioa Data: Sol;Site Addnss: AtLRCh a Copy of the workers' compeasst ' apolicy declaration page(showing the policy number and erplratioa data). Failure to smowo covorage as required under Suction 25k of MCrL c.152 can Iead to the imposition of criminal penalties of a frac up'to$1,500.00 and/or one-year imprisoammt.as weIl as civil pmaltim in the foan•of a STOP WORD ORDER and a fine -of up to 5250.00 a dagainst t o violater. Be advised that a copy of this statemmt may be forwarded to the Office of ay Investigations of tho DIA far insurance coverage verification. Ido hereby c !!u er the paints and penalties injury that tite informationproYided above is trusand correct �; ' . . Silraatnre: . Phone#' ,(ficial use ortfy. Da notwrite in this area,to be camp d by city or taxln a fecdaL City or ToQtw PermitlLicease# Issuing Authority(circle one): 1.Board of Health 2.Building Depi<rfinent 3.Oty/To4rn Clerk 4.Electrical lrispector 5,Plumbing Inspector fi,Other Contsct Person: Phone#: INfivisachusetts - Department of Public Safety -Board of Building Regulations and Studar.ds 'Construction Supervisor License License: CS 85707 BRIAN DENNISON. 86 CREST CRCLE ° WORCESTER, MA.Q1603. Expiration: SWO12 Commissioner Tri: 2522 4 7)j jf0mwwftww& ttk Qffiee or Commer A li, &$asine:s'B.egnt:fioa HOME IMPROVfMENT CONTRACTOR 1wsoon • Re9lsftG0 ' LD1 , Explra •12 y e Card RENEWAL BY • BRIAN DENNIS _ 104 0T{S S — NORTHSOROUGH, _ I3ndetsecretuy ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYYI T02/10/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP MCKeone insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC# INSURED Renewal by Andersen INSURER A: Hartford insurance company J and L Windows, Inc. INSURER B: Nautilus 104 Otis St , INSURER C: Northborough,MA• 01532 LNMER D: INSURER E.- COVERAGES :COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT, 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A00'L POLICY EFFECTIVE POLICY EXPIRATION TR POLICY NUMBER LIMITS B GENERAL LIABILITY NC958461 10/01/2010 ATE fMMIODNM/2011 EACH OCCURRENCE i 1 ODO ooD COMMERCIAL GENERAL LIABILITY PREMISES omurence c 100,000 CLAIMS MADE OCCUR MED EXP Any one person) i 5,000 I PERSONAL 6 ADV INJURY 1,000,000 GENERAL AGGREGATE S 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG t 2,000.0000 POLICY 7PRO- JECT LAD A AUTOMOBILE LIABILITY 35MCC XD 6390 10/0112010 10/01/2011 COMBNED SINGLE LIMB l ANY AUTO (Enaeddent) $ 1,000,000 XI ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per person) HIRED AUTOS BODILY INJURY. I NON-OWNED AUTOS (Per accident) i PROPERTY DAMAGE i (Per acoldenl) GARAGELIABILtIY •• AUTO ONLY-EA ACCIDENT I r l ANY AUTO• EA ACC i i - OTHER THAN AUTO ONLY: AGG i EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE i OCCUR 7 CLAMS MADE AGGREGATE i • I DEDUCTIBLE I i RETENTION S S A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/201.1WD srA L' oTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT i 5D0,000 OFRCER/MEMBER EXCLUDED? El DISEASE-EA EMPLOYEE I 500,000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT I .5D0 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THF-CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENT'S OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 252 ( OQ7/DB) m ACORD CORPORATION 1986 ewa • �� byderberL : . r-21uear ® • ; • � r`�d �Wca�+L►aryI Lbmpe�F • I IDD-DD414sM.S;DD7 s . ' _ s �3C,CdI'�.s�-p• SDI3r.F'��{C3gi1 G`D=E7CE.,.IT� - •• • . lam Mon • Im • 111 r.TERC 1 In I ll-a"e 1limit