HomeMy WebLinkAboutBuilding Permit #978-15 - 74 BELMONT STREET 5/28/2015Permit No#: 9
,�6
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
C*"�_ ..h
TYPE OF IMPROVEMERT-
PROPOSED USE
Residential
Non- Residential
New Building
_PQ0,ne family
El Addition
11 Two or more family
[I Industrial
0 Alteration
No. of units:
0 commercial
[Y.Ke'pair, replacement
0 Assessory Bldg
0 Others:
-E] Demolition
El Other
_7�_
�fff_ f(� � � -' - - - W -.,t -
El, - t o 1-�0n. n _:e jan
otprshed�Vist Jc
Ow -
OWNER: Name:
A A A - -
UF-5(;KIF I IL)N L)I- VVL)Kr\ I U Dr- rr_r%r%JF%1V1L-L'-
:c-e '77
-7, Identification - T P * t
_�PY-Xe ;1pe rin
A
e- Pr -44
Phone: VS
ARCH ITECT/ENGI NEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12-00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost:$ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to,#e guarantyfund
Location
No. is Date
C he ck #
. 2884.4
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
$
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTA L $
Buildi hnspector
7
Plans Submitted Plans Waived Certified Plot Plan 0 Stamped Plans F1
TYPE OF SEWERAGE DISPOSA-L
Public Sewer El Tanning/Massage/Body Art F1 SwiUnning Pools
well 11 Tobacco Sales El Food Packaging/Sales F1
Private (septic tank, etc. El Pennanent Dumpster on Site 0
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature—
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Os-qood Street
oc -"�dlla-Vl al tee
it -e
n 1� U 6.
We
11
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
Doc.Building Permit Revised 2014
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
4. Workers Comp Affidavit
,;6 Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4. Copy of Contract
4� Floor Plan Or Proposed Interior Work
�& Engineering Affidavits for Engineered products
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4 Building Permit Application
,4, Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
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
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
,16 Building PeFMit Application
4, 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
IOTIE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
11 1
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appea s
tha' the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
1�
must be submitted with the building application
Doe: Building Permit Revised 2014
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Renewal
byAndersen,
Wfftvaw REPLACEMEky
3 L4 01
MA Home Impro
ticense '1170810
Renewal 4y Andersen Corporation
Federal Tax
30 Forbes Rd. Northborouah, MA 01532
,(508) 351-2200 Fax (50)-,"6-7072
CUSTOMER WINDOWAND DOOR REMODELING AGREE�IT
Buyer(s) Name Date:
APRIL,20�',-2015
GEORGE WHITEHEAO�
Buyer(s) Street Address Cfty State
Zip Code
74 BELMONT STREET NORTH ANDOVER, MA 01845
Email Address Home Telephone Number Work/Cell Telephone Number
ajreeriwnt and on the attached specification sheet(s (c
has completed all work tinder this Agreement�
redit Cwd Pt
w(s) agrees and'urttlerstands that thts Agreement cortstitutes the entire understanding between.the partles,,atid that It are no verbal unde;
ifing or rnodif�inqany of the ternm of this Agretimmt. No afteration toot deviation from this Agreentard will be valid without tM signed, wrffl
dh Buyar(s� and Contract ' or. Buyer(s) heaby acknowledges that "r(s) i) fies. read this Agreement, understands the ternm of this Aoroome
heed a,completed, signed and dated coPy of th is Agreement, including the two III ached -Notitag at Canceltagon, an the date first written abovi
1 1 nfo nued of Buyses right to cancel! this Agreement. 00 NOT SWN THIS CONTRACT IF 714ERE ARE ANY BLANK SPACES.
Renewal by Andemen torporMon
Buyer(s) Buyer(s)
By�
signatute of Consultant
X G60RGI� HOLT GEORGE -WHITEHEAD
PrWed Naffm of ConvUhant. Pmled Namb PrW-ed Manw.
YOU, THE BUIVER(s), MAY CAMMTHS TRANSAMON ATANiTIME PAJOR40 MIONIGIft OFYN151HIRD OLMINESS DAY AFTER THE DATE OFInittTOANSAcnort,
SIE& THE ArfACHED NOTICE Of CANCELLATION FOPAM FOR AN EXPLANATION OF THIS AICWT�
w - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - --- - - - - - - - - - --- - - - -
NOT"ICE617CANCELLATION
NOUCKOYCANCEIJA31ON
'Dote of Transaction VA -M, 'Nuu may ea—�A this ose. of Taatua 4nAi/ll Ve- may —el this
fiv— the t—wardow, without xaypeuky�— —.bfigud.� -Uhl. three b". dys..Irom the
�tr .. uctlo"';vithout any pettalty or bilgatlon, withtu three busia. da"
-16—* date- It y W%-- ty trat led in � any p sy— mad t, try yea u. der h— date� It you vaate4 say property tradva io, say paymim" made, by you under,
'the (Imaract of Sale, aud,Aay negadabie Instrument executed by you will be the Contract of Sale, aud by),auwilthe
uryuur
ruatettation nodee, mid atty security iate.�eut risiog. out of the trassactifta ulat be I tancelffatlo. umiet,. and atty Security inteeest ariAng out of the trAusaction wig he
�u your re&iaeuee' ift i v*akvle& If yea caerel, you must mahe aviflabW to the Seger m your,tesideme, is.
Aulw4antially as good coadition, as when recek*d� say goods, defivetwd to you mular I .boaaxlollyasgoodroaditloa� any goods delivered ut�vu under
th& Commet or Sale, or you ma% if yea -wish, to—lity With the instracdoas of,the I thig Contravt or Satq or you may, if you vdh' comply with the imtructid— of the
Seller reganfing the retura tihiptatai of the k" at the Seller's expemio aud rlal� I SdIer regarding the return shipaueat of the goo& " ifit, Sm4.kr,#*xpeose and Ash.
It you do make. the.ganda a—Huble to the Seger and the Seger does not pkk the— up V von do snahe the goods avagable to the Seger wad the Selter deen tot pith them up
w dtin 20 days ofthe date of your Noder of Caucanadou,)vu may retala or disp. wiihia 20 dqs of the date of �.. Ntk* of Cancellation, you may "rain or di , spose
i
of the gooda without nay furitherobligation. If youtka to make the gakuUavailable of the goo& without any further obilgadwL Itiou fitil to mahe the goods d"U'
to the SeUer, or if you agree to eettero, the goods to the Seger and fan to do sodtea
Von remain kable for perfur—aur,& of all obilgations trader the Cmaraec To v�el you ..I. utthte Set, p". eir an aaigui— trader th. Costrart. To —eet
d%6 traasactlot,4 xuait or deliver a signed, and dated copy of this emovetlatim not" this transacdoa, mag oe� delivet, a signed 2M AateA VOW of this �arellx6ou umk�
— say other writtv a ateiveor &ftkd . telegram Renewal by Aade—.,: Ren#wulbyAnd�.w,
s0farl*e%Rd� N Rd. Northl .. gh, NIA 01531.
1 HEREBY CANCEL T HIS TAANSACTIWV� f HEREBY CAWTL rms TR"NAGMGN�
Est. §tad
Method of
Tiftal Job Amount $ 11,868
k1hount Fma.
'v ChecklCash
Dep%ft Received (33%) $ 5,00a �00
S 3,434�00
B-10 weeAm
Balance Stan ofJob (33%) $ 0.00
195
Check
,"ame on�Substaniial.
ckxrtpletk�n 61 Job (31G -Q S 0.00
compi"m $ 3;434,00,
Est Instalitirtle
Credit Card
1-2 days
cald js w1ected,
redit Cwd Pt
w(s) agrees and'urttlerstands that thts Agreement cortstitutes the entire understanding between.the partles,,atid that It are no verbal unde;
ifing or rnodif�inqany of the ternm of this Agretimmt. No afteration toot deviation from this Agreentard will be valid without tM signed, wrffl
dh Buyar(s� and Contract ' or. Buyer(s) heaby acknowledges that "r(s) i) fies. read this Agreement, understands the ternm of this Aoroome
heed a,completed, signed and dated coPy of th is Agreement, including the two III ached -Notitag at Canceltagon, an the date first written abovi
1 1 nfo nued of Buyses right to cancel! this Agreement. 00 NOT SWN THIS CONTRACT IF 714ERE ARE ANY BLANK SPACES.
Renewal by Andemen torporMon
Buyer(s) Buyer(s)
By�
signatute of Consultant
X G60RGI� HOLT GEORGE -WHITEHEAD
PrWed Naffm of ConvUhant. Pmled Namb PrW-ed Manw.
YOU, THE BUIVER(s), MAY CAMMTHS TRANSAMON ATANiTIME PAJOR40 MIONIGIft OFYN151HIRD OLMINESS DAY AFTER THE DATE OFInittTOANSAcnort,
SIE& THE ArfACHED NOTICE Of CANCELLATION FOPAM FOR AN EXPLANATION OF THIS AICWT�
w - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - --- - - - - - - - - - --- - - - -
NOT"ICE617CANCELLATION
NOUCKOYCANCEIJA31ON
'Dote of Transaction VA -M, 'Nuu may ea—�A this ose. of Taatua 4nAi/ll Ve- may —el this
fiv— the t—wardow, without xaypeuky�— —.bfigud.� -Uhl. three b". dys..Irom the
�tr .. uctlo"';vithout any pettalty or bilgatlon, withtu three busia. da"
-16—* date- It y W%-- ty trat led in � any p sy— mad t, try yea u. der h— date� It you vaate4 say property tradva io, say paymim" made, by you under,
'the (Imaract of Sale, aud,Aay negadabie Instrument executed by you will be the Contract of Sale, aud by),auwilthe
uryuur
ruatettation nodee, mid atty security iate.�eut risiog. out of the trassactifta ulat be I tancelffatlo. umiet,. and atty Security inteeest ariAng out of the trAusaction wig he
�u your re&iaeuee' ift i v*akvle& If yea caerel, you must mahe aviflabW to the Seger m your,tesideme, is.
Aulw4antially as good coadition, as when recek*d� say goods, defivetwd to you mular I .boaaxlollyasgoodroaditloa� any goods delivered ut�vu under
th& Commet or Sale, or you ma% if yea -wish, to—lity With the instracdoas of,the I thig Contravt or Satq or you may, if you vdh' comply with the imtructid— of the
Seller reganfing the retura tihiptatai of the k" at the Seller's expemio aud rlal� I SdIer regarding the return shipaueat of the goo& " ifit, Sm4.kr,#*xpeose and Ash.
It you do make. the.ganda a—Huble to the Seger and the Seger does not pkk the— up V von do snahe the goods avagable to the Seger wad the Selter deen tot pith them up
w dtin 20 days ofthe date of your Noder of Caucanadou,)vu may retala or disp. wiihia 20 dqs of the date of �.. Ntk* of Cancellation, you may "rain or di , spose
i
of the gooda without nay furitherobligation. If youtka to make the gakuUavailable of the goo& without any further obilgadwL Itiou fitil to mahe the goods d"U'
to the SeUer, or if you agree to eettero, the goods to the Seger and fan to do sodtea
Von remain kable for perfur—aur,& of all obilgations trader the Cmaraec To v�el you ..I. utthte Set, p". eir an aaigui— trader th. Costrart. To —eet
d%6 traasactlot,4 xuait or deliver a signed, and dated copy of this emovetlatim not" this transacdoa, mag oe� delivet, a signed 2M AateA VOW of this �arellx6ou umk�
— say other writtv a ateiveor &ftkd . telegram Renewal by Aade—.,: Ren#wulbyAnd�.w,
s0farl*e%Rd� N Rd. Northl .. gh, NIA 01531.
1 HEREBY CANCEL T HIS TAANSACTIWV� f HEREBY CAWTL rms TR"NAGMGN�
Renewal 'k6d4sen-'d-cieporation IM Home Improvement Contractor
30 Forbes rd Northborough, iAA 01,562 License #170810 (Expineg 11212�Ml 5)
byAn&rse�n, am
wMeew nt:r t. C t in &A! 4ft10A4q
Window Specitioation Sheet
aniv AgructriCut
GEORGE WHI . TEHEAD
MOINI,-A'Piz�40i-,90115.
rhe buverNlis'ler] al"'c helkA)yjointly andsevverafly agree to purchase'die gwids and/orscmi�" fisted below, in accor,&Allce with dieprices and terawi di�,cribvcl
jbe. spr6fication Sheet ancl vVeiv, of acirompally 'of %01i
the fiyxit allri Ihe I hig (,USTOM WIN'DOW, AND DO(.)R
ithe $pc-C11fi('afio11 Shret,is part.,.
WINDOW & DOORDIETAILS
All M ExtenorImerior Color HafdM' Haldwitre LCA"4 Grills Wass
"�' A,.. A '0 �Kle
AMP # h01419 uk' Window/Door sw Detai Casings' ExMnt Color styl. satiem sknartsun Grilles s2qhq1J3 Sh 9 Ufts' optlarr
F G
Bed 1, 20 33 1' 96 138 so fall equal Insert sloped sill EXL Wrap WHIM �:StOne Standard FFG kin.rtsue Nero No No�
sed�" 2029 Ill 47 M Ce sq rail actual insert sloped sill Wrap, WHIPN Standard FFG artsur No,
__E�j _Ltorie
mancave 203 33 47 80 DB 99 rail 2MI insert 2!2E!� sill Wrg WHIM Stone Standard FFG martsur t*m No No
ivlaneava 204 33 4-1, go De so rail equal in� sloped sill Ext. Wrap WHIPN Stone Standard FFG martSur timm No No
OFFG
sod 3 205 31 47 80 08 $4 rail equal in sort sloped sill Ext. Wrap WHIPIN Stone Standard FFG ansur ?40,ft- No No
Bed 3 206 4'� 80 DB so rall equal Insert sloRed sill Ext. Wrap wH/pu Stone, Standard FFG, martsur, t4onii'. No No
marts", 'Tamper
Istandard No
sath 2 207 21 37 58 Ds sq rail 2MI insert sloped sill Ext. Wrap wHiPP4 Stone.. standard
. . .. . . . . ........
T&AI 7 BAY, BOW & BlUILD OUT DETAILS
A
4
$V. DW Wi4thl, AMXoiL Number Frarre, window End Camar
Room Count st�lo Fbr*0AMVn5 h'in Lftes Gill
Milt C"nga Ang% Interior ExVIm Corvor WA mhm aashm
So LowE I Roof I Hardware,
roons smmtsun Somt Color
SPECIALTYWINDOWDETAILS
MY/HOW ADDITIONAL WORK NOTES,
FL41 / Approic. LOWE,' sped^
Room:� Count st)�'q Insert uI., sae -%A "On "t styw Exont Coter 0,�� 71,� 140".
al tV"iq"ifWxn
ADDITIONAL wORK DE-7AILS:.
No Contractor will wrap exterior casings with coil stock color of
2
Owner Is aware that ConlYaclor does not do anypaintipg/staining or mmovalfinstallation of alarm system or window tileatmentsit? It is the tesponsibility, of
the homeowner to have the aAarm system and wwtdDw Veatmentsftridware removed prior. to installafto ft make no guaranteers to whellwalarms ar window
traatments/hardw"�wffl fit after replacement Customer it also aware in same cases Ittere *jV be glass IOM If them i-� the amount will be dependent on the type
ofeKisting windows, type ofinstaliationand windowstyle.-ft make no quarantee as to the amount ofglass hoss. Customeris aware andunderstands anyandall
unseen rot is not Included in this contract. Shouldany rotbe Wrlditheii will be an additionai charge W d" and matefts� unless so statecrin this contract
Contractor will Insulate, cwAk and seat Windows with 3 -point system to prevent water and air Infiltration. Removal and disposal of WI
yes job rela led debrls�
windows, door., storm windows and vacuium.nightly included. Upon completion of the job and payment in full, a limited warranty shall be issued.,
I Yes Building PLnerift—Contractor Will secure any and all necessary pe"its. 'Ihe fee for the parmit(s) Is Included in the total contract Price—
Yea All d1scountia have been Applied to this agreement,
Yvs No Owm agrees to -be present on the final day of installation for final inspection and to deliver final payment finance form(s).
1 �i kpi�(,d and underm(K)d fi� am I lkiriks 11111 1h6 Sp-xifim(ioil "hert- ab;lip %� ith th� CUSTOM A,%TXI)0kV AND D(,,K,,)R RNN40J)JJJN( AGRH , X' (It"
'NIJA "nsinine clikin,
imdt�'qlaodir lwkw'�n the pailie'i, aad ilwivan' no wylvil 4, ld,ivilfidinp d'. ugin� ujwlil� iii au� 4 11u, edin
'gay w;tF anllcm ih6idmiw, aw iii wrifink-:md -4 wd I FAW1 011, Ho Coln"iar, twtl41� w1li'mitAv V (�Adoik slu'vi,
Ru 1-"" ha.� Mid thi,
Renewal byAndersen Corporation Bt
Signature of Consultant !gna r Signature
GEORGE HOLT GEORGE WHITIiHEAD
Print Name of Consultant Print Name �Print Name
R6newal by Ander'sen Corporation
lo fadws. Rd. - Mmifitbormush, 01532
.,bYAr&rsen. Aoni2, (MA) �51 -2200 - Fax (508j� 99,640112
�MA 01,71bbW f,9*fllfVi
06% -AMOMMOU P& l'o, ato cusm-)-m N�,lwow AM,) ric Ilk, Rxxlocwfmc� 10Amu. -IT r v,�4wyoerlwartrlilw amd,
NAWealt Rorimal t*Afl&',vwn C�n!"'wr3tial, alta Ckofo�. VVPddi&W f-buv
tile Avitoe
tfilonfms 1"Ji4kaled KoLw. L)tiiej-:Iitilt.ls;,Pxv.�if",ILIIII,v It aw- all the lcrvm�, Acid toudifkms a'
trewment, will
am CV, , Ll;�
'ret'vi T) lv� AfmclWaloll. is �iul*"xf fil Ow t I J's a va avd[limls of thso Agmsaiveo, "I li�,;! 4"51lowilug uldilio all'olutio "or &—W, -
I som's ILI 111c. jwd"cig �,Jtjd SeMcoi R", er(O ardeled An beipg atd&�:
WindoWs Irk Metolle family'atteched homato customer (#205, 206 iind 207) wIll norw be whko,dn b4th extedor and'
r Wof flun.'k ellrlrws�- dw f01o�lflg'l.--rjm d.1he Agreotiod akliulsa chngLag (it flacre is 110 �llaage, a," ji M-1 'wilfl lag.
m,arked Ai �N/A"I'f hilkill'ing 11tal no clu It* angiotl
uUt Ile,
fleilli Nanw �.-4 PiWovi ��Wmkgiof,
............
77=V=7 I -KA -1 TI -H- —1% 1711 !=I 4 M477lt 77
V 4NA I Irt � I � A 1AIL: . . . . . . ....
IE -Signed, OV4.07015 WeNT
wl
George'E hiteftead
m it'! tbooxam
C41 US 13 U 1, OJ UZZI
S
The Commonwealth ofMassachusetts
Department ofIndusirialAccidents
Office ofInvestigations
I Congress Sered, Suite 100
Boston, AL4 02114-2017
www. mass-govIdia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electiicians/Plumbers
ApRficant Information Please Print Leffiblv
Name (Business/Organizadon/Individual): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
NORTHBORO,-MA 01532 Phone 4: 508-351-2200
Are you an employer? Check the appropriate box:
1. El I am a employer with 30
4. 0 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. F-1 I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insuranceJ
required.]
5. E] We are a corporation and its
3. El I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. fNo workers'
comp. insurance reouired.1
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. E] Building addition
10. El Electrical repairs or additions
I 1 .0 Plumbing repairs or additions
12.[] Roof repairs
13.E] Other
*Any applicant that checks box fl must also rill out the section below showing their workws, compensa on policy information.
f d
Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit anew affidavitindicatingauch.
tContractors that check this box must attached an additional sheet showing the name of the sub-conumtors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their. vA*ers, comp. policy number.
I am an employer that Isproviding workers'compensadon insurancefor my employees. Below is the polky andjob
informadon.
Insurance Company Name: OLD REPUBLIC INS. CO.
Policy # or Self -ins. Lic. M MWC 30293800 Expiration Date: 10/01/15
Job Site Address: City/State/Zin. Alo 4,ovrd"
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 S 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 kereb� 4V63W" the pains andpenaMfes ofperjury tkat the informa&n proyMed above is fte and correa
-2200
05/19/15
OfJklal use only. Do not wrUe in this area, to be completed by city or town oirkial.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/Ucense N
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone#:
ANDECOR-01 YADAVY0
kk..� CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
1 101112014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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 pollcy(les) must be ondorsO. if SUBROGATION is WANED, subjed to
the term 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 endorsoment(s).
PRODUCER
Willis of Minnesota, Inc.
do 26 Century Blvd
P.O. Box 305191
Nashville, TN 37230-6191
1��cateq"Illsxom
?WN6..EdI:(877) 90-7378 hol: (888) 467-2378_
E4WAIL
IWSUTnP)AFrORD1NG COVERAGE N=0
MUIUM A: Old Republic Insurance Company 24147
INSURED
Renewal by Anderson Corporation
30 Forbes Road
Northborough, MA 01632
INSURER 0:
INSURERC:
INSURER 0:
INSURER E:
INSURERF;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN 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 POUCIES DESCRIBED HEREIN IS SU13JECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
A13DL
SUOR
POLICY NUMBER
POLICY EFF
09NODIYyyyj
POLICY E)U`
011MODITYM
Lam
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS-MA13E 111 OCCUR
MWZY302940
11=112014
10MI2015
EACH OOCURRENCE 3 1,000,000
pREMISES (Ea $ 600,00q
MED EXP (Aq cm p9mon) $ 10,0001
PERSONAL & ADV IWURY $ 1,000,00M
GEWL AGGREGATE LIMIT APPLIES PER:
RO- F I Loc
POLICY F SECT
OTHER:
GENERAL AGGREGATE S 4,000,0011
PRODUCTS - COMPIOP AGG $ 4.ON,00(
$
A
AUTOM0131LE
LIABILITY
ANY AUTO
ALL OVVNED SCHEDULED
AUTOS AUTOS
NON4)WNED
HIREDAUTOS AUTOS
MWTE=2575
1010VM4
1010112015
=15, NO L E I JMIT— $ 6,000,00c,
BODILY INJURY (Par permn) 3
BODILY INJURY (Per a=ide" S
M5VEW 5—WME--
(Peraccident)
UMBRELLA L"HOCCUR
EXCESS LIAS
CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE
DED RE�NTION$
A
I
wMERS COMPENSATION
ANDEMPLOYERS'LLABIL17Y YIN
ANY PROPRIETORIPARTNERIEXECUTIVE [-jjj
OFFICERIMEMBER EXCLUDED?
owummy in NH)
'b
�'tIPBTCInOONUOr'FdoOrPEI,ATIONS Wow
NIA
M=30293800
iGM112014
iGM112016
OTH-
x I MUTE I FER
E.L. EACH ACCIDENT 6 1,000,0(m
E.L. DISEASE - EA EMPLOYEE $ 1,000,00(
�E.L. DISEASE POLICY LIMIT 3 1,000,00(
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AdAdonal RmmrkB Schadt9e. nay be oftdmd ff mom spow In niquhud)
CERTIFICATE 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.
AWHORIZEDREPRESENTATNE
Evidence of Insurance
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACIORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards,
Oms"ction Supeni%or
License: CS4)90125
JAIM L MORIN -
86 GARDINICR ST.
LYNN MA 0190f
)I Ila NX
Expiration
Commissioner
1010612016
fflee Of COU"Mer Affairs & Business Regulation
C
E MMVEMIENT CONTRACTOR
Type:
-I V2 312015
Supplement,
RENEWAL BY ANbkR-s6m;coRPORATIOU
JAIME MORIN
104 OTIS STREET
NORTHBOROUGHj MA 01532
Undersee"ry
. _adnahi-
Renewa
byAndersen. mo -R&
H-LC25
WINDOW, REPLACEMENT auAndersen(>mpAoy
RbA DB' Sloped SIM DHI IN
ood/Vinyl Composite IF
Dual Argon Low E4 SmarlSun
Double Hung
100-00473618-010
PERFORMANCE RATINGS
ENERGY
Q -Factor (U.S)/I-P
Solar Heat Gain Coefficient
0.29
omig
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
UA2.
it.- tihMc..f-. I..pp%.able NFRC procedures f-d.1d,.iinqwhoM product
perfoorrance, NFRC ratings we defem ined for a fixed set of environrnentalcoaditions and a specific product size.
NFRCdossftol Faconirnandany product and does "I mranant the suitabby of any product lot aaySpeCilic USO.
Consult manufacturer's fiteralure for other product perfonnance informatiDn.
www.nfm.ofg
This product meets Green
le,ft e"virornne,11
standard. governing energy
efficiney. heavy metals in
thefra" and sash
1 i&L and
4niste packaging
Mweriake.
DESIGN PRESSURE (PSF)
MAIRTM
H-LC25
RbA DB' Sloped SIM DHI IN
Jeets or exceeds M.E.C.. C.E.0, & I.E.C.C. Air Infliltration requiremots WOMA Haftmark Certification Program
1�
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