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HomeMy WebLinkAboutBuilding Permit #310-12 - 89 BEAR HILL ROAD 10/11/2011 BUILDING-PERMIT F NORTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o � - Permit NO: Date Received A��->• .-<- �• Date Issued: SSgcHuSE� - t_�p �-5- `°��{SW IMPORTANT:Applicant must complete all items on this page r-54 �"w ��-�`, ••.x yx, :::Sii4;y'..._>('rt' 4.t. ,t� f rr:J�_rri INS + ` _e. ,...{-,:a, ;c :.{e.••r_ - _ =f= - - :;t-'r:.,.' �:� .X. - - __ .x- =`:hr'x:<'x..,t•`` - ,.*. � 5.�,. s'r._�`� .�-�':.l_tit.3_•.,,>.,. .�. y..r',;:' , M-e, -' ._-rCt..,u.=:� _"k�i:-r, _ y�r^�`-' zr.-.r> _ff':'*«:,a:-•f•4�. - _�-�c:,...,x...-� r.;.fKo•. { .f'_3...:4.1:1^' •r{,:= ":jt li==f`'.-'-�Cu�. - ":�_•':YiVS!^i7y"�i%i_'_:y't}SM:.'<''>:'^,�!d. ,'��. 1 - Y... a.�-_ r`};_ 3-!`_;d;_�i., i.—.. -.rr.::.��3ar�,rr .-:r''vfK;;'r'ti _,�./.'•:.4 = ..€;,•' 9V_ (x' nr�•yyy_,.��>4.% t> - :'T•. = q�4i'-.._ -'.'Y'4-.'.. .'1_r:,•fa.. `^v ::LX.°.r_:..F -_ur. _n�: ..x.:."t'�'-�;-'-..n .eat.: S '�`.' - -`.t.�r.Nf s��•�v.� - d - •� .. •e -�r•rra _..f..._ .r....00 7r .-7'_"t�- .,- v 5F^-u,.Y...:•smw'r:sr.y.-� .,,T - _ -- .'Y,.. ...�i.��f:., _:'�°-7"_— vim:.. `v;;3.3':v;;91:$r' }':- _ L - �.... • :�-•4.:k..w .3'u.i,,,t...rr :1=-�-. .' : ,� , .: --y� T..'-:�...a';�^ r�H• - _ _ _ rA-. •-:, ,`aa...r� r.•._�t-.x,'x, n•<.rk .�,P.. 7 F. 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TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family Addition Two or more.family Industrial Alteration No. of units: Commercial epair, replacement Assessory Bldg Others: Demolition Other s ..> •` 4h,L..0 J i r"1 rx. 0,%&,�4!� �-T�-'"rY�--'a ry°JF -�i`„s!.;�5,.x"� .�~<a- rr.p•ac_ �4 i - �,ti „s'�t°f-i"•. x �., _,r. ,r, i�•5.;+5._ �_._.;G"..--..,.-'� r- �'� a=b.,�lpl�ra .�•� l�t1arat}��'-�--'�°�����t'`s�te��. -�',�� �.,_,�:r;. i:,,�,.z_ ���",".�dl'e����� t�,��e��, s'.��".�,-_3a��”�r ^������„r�`�`�,���”'�u>`;'�`��iG's;:� s",.•^� a7�=+"...��1,�� �IL���{�'{�r t-L"�;���{��+"e.�'a,�sl .. ........-...•_.... �-__.$`...x„._.. 1L�•i<.i:=:��.rv� ,cc �'Ee5.3,�`sl��'�v�� �.Ytrss•�:..7n�y}•ai.., �F�,�.-y�} Zc��#'g� `��`�FLI i{y_ ,�Ak� f r�r' �'r•�� DESCRIPTION OF WORK TO BE PREFORMED. Identification PIease Type or Print CIearIy) OWNER: Name: Phone: (3 Address: �.a, ��• r"-_,'� m�j:'a�i'-shit"-ir.,��4_.�__ m'1 ���'._''}'.c:_. v:.� .:--r5�:,.r-.�•a,= -;s.s•.... - - - `�°.4�-"`. s,,,yi "5"r� •55Z.i��rTM�- .ted{�r •�zYF 'c'' "t.va�,25>'" ��r'� �A""-rA�r•N„;�`H.au.•-.,d�< ^�'.""F°'��.h '� ,t1f`n?-✓�.- N.i�"^; f � .r7 T.. as�.�`r.�,u+-seri 'y ,a v a�'r'�u'- .,�. J•j � ,t"zvs�E't- 3 �L.x •_'+, :»fiii,'t' �r{,�i' y=;e�;?. -amu. RE M '��r..°�°'.�;-� �-�'s �h >rT• '-.eh--�._ � �i,>,4�'� �.•' 'r �_-.,._s r"-.g1�^�" •�,...-�- • .7c' "?,g EN '�''�'� � �f , ';l- a '.k 1xE''ti; .t,.�+ .i`�. l•.,,�'' �•,`�-ter- -y�r ?'i�f w - -�� '!.. _ '1 �•t°�`••-y� a �=`^-?��>'P'�� {��.r 'F+"rr�'Jti'�a dl � .�`'� $ - � � •.rz, T^'�.:_ 'aT-+'iia'..' �tr� tir,n .-,>-L�r^t r Cf rti�,Oy r c Y,r 1 2 ' '`.� -u¢k`��-cs+ -•g'ilvf, ir�t"'} '{ -~�x'i�`-�"- s-' 'i' a5 £ n i•1 �' '�:i��'e�a«fir• m f 2*-.m'`�fY �� � ��-�'� ns�r.�,:; ,�,�' I,� ��'�'�s,s•- s� > a� .�7 5 �` ���°4a�'C�' _ s� r i p��iba rear•,-3 xhxi`���s�, J -���Y �'�r`r '��,.c-7�s'���r� .�` `JJ�']t" 'r i i `I �9]r�,ay�e r W o, r J ,��rS`,;-' }'9 fi 7�' -:9;r'A ._ -Ga�•,YL, -ii '�' x rPii..(.I-,','�, "�"1 �r a+e... E"'M_-x:"•• ,p"�I , .G.> � Tvf•+ �il' -. rte" °r��4�".j�����:�z-, '`r.�.'-�� 5��•.,,, _ .--�'_ r4 i'YJ� 1+,� f.-� s y`Co. t�y�.j L} '.,1. �r�?:,r:..6✓d'�:,f ,;1'a3'rE,,a;�r°`�C�'1'�i�-.,•'�'' "'"-s. ''r.Y..";r-7�=�'=`<�'''.a��`�]e°-"•f, � `fitFi���-y'sr,+'33-'-v' "moi-4-' -z."a[' _ ..; dY :it _ s.�. h3- _'i",> �S�a' ^ 51F.x"�.-".r� K:`�rrd! .•„?:'t `rte, �Gak�- c.o-"t'..:�• �r.'�•_•_�r� ��si�;f+:� ,j' ,�rz}S4'��'� ��uE�i-a-�.�" �ice•:rrf��<ti�er.F- d..l :-ac�-•'��a• ry �'u:,tr."�-' >.,M��`-d;"�.'-:i„�;.�,s_x; ,�.y ,R ,��-v a t�r�'"'trh..`i'�t,.!ti'-�,"`i<'•t ��.. �-^•s,?.n �rr:=i�s ;7�.`��; `- � 010 ^.&•f3 SI-�--;r^.YzT fssu'y d .•• , �.r_ s.. 4.r r`�".,�' .,r ., d4.�'�.,""_-i -Lia'''-ate.-�:-,.�"'u' Vic: `+•_ ;ry.��.� p.� '`-fir, s ref .r:.. �lei' � �ir• fs"�� •hh't-"` -.n ar w:,rvL•:.e--:-. i Y .rM.,._�� '63�i71t�G+�..�r..•���.7,.' '.T.it'�Y^ _,.Il•�..'��1�_ �'S;�'1{ { � ���c`'� �r �5+ .YE� �'S~� �f p ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$123.00 PER S.F. ®b 2 Total Project Cost: $ � 7 FEE: $ V0 Check No.: i �a - Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location No. � 1� v ` � Date �aRT►, TOWN OF NORTH ANDOVER f 'Ih C t � ? 9 Certificate of Occupancy $ 9 Buildin /Frame Permit Fee $ skMust Foundation Permit Fee $ - Other Permit Fee $ TOTAL $ 5,01Check # 24690 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools 'Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED. PLANNING & DEVELOPMENT COMMENTS • i CONSERVATION Reviewed on Signature CO I S I I 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 f DPW Town Engineer: Signature: Located 384 Osgood Street��r��=sfie�r:s.o°+ ��;E� Elp• � � erD! rr` _ ,.N •d:.�f�2��rlai r•.Str eI.J:.'—. ....,�.. . .. n. r-�. .t_. - - - _e,... gad=^•' ij}.�2s:;.,.....r: _ e .i yr. - r<]•tr-:zL._—..4:....�.... .. .. - •_�,. 5: � ,r. Q. S - - M�� 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 f { ❑ Notified for pickup - Date i Doe.Building Permit Revised 2010 1 1 T J Building Department 4 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 i ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products M NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I Addition Or.-Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract 1 o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check.Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit -,.New Construction (Single and Two Family) ❑ Building Permit Application ❑ -Cel ified Proposed Plot Plan. a 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 (VOTE: 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 Rea stry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2008 IAORT)y Town of 0 o , d©ver, Mass., Q -- LAKE y` ACOCMICHEWICK G �J DRATED PPa\ t 'J '9S ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT............ .. .. ........... .............. .............. .............. ....... ......... ................. ........................ Foundation I has permission to erect........................................ buildings on ..... .. ...... Rough to be occupied as...........I................ .. �sham ......... !! .Ih. .. ..... .................................................. Chimney provided that the person accepting this pfmvery 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 O . PERMIT EXPIRES IN b MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS 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. 104 Otis St.,Northborough,MA 01532 J&L WINDOWS,INC.,D/B/A MA Home Improvement Contractor (508)919-0900•Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012) by Andersen. Federal Tax ID#83-0404201 WINDOW REPLACEMENT an Andra Com y CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date of Agreelent Buyerlsl Street Address,City,State,and Zip Code f Z5 1 60-61, 11 o ate- E-Mail Address Home Telephone Number Work Telephone Number Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen ("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. j�-7 Method of Payment:❑Check i3Credit Card ❑Cash Total Job Amount: ! / Estimated Starting Date: ❑Financed Deposit Received(33%): q �O Balance at Start of Job(33%):___M L l f0 Estimated Completion Date: If payment is by Credit Card, please fill out Balance on Substantial � 062 the Credit Card Receipt of Deposit Form Completion of Job / ��' E_ By signing this agreement,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. J&L Windows,Inc.d/b/a Renewal by Andersen ye s) Buyer(s) n By: Signature ro t Manager Si ure Signature Print Name of roduct Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. - - — — — — — — — — — - - - -x- — — — — — — — — — — — — -�<- - - - - — — - - — — — — � NOTICE F CELLATION X NOTICE Oa CA ICE TION Date of Transaction /t 0 — You may cancel Date of Transaction . You may cancel this transaction,witho any penalty or obligation,within this transaction,withou any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if You wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If fou do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them up within 20 days of the date of Your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the goods without an further obligation.If you fail to without any further obligation. If you fail to make the make the goods available to the Seller, or if ou agree I ir�psei­Formanc available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so,then I s to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I e of all obligations under the Contract. the Contract.To cancel this transaction, mail or deliver a t To cancel this transaction, mail or deliver a signed and Msigned and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written er written notice,or send a telegram 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, Northbo 0 532, BY NOT LATER THAN North u ,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF .(Date) OF T 191.2 / .(Date) I HEREBY CANCELi IS SAcnON. 1 HEROY'cAkEf ihisTRANSACTION. Buyer's Signature Print Name Date Buyer's Signature Print Name Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink _ 104 Otis Street,Northborough,MA 01532 J&L W mdoWS,1nc.d/b/8_ Renewal MA HIC License#149601(expires 1/24/12) Phone 508.919.0900•Fax 774.987.3013 Federal Tax ID# 83-0404201 byAndersen. '%� WINDOW REPLACEMENT mAnderaenCompmy OF GREATER MAssAcHDsErrs AND NEw HAMP%= WINDOW SPECIFICATION S=Buyers)Name Date of reeme t j) The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed belo ,'in accgidance 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 DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) &Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) �—' Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) /'Picture Window(PW) Bay or Bow Window 'Patio Doors(see separate Door Specification Sheet) 2. [ Yes ❑ No Qty of Windows to be Custom 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)and actual Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: K HP Low-E-4 TM er If other,please specify: G. Exterior color to be: ❑ White ❑ Sand Canv ❑ Terratone ocoa Bean 7. Interior color to be: ❑ White ❑ Sand E] Canvas ❑ Terraton Pine Maple ❑ Oak Note: Interior co an my be white,wood or same color as . Wood interiors need to finished by Owner. 8. Hardware: ❑ Whit � Stone ❑ Canvas F] Brass F-1EstateHardware: Style: 9.SkYes O-No Install s Double Hung Windows 10. Screens: windows to have: ❑ Half or �A Full screens Screens to be: g Fiberglass ❑ Aluminum ❑ TruScene GRILLE DETAILS 11.Windows have grilles: ❑ Yes CgLNo If yes:❑ Grille Between Glass(GBG)❑ Removable Interior Wood(mmv)❑ Full Divided light(FDL) Qty Qty Qty: Qty: Qty: Qty. Qty; 1. DH DH DH OH cw/Picbire Gilder CPW ar G Draw grille patterns above 'Use additional sheet if needed Owner approved(initials);( ) ADDITIONAL WORK DETAILS 12.❑ Yes No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes No Contractor will install new paint-ready or stain-ready casings. inteW casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Yes No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior sto s b o enings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any paintir Owner Initials 16.❑ Yes El No Contractor will wrap exterior casings with aluminum coil stock of color. 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 ❑No Clean up all job related debris including old windows will be removed.Vacuum nightly. 19. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 20.[ Yes ❑ No BuildingPermit—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. 21.&IYes ❑No All discounts have n app to this agreement price.�J 22. Additional job details: t J. A1-lok 23. Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction of all parkes. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge (s) Specification Sheet. Renewal Andersen of Greater MA and NH Buyer s) Buyer(s) By: Signa of uct Manager Signature Signature Print Name of Product Manager Print Name Print Name I Coimoawealtls of hsassae dents Department of fiedustrtal Arc rn idents of investigations 600 F"OdA On Street Boston,MA 02111 . .atass.gov�dia , orkere' Com tnsatiane lnsur$ncedsvit;$uilders/Cantractar�/�Pla Par atbf W r A10sant Information' on/lnd4vidusl: a er Name(BusinmdOrpnizati ro riete but Type of project (required)' Are you an employer?Clock f scpp P =m"'I conizaetor end I 6. F1 New oonstxuciion L.E-I iona employerwif L D 4. 11w hired the sub-oauixncton ,I` ,�rFrng employees(fzilf and/or port-time). M•o attancmd shoot# Z. I am a sole proprietor orperbzr- g, Deanofifioa ` These.sub-eontmetnrs have �� ship end bnM nn employeos j Wim, comp.inGIIIHnBG. g, ❑Bulling Cin Working for mo m any capacity. We arc a corporation anti its 1D.[] ctrieal repairs or additions [No vaorkcrs'comp.insmeace afM bane=M—cised thein ar additions rD °d') right of czeaipfion per MGL 1L Rlnmhiag repairs 3, I em a homaownac doing En Work 152, 1(4).aad we bevo no 12.❑Roof itpairs e. myself.[lso.Wa�='comp' empioy�ti. a ryporimn, IIISLIrEneO rL d { .exp,i anzaa PODY *Amy t4u�eheeLs bot#1 neo fl1 out the seefioa 6r]me showiag their�vn�s cOmpean�ian P OY em dOissY alt and 1hm biro si3o oonhaot nmrt=bM*Ln efndavft iadicafiuE sura t)3nmruwnm who suhmtt this eS6avitia Y y of the sob-eoa��th*V36...'u�P PD40Y infi=6= • �oahaukets that oher.Y tha 6mc mm���ea eddi$ansl rha� eta, ;$elo•►v.ish te po licy=djob sift . I am arc employer thatispraNidrng.x'orkr.'ra'eorrtpensasva�,�¢nce far my employ . infarraatian. 1 l ) _ hw=anco cDmpany Name' �`Jl /•I,�� "'��•��7�_ E�P.iratinn Dain . Policy#or Self-ins;Lin.t Gtl lob Site Address,_ 1 -- , , - amp giber and espiratian date). AttRCE a rZpy of tam Workers'campensstinn policy detlsr afinu Pgtre(shareiag P pure to sr,0M'cavaage as roqurted ander SGCfinn a of MrrL n, 152 can 1Lad to fbL imposifian of criminal ponalfios of a up7n$1,3DO.00 and/or ono-yeer impasonment,as well as civil peBw nalties in the fivm of a S IY]PORI�ORI3ER and a Df up to MGM a day against ft violator. Be advisod that a cope-Of this statement map be fnr�varded to fbn Office of Invesfipfinns of the DIA for snsurenco cove=agr verihea6 ` I do hereby ce u r the pains a=ndp= y�P�jr 1 that the informative pruvilel nivve is true¢nd correct . • ' Dasa• � • . Sieneinret - Pbanc# v U f - LIFO . ar tax'n o atat use orgy. Da nvtxritt in this area,to he eompieted by city . • • permitlLicense# � or Tors: . City • Iasuiag Auf3writy(circle ane). attar S.Plumbing Inspector L Board of Health Z.Big Department 3,GV3gown Cjwk 4.Mectricall asp , 6.Dozer ' Phone Contact Perm V. Massachusetts - Dclrrrt lent of Public Safeti Boardlof Buildinty Reuulations and Standards Construction Supervisor License License: CS 95707 BRIAN DENNISON R_ 86 CREST CIRCLE - WORCESTER, MA 09603 Expiration: 9/8/2012 (lnnmissilInrr• Trm: 2622 67/7 Office of Consumer Affairs&Business Regulation J. HOME UPRO EMENT CONTRACTbR 4. RegistrationL1501' Exp1 t33 12 t Carr! RENEWAL BY 1, (� BRIAN DENNIS '104 OTIS STREg — NORTHBOROUGH,�M ?f3'Tra2 Undersecretary '4`020• CERTIFICATE OF LIABILITY INSURANCE °"'E(M"'°°"YM THIS CERTIFICATE IS ISSUED AS A M2J09/201 1 ATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON HE CERTIFICATE HOLDER.1 DER.HIS 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 endarsenient. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Joseph McKeone PNAME HONE . 734-662-8100 FAX JP McKeone Insurance Agency, Inc. EMAIL ac N0 P.O:BOX 333 A°DRESE• Ann Arbor, MI 48106-0333 INSURER AFFORDING COVERAGE NAIC9 INSURED y INSURER A.: Hartford Insurance Company J&L Windows,.Inc. Renewal b Andersen INSURER B:Nautilus 104 Otis St INsuRER c.; Northborough,MA 01532 INSURER D INSURER E; . INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 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, IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POUCYNUMBER POLICY EFF POLICY EXP B MM/DD UMITS- GENERAL LIABILITY MM/DDRI' EACH OCCURRENCE i 1 ODD ODD COMMERCIAL GENERAL LIABILITY A A RENTED NC9.58461 iD/01/2010 10/01/2011 REMISES Esaccu oe S 100 DDD CLAIMS MADE ©OCCUR MED EXP Any tine person 6 5.000 PERSONAL&ADV INJURY S 1 DDD DDD a GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000.000 POLICY PRO_ LOC PRODUCTS-COMP/OP AGG 6 20DD000 AUTOMOBILE LIABILITY S 4 35MCCXD6390 10/01/2Q10 10/01/2011COMBINED SINGLE UMrT 1,000,000 ANY AUTO accident ALLOW NED SCHEDULED BODILY INJURY(Par person) j X AUTOS SOOILYINJURYfPerecoldenQ 8 AUTOS HIRED AU7DS NON-OWNED AUTOS PROPERTY DAMAGE er ecclde UMBRELLA LIAB S EXCESS UAB OCCUR I EACH OCCURRENCE _ CLAIMS-MADE AGGREGATE _ DED RETENTION S A WORKERS COMPENSATION i AND EMPLOYERS'LIABILITY Y/N 35 WEGPPI444 02/17/2Q11 D2/i 7/2D12 WC STAT OTF, ANY PROPRIEIDRIPARTNEgIEXECUTIVEER OFFICER/MEMBER EXCLUDED? ❑ N/A E-L EACH ACCIDENT a 500.000 -If(Mandatary In NH) El DISEASE-EA EMPLOYEE 5DD DDD Dyes desodhN under DESCRIPTION OF OPERATIONS below ' EL DISEASE-POLICY LIMB t 5DO DOD F DESCRIPTION OOPERATIONS/LOCATIONS/VEHICLES (Attach ACORD Iin,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION INSURED DOPY kAUFHORIUM OULD:ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE E ExATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CORDCE WITH THE POLICY PROVISIONS. REPRESENTATIVE CORD 25 2010/D ®1988-2010 ACORD CORPORATION. All rights reserved. ( 5) The ACORD name and logo are registered marks of ACORD 1(L7�Jx� - e' va l mum— • �J1 Td �t�L'�.d�.J'�.•Y i� � • nmki umv _ - . • 1 aa-•ao-�ta--m c • L�-Fa�ae�L1,.5�4-•P �u-}��#•C�a'¢� Co�pletat • X Qx � " •: •ABLICPIDH�4,L PEF,C-� �E.B�'i�lt�. i • ,....�r W�—L !13B ' . ,►.����Qa.Fz.r-fir�����y,�..s.,,T.,�.� r.�...� - -