HomeMy WebLinkAboutBuilding Permit #321-14 - 90 OLD FARM ROAD 10/4/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N01: 17D — �14 Date Received J Date Issued:. IMPORTANT:Applicant must complete all items on this page 7 rPFt -15 JL I&N ME -R T urgi ,e '2 trio ' Print D_STR-I -gDistract eA iQQ 1 1 TYPE OF IMPROVEMENT J PROPOSED USE Residential Non- Residential 0 New Building One family El Addition 0 Two or more family 0 Industrial El Alteration No. of units: [I Commercial air, replacement 0 Assessory Bldg 0 Others: 11 Demolition 11 Other W5 in i ye n 4[fl 't ' 01&pti�q)- IBW' �W- DEW,RIPTION OF WORK TO BE PERFORMED: Identification Ple C Type or Print Clearly) OWNER: Narne::�O&V\ _e A A 0J e Phone: - r Address: Q0 okc� � e- A, 4,-� 1-1 1-10 Nam - C ff Jf �A'q,IT n r . a-i pmej m ,Tc!vemen 3t- p t4lJ�ipph 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. Total Project Cost: $ L/O - DOO> - c FEE: $ &-As Check No.: cD C1 (10 Receipt No.: 1,b qiy NOTE: Persons contracting with unregistered contractors do not have access tot uaranty fund f igna ure-b --c d6 id.h"a"tu'"' A-* r!t/OWh6r:..;' ontra r-1 F-1 F-1 M Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF•SEWERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. • 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 I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ .❑ I 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: f9ignature: Located 384 Osgood Street FIRE•DEPAkTM�HWT -Temp Dumpster on site yes no D Located at'124 MainStreet Fire Deparitmer t•sigriature/datd COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Defer location, mast or service drop requires approval of Electrical Inspector Yes No ]ANGER ZONE LITERATURE: Yes No AGL Chapter 166 Section 21A-F and G min.$100-$1000 fine �O TES and DATA—(For department use ® Notified for pickup - Date oc.Building Permit Revised 2010 Building Department 'rhe folfawing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits u - Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L: Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 10TE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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) a Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Q Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 o Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the app.al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm'Ated with the building application Doc: Doc.Building permit Revised 2012 Location qc) n1 +-N M =me- No. Z I— I LA Date . = TOWN OF NORTH ANDOVER TLED . • Certificate of Occupancy $ Building/Frame Permit Fee $4F50 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# -Il( J �Bu`illding Inspector NORTH Town of t � : Andover 0 No. y ;O�#-Ah ver, Mass O coc«Ic«.Wic" a. ADRATE D '�5 S V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT T Std 1� BUILDING INSPECTOR ..... + .... ............... ...... .. ....... .... ............... ....... ..... .. . . . ......... t—A has permission to erect g �� 0� Td � Foundation .......................... buildings on .... ........ . ..... ...................................... /� Rough to be occupied as ......c .�. ........31.......w .0.J o.'A5 .............................................. 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 CONSTRUCTIO ' ARTS Rough ............................ Service .............. ...... . .. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE enevWaI Home Improvement Contractor ibyAndersen, License#170810(Expires 12/23/2013), .WINDOW REPLACEMENT :in.lmkrxnC:.m,Fvm Renewal by Andersen Corporation Federal Tax ID#41-1918413; 104 Otis St. Northborough,MA 01532 (508)351-2200 Fax(508)-986-7072 CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT lBu er s Name Date: JOSH STACEY - JENNIFER STACEY AUGUST 26, 2013 Buyer(s)Street Address,City,State and 7i Code 90 OLD FARM RD NORTH ANDOVER MA 01845 IEmail Address Home Telephone Number Work/Cell Telephone Number Jodostacey@gmail.com 781-285-8641 781-603-2691 [Buyer(s)hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("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 I"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount$ 40,000.00 Amount Financed$ 40,000.00 Est,Start Date Method of Payment Deposit Received(33%)$ 0.00 ,J Check/Cash i 7-10 weeks Balance Start of Job(33%)$ 0.00 Front Deposit(50%)$ 20,000.00 Est.Install Time G Credit Card j Balance on Substantial Substantial Completion of Job(33%)$ 0.00 Completion (50%)$ 20,000.00 T B p If credit is selected,please I see Credit Card Payment Form. ;Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal Junderstandings 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 i EANY BLANK SPACES. Renewal by Andersen Corporation Buye yer(s) By, wid i Signature of Project Manager J biKature ature t WILL SALEM JOSH STACEY JENNIFER STACEY t Printed Name of Project Manager Printed Name Printed Name i 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 NOTCIE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. ' ------------------------------'-------------------------------- N i NOTICE OF CANCELLATION NOTICE OF CANCELIATION $Date of Transaction 8/26/13 You may cancel this 1 Date of Transaction 8/26/13 You may cancel this !transaction,without any penalty or obligation,within three I transaction,without any penalty or obligation,within three :business days from the above date.If you cancel,any property I business days from the above date.If you cancel,any property f 'traded in,any payments made by you under the Contract of Sale, I traded in,any payments made by you under the Contract of Sale, i land any negotiable instrument executed by you will he returned I and any negotiable instrument executed by you will be returned !within 10 days following receipt by the Contractor("Seller") of I within 10 days following receipt by the Contractor("Seller") of your cancellation notice,and any security interest arising out of I your cancellation notice,and any security interest arising out of the Ithe transaction will be canceled. If you cancel,you must make I transaction will be canceled. If you cancel,you must make I available to the Seller at your residence,in substantially as good available to the Seller at your residence,in substantially as good F condition as when received,any goods delivered to you under I condition as when received,any goods delivered to you under this this Contract or Sale; or you may,if you wish,comply with the I Contract or Sale; or you may,if you wish,comply with the instructions of the Seller regarding the return shipment of the I instructions of the Seller regarding the return shipment of the !available at the Seller's expense and risk. If you do make the goods I goods at the Seller's expense and risk. If you do make the goods 1 available to the Seller and the Seller does not pick them up within I available to the Seller and the Seller does not pick them up within 120 days of the date of your Notice of Cancellation,you may 1 20 days of the date of your Notice of Cancellation,you may retain Iretain or dispose of the goods without any further obligation. If I or dispose of the goods without any further obligation. If you fail ' you fail to make the goods available to the Selle>or if you agreeI to make the goods available to the Seller,or if you agree to return to return the goods to the Seller and fail to do so,then you remain I the goods to the Seller and fail to do so,then you remain liable for j liable for performance of all obligations under the Contract. To I performance of all obligations under the Contract.To cancel this i cancel this transaction,mail or deliver a signed and dated copy 1 transaction,mail or deliver a signed and dated copy of this lof this cancellation notice or any other written notice,or send a cancellation notice or any other written notice,or send a telegram .telegram to Contractor. Renewal by Andersen,104 Otis St. I to Contractor. Renewal by Andersen,104 Otis St.Northborough, INorthboroueh,MA 01532,BY NOT IATER THAN MIDNIGHT I MA 01532, BY NOT LATER THAN MIDNIGHT OF 8/29/13 .(Date) I HEREBY CANCEL THIS TRANSACTION. I OF 8/29/13 .(Date) I HEREBY CANCEL THIS TRANSACTION. I i I I i Buyers Signature Prim Name Date I Buyers Signature Print Name Date i I i 1 _. ............. -........ . _.._........... ... ...... ... ...... -A ..._............ ---- - ---- - -....._.._.........__......_ ene_.. wa Renew.. al ndersen Corporation MA Home Improvement Contractor :Andersen, - 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2013) iWIMDOW REPLACEMENT .n An.l<ne,C;-gvvc (508)351-2200 Fax:(508)-986-7072 Federal ID#41-191841 Window Specification Sheet �Bu e s Name Date of Agreement JOSH STACEY JENNIFER STACEY AU Ust 26,2013 The buyers)listed above herebyjointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described oh the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which the Specification Sheet is part. WINDOW DETAILS Style Full/ United CWVVHWH Hardware Hardware LowE4/ Grille Grille '12mper/ Room # Style Detail Insert Inches Casin Sills Color _Style Steens Smartsun Grilles Sash 1/3 Sash 2 lifts laminated Ent 2 DB:S ware Equal Full 70 Full Flat White Standard FTS Low-E4 GBG 2/2 2/2 No No Living4 DB:S uare Equal Insert 80 WrapSloped White Standard FTS Low-E4 GBG 3/2 3/2 No No Office 2 DB:S uare Equal Insert 70 WrapSloped White Standard FTS Low-E4 GBG 3/2 3/2 No No Office I PW Equal Insert 80 WrapSloped White Standard FTS Low-E4 GBG 3/2 3/2 No No Kitchen 2 DB:S uare Equal Insert 80 Wrap Sloped WH WH White Standard FTS Ivw_E4 GBG 3/2 3/2 No No Kitchen 1 PW Equal Insert 80 Wrap Sloped WH WH White Standard FTS Low-E4 GBG 3/2 3/2 No No Kitchen I CT Equal Full 100 Full Sloped WH WH White Standard FTS Low-E4 GBG 3/2 3/2 No No Kitchen I CD Equal Full 70 Wrap Sloped WH WH White Standard FTS Low-E4 GBG 3/2 3/2 No No Bath 1 1 DB:S uare Equal Insert 70 Wrap Sloped WH WH White Standard FTS Low-E4 CBG 3/2 3/2 No No Garage 2 DB:S uare Equal Insert 80 Wrap Sloped WH WH I White IStandard FTS Low-E4 GBG 3/2 3/2 No No Bed I 2 DB:S uare Equal Insert 1 70 Wrap Sloped I WH WH White Standard FTS Low-E4 GBG 1 3/2 3/2 1 No No Bed I 1 PW Equal Insert 80 Wrap Sloped I WH WH White Standard FTS Low-E4 GBG 3/2 3/2 1 No No Hall 2 DB:S uare Equal Insert 80 Wrap Sloped WH WH White Standard FTS Low-E4 GBG 3/2 J3/2No No Bath 2 1 DB:S uare Equal Insert 70 WrapSloped WH WH White Standard FTS Low-E4 GBG 3/2 No Bed 2 3 DB:S uare Equal Insert 80 WrapSloped WH WH White Standard FTS inw-til GBG 3/2 No Bath 2 1 :Square Equal Insert 70 WrapSlo ed WH WH White Standard FTS Low-E4 GBG 3/2 No Total 27 BAY&BOW DETAIIS *See Ba /Bow Measure Sheet Style Detail/ United Appmx. Number- Exterior Interior Center L—E/ Roof/ Hardware Room Count style Flank— inch Casino Angle Lues Color Color Grilles End sashes sashes Screens Smamun Soffit Color 0 0 Full/ United LOWE/ ADDITIONAL WORK DETAIL NOTES Room Count Style Insert Inches Smarts- Grilles Grille style Manager has informed customer that Bay and bow windows 0 Under 72"will have significant glass loss 0 Use L trim on ext.and wrap sill 0 Smooth wrap on sill 0 ADDITIONAL WORK DETAILS 1 No Qty of 0 Sills 0 Sill noses to be replaced by Contractor. 2 No Contractor will remove metal frames of windows. 3 No Contractor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior casings in 0 Pine 0 Maintenance-bee material 4 No Contractor will install new 0 paint-mady or 0 Stain-ready 0 Interior 0 Exterior stops in0 Pine 0 Maintenance-free material 5 No Contractor will wrap exterior casings with coil stock of color. B Owner is aware that Contractor does not do any painting/staining or removaVinstallation of alarm system/bardware.It is the Lresponsibility of the homeowner to have the alarm system/hardware removed prior to installation. Customer is aware in some cases there will be glass loss. If there is,the amount will be dependent on the type of existing windows,type of installation,insert or full frame and window style.We make no guarantee as to the amount of glass loss.Customer is aware and understands any and all unseen rot is not 2 Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris,windows, 1 storm windows and vacuum nightly included. Upon completion of thejob and payment in full,a limited warranty shall be issued. 1 8 Yes 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 j required at the time of sale for this fee. Check# 8 19 Yes All discounts have been applied to this agreement. l0 Yes L; No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). Iliis agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM 4vIND6W AND DOOR REMODELING AGREEMENT,constitutes the entire tunderstanding between the parties,and them an no verbal understandings changing or modifying any of the terms.This Specification Sheet may not be changed or its terms modified or varied in Jany way unless such changes art in writing and signed by both the Buyerfs)and Contractor.Buyers)hereby aclmowled at r(s)has read this Specification Sheet. IlRenewal by Andersen Corporation Buyc s) uyers) t Ws � BY — Signature of Project Manager J bibriature ignature . WILL SALEM JOSH STACEY JENNIFER STACEY Print Name of Project Manager Print Name Print Name enewa Renewal by Andersen Corporation MA Home Improvement Contracto byAIdersen. 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2013) wiNCo. REPLACEMENT ar,1,..*. ,,::,,.,;.,,,. (508)351-2200 Fax:(508)-986-7072 Federal ID#41-1918413 Window Specification Sheet fBu er s Name Date of Ageement JOSH STACEY - JENNIFER STACEY AU ust26,2013 The buyer(s)listed above hereby jointly and severally agree to purchase 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 the Specification Sheet is part. WINDOW DETAE S Style Full/ United Exterior Interior Hardware Hardware LowE4/ Grille Grille Temper/ Room # Style Detail Insert Inches Casings Sills Color Color Color Style Screens Smarts— Grilles Sash 1/3 Sash 2 lifts laminated Hall 1 DB:S uare Equal Insert 80 Wrap Sloped WH WH White Standard FTS Low-E4 GBG 3/2 3/2 No No Bed 3 2 DB:S uare Equal Full 80 Wrap Sloped WH WH White Standard ITS Low-E4 GBG 3/2 3/2 No No Bed 4 2 DB:S uare Equal Insert 80 Wrap Sloped WH WH White Standard ITS how-E4 GBG 3/2 3/2 No No Bed 5 3 DB:S uare Equal Insert 80 Wrap Sloped WH WH White Standard FTS Low-E4 GBG 3/2 3/2 No No 0 0 0 0 0 0 0 0 0 0 0 0 Total 8 BAY&BOW DETAIIS *See Ba /Bow Measure Sheet Style Detail/ United Approx. Number Exterior Interior Center InwE/ Roof/ Hardware H-or tS le Flank— inch Casin An a liter Color Color Grilles End sashes sashes Screens Stnaesun Sffit Color Ful/ United LowE/ ADDITIONAL WORK DETAIL NOTES 4 Room Count Style Insert Inches SmartSun Grilles Grille Style -Manager has informed customer that Bay and bow windows 0 Under 72"will have significant glass loss 0 0 0 ADDITIONAL WORK DETADS E I No Qty of 0 Sills 0 Sill noses to be replaced by Contractor. ! 2 No Contractor will remove metal frames of windows. 3 No Contractor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior casings in 0 Pine 0 Maintenance-free material ( 4 No Contractor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior stops in 0 Pine 0 Maintenance-Gee material ( 5 No Contractor will wrap exterior casings with coil stock of color. € 6 Owner is aware that Contractor does not do any painting/staining or removal/installation of alarm system/hardware.It is the rresponsibility of the homeowner to have the alarm system/hardware removed prior to installation. Customer is aware in some cases there will be glass loss.If there is,the amount will be dependent on the type of existing windows,type of installation,insert or full frame and kwindow style.We make no guarantee as to the amount of glass loss.Customer is aware and understands any and all uaseen rut is not Iract,S _d Them will be an additional charge for time and materials xinless so stated in this contract, E 7 Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of alljob related debris,windows, storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. B Yes 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. Check# $ 9 Yes All discounts have been applied to this agreement. 110 Z Yes Li No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). !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 an of the terms.This Specification Sheet may not be changed or its terms modified or varied in iany way unless such changes am in writing and signed by both the Buyers)and Contactor.Buye ereby acknowledge uyWs)has read this Specification Sheet. Renewal by Andersen Corporation Bu Buyer(s) Ws —Q - BY i Signature of Project Manager Signature Oignature WILL SALEM JOSH STACEY JENNIFER STACEY Print Name of Project Manager Print Name Print Name 1 RenewalRenewal by Andersen Corporation ���� 104 Otis Street•Northborough,Massachusetts 01532 MA Home Improvement Contractor byAndersen. Phone(508)351-2200•Fax(508)986-7072 MA License#170810(expires 12/23/2013) WINDOW REPLACEMENT an MdemnCompany Federal Tax ID# 41-1918413 CONTRACT AMENDMENT This Amendment ("Amendment")is to the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT("Agreement")by and between Renewal by Andersen Corporation and josh StaceX("buyers"). Contractor and Buyer(s)hereby agree to amend and modify the Agreement as indicated below. Other than as specifically indicated below,all the terms and conditions of the Agreement will remain in full force and effect. This Amendment is subject to the terms and conditions of the Agreement. The following additions,alterations,or deletions to the products and services Buyer(s)ordered are being made: Adding 3 Double Hung windows to contract. Contract price is not changing. As a result of these changes, the following terms of the Agreement are also changing (if there is no change, an item will be left blank or marked as"N/A",indicating that no change applies: NEW Total Job Amount: $40,000.00 Payment Method: New Deposit Received(33%):$20,000.00 Enerbank Finance New Balance at Start of Job(33%): New Balance on Enerbank Finance Substantial Completion of Job(33%):$20,000.00 "Please Note-Your job will be delayed until amendment is signed and received. It is agreed and understood by and between the parties that this Amendment and the original Agreement constitute the entire understanding be- tween the parties,and there are no verbal understandings changing or modifying any of the terms of this Amendment. Buyer(s)hereby acknowl- edges that Buyer(s)has read this Amendment and has received a completed,signed,and dated copy of this Amendment on the date written below. Renewal by Andersen Corporation Buyer(s) By: Signature of Product Manager Signature Date Will Salem 9/16/2013 E-Signed : 09/16/2013 01:18 PM CST Print Name of Product Manager Joshua Stacey Date jodostacey@gmaii.com IN 65:204.229.11 Doc ID: 20130916102228596 DCtTD:20130916102MS96 Sertifi Electronic Signature The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information {� (� Please Print Le >W Name' (Business/Organization/Individual): e W c,,� �(j� `—�����•• C� Address: y \1 City/State/Zip: y o >hone#: 5.08 Are you an employer?Check the appropriate box: L,Laoli am a employer with 3 J 4• E] I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 1It'emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' comp. 1 • ❑Building addition [No workers' comp.insurance p.insurance. 9 ' required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees, [No workers' 13.F]Other comp.insurance required.] *Any applicant that ohecks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aredoing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they.must provide their workers'comp.policy number. I an employer that is providing workers inffoormation. 'compensation insurance for my employees. Below is the policy and job site 1 � _ Insurance Company Name: ,n S C n Policy#or Self-ins.Lic.#:nm G(n C� Expiration Date:Job Site Address:_�� ��t"/V1 r City/State/Zip: �� ©��y S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby e n r thepains and penalties ofperjury that the information provided above is true and correct Signafore: �a�l Date: Phone#- F : � Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.city/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6:Other Contact Person: Phone#: '4 CERTIFICATE OF LIABILITY INSURANCE °10/01/2013 Y' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-612-333-3323 CONTACT Nays Companies NAME: PHONE 612-333-3323 C N No: 612-373-7270 80 South 8th Street E-MAIL Suite 700 ADDRESS: Minneapolis, MN 55402 INSURERS AFFORDING COVERAGE NAICS INSURER A: OLD REPUBLIC INS CO 24147 INSURED INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 Renewal By Andersen Corporation INSURER C: 104 Otis Street INSURER D: Northborough, MA 01532 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 36122490 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. ILT ADDL"'NLTR TYPE OF INSURANCE POLICY NUMBER MM/DDY EFF MMIDDY YYYI DCP LIMITS A GENERAL LIABILITY MwZY 300361 10/01/1 10/01/14 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE T NTED 500,000 PREMISES Ea o=ence $ CLAIMS-MADE a OCCUR MED EXP(Any one person) $10,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 —il POLICY PRO- LOC JECT $ A AUTOMOBILE LIABILITY MwTB 300026 10/01/1' 10/01714 COMBINED SINGLE LIMIT X Ea ac ant 5,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ Per aooident E B X UMBRELLA LIAR X OCCUR 20562235 10/01/19 10/Ol/1 EACH OCCURRENCE E 25,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $25,000,000 DED I X I RETENTION E 25,000 1 $ A WORKERS COMPENSATION MI9C 300359 00 WC STATUTORY - OTH- ANDEMPLOYERS'LIABILITY ,,/N 10/Ol/1 10/01/14 X ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? N❑ NIA $1,000,000 (Mandatory In aE.L.DISEASE-EA EMPLOYE E 1,000,000 K es,describe under DESCRIPTIONnd OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE To whom It May Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Insurance Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jhargrove 36122490 . � ��ie�po�nmco�a�uea�t�i a�P/�,a�eczc�iudeG2G fficc of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR j egistration: 17.0810 Type: Expiration: il'Q 2013. Supplement r i RENEWAL BY ANDERSO >N CORPORATION JOSEPH RE2ZA 104 OTIS STREET NORTHBOROUGH,MA 01532 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor {" License: CS-065272 �t JOSEPH P REZW - 168 KELLEY BLVD s N ATTLEBORO MA�1 fie. '� �"�� Expiration Commissioner 04/25/2014 p l 5J e o Jkf I Renewal ` ° byAnderserL WINDOW REPMCERENT u►Md/tw►Gir�wy •WoodMMJI Composite IF Dual DoubleHun- Low E4 Smartsm 100-00473618-010 ENERGY PERFORMANCE RATINGS U-Factor(U.Syl-P Solar Haat Gain Coefficient 0 p 0M19 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance OIW42- M.wMmwwr�Wruw tMrt wllprwMrwry�teMY WIIO�n..�.ti.M M �wllDwtipwMwiwfwd/r�11WwM��wir�wW�r4WirrMw ~wMi�wMI • wAo rw w wrww�M +�knew who. Cwrwrl ww�dstwh MrY�Iw�aM wN w w.rwe w ar1oJMYrwU Pmt Mvyyr Wrb r.. ►rWUG/wtwgMe�illrw�lLn. _ i 7� MMrwaAw.�10 I . �wt SEAf ?Yr Prww www.ew.. -- i q�N, �W�MYYMwy1Y �h • �a.wrwra DESIGN PRESSURE(PSF) N I�r w i� • H.LC J� tRbADB Sloped•Si 1 DH'IN tow •tnara � Ywua warn M.l.Q.QfA.•L!-0.Q.Air MIIrwNr w�Mwrryrr WOMA1YiwlcpnYlcwlw�� I ' I ' I I wde"Nam- ea"10 - 1�ndersen . me npomftDAg larr�4 P,edu�c ryp• Gti..e air PCE PATOM u-rsc sots Fiee3 Oaln POdPOWt 0.29 1.65 0�2� VM*TliMe*Wl= MOWN iyRa.iwrww�o^*tu'aw` oP pd DPW