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HomeMy WebLinkAboutBuilding Permit # 4/10/2015 t%ORTH BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 77 C' - 1-4 Permit No#: Date Received 0OA7Ep oPpycS Date Issued: IMPORTANT: Applicant must complete all items on this page !I I NO I I ''i'l �� �>�� r, ��� � ,/����>ar �/ f ,,,1 ,ern ���„�„r„rrr .,,,�� ��,,,,!„r,��l����,�,�,o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family [I Addition 11 Two or more family 11 Industrial Li Alteration No. of units: [I Commercial Li Repair, replacement [I Assessory Bldg El Others: El Demolition 11 Other V, Fir /IlSao W MWE )all aln1111/11, NO e 8110 lat DESCRIPTION OF WORK T BE PERFORMED: 6U1-"0VL>d 4.J -5 'c 5 Identilicatio - Please Type or Print Clearly OWNER: Name: Phone: Address: be R� � � n � /P ones J dr I rr ,l!I o, FIR 10^101 j"',W11"I 0, ARCHITECT/ENGINEER 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. el L�' Total Project Cost: $ 19, V117 04) FEE: $ Check No.: 40 2/6, 7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce the guaranty fund n”, I AORTH own of 2 . t E ndover ® :, - :� 0% • I • f t'• __ C, ver, Mass, COCMIC"9-11. ORATE0 P4��,�5 S tI BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT .....yl.�G� .....................................�G`� ......... BUILDING INSPECTOR .. ...... .... J� `. � G/� has permission to erect .......................... buildings on ......................... ....................�............................ Foundation Rough to be occupied as `��` ` ................................................................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T RTS Rough Service _'e,,...,,............................. Final � BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. MA Home Improvement Contractor Renewal License 917081Q(Expires 121231201.5)byAndersen, Renewal by Andersen Corporation Federal Tax ID#41-1918413 30 Forbes Rd. Northborough,MA 01532 (508)351-2200 Fax(508)-986-7072 CUSTOMER AWNDOWAND DOOR REMODELING AGREEMENT Buyer(s)Name Date.- F— DIANE SULLIVAN MARCH 15, 2015 Buyer(s)Street Address city State Zip Code 306 HILLSIDE RD NORTH ANDOVER MA 01845 Email Address Home Telephone Number Work/Cell Telephone Number DIAN ESOMSLAW.EDU 978-725-5980 978-382-5674 '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"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Est.Start Date Method of Payment Total Job Amount S 19,447 Mamount Financed S 19t447 Deposit Received(33%)$ 0.00 oepwiit at 5 g--q$ 9,723.50 10-12w,-eks Check'Cash Balance Start of Job(3340$ 0.00 Check,4 Balance on SubstantialAt 8ubEtanSal Est.Install Time Credit Card Completion of Job(33%)$ 0.00 9,723.50 3-4 days If ctcdit card is selected,please Credit Card Paywent former Buyerfs)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. 'Renewal by Andersen Corporation Buyer(s) Bum(s) Signature of Consultant Signature Signature X CHRIS SWEET DIANE SULLIVAN Printed Nam Pt Coni Otani PrintDd Narno Ponted Nornp YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE T141RD BUS114ESS DAY AFTER THE DATE OF THIS TRANSACTION, SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT, - ---------- -----------------------------------------------------------------I NOTICE OF(LLNCEI1,%TIO.N NOTICE OFCANCIELWION Date of Tkun*actioa, You may eaitcetthis I Date of you nt.ycancel th6 traosaction,svithouf any peaalt}'-r-bIi¢afian,within three.business days from the t-usartiou,%sith."t any Penalty or obligation,wHh­three b.41..ss days from the ahnse date.It yo.caatel,any property traded in,,any f»vments ennde by,you under I aluAttlute.Ifyou cancel,any property traded in,any paynteatfimade by youttinter the Contract of Sale,and any otgodahle lastrumem executed by you%vul he I the C:unset aftiaje,and anyegoaahle i"tru­t exteated hyyou will he, returned widxbt 10 days faffolg revelpt by the C.meartor of yaur I returned witidu lq duy:s f-Ik+wiug receipt by the:Contractnr{"5ener") of pour ranrrlhtimt nottc°r,and any security interest arishtg out of etre trap}action silt he I cancellation notice,and any seturity interest arising out of the tt­a"astian cull be .ea-eled. If you cancel,you must make tt­Wble to the Stu.,at your-idt-v,in 1 ram,,tI,cL If you aaorel,you must snake atiailable to the Seller at your reAldeute,In ..Itst-tially a'. gcul'-dithn,as"hen rrre1­4,any#.ad.d,-H—d E.).0 tnulier this Contract or Sale;or you may,if you wish,vamjAy with the instructions of the t this Contract or Sale, or you xuAy,if yva wish,comply with ilte instructions of the Seller regarding the rttura.hitan.m of the goods at the Seller's expense aude6k. I Seflerregadba;the rt-shipment of the goods at the 8,11WR expense and risk. It you do make the goods.%-.liable to the Sethr Rad the S.11e,d-.nut Pick them up I It wu do make the good.,­all.ble to the Sell.,and the Sell-,d-e-,-at Pirk then,up withiu 20 days of the elate of your Notice of Cancellation,you may retain at disposewi;hiu 70 days (the date Of your Notice of C"Cellati--,you may retain,or dial-se ofthegoodswldtoutau�furtheroblIgAtion. If you fail w tushe the goo &as,"lable of the goods: sithbut any rurther obligation. If you fail to make the goodsavailattle to the Seller,ur if'yon agree ic+rntus•-.the goods to IIIc Seder and Pal to tt-sa,then to the Selle."o,iryou agree t"return the.goods to tile Seller and fall tadoso,then you remain liable for perforntattte of all oblilgwioosumler the Cotaatt.In cancel you realain liable to, of aft obligations under the Contract.'to".Vet this waus..d..,-all or deliver.signed-d,dated ropy of this cancellation­aice i this transaction,-I a,deliver a.signed and dated ropy of this caneellarian stutht nr any other%vrlttea-oder.or send a trlegrarn to C-ntrartan Rruesval by Anderzrn,i or any molter w•rittra-mice,-r send a telrgrasi%t-Cantracwrs IterkAjbyAaaIe-e., 3OFarb"Rd, NrthbwroghN11A01532. I 30 Tarbes Rd.NorLhitrough,NIA 01532. I HEREBY CANCELTH181JU-NSACTION. I RVALUY(ANCFA�IMS TILANSACTIOIN. Fl,i,l N- s /a t Renewal by Andersen Corporation MA Home improuenleflt Contractor IaYACIC f �,n 30 Forbes rd Northborough,AAA 01532 License#170810 (Explies 12123/2015) WINDOW REPIAGEMUll ,,..:t,:,r......:...:..::.::..:.. (508)351-2200 Fax:(508)-986.7072 Federal ID#41-1818413 Window Specification Sheet 13uvet s?lams+ Date of Agrcetnrut DIANE SULLIVAN SUN, MAR 15, 2015 1h1 innr:ris hsred abrnft,ben-b% itthuls'and everally Agra'to pun—haw thr gm'(k anddcrrwrvirra iisgvfl sl+m,in accordane(-tiillt tits ptivv�aud l rnis dcsc-ribcd wl thr Specili+ation Shcet and the fiont:rnd the of Ill,:u(nvnpuul nll (.;(;i'1`fJ1�1 WINDOW AM')I)OOR Ris1101)1"1ANt1,�1Cl1tLt 111��:A'1;t�,i'which the`ipcc ilu stir?n Shcet i.;mart. _ WINDOW&DOOR UEMUL5 Eatttroulaw , calor Hadvarr F,t-.. tcv:E4; cnsirr 1,64, G4-is Reim N ,:rig Retsrm u.i. 4Vindoyrtt3oar Style Gefail cassnys Ext-lr�t Color _ t le cm S—rt' Grilles Sa=t:lry 5a 112 Ufts 6 tions Kitchen 1011 i 0 if() 140T FWH INSWING MAL PANEL Ext.MF Flat vvivNH Brt.Brass Nnitmofe None jmitsur Gee 3f5 :L5 No Tem r Kitchen iii`_' 32 32 64 GW insertlafo L-Trim H(WH White Standard FTS rnartsw Gail 213 213 No No 'fatal :3 RAX 110 &BUILD OUT DE'TAILS APprox�� ;•tyle Dotal 1 vi Approx. Numder 11 nro wt?tdoar End Centor Lovri:i Raoi l tiardlvare Rooln count Style RI-IRM i ai ht Garalri Andra Liles Irrtmrcrr ExBhtt Ciao Grd',1s .Callas fimlmi Scnrrats Srnancsun soffit color t7inin ii{i Bay 1!2:1 DCt.pbY.D¢rst It', [tt Wrap 26.2 9 Birch WHt1Nh1 G3G 2f2 v4f4 FTS Smartsun novf White SPt m1ALTY WINDOW DE`I U S m full r Approx. La,.%.i � SpcY:iaity HAY111OW ADDITIONAL 1VOM NUMS Rarm Geunt Styla µ s£rt U-I. SmattSun G tiles Griilu Sryi Exithtt Go:ot t r,:leu «c � 1 '61 r t,;i b i 1, -....._... ... .....« i'. ADDITIONAL WORK DETAILS: No Contractor will wrap exterior casings with coli stock color of � Owner N aware that Contractor does not do any paintin lstarning or removal installation of alarm system or window treatments/hardwate,It is the resp onsibility of the homeowner to have the alarm system and window treatmentslhardtrwe removed prior to installation. Vve make no guarantee as to whether alarms or window treatments,?[ardvrare will fit after replacement. Customer is also aware it)some cases there will be glass loss. If there is,the amount will be dependent on the type of existing windows,type of installation 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 included in this contract.Should any rot be found there will be an additional charge for time and materials unless so stated in this contract .; YesContractor will insulate,caulk and seal windows with 3-paint system to prevent water and all infiltration.Removal and disposal of all job related debris, windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment fn full,a limited warranty snail be issued. I Y0,; Building Permit--Contractor will secure any and all necessary permits. The tee for the permit(g)is included in the total contract price. Yes All discounts have been applied to this agreement. No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment f finance fo€nis)_ A is r�cod and unJrr�t,Erxf kir:rnrl Intieror,t6r it;u tion.thsi i6ir'�,.:<der atin.i hrcf,ulun,!tvirlr Ihr(t ti"1'('Y\1 111ti1k)1V'.Ati i)Dr)(lti itl�lff S!)I,1,1\tJ:Af41.i.t'\It.!�t',i+n,titrd.rr ring Cuiim tntarrsl;tnGlitti;IntRoru duIca lir.,anri ill;.,-r;rrr-uu torl,a!iuidr t 6us:.i,ut,,,haiu;ms;nr i rt,dn�,itn,ett}nF i6r civ nrs_"ihis ti., iii.,iinu`+nret urns r. t I re,h:rn;etE,ait:ireru�n,cnti6rtt or rittir<1 in Irmo t;m unk, surly rlt,urur.arc in:uitin,and<i:;ar,i Ilk Erudr iiu ('nutrart.u, ILnrrs:ho;'h,arLt i;h,h,r thni 11,1"I r=.h-e.,id tlf1'-Sl,:dtrat4;a Ylisrt. Renewal by Andersen Corporation lim"'I Signature of Consultant Signature Signature CHRIS SWEET MANE SULLIVAN Print Name of Consultant Print Nerne Print Name Renewal by Andersen Corporation MA Home improvement Contractor 30 Forties rd Northborough,MA 41532 License#170810 (Expires 12123/2015) (5084 351.2200 Fax;(5081-986-7072 Federal ID#41.1918413 Provia Door Specification Sheet I3tt4't�r;s \atrte I)ali'oC:lt,rrt�elretet CHANE SULLIVAN March 1 5.2015 1 lee[)/Iver li,trrl aI >tt hereby joiluk and agive tf,plat faa..r tial ,,xt'N anti/"t 't n i,t"li'n'tl itt uecunl4rL_v frith tho prir"lon Ow 5t}r=ti$eatiunShet^rstaidthrtir)1ttantithe^r„t,x-voCtial/•,ar['henJranSinE.UI'S'IOM\ kINIA% ANI)IMORRI-ARMLIINGaf'RIll-AIENLofwhi,htau, sprciiication Shr"t is pa"- ENTRY DOOR DETAILS I.exatftxt Ja ,b d.ptlr—4 9116 49/16 _ 4 9/16 4 9116 49/16 49/16 ft•ide,t;,ie 1 r�')tl(3 �. � - - - .ffi..e -�,�,.. _ .�-.ma� — -,..2.....�,.-..�..._.. _.s�_......._.a.._» ._ - ._.. ...._....,_w.�.......-.,�,......_«._ .ems... - f')utsidesh=ta tvL!206 -- —� ----- f Cl:+1•.t L�lf?Ini Clwlvan <tu€,i.iL• 'ulur .`tlr,uutaiat llt•rn .�-.._...._., _ _...._._._ .,.�....,._.M.._.. .__._v �._..,�..�w.__.a__r_..__.._.,_�._... ..�.,.._..�-.._..,_.,....k ,.._<,._.,. --�.. �.1<411dS`11tL' .4e3 '<"�' - ___ •.-..» _.,.,v,.,„...,.a. - ._.. -- ......,..«..<... tnsidL�f:olLv f.)iFtyicll:(.nlor (,lass etyl' Clear% /logy E, ConrtnA �ernc v�..u_ Doorekin SM00111 _. =...u..._.,.�,.... .w...� „�....<..�.v.a..- i)Ivrotion tiRt=t).m.n.�... Add GMI. Grille options Nonc _ inside(-clot, NoviP _ - ._...«... .w. m.... w .......... - "-- outvdu Color -Nont.• Int ltxk.�,,t (ic4wgian - - _ Int Fini,h Get.tockwt Im Fint:.h - 11rivshotd Sih-er f:ickplatc IWI,lurle tt;,i[sint � tie, Ch dding mtur Transoint No 1)tx,r 5h=le 974 --- --Storm Color Ilandlc 4tylL (-t. nlH errrti fiandleC'olor I--- Job torm will have glass sash also included �4v49 R � LT tional Notes: er is aware that Contractor does not do any paintingistaining or removallinstaliatian of alarm system and door treatmeotslhardvvare.It is the responsibifity of homeowner to have the alarm system and door treatments/hardware removed prior to installation. tyle make no uaranfee as to whether alarms,door Y P gments or hardware will fit atter replacement. Custotneris also aware in some cases there will be glass loss. if there is,the amount Brill he dependent on the of existing doors,type of installation 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 included it)this contract.Should any rot be found there will be an additional charge for time and materials unless so stated in this contract. Yes Contractor will insulate,caulk and seal criadovts with 3-point system to prevent water and air infiltration. Removal and disposal of all job related debris,doors, storm doors and vacuum nightly included. Upon completion of the job and payment in full;a limited warranty shall be issued. Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is included in the total contract price. Yes Ali discounts have been applied to this agreement. in /pis ;Ver Owner agrvec to he prt_+c'tt rtn the final dal,of ifl rall:ni;m f'irr final insproion cult to dolivct,finat paymem/linance t6i nv" 1i)i^iklot Jtr;tnr.rn i4aIl he d•rrtrrrnkd until rh ronftrrrl i,i totlilelr#to tr,i.rf allf+ruti,i. fF i-.:{rat+t:ux#ui.rlrr,;twxl he '11(16&kt t,du parer,that iiia,Six tihratifnc ih, G(S"I(PM%%I\IX IXk*AND I)(P:#K KKMt.)DI1-1\i,.-1(AMIM1111 il,c,i iw '. tntd,:Iardini,lw pt„m fin^1—ire-:ntd ibcru an;w-..,,4)A umiti ter dirtEs.rl;r.,;ia ­ta-eugiitl;nn}of tIu a rat. I his 5nrri..,:oi?n Shf-, n a}•.nn It,I 11tu.'-d o:it tern,<r.,_sti,'rl rrc Suer-,in an,s a, ah,: ttth t)t.mr.sari itt t,neat.antl 4z t,d ln•F;ah ii l;,zccrs.1rt^I Get;i ra.nal 11"g,r Iur,I,j eel.0,,I'As;r tht.ltt,'r .Nast/-d111i,Sp,L u.::.:n'#]r I Renewal by Andersen Corporaiion Iinr'rr:"s1 Iiuti';r S' rr l� Signature of Consultant Signature Signature CHRIS SWEET CHANE SULLIVAN Print Name of Consultant Print Name Print Name i. PRODUCT PERFORMANCE Andersen'NRC Certified Total Unit Performance(cunumd) P MdersenT Product. Glass Type U-Factor' SHGC' VI' _ .200 series. r< .. Clear Dual Pane 0.45 0.60 0.63 - . 'Clear Dual Pane with Grilles 0.45 0.54 0.56 - Tot-Wash Lmv-E 0.30 032 0.55 Doable-Hung•Window Lnw-Ewf h Gilles 0.30 029 0.49 HP Lm 174 SmartSun 0.30 021 0.49 - - HP Law-R SmartSun w/Gilles 031 0.19 0.43 - Clear Dual Pane 0.45 0.61 0.64 - Narrofihe'. Clear Dual Pane with Gilles 0.45 0.54 0.57 - Douhte-HungWtndow_ Low-E 030 032 0.56 Low-E with Gilles 0.31 029 0.50 Clear Dual Pane 0.44 0.63 0.66 - NartoNne: Clear Dual Pane with Gilles 0.44 0.57 0.59 - Transom Window Low-E 0.27 034 0.58 3 - Low-E with Gilles 027 030 0.52 _( Clear Dual Pane 0.45 0.60 0.63 - ClearDual Pane widt Gilles 0.45 0.54 .0.56 - Low-E 0.30 032 0.55 Gliding Window Low-E with Gilles 0.30 029 0.49 Lmv-E SmartSun 0.30 021 0.49 Low-E SmartSun with Gilles 0.31 0.19 0.43 _ - Clear Dual Pane 0.43 0.61 0.65 - Clear Dual Pane with Gilles 0.43 0.55 0.58 Fixed,Transom;. Low-E 028 033 0.56 Circle Tap'Wind'ow Low-E with Gilles 028 0.30 0.50 Lmv-E SmartSun 027 022 0.51 0 Low{SmartSun with Gilles 027 020 0.45 ' - Clear Dual Pane 0.44 0.61 0.64 - '... Clear Dual Pane wn Gilles 0.45 0.53 0.56 - tow-E 029 032 0.56 - .Narriil.1W Low-E wMi Gilles 0.30 029 0.49 9-1 DIE ..Gliding Patio Doers Lmv-E San 029 020 0.31 2 -7�jM '.. Lnw-E Sun with Grilles 0.31 0.1a 027, low-E Smansnn 028 021 0.50 - Lmv-E SmartSun with Gilles 0.30 0.19 0.44 '.. _ - Clear Dual Pane 0.43 0.61 0.64 Clear Dual Pane wbGilles 0.43 0-51 0.56 - Lnw-E 028 032 0.56 - Penna-Shield'.... Lmv-E with Gilles 0.30 029 0.49 . E Gliding Patio Doors Law-E Sun 0.29 0.19 030 tnw-E Sun with Gilles 0.30 0.17 027 Lmv-E SmartSun 027 022 0.50 Lnw-E SmartSun wilft Gilles 0.29 0.19 0.44 ' Clear Dual Pane 0.43 0.45 0.47 - . Clear Dual Pane with Gilles 0.43 039 0.40 .. Low-E 0.32 024 0.41 Hinged.lnswing Lmv-Ew,ith Gilles 033 021 0.35 - ':Patio Doons. LDw-ESun 032 0.15 023 _ .. lmv-E San with Gdlles 034 0.13 0.19 - Lnw-ESmartSun 0.32 016 0.37 .. Low-E SmartSun with Gilles 0.33 0.14 0.31 - so• a Do nbt remove un®boil code Wpectlon.Save label fir We rMkwce: 13 Cli EI* 6 E U 4 *WW grsoa+dthdm(v3b , i j RenewalbvAndersprL. � trlManW +OueQ+E1R rA+d.maC�.4 � ' Nib AND-N45 WoodVrnyl Cam sits FF Dual Argon Low E4 SmartSun j Product Type: Glider i ENERGY PERFORMANCE RAMNG5 U Factor Solar Heat Gain Ceefffclent 0:29 . 1.65 0,21 .s�� atrIr151 ADDITIONAL PERFORMANCE RATINGS Vlsible.Transmtttanca 0.49 • � • - prrm.n.rrnc,+�w••�srrr.rsr.,e...w ssa.a.+.rue�..• • Anonuti[Irmwma+n/1�Qamr�tw�..n.rvW�rl�r�'�'la�� ersan o art ' r ++rwrr�.rw. m Standard Raeng '?' rvram.rkawna+vwA�wut o ••DPpsfHS-Q5. , �I I • 1060�512D3rr-015 � '.. i • I �l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 F Boston, MA 02114-2017 VQ www mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contraptors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RENEWAL BY ANDERSEN Address:30 FORBES ROAD City/State/Zip: NORTH BORO, MA 01532 Phone #:508-351-2200 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 30 4. ❑ I am a general contractor and I 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance. $ 9. Building addition required.] 5. F] We are a corporation and its 10.❑ 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.Q Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing 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 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:OLD REPUBLIC INS. CO. Policy#or Self-ins. Lic. #:MWC 30293800 Expiration Date: 10/01/15 Job Site Address: LP ��// S/G�Q City/State/Zip:W,0 A/ 'd 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 rtify der the pains andpenalties ofperjury that the information provided above is true and correct Si mature Date: Phon,K14X08-351-220 0 Official 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): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AN®EC®R-01 vAnAVv ® CERTIFICATE F LIABILITY INSURANCE DAtoll-01112014 UNYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMA71VELY 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER RINSURERF. CT Willis of Minnesota,Inc. certificates Ilis,com c/o 26 Century Blvd a Erd:(877)545-7378 N Ne;(888)467-2378 P.O.Box 305191 Nashville,TN 37230,191 ADDRESS: INSURE S AFFORDING COVERAGE MAIC IM RA:Old Republic Insurance Company 24147 INSURED R B: Renewal by Andersen Corporation R C: _ 30 Forbes Road R D Northborough,MA 01532 R E: R F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L711 TYPE OF INSURANCEPOLICY NUMBER ylpq/ppP UNITS _ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE ®OCCUR WZY302940 10/01/2014 10/01/2015 PREMISES Ea occurrence $ 500,00 MED EXP(Any one person $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEML AGGREGATE LIMIT APPLIES PER: X POLICY F1 JECT LOC GENERAL AGGREGATE $ 4,000,00 PRODUCTS-COMPIOPAGG $ 4,000,00 OTHER: S AUTOMOBILE LIABILnY COMBI D SING LIM Ea accldern $ 5,000,00 A ANY AUTO ALL OWNED SCHEDULED WTIB302575 10/01/2014 10/01/2015 BODILY INJURY(Per person) S , AUTOS AUTOS BODILY INJURY(Peraoddent) $ NON-OHIREDAUTOS AUTOS PPROP nDAMAGE S S UMBRELLALWB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS'LMBIU V Y r N X STATUTE ERS A ANY OFFICEO RIE ER PARTNDED'1 EECUTIVE ® N r A C30293800 10/01/2014 10/01/2015 E.L.EACH ACCIDENT E 1,000,00 (yesory be under NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 dd escrib Iiyes, DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS r V€HICr ES(ACORD 101,Ad&Jon.l Rei-nark"Schedule,fray be aiiacl,ed If wrrore space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE IMTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-090125 u " fi JABW L MORIlVr 86 GARIM NER ST' < LYNN MA 0190 Expiration Commissioner 10/06/2016 I CTfie�pan��zoouoea�,�z a�C�/�/laz�aolucaella ffi¢e Of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration: 170810 Type: Expiration : 12/23/2015 Supplement RENEWAL BY ANDERSON CORPORATION t' JAIME MORIN 104 OTIS STREET NORTHBOROUGH,MA 01532 4. � ilnderseere,ary ,` I