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HomeMy WebLinkAboutBuilding Permit # 6/9/2015 FORTH f UIL IN IT o��4LEo /bgtio T O NORTH A .p APPLICATION FOR PLAN EXAMINATION p _ ✓ Y COCNf awic my Permit No#: t Date Received �'yssAcHus���� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION AQ3 Pn III PROPERTY OWNER Print 100 Year Structure yesno MAP 6 PARCEL: 'P ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside tial Non- Residential ❑ New Building trune family ❑Addition ❑ Two or more family ❑ Industrial ❑Alt tion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �i 1p8�iM u �r DESCRIPTION OF WORK TO BE PERFORMED: la, P � Identification- PI e se Type or Print Clearly OWNER: Name: Ga S" Phone: Address: Contractor Name: A0 AW44� Phone ! � U Email: Address Supervisor's Construction License:— ✓ Exp. Date: Home Improvement License: `' �7 0 ?,1.9 Exp. Date: 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. Total Project Cost: $ tlb i W01100 FEE: $ Check No.: a2ohq,s,� Receipt No. � NOTE: Persons contracting with unregistered contractors do not have access to guaranty fund ,..., - ',,—, ,_um' h�;n`;r r ii/.✓!' r ,/rdyimtirTr% 7lrr,"Jl//`>,71�%//iTJ,'% n(N�, A//i/9/ X 11//T�r�rrT 1 WSW ,tl iT ,rte FORTH o w n o '� s E. :..'.�, i1du v ur ® ® T �+ O h h ver, �.SS, GL LANE 1• COC NIC NQ WICK 4 S U BOARD OF HEALTH P E �R M �T� LD Food/Kitchen Septic System THIS CERTIFIES THAT ....... C bt �, BUILDING INSPECTOR JAI I Foundation has permission to erect .......................... buildings on .. ....................... Rough to be occupied as ........ .... ....... ... .. .........CAA... ..A*W h!1R5........................................ Chimney provided that the person acceptin 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR . UNLESSI STARTS Rough Service ........... ..... .................h:...... ............................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® ccupy Builclin 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. MA tome improvement Contractor Renewal byAndE'merl, Renewal b "dersen CorporationLicensa#t?Ba10(Expires 1za2��2o1a) ' Federal Tax ID 941-1918413. teertoow seswtaceraENr ..,,w t `e., a:rn, 30 Forbes lid. Northborough,MA 01532 (508)351.2200 Fax(548)-985-70172 CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT Buyers)Name Date. COURTNEY SCRUGGS - MAY 12, 2015 Buyers)Street Address City State Zip Coda 1423 SALEM ST, NORTH ANDOVER MA 01845 Email Address Nome"Telephone Number Work/Cell Telephone Number CORTNREYWELLS1 9(9YAHOO.COM 978-688-4177 978-684-2434 Buyers)hereby jointly and severalty 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"), Buyers)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. EsL Start Date Method of Payment Total Job Amount $ 23,163 Amount Financed$ 23,163 Deposit Received 133%)$ 0.00 Dgpa,,dat Wg; 5 11,581.50 Check/Casa 8-10 weeks Balance Start of Job(33%)$ 0.00 Check r Balance on Substantial: Est.Install Time Credit Card At Subslantk8i aaomple0on of Job(3394,) 0.0{) Carnpl t[odt S 11,581.50 1.2 days It ctedlt card is seiisc4rrd,P{©silt ' r»lino].a meat ar t e cera vMe i Nat=a t es are ssafirea sea€rr dlt Card Payment form Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there aro 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. Renawal by Andersen Corporation Buye(s) Buyer(s) Ley° Signature of Consultant nature Signature X BRUCE PECK COURTNEY SCRUGGS Printed Nam at Consultant PrintDd Name Phniied Nam YOU,THE BUYERIS),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. .Y--------------------------------------------------------------------------I NOTICE OF CANCE.LI-X1102+1 NOTICE OFC ANCEL.LAXION t r Date of Transaction :+,'42.^1, You may,Cancel this Date of TrtAnaae don V W i`, situ sway c-a"el th.iu tramsactiory without any Penalty or attligatiou,within three huslness days.from the trrnsartion,without any Peualey or ntat£gatinn,within three bus£niss days from the afruve.date,if you cancel,any property,traded in,,any traymenis made by you under I ahove date.If you cannel,any property trade,]in,any payments made by you under .the Contract of Sale,andany negotiable instrument executed by you will be I the Contract of£Fate,and any negotiable instrument executed by you willbe returned within 10 days following retelpt by the Contractor("$*-Her") of your returned within le days following recelptby the Contractor("Seller")of your ranreltathc.notice,and any security interest arlsiug out of tite transaction will he I ca tenHatioo nbt£re,and any security interest arising out of the transaction x411 be rsuci£ed, 1I you vanrel,you...ssyt snake avanabie to the Sraer ar your risi,leurC,£u I c'aner". if you Cao rel,you roust,xtake avaDable to star,Se11ir at.your risldency io arsbstantiaRy,as goad(nealidtnt as when received,any goods delivered to you under I substaut€ally as gaud canclhion as when reelved,any goods delivered to you uncle, f1t3s Contract or Saler be you may,.If you tw€fila,comply with the Instructions of the I this Contract or Sale, or you ruay,if you wish,comply withthe hestrueti eas of the Seller regarding the return uhiputent of the goods:at the Setter's expense and rink. I Seller regarding the return shtpment of the goods at the Setter's expense and risk.. 1t you do orrke the goods available to the Seller and the goner does not pica Went uP I It you do make tire goods ova£Lthle to the Better and the Seller does not Pick thins up :within 20 days of the date of yrcrnr biotivi of C.anvittaifau,you map retain or dispnsi I within 20 days of the date of your Notice of Cancellation,,you may retain or dispose or the goads without any further obligation. 1f you fail.to quake the guoslr availaltte of the goads without any.farther obligation, tf you fail to make We goods available to the Selltr,.or If you agree it,return the goods to the Seller and fail to do so,then I So the Senor,or if you agree to return the goods to the Seller and fait to do so,then. i.you rirtm'ro liable for]urt'ormartrte of all obHgadous coder the Contract.To cancel I you remain liable for perfbrmance of all afftittlonsunder the Contract.'to cancel :this transaction,mail or deliver a signed and dated copy of this cnueetlation notice i this transaction,tuail or deliver a signed and dated,copy of this cancellation notice or any other written native,or send a telegram to Gontrarxon Renewal.by Andersen,I ar,try biker written notice,or send a telt-grant to Contractor, tteuewal by Aoderse.. ''.1:10 Forbes lid. Northboroogh hfA 01532. i 30 Forbes lad.NorWhorough,MA 01932. I I HEREBY CANCEl THE'rRAN5AC.TtON. i I HERL"1fY C h`:i:EL T1i1S 7TiANS.It."'TSCf k, I Gray>*.rm �,s,Ruro fldwzE Naa,wa �An ayn.r'ar ,fir vw-ves A4,1 Noma Renewal Renewal by Andersen Corporation MA Home Improvement Contractor byAndersen. 1"' 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12123/2015) Wrnoow rteai.AcewteNz ,,,.,.;,,,,k�.�,;,;..,,;:,.,,,, (508)351-2200 Fax:(508)-986.7072 Federal ID#41-1918413 Winslow Specification Sheet :Buvvrts Nam(, Late of Agn'I'tnelit COURTNEY SCRUGGS TuE, MAY 12, 2015 1 hl))uvcrfs listC(t alx)i'ts hLl'Ch}'JEntitlp`Hut]ueFCt'all}`agrev to purdla."c Ow gowds and/or svrvicvfi listed hd(m,in accfmiance,kraut tilt'pricc-s arid tvrt))ti dCsVIib d Ion dw spi'dlii atiou Slicer And the(II)IIItint!tilt,I-v%vist,tit'dw avctnllpau�iui{ Cl_`ti 1'0\1 WINDOW AND DOOR iLl•MODFAANG At,REE'Ndl:N'i;of i+hitrh hhr tiperiitc,uiuu>hrct is hark. WINDOW&DOOR DETAILS Apt, Apo, MrDs Ext iDr/!Hirst}t1r G(ylrlr HEtrdYfdrfl t�:3Rf'h'fYe Lnv.G4! Cirri (;title Gi3SS Room i! -matt, fi'iaht ul 1Nindow/Door S. e Detail Casings Extant Color Style SaaOnS Srr-Arr=an Grilles Sash 1733 Sash 2 Ufla I Options Porch l of €i' 130" 0 PS rafo MUExt MF Flat w141WH Sat.Nicki piewbuty FFG 'marts. Nene Porch 102 ti 80" 0 P5 rare Int/Ext MF Flat WRIM Sat.Nickt NewGu FFG martsu- Porch 103 lift 91} 156 OT full frame 1.2:1 Int/Ext MF Flat Yti/WH White Standard FFG -manse. ua.. Bed 1 201 :11 45 76 DB sq rail a ual insert siaRed,ill None HAVH White Standard FFG martsu. amit 342 312 Bad'1 °r)2 ;I m 1;r 76 Df3 sq rail equal insert stoped sE(t Nolte NHAVH Waite Standard FFG a tS tatW m 312 312 Bed 1 20;3 :fit 64 84 DB s care Cott hitt frame int/Ext MF Flat NHAVH White standard FFG artsu INTW 212 214 Temper Bad 1 201 20 tit 84 DB square coil full frame int/Ext MF Flat VWWHI White Standard FFG 3mansur ttatw, 212 2i4 Tem r Bed 2 20,1 :31 45 76 DB sq rail equal insert sloped sill None VH/WH White Standard FFG martsu; ltmv 312 3,12 Bed 2 206 31 15 76 DB 54 rail equal insert sloped sill None NNPNH White Standard FFG _answ INTw 3/2 3/2 Bed 3 2)07 :3I 4.1 76 DB sq rail equal insert sloped sill None IVH/WH White Stmt isrd FFG mxrtsur INIW 3:2 1-'2 Total 10 HAY HOW Bt,AUILD OUT IMAILS Style Mail/ Widt x Appox. Number Frame Wuldo•w End Center LowE t Roof J Hardwar,3 Roo,ti Count Style Fanhe's filarqht Casinga Nigro Liles Interior Extrint Color GtilLs9 sashes nasties fk:rrlans Srransun Soffit Color SPECIALTY WINDOW DETAILS Full Approx. LowF' spscia}ty BAY/HOW ADDITIONAL WORK NOTES Roam Count y-... ,Stto,...-,. insert M. 3awrfSua GrtUfls Ext/Int fl!'sr t u,t�w�,c:,r.-, „t t,raE,f:rv.E 4:a}nrs aafi•e�9 irn'h<-a if,Fas+Tl tu•aivaitk,,rt gUa.In?r. ADDITIONAL WORK DETAILS: i No Contractor will wrap exterior casings with coil stack color of Owner is aware that Contractor does not do any painfingtstaininq or ret; raginstailatfon of alarm system or window treatmentsfhardware,It is the responsibility of the.homeowner to have the alarm system and window treatmentslhardwara removed prior to installation. VW?make no guarantee as to whether alarms or evindow treatmentslharzf'ware will tit after replacement. Customer fs also aware in some cases there will be glass loss. H 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 bean additional charge for time and materials unless sa stated in this contract. i Ye, Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all jab related debris, windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. t Yew Building Permit--Contractor will secure any and all neoessary permits. The fee for the permits)Is included In the total contract price. Yes All discounts have been applied to this agreement. les No Owner agrees to be present on the final day of installation for Orlaf inspection and to deliver final payment/finance form(s). 1t is ags-"A aad uudclmke -1 to:vid I:riitool the,Ii,utir+>,Ilial rhi Ytv.eificati,ia""ll"o.n1um;uitIt}lie CJ'S'I'ON I WIN])t)It'ANI)MY W IUAff)I)LIAN(1,AGR M Els"I tans€hairs thr,ciitiw lnrsul-rkewctinit In•usrru du'pa,iics,acrd tlsis,•:ur uu ivr(r.,l,aid r�laurGrt#,.� 6snctinp;qr m,xldu,it,:r,:u n,+,C dw o—l"."Chis sli,rdfr':,€run Sf„rt in:,x nn1 t,r rtrant,•d,tr itry i,•nns nrci+liiivrt u:rasic<d in {rats siae l,nless such tiialt4ra an•in wine,';,lld sin ti'A fry iloilr IlItuvrs real f'r,itls:,t tu,:j;,r�r` )+,urn arkiune'tc<ii,,�ih d tf,t.r,,;�t Ikts.read t1ti.`r(u,xituaGt.i Renewal by Andersen Corporation Signature of Consultant Signature Signature BRUCE PECK COURTNEY SCRUGGS Print Name of Consultant Print Name Print Name Renewal Renewal by Andersen Corporation YJ F'mbv"161, 1)21 5�2 MA I"mite Imps o%'i'mar'l AJA 4, ;71,%h Ivrrmh,.� ' a 121111Z:4+201 byAndersen,C.-Ali 1 1:4-mae(50,40 3il-1200* Fa"� WINDOW REPLACEMNT mA'—&t;ai't, Aj'�Y'% COMUCr MUNPM' Thvs AmouhtwiO (";WwtuIrN"W") v,;10 111v cAtsR)AA WISM-1w ANE'l 110011 PYA,101,1131M, A(;V1,-1L*4t:Xr aml, [vtwecri the A;�jlvrlwrjl,6 khfh.',&J1%A,'fW. 0111IL.1,11)"IM,k� Hic Agtwmol( WM Ivimmo in fi-ill kmlt:'*'"�L:t to -on";Flt 1110 Tj":!JoAloww" �Pi , I jcfmt;G'6l 14,1 oil I,I C b"o t iU wvv ltiq or(%f o,rde+M.-nw,Im ragv,I Dropped I GT and 2 PS gliders from original contracL $12,3811,00 subtracted from total cost. A,4;I n24,uh of ilwmcliaqgL'';' flt'.? 10111,11.'i ed 1he A,zlivownt 4tv LLia Jutn'gin'L M lh-;"r' k !io dilvt,,?y, ,m item will he Idl Hank i,,i N-L-W 0�crviit Gicen Sky Fi I'LUACC \MAV 0ol'XII'v�11 St'aa of lob: NOW �� l tit co']sk'aj Fi 1xwICQ It is aSmod mad undergwd by and bawoen the piaffia that IhU Amoindmervi and the,orlgkmf Agrmmm omliftift Iha mdre undemandiAg be- twmn tho Patti",and%M*IV no VMWI Un4momunp ChAr4ing or modUft any of lar,W=o(titim Amvndmmt, 10a0m) haoby mbiowl- OW thwt Sayor(s)heo md this Amvmdmv*,%nd has mmind x om-pki!W,sivcd,And 4*4 mW of Ws Amerdmmvt on 0m;WwT*vn bplvrw, Rcrimal by Andn*m CoMoration Burr(O AM M IV:�'11' Courtney W. Scruggs K MMITV! 5/15 2.11,5 Mix 44 hwdl.j�l N"Lm4,!� r PRODUCT PERFORMANCE Andersen' NRC Geeiified total Unit PeYf0VMaflee (continued) Andersen.Product.' G1assType U-Factor' SHGC' VP ..200 Series. - - ClearDualPane 0.45 0.60 0.63 - 'Clear Dual Pane with Galles 0.45 0.54 0.56 - Tilt-Wash - Low-E 0.30 032 0.55 rl -Douhle-Hung Window- Low-'c with Galles 0.30 0-29 0.49 HP Law-Ell SmartSun 0.30 021 OA9 ate. HP Law-E4 SmanSun w/Galles 0.31 0.19 0.43 Clear Dual Pane 0.45 0-61 0.64 - Nanuline, Clear Dual Pane with Galles 0-45 0.55 0.57 Double-Hung'Window Low-E 0.30 0.32 0.56 - Low-E rdth Grilles 0.31 029 0.50 Clear Dual Pane 0.44 0-63 0.66 - Narraline: Clear Dual Pane with Galles 0.44 0-57 0.59 - Transom Windnw Low-E 0.27 034 0.58 Limy-E with Galles 027 030 0.52 Clear Dual Pane 0.45 0-60 0.63 - ClearDualPanewhGalles 0.45 0-54 0.56 - Low-E 0.30 0.32 0.55 Gliding Window Low-E with Galles 0.30 029 0.49 Low-E Sm irtsun 0.30 021 0.49 " Low-E SmartSun with Grilles 0.31 0.19 OA3 Clear Dual Pane 0.43 0.61 0.65 - Clear Dual Pane with Galles 0.43 0.55 = 0.58 - Fused;Transom;. Low-E 028 033 0.56 Circle Tap-'Window Low-E with Galles 028 0.30 0.50 ``=1 Imw-E SmanSun 027 0-22 0.51 2 2 M Low-E SmartSun with Galles 027 020 0.45 7j ' Clear Dual Pane 0A4 0.61 0.64 - Clear Dual Pane with Gnlles 0.45 0.53 0.56 - Imy-FE 029 032 0.56 - Narmiine' - _ tow-Ewith Grilles 0.30 029 0.49 `Gliding Patin Doors Lmv-E Sun 029 020 0.31 - Low-E Sun with Grilles 0.31 0-18 017 Law E SmartSun 0.28 021 0.50 s '... I.AwE SmartSun with Galles 0.30 0.19 0.44 3 - Clear Dual Pane 0.43 0.61 0.64 - ear Dual Pane with Galles 0.43 0.54 U6 - Low-E 028 0.32 0.56 Zlidinj lld:. Low-E with Galles 0.30 029 0.49 tio Doors - tnw�Sun 0.29 D.19 0.30 Low{Sun with Galles 0.30 0.17 027 Lmv-E SmarlSun 0.27 0-22 0.50 Lm%E SmartSan with Galles 0.29 019 0.44 ' Clear Dual Pane 0.43 045 0.47 - Clear Ducal Pane with Galles 0.43 039 0.40 - Low-E 0.32 024 OAS Hinged Inswing Law-E with Galles 0.33 021 0.35 - Patio Doors '-. - Low-E Sun 0.32 0.15 023 Low-E Sun with Galles 0.34 0.13 0.19 _ - Lnw-E SarriSun 0.32 016 0.37 Low-E SmartSun with Galles 0.33 0.14 0.31 - a> f Renewal byAndersena WINDOW, REPLACEMENT AnMdecmCompaw! WoodNinyl Composite IF ' .>frcl: =` = `` Dual Argon Low E4 SmartSun Double Hung 100-00473518-010 ENERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient 0 ® zAwb, 9 001, ® 19 v ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 m 4Z Manufacturer stipulates that theca ratingsconform toappfcabta NFNC procedures for datarmining WhoFa product performance•NFAC ratings are datemtined for a fixed sat olenv'xonmentalconcIR nsandaspecir.:products¢a. NFNC dons not recommend any product and does not warrant the sukabSity of any product for any sf,006,use. Consult manufacturer's Fnarature for other product performance information. t� s wvnv.nitc.olg This product meets Green + - - �iO Sears environmental cwra> .tet••; , >•�'c-•-��r,y standards govaming energy r '•'+•'%n-„ efficiency,heavymalars in the Irama and esash A.-R� 4materet,packaging,and .,•t.�t A,consumer educational t materials. et nil, DESIGN PRESSURE(PSF) r a w aoa am Door r Manutaewrcr9 A450chtbn� 1 ® J 2 ® www. dnta.RbA DB Sloped Sill DN IN TstAlolMfSMarAAt:IAA'AX4AICSA101ASlA440,M Manufacturer stipulates confomtance is sna ljW)leslawards. Neets or exceeds M.E.C.,C.E.C,&I.E.C.C.Air InOJf ration requirements WDMA Hallmark Canlfcation program. t Do not remove until final code inspection. Save label for future reference. , 1 _\•`+ �i~�rpt. e.ergystanirip-an- zy i rncan.go.ca N ti 1 1 yr•• cc r Q a=i j U c E � LLJ ener'gystar.gov L<qualified/Admissible e e al ;. WINDOW REPLACEMENT an AndcrsenCompany t: t;^•: Eio 32Z:?si AND-N-35 ,';:% Wood/Vinyl Composite FF •. Dual Argon Low-E4 SmartSun Product Type: Glider ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0.29 1.65 u.21 U.S./I-P Metric/SI ADDITIONAL PERFORMANCE RATINGS Visible Transmittance All 49 e Hanutacturer stipulates that alese ratings conform to applieatlle NFRC procedures for aeterrrilning wnole product performance.NFRC ratings are determined for a rcfeo set of environmental conditions and a specific product size. NFRC ages not recommend any product and does notwarrant the suitaoirey,at any product for any specific use. Consult manufacturers literature for otner product performance information. waw.nfrc.org wnaow dna Ddor � Ii � rd nufapturers �sdclstion Andersen Cor oration:RA Glidin Window anutac urer s pu a as conrormanca o aro ovnng s ein ar s Standard Rating DP psf-HS-G35 t�1 SE This product meets Green seals anvlrorimental standards governing energy efficiency neavy mEtals in tree frame and saast, - material,pacKaging.aria consumer eaucational materials. 100-00512036-015 meets or exceeds fA.E.C.•C.E.C.k 6EA.C.hir Inailtration requirements WDM%.NailmarK Certification Program. The Commonwealth of Massachusetts Department oflndustrialAccidents Office of investigations ' 1 Congress Street,Suite 100 Boston,MA 02114--2017 www mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print lLeLdbiy 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. ® 1 am a general contractor and 1 employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' insurance.: 9• ❑Building addition comp.[No workers' comp. insurance p• required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.® I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12.(]Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.nOther employees. (No workers' comp.insurance required.] *Any applicant that checks box 111 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. 3Contractors 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: 10/01/16 Job Site Address: /173pla;, Sr City/State/Zin• !r"OtZ- 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 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 A for insurance coverage verification. I do hereb c rt a' s and penalties of per,jury that the information provided above is true and correct e: Date: 05/19/15 Phone • 507A-51-22p� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Ucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• ANDECOR-01 YADAVYO A4C' CERTIFICATE F LIABILITY INSURANCEDA10/1/2ns 0TE 14 1 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 certfficate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER N MEACT CerUMICatesaWIIIIs.Com Willis of Minnesota Inc. PHONE F c/o 26 Century Blvd No Exti:(877)945-7378 No)- 888)467-2378 P.O.Box 305191 AED R'L88: Nashville,TN 372305191 _INSURER(S)AFFORIxNG COVERAGE NAIL N INSURER A:Old Republic insurance Company 24147 INSURED INSURER 8: Renewal by Andersen Corporation INSURER C: 30 Forbes Road INSURER D: Northborough,MA 01632 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. /NSR TYPE OF INSURANCE L POLICY NUMBER MMID MOLICY XP LIMITS A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S 1,000,00 CLAIMS-MADE a OCCUR MWZY302940 10/0112014 10/01/2015 PREMISE$Ea occurrence $ 600,00 MED EXP(Any one person) $ 10,0 PERSONAL&ADV INJURY $ 1,000,00 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,00 X POLICY a JECT LOC PRODUCTS-COLIP/OPAGG $ 4,000,00 OTHER: $ AUTOMOBILE LIABILITY COM 1 ED(E WdiISI LE LIMIT $ 6,000,00 A X ANY AUTO WTS302576 10/01/2014 10/0112015 BODILY INJURY(Par person) $ A AUTOS SCHEDULED BODILY INJURY(Peraccidenl) $ AUTOS NON-OWNED PROPE-AWDAMAGE S HIREDAUTOS AUTOS Peraccide t s UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED F RETENTION$ $ WORKERS COMPENSATION X AND EMPLOYERS'UABIL.ITY STATUTE ER A ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N MWC30293800 10101/2014 10/01/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? ® N I A (Mandatory In NH) E.LDISEASE-EAEMPLOYE $ 1,000,00 If yea,describe under DESCRIPTION OF OPERP.I IONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached N more apace Is requlr ad) 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. AUTHORIZED REPRESENTATIVE Evidence of Insurance 14,50 01968.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD i1 Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supemiror License:CS4=126 J,. fife JABS L MORIN 86 GARDINER ST LYNN MA 0190 �'? } r 'r"` X Expiration Commissioner 10/08/2016 ��e�sxmtoxurerx,��e!�aat�s ". j Met of ConsumerAffioirs&Business Regulation OME IMPROVEMENT CONTRACTOR Registmilon: 170840 Type Expiration: 12123120i55upplsmenr RENEWAL BY ANDERSON CORPORATION JAIME MORIN 104 OTIS STREET NORTt•IBOROUGN,MA 01532 Undersecretary y sti v 3 ¢J I I