HomeMy WebLinkAboutBuilding Permit # 8/31/2015 NORTH
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BUILDING PERMIT s-E eo "
TOWN OF NORTH ANDOVER 0 ; A
APPLICATION FOR PLAN EXAMINATION -
Permit iVo#: �' �r ' Date Received A�RA7EV 1r �g
�Ssgcwus��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION (0G0 Ut f o" S
;�
PROPERTY OWNER /vPrint
�At.S ✓µ �P,7iyP
Print 100 Year Structure yes no
MAP 00 9 PARCEL: ®®"f- ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building n family
[I Addition El Two or more family 11 Industrial
❑Alteration No. of units: ❑ Commercial
repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Q Septic ❑Well ❑ Floodplain ❑Wetlands ❑ W
a ershed Dis
x
❑Water/Se�reX` ,(„ r , ;
t '
DESCRIPTION OF WORK TO BE PERFORMED: /J
0) Door �Alo S a c Oro (fit
Identification- Please Type or Print Clearly
OWNER: Name: avAv A1(' Phone:
Address: 6,l ale A,.- 6/'
Contractor Name:Ti rte'i (o " '�® R l k' Phone: 6 / 7
Email:
Address:_ <, dam' ` Ps
Supervisor's Construction License: 9® / '� Exp. Date:
Home Improvement License: /7,f> -Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ i�o ®U _FEE: $ �
Check No.: 4 el- Receipt No.: 2:2 ZS"?-
NOTE: Persons contracting with unregistered contractors do not have access t uraralzty fu
nd
T -
%40RTH d 0,& v le r
I F
i own ot
0
No. 2(905- 200%v
L^KE h ver, ass, 5�
c0c.41c"t-4. �1'
AoOATE o I-" �,c5
S U BOARD OF HEALTH
PERMIT 1�1� L D Food/Kitchen
Septic System
THIS CERTIFIES THAT .... �� �� �� ................. . . .. .. .... .. .. BUILDING INSPECTOR
........fit...... ....
., Foundation
has permission to erect .......................... buildings on f.....................................
Rough
to be occupied as ,1. /„ G; .. lJy'..:.............................................................................. 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 ®NTS ELECTRICAL INSPECTOR
. UNLESS CONSTRUC'TIO Rough
Service
.........tel......... !,..ARTS
............. ..y ......... -- .... ..� Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required t® Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
LathingNo or all ToBe Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
. ..._.-.........._....
MA Home Improvement Contractor
Renewal License#170810(Expires 12J23/2015)
'.
f :
b>`/nder5en iz Renewal by Andersen Corporation Federal Tax ID#41-1918413
w r,,00m seatactm+esr
30 Forbes Rd. Northborough,tv1A 01532
(508)351-2200 Fax(508)-986.7072
CUSTOMER MNDOW AND DOOR REMODELING AGREENIENT
Buyer(s)Name Date:
DENNIS DUFRESNE - JULY 8, 2015
Buyer(s)Street Address City State Zip Code
66 UNION ST NORTH ANDOVER MA 01845
Email Address Home Telephone Number Work/Cell Telephone Number
ADUF2551OVERIZON.NET 9786854899 1 9786094083
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 6,812 kniount Financed S 6.812
Check/Cash
Deposit Received(33"6)S 0.00 Dego t a1 cc-g S 3,406.00 8.10 weeks
Balance Start of Job(335)S 0.00 Check N
Est,Install Time Credit Card
Balance on Substantial AI Sup
z1
Completion of Job(33°5)S 0.00 e p awn S 3,406.00
1-2 days if credit card I so;ect d,plea.-
Credit Card Pa•;mont form '
C o n I avn�". "��1 Ce tlema n� 3 ani a i one�s Sreb
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 Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation �Buyer(s) Buyer(s)
(f/Z�
By: Signature
Signature of Consultant Signature _
x GREG DEMPSEY DENNIS DUFRESNE
Printed Name of Consultant Printed Name Printed Name
YOU.THE BUYER(S),MAY CANCELTHIS 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.
_ __
-------------------
-----------------------------
-------------__NOTICE OE'C.CNCELLATIOS
NOTICE.OE'QANC£LIA'fION 1
llatc oI 1 - cti u
you nt v cancel d t. I Date of I ansae/of L/I fi Y u ont c—el fids
traansactioay wiW l a y pe talk or obhgauoay avithin Wrve ha mess dal-f ,the t s u ink-tit n)penalty obhs,auon,avttla3 three business da)s from the
aborti dale.►f you cancel,any property tradedin,an}payments anade by you under I above date.If von cancel,an)-Property traded ht.any pavmcnts made b))-iu under
the Contra"- of Sale,- and ileonegotiable instrument-x •arca by you will be I We Contract oC Sale,and aa,y n gottab4 i .:cru teat ez cured by Iva tall be
oC r returned within 10 days roil-v i N --e pt by til C Contractor actor("Si•llcr""} of),or
returned within 10 days Gall- i Y rc�rpt b)the Contractor- ( Sell r �. you
canccllatioat nod'.:,and a,t)security Interest eels/t%out of the transaction trill be I cancellation no
e,and un .curt N•interest artsGr,t out of We transaction will be
canceled. If you cel,you a st make available to the Seller at your residence,sidece,in I canceled ll')o _lcel,you nnust teak._available-t. the Seller at your re d-tee,in
substantially ac d rondiuo,ns when received I s;oods d h ercd t-lou under 1 snbsr itally as nod nditien as wha t n neat y goods delivered to you under
thiSale,or you.nay.[f you wish,ileo-ply'Ith the instructions of the 1 tbis Contractor Sale: or you ma),if
s Contractor you wish,compLl vviW the instructions of the
Seller rntractgardor tireturn hip-tesst of We goads al We Seller's expeatze and risk. I Seller regarding the return shipment of Ute goods at We Seller's expense and rk k.
If you do make the goods available to the Seller and the Seller does not pick then,up I Il'you do make the,;--d'--liable a-the Seller and the Seller dues not pick/heat up
wi thi,t'20 days of We date of your Notice of Cancellation,lou may retain or dispose I e,idda 20 drays of the date of your Notice of Cancellation,you ntay retain or dispose
:of the go ds withnut any further oblig a n. If vfall to make the go-dathable I of th h d. veld t ty fu tl r ob1lg a if y u f it to make We good •aaable
to e Seller,or ifyou ague to return lb a goods to the Seller and fail to do s o,then to theSeller,or if v u agree to return th goods to ll-Seiler and Ina to d -,then
th
you-main liable for Pertm-on nce of all obligations under lite Comeau. In cancel I yatu remain liable for Pcrforrnau a
'fall obligations under the Uuntract. to cancel
/lds transaction,mail or deh a signeal amt dal d Py of this cotcer ation notice I this transaction tail ur deliver a signed anddated copy of this cancel)-tion--lire
or any-cher vvrivan notice,or:end a tclegraau to Cont actor: Reuee,al b)Ander. n.I or any other vv ettten notice,-r -fid a tcicgrun to Contractor: Reuevv al by Andersen,.
30 Forties Rd. No-none.or ALA 01 tele I 30 Forbes Rd.Northborough,flet 01532.
I HEREBY CANCEL EHIS TRANSACTION. I i HEREBY C.ANCEL'TEi1S TILANSACTIO\.
I
I
Renewal
L��onRenewal by Andersen Corporation MA Home Improvement Contractor®�®�')'I�i 1CIEYS�C1. 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12/'23/2015)
WINDOW REPLACEMENT „":,..,,,1..,. (508)351-2200 Fax:(508)-986.7072 Federal ID#41-1918413
Window Specification Sheet
13u}'rrs�Vatne Datc o1Agrecurcnt
DENNIS DUFRESNE WED, JUL 8, 2015
I'llc hmells)listed,hoar Herby jointl% and srvcralh arzrce to purcII111,1};nods and/ur xervires listed helow in accoldalli r with flu•price,and terms(1cwtihed
cru the Specifieahou sheet and IIIc fnull and the rc\et'c of the a(companm in,; CL'S'1'()\1\111\ll0\V'.kV"I)DOOR Kl?JIl)ll1sL1V'G AC RLLMlV'T;rmf which
the Spvcihcation sheet i.,lean.
WINDOW&DOOR DETAILS
err. r+rex axtuiar/lntor�or Golor HarClv;nro H,rrhn ars Lo irF.tl erne Gr"le Glass
Rc:om n of uJ VJindot�/Door Style Detail_ Casings _Ext-Int Color Style sr~e�-n s isun Gnllcs mash 1.3 sash 2 Lifts Options
—Llv;ng 101 7l1 i.S 198 �AFIVG L tatoExt.Wrap WH/PN_Black Novrbur ff FFGmanSwINPN 3/5 315 No No
Total 1 BAY BOW&BUILD OUT DE'T'AILS
Approx
Stylo Qatar)/ width? Approx. Ntunoor F,uo Window End Ceoter LowE/ Roof/ Ilaidwaro -
Room Count Style Mnkcrs hgg Itt Casngs Anglo-a Lltos Interior ExVint Color (tnitm sa.�hos saOsf, Screens Smartsun Soffit Color
SIT CL EFY WINDOW DETAILS
Fun: Approx. Lo,.Er Specialty BAY/BOW ADDITIONAL WORK NOTES
Room Count Styla lnsert I U.I. srrartswr Grilles Gnlosvile ] Ext/Int Color
dem+,1]l ,,h:ua,I�.I,., _
ADDITIONAL WORK DETAILS:
Vembm7,hardware in hlack.Custom sized li•enchwood glidhr q patio door-.thatch interior colonial casing
Pine interior white exterior.Removable wood grilles(inhcJ
No Contractor will wrap exterior casings with coil stock color of
Owner is aware that Contractor does not do any painting/staining or removallinstallation of alarm system or window treatments/hardware,It is the responsibility of
the homeowner to have the alarm system and window treatments/hardware removed prior to installation. bVe make no guarantee as to whether alarms or window
heatments/hardware will fit after replacement. Customer is also 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 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.
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,
windo:vs,doors,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued.
I 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 All discounts have been applied to this agreement.
✓ 1'r.; No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s).
!t i,.rerr,it,roil undrniu+.d Inc:wd I ri--ih� p.,ow,IlLu thi,sl-ifi—lio I Sh ]';d my i.nh the(VU I O\I A1'I\D(')AA'AND DOOR RI'.AIC)I)I'J.IV(::1GRI;L\ILA`I'.nimliuuiti the rutin
undrr.ruulim„h, it der Irani—ami th, r-ur nu—d.;'].;']andk t'land o.p, ,l (hr tent, hhn'�p,,dh"ii on she -t tun nut b ,h:uy,'d ur it,trim ulodiGr-d or eerier)in
:tic u:n w 1- nn,h dh.ruc,r,:oo in++mins duel.ivm.rl h,Earth the Wn,r a and C.... inr R r,,ri.i hrrz'uy:u'knoM.dl that ll-', i Iet„r.,d ilii,"J.",ilintion Sirrri.
Renewal by Anders/en Corp/oration Ilmx tie IArcrrlsl
Signature of Consultant Signature Signature
GREG DEMPSEY DENNIS DUFRESNE
Print Name of Consultant Print Name Print Name
Mdew"fosen.WS•DOORS
Andersen' NFRC Certified Total Unit Performance (continued)
I
rI U-Factor'I SHGCr V c
`=f
Andersen*Product Glass Type
U_Factor' SHGC' VL r,
Andersen*Product Glass Type Architectural
i HP Low-E4 0.32 028 0.47q
400 Series`
Hp l0+{4 035 0.60 HP Low-E4 with Grill. 032 F.32 025 0.42 ''
0.28 0.31 0.54 ? HP Lan-E4 Sun 0.32 0.17 0.26 7ff
ff-
HP Lm+-E4 with Grilles 0.33 0.16 0 23 (
HP Law-E4 Sun 0.27 0.21 Casement Window Hp lu+r_E4 Sun with Grilles 0.32
Circle Top 0.2g 0.19 0.30 F f lip tux-E4 SmartSun 0.31
IM
Casement Window HP taw-E4 Sun with Grilles F.r 0.17 0.38 l
HP lux-E4 SmarlSun
0.26 023 0.54 HP torr-E4 SmadSun w/Gillies 0.31Fil
H: fox-E4 SmartSun w/Grilles 0.28
021 0.49 F1 �-
HP Low-E4 0.32 028 0.47 '
I HP tmv-E4 0.27 035 0.60 )' HP Law-E4 w,Gdlies 0.32 025 0.42
HP Low-E4 with Gillies 0.28 0.31 0.54 FT ryP taw-E4 Sun 0.32 0.17 0.26
Hp lux-E4 Sun 0.27 021 0.33 f Wad hvCasemenf Hp Lmy_E4 Sun VIM Galles 0.32 0.16 0.23 t
0.30 f'' _. 0.18 0.42 ('
Circle&Oval Window�, Hp LOw-E4 Sun with Grilles 0.29 0.19 HP torr{4 Sma-un 0.31
HP low-E4 Sman$Un 0.26 023 0.54 HP Lox-E4 SmartSun w/Grilles 0.31 017 0.38 M
HP Low-E4 0.32 028 0.47
Hp Law-E4 SmartSun yr/Grilles 0.28 0.21 ::0.49::::" - HP lox-E4 wfth Grilles 0.32 025 0.42 �'!
0.33 0.58
HP Low{4 0.28 t3 0.17 0.26
_ HP Law-E4 with Grilles
02g 0.30 0.52 HP Lor-E4 Sun 0.32
HP foN-E4 Sun 0.28 0.20 El
U.31 ( Awning Window Hp Luw-E4 Sun with Gnlies 0.32 0.16 0.23 !Y
0.29 0.18 0.28 `i ` !IRT M
0.18 0.42
Arch Window - lip Lox-E4 Sun with Grilles HP LOW-11,41 SmartSun 0.31
HP Low-E4 SmartSun 0.27 023 0.52 f Hp Law-E4 SmartSun w/Grilles 0.31 0.17 0.36 )
P M
tip
0.32 0.55
Hp Low-E4 SmadSun w/Grilles 0.28 02Hp
1 0.46 ."{ ` - HP Iox_E4 vrth Grilles 0.31 029 0.49 ("
Hp Lor{4 0.27 0.33 0.56 (�
HP Low-E4 with Grilles 0.28 0.30 0.52 (^+ HP Lax-E4 Sun
0.31
0.31 020 1
HP low-E4 Sun 0.27 020 0. Picture 31 Casement/Awning
0.31 0.18 0.28 �'�
Window HP low{4 Sun with Grilles 021 0.50
029 0.18 0.28 Hp Low{4 SmartSun 0.31
Fleaiframe'Window Hp lax-E4 Sun wrfh Grilles r, pig 0.44 t'
.� I Low-E4 SmartSUn 0.26 023 0.52 <. up Low-E4 SmartSun w/Grilles 0.31 037 0.64 M
HP Lorr{4 Sma6um w/Gillies 0.28 0-21 0.46 ( HP Low-E4 0.30 '
HP low{4 0.31 033 0.58 HP w{4 with Grilles 0.30 033 0.57 F LL
u 030 0-52 HP lox{4 Sun 0.31 022 0.36
I HP tux-E4 with Grilles 0.32 020 0.32
020 0.31 g"® Specialty Window Hp�y{4 Sun with Grilles 0.31 r r.
HP Lox-E4 Sun 031 024 0.58 F '
Spdngline Window HP Low{4 SmartSun 0.30
HP Low-E4 Sun v+ith Grilles 0.33 0.18 0.28
Hp lour{4 SmartBun 0.30 023 0.52 r� Hp Lox-E SmartSun w/Grilles 0.30 022 0.52 F
HP lox-E4022 0.37 I
i HP Luw-E4 SmartSun p Locales 0.3Mrs
0.2 0..4 HP Lor-E4 with Grilles 0.33 020 0.33
0.27 0.45 =
HP Law-E4 0.30 _
0.23 0.394 0.14 0.21
HP Low-E4 with Grilles 032 HP lu+r-E4 Sun 0.33 -
0.16 0.25 PA U Hinged Inswing 0.13 0.18
HP Law-E4 Sun 0.31 French Door HP Lor{4 Sun with Grilles 0.34 f„f 11
Frenchwood• _ Hp Lux{45mart5un 0.32 0.15 0.33
Gliding Patio Door HP for-E4 Sun vrNr Grilles 0.32 0.14 022 ® � Hp lav-E4 SmarlSun w/Glilies 0.33 0.14 0.30 - dS
HP Lux-E4 SmartSun 0.30 0.18 0.41 �t{ - "
0.31 0-16 0.35 1"`9 HP low-E4 0.33 025 0.41 ..p�
HP LRx-E4 SmartSun YIN 024 0.41 P` i ® p22 0.36 Is
-
HP Law{4 0.31 ® HP Lox{4 with Grilles 0.34 0 0
HP Low-E4 Sun 0.33 0-16 0.23 =Q
Hp farr{4 with Galles 0.32 021 0.35 -
Frencfi Door HP Lox-E4 Sun vmh Grilles 0.35 014 0.20 m
Frenchwoed•Hinged HP Lox-E4 Sun 0.31 0.15 0.23 ' 'Hit
Hinged Ouiswing HP Lox-E4 SmartSun 0.32 0.17 0.37 } EV
Inswing patio Poor ! Hp Ly,-E4 Sun with Grilles 0.32 0.13 0.19 - -
0.16 0.37 '•, ryp Lott-E4 Smar[Sun w/Galles 0.34
0.15 0.32 =
HP Lor-E4SmartSun 0.30 t,_.s� - 04$ 0.38 - ��'
HP Lor{4 0.33
Hp lux-E4 SmaRSun w/Grilles 0.31 0.14 0.31 Y< 0
Hp lox{4 with Gillies 33
0. 21 0.34
'� HP for{4 0.31 025 0.41 F,z i "
Hp Lox-E4 Sun 0.33 0.14 0.21
HP Lax-E4 with Grilles 0.32 021 0.35 -
HPtun-E4 Sun 0.31 0.15 0.23 +11''t ' SidelighFiled t ch Door- HP Lux-E4 Sun with Grilles 0.34 0.13 0.19 _
Frenchwood'Hinged _ Hp +{q SmartSun 0.32 0.15 0.34
Outsving Patio Door HP Lax-E4 Sun with Grilles 0.32 0.13 U. L Hp Low SmartSun w/Grilles 0.33 0.14 0.30 -
0.17 0.37
HP Lux-E45marisun 0.30 -
_ HP Lox-E4 0.32 025 0.41 i
Hp Lm+{4 SmartSun w/Gdlles 0.31 0.15 0.31 f HP {4 wiOr Grilles 033 022 0.37 -
HP Low-E4 0.31 0.72 0.37 HP Lax-E4 Sun 032 0.15 0.23 -
0.32 020 0.33 F1 '
HP lax-E4 vri0t Galles 014 0 21 P+i i Fued Transom 0.33 0.14 020 - j
HP lar+-E4 Sun 0-32 French Door Hp Low-E4 Sun with Galles 0.37 - i
Frenchwood' 0 32 0.13 0 18 +'1. `% HP Law-E4 SmartSun 0.32 0.16 _
Patio Door Sidelight NP law{4 Sun with Grilles 033 'rt' sEll 0.32 0.15 0.33
HP lm+-E4 SmartSun 0.31 0-15 ,'. HP Lox-E4 Smartbun w/Grilles -
` HPLmr{4 0.35 026 0.44
Hp Lor{4 smartSun v+/Grilles 0.32 0.14 0 29 HP lmr-E4 with Grilles 0.36 023 0.38 -
HP lux-E4 0.30 024 0.40
F _
021 0 35 °" 0.35 0.16 0.24
Hp Inca-E4 with Grilles 0.30 HP Lax-E4 Sun _
HP Lav-E4 Sun 0.30 0.15 0 22 � Folding Door HP lore-E4 Sun with Grilles 0.36 0.14 0.21 -
Frenchwood' 0.13 0.20 !"{ 0.34 0.17 0.39 -
Patio Door Transom
HP for{4 Sun with Galles 0.31 HP Lax-E4 SmadSun 0.34
HP Lax-E4 SmartSun 0.29 0.16 0.36 1
HP Low-E4 SmartSun w/Grilles 0.36 0.15 continued on nerl page
" 014 0.32 1 1
HP Low-E4 SmartSun w/Grilles 0.30
g lass.
lass can
the lass heat is lost through the entire product-Window values represent non-tempered glass.Use of tempered g
•
For NFRC certified total unit performance on units with capillary breather tubes for high attitudes,please visit andersenwindows.cam.
•'High-Performance'Low-F4" Low-El[), -Performance"Low-E4'SmartSun'(HP Low-E4 SmartSun and•Hi h-Performance Low-E4'Sun'(HP Low-E4 Sun)are Andersen trademarks for"ow-
the
' U-
Facturdefinestheamountofheatlossthroughthetotaluni[inBTU/hr sq-fL'FThel Door values re,
increase U-Factor ratings.See andersenvrindows.cmm for specific performance values.Door values represent tempered glass.
value,from Oto 1,the more daylight the product lets in over the product's total unit area-Visible Transmittance
'Solar He at Gain COelings-l(SHGC)definesthefrac0onofsolarradiationadmittedthroughtheglassbothdireceYfransmittedandabsorbedandsubsequentlyreleasedinward.Thelowerihevalnitare-Vsheadsmittatransmitted
through the product ha roduct(glass and frame).The higher lh
'Visible Transmittance(VT)in how much light comes through P
is measured over the 380 to 160 nanometer portion of the solaf spectrum-
•NFRC ratings are based on modeling by a thud Party agency standards or requirements,this data may change over time_Ratings are for sizes specified by NFRC for
a enc as validated by an independenttestlab in compliance with NFRC program and procedural requirements.
•testing and certification.Ratings may vary depending on use of tempered glass,it
grille options,glass for high altitudes,etc.
This data is accurate as of December2010.Due to ongoing product changes,updated test results opt or new Indus
277 j•PassiveSun glass values are available online at andersenwindov+s.cam- `
The commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass•gov/dia
Builders/Contractors/E4
umbers
Workers' Compensation insurance Affidavit: ractors/ElePl
Please Pr nt Le ibl
A ilicantinformation
RENEWAL BY ANDERSEN
Name (Business/Organization/Individual):
Address:30 FORBES ROAD
508-351-2200
City/State/Zip:NORTHBORO, MA 01532 Phone#:
Type of project(required):
Are you an employer?Che3e0k the appropriate. E]box- a general contractor Jan
6, []New construction
1,❑ 1 am a employer with______ have hired the sub-contra
employees (full and/or part-time). 7. Remodeling
listed on the attached she
2.® 1 am a sole proprietor or partner- These sub-contractors ha8. ❑Demolition
ship and have no employees employees and have worg E]Building addition
working for me in any capacity. comp,insurance.l
[No workers' comp.insurance 5 ® We are a corporation anlo•❑Electrical repairs or additions
required,] officers have exercised t11.[�Plumbing repairs or additions
3,❑ I am a homeowner doing all work right of exemption per M12.0 Roof repairs
myself. [No workers' comp. c, 152, §1(4),and we haI3 ❑Other
insurance required.]t employees. [No workers'
comp.insurance required.]
*Any pp are doing all work and then hire outside contractors must submit a new affidavit indicating such.
applicant that checks box ill most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they
the must provide their workers'comp.policy number.
#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, Y Below is the policy and job site
I am an employer that is providing workers'compensation insurance for my employees.
information. —
Name.OLD REPUBLIC INS. CO.
Insurance Company Expiration Date:10101/15
Policy#or Self-ins. Lic.#:MWC 30293800
City/State/Zip: North Andover, MA 01845
Job Site Address: 66 Union St
er
Attach a copy of the workers' compensation policy declaration page(showing d toe policynuot and exp ratio penalties of a
Failure to secure coverage as required under Section 25A of
MGL c.u to$1,500.00 and/or one-year imprisonment, as well civil ofthisrstatement may be forwes in the form of a arded ded tto the Office f d a fine
floe p
of up to$250.00 a day against the violator. Be advised that a copy
Investigations of the DIA for insurance coverage verification.
nder the pains andpenalties of perjury that the information provided above is and correct.
Ido hereb certify p p
r Date:
Si iatur .
o 508-351-220
Offklal use only. Do not write in this area,to be completed by city or town official.
Permit/License#
City or Town:
Issuing Authority(circle one):
nt 3. City/Town 4.)Electrical Inspector 5.Plumbing inspector
1.Board of Health 2,.Building Departme
6.Other Phone#:
Contact Person:
ANDECOR-01 YADAVYO
PATE(MWDDNY'yy)
CERTIFICATELIABILITY
101112014
EGATIVELY AMEN, EXTEND OR ALTER THE COVERAGE ISSUING IN URER(S),AUTHORIZED
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGH S UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR
BELOW.EN ATIVE OR PIRODU ERfANDRTHECERTIFICANCE DOES OE HOLDER. A CONTRACT BETWE
REPRES les must be endorsed. If SUBROGATION 15 WAIVED,subject to
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy( )
the terms and conditions of the policy,certain Policies may require an endorsement. A statement on this certtflcate does not confer rights to e
certlilcate holder in lieu of such endorsement(s). CONTACT certificates@wiilis.Com
NAME' FAX (886)467-2378
PRODUCER PHONE (677)9466-737$ (AC.
AC No:
A1C No Ext
Willis of Minnesota,{Inc. EMAIL
clo 26 Century Elva ADDRESS: NAIC ft
P.O.Box 305791 INSURER(S)AFFORDING COVERAGE 24147
Nashville,TN 37230-5191
INSURER A:Old Republic Insurance Company
INSURER 0:
INSURED INSURER C:
Renewal by Andersen Corporation INSURER D:
30 Forbes Road INSURER E:
Northborough,MA 01532 INSURER F
REVISION NUMBER:
COVERAGES CEOD
RTIFICATE NUMBER: CH THIS
REQUIREMENT, TERM OR CONDITION OF ANYHCONE POLICIESTRACTOD SCRIBEDR OTHER OHEREINISSUB ECTTOALLLTHEITERMS,
THIS IS TO CERTIFY THAT THE POLICIR S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI
INDICATED. NOTWITHSTANDING ANY
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY ppucYEFF DUG EXP LIMITS
EXCLUSIONS AND CONDITIONS OF SUCH AOLLICIES.LIMITS SHOOWN MALICY T eE VE BEEN READ D PMI CLAIMS.
1,000,00
INS TYPE OF INSURANCE EACH OCCURRENCE S 500'00
A 11MX COMMERCIAL GENERAL LIABILITY MyyZY302940 1010112014 10/0112015 PREMISES Ea occurrence S 10,00
CLAIMS NAPE OCCUR MED EXP(Any one person) S
PERSONAL&ADV INJURY $ 1,000,004,000,00
GENERAL AGGREGATE S 4,000,00
PRODUCTS-COMPIOPAGG E
GEN'L AGGREGATE LIMIT APPLIES PER: $
X POLICY❑JECT El LOC
COMBINED SINGLE LIMIT S,000,OO
OTHER: Ea accident
AUTOMOBILE LIABIUTY MWTB302575 10/0112014 10/0112015 BODILY INJURY(Per Person) $
A X ANY AUTO BODILY INJURY(Per accident) $
ALL OWNED SCHEDULED PROPERTY DA AGE $
AUTOS AUTOS era dent)
NON-OWNED $
HIRED AUTOS AUTOS
EACH OCCURRENCE $
UMBRELLA UAB OCCUR AGGREGATE $
EXCESSLIAB CLAIMS-MADE $
Ol'H-
DED RETENTION$ X STATUTE ER
$ 1,000,00
WORKERS COMPENSATION MyyC3D293800 10/0112014 10101/2015 E.L.EACH ACCIDENT 1,000,00
AND EMPLOYERS'UABIUTY Y f N E.L.DISEASE-EA EMPLOYE S
A ANYPROPRIETORfPARLUDEDXECUTIVE ®NIA 1 000,Q0
O ICERIMdatory In ER EXCLUDED? E.L.DISEASE-POLICY LIMIT $
If yes,describe Under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may bo attached H more space N required)
CANCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ACCORDANCE EXPIRATION
THE POLICY PROVISIONS.NOTICEATE THEREOF, WILL BE DELIVERED IN
AUTHORIZED REPRESENTATIVE
Evidence of Insurance
1968-2014 AGORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
t g Massachusetts -Department of Public Safety
Board of wilding Regulations and Standards
Construction Supen-isor y
License: CS-09012 -;
t t r\
JAIM L MORIN
86 GARDi[PIER ST
LYNN Wk 0190f ki
"A Expiration
Commissioner 10/06/2010
� e-���p'arrna�zurea�a�Ce!�aaaac%uro%`1
ffce of Consumer Affairs&Business$eguiation
OME IMPROVEMENT CONTRACTOR
Registration: 17081D
Type.
Expiration: 12/23/2015 Supplement I
RENEWAL BY ANDERSON CORPORATION
JAIME MORIN
104 OTIS STREET
NORTHBOROUGH,MA 01532
Undersecretary t