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HomeMy WebLinkAboutBuilding Permit # 10/5/2015 .............. B ®F %AORTH .,,�ED UILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Date Received Permit IVO : US Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print 5 A PROPERTY OWNER �Jb SC/71 Print 100 Year Structure yes no MAP 0'7? PARCEL: 004'1 ZONING DISTRICT:_12" Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family [I Industrial D Addition [I Two or more family Li Commercial D Alteration No. of units: El Others: [&Akle'pair, replacement [I Assessory Bldg D Demolition [I Other Se M",Vx�, b'dp lgv, 01 IF ON H/11 5101001,11011) UNION)/ DESCRIPTION OF WORK TP BE PERFO MED' 0)e) ae .,Identification Identification- Please Type or Print Clearly Phone: '17,P— 6;?7— AI 7, -1— OWNER: Name: A Ak1 5` 5&--6 Address: Contractor Name: VOP I ze R I,/-/ Phone: 417 An 6 dye Email: Address: Y(a qtrc,_ell- Supervisor's Construction License: r —Exp. Date: /e Home Improvement License: 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. 9, FEE: $ Total Project Cost: $ Check No.: Receipt No.: 6, NOTE: Persons contracting with unregistered contractors do not have access th guaranty fund 77 77 irebf',""d myuwner q P t%OR TH Andover Town of 2 e ' 0 ® 47A/ t„K� h h ver, ass, �L ' s^ is CoCNIC MI MACK �1. / �0RATEDPt 'RMIT TE..1111111.E BOARD OF HEALTH Food/Kitchen Septic System / ..............................'... BUILDING INSPECTOR THIS CERTIFIES THAT .................../ IV �.-5; 6. ..................... .............. .......... .• Foundation has permission to erect buildings on ........................... Rough �C�'�'J/Cc- � ... .�.4?y. Chimney to be occupied as ............................... ..:..:............:�. ..... ................................ � e .. . . 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 PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST RTS Rough Service ..... .. .......... ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Butldtna Rough Final p� {� Display in a Conspicuous lace on the Premises — Do Not Remove FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Burner Until Inspected and Approvedby the Building Inspector. Street No. Smoke Det. __ __ ___---.__ ---___ __---__.___.__�.______- �neWa � M e#170 Improvement Contractor :'+ License#170810(Expires 12/23/2015) byAndersen. �` Renewal by Andersen Corporation Federal Tax ID#41.1918413 Winall\V N/:MiAGi'.M[.l ,i.4.1, i. -�.•„ 30 Forbes fad. Northborough,MA 01532 (508)351.2200 Fax(508)-986.7072 I CUSTOMER WINDOA'AND DOOR REMODELING AGREEMENT !Buyer(s)Name Date; JOHN HASSETT - AUGUST 12, 2015 Buyer(s)Street Address city State Zip Code 210 ROSEMONT DR N ANDOVER MA 01845 Email Address Home Telephone Number Work/Cell Telephone Number 973-637-7212 978-390.4356 '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. Total Job Amount $ 6,520 kniount Financed S 0 Est, Date Method of Payment Deposit Received(339.)$ 2,173.33 nepo;;r at signtag$ 0.00 Check/Cash 8-i0 weeks Balance Start of Job(3396)S 2,173.33 Chock# Bitlance on SubsluntialAI SUUIanllal Est.install Time / Credit Card Completion of Job(33".)$ 2,173.33 complelwn S 0,00 1-2 days If credit card is selected,please No final paymera shall be demanded untl all panles are saLsfcd sea Credit Card Payment form `Buyor(s)agroos and understands that this Agreement constitutes tho onilre understanding between the parties,and that there are no verbal understandings ;changing or modifying any of tho terms of this Agroomont. No aitoration to or deviation from this Agreement will be valid without tho signed,writton consent ;of both Buyer(s)and Contractor. Buyor(s)hereby acknowledges that Buyor(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 Anderson Corporations Buyer(s) Buyer(s) a By: Signature of Consultant Si a Signature x DUNCAN FIELDS JOHN HASSETT Printed Nano of Consultant Printed Namo Printed Nome YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOn TO MIDNIGHT OF THE THIRD BUSINESS DAV AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. ------ ---------------- ---- ------------ r NOTICE OF CANCELLATION NO"CE OF CANCELLMON ; Dweeif'1"ransncliim a!1'.!/Ifi 1'oumayCancel fill. I IhUruf'1'r:aisucdou IHt1/I;, Younutye:uicclllds (lrmsacthon,without any penalty or obligation,within three business days(rout die transactlon,without any penalty or obligation,within three business day, r—en tit, ;above date.if you cancel,any property traded in,any payments made by you under 1 above date.if you cancel,any property traded Ili,any pay inents made by you under `tithe Contract of Sale,and any negotiable inslrwuent ellecuted by you will be 1 the Coutracl or Sale,and any negotiable lnsirument executed by you will be (returned within 10 days following receipt by the Contractor("Seller")of your r returned"9thln 10 days following receipt by the Contractor("Seller") of your ;cancellation notice,and any security lulerest AdAng out of tike leansacdon will be t caueella Iron not lee,and any security interest arising out of lha tr:utsaction will be Ir.ucrled, If you cancel,you untst nialu,avalloble to tui Seller Al your residrnre,In I canceled, 11'you cancel,you must make available to the Seller at your residence,in i.ub.tandally as good candillon as when recelved,Any goods delivered m you under 1 sub.lanlhtly ns gewd rondlllon As when recohv><I,any goods Joliwsrrd In ymi under this Contract or Sale;or you may,it you wish,coniply"-fill the lostructioam of the I this Contract or Salei or you may;If you wish,comply with the fiislrucilons of[lie `Seller regarding the return shipment of the goods at the Seller's eapraise and risk. I Seller regardlieg the return shlpnrent of the goods at the Sclicr's expense and risk. 1 I you do make the goods available to the Seller and the Seller does not pick there up I If you do make the goods available to the Seller and the Seller does not pick them up "9thln 20 days of the date of your Notice of Cancellation,you may retain or dispose I within 20 do"of the date of your Notice of Cancellation,you may retain or dispose for the goods without any further obligation. If you fall to make lite goods available i o(the goads whlmut any(urdter obltgatimi. If you fail to make dtc goods avallnble len lite Seller,or if you a tyro to return Uro goads to dee Seller and rail to do so,then I n the Seller,or if you agree to return the gond.to(lie Seller nod fail to do.o,Then ;you ranula liable for porformuncr oC All obligtttlons wulrr Ino Conlrnrl. Tit cancel I you remain liable for performnnee of all obligations under the Contract. To eanevi ithis tranxnellon,Droll nr deliver a signed and dated copy of this cancellation nollce I fills Iransacllon,..tail or deliver a signed and slated copy of this cancellation notice (or any otter written notice,or send a telegrain to Contractor:lleneival by Andersen,) or any other written notice,or send a telegrsm to Contrac[on Renewal by Andersen, 30 Forbes ltd. Northborough,NtA 01532. r 30 lorries ltd.Northborough,NIA 01532. iI HEREBY CANCEL THIS TRANSACTION. I I HEREBY CANCELTHIS TRANSACTION. 1 �. avmx�-y aw.,: Ptlrd uta, h":n I Ilu vY.N;rra'ssu Paul R,v o;aa f I I��ne alCAM-501-i- Renewal by Andersen Corporation MA Home Improvement Contractor byAndersen. 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12/23/2015) ,WINDOW REPLACEMENT (508)351-2200 Fax:(508)-986-7072 Federal ID#41-1918413 Window Specification Sheet Buiver(si Name Date of Agecment JOHN HASSETT WED, AUG 12, 2015 The buvt t{ j listed above hereby joiudy and se�`elally erre to purdtase the gootLs still/or service,listed hch�t�;hi accordance uiUr the ptia�s and tcrn>v described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW 2\ATD DOOR REMODELING AGREEMENT of which the Specification Sheet is part. WINDOW&DOOR DETAILS App. nr-v Awp ExienorRntorior Co!or Hardware HarsPAaro Lo,E4 r Gnlla Gril's Glass Room k w&.h hEight U.1. Window/Door Style Detail Casings Ext-Int Color Styli Sued- Strartsun Glilles Sash tri Sash 2 Lifts Options Kitchen 101 60 80 190 A-SERIES CUSTOM DOOR Ext.MF 908 WH/PN Sat.Nickl Anvers FFG smansur mono Total 1 BAY,BOW&BUILD OUT DETAILS Approx StyleDelal! vidthr Approx. Number Frame WindowEnd Curter LowE/ Roof/ Hardware Room Count Style Flankers hel ht C-Ings Ang'o Litter Interior ExOnt Color G611. sashos sashes Screens Smansun Soffit Color '.. SPECIALTY WINDOW DETAILS Full/ Approx. LmaE/ spe&alty BAY/BOWADDITIONALWORK NOTES Room Count Style Insert U.t. Smari5un Grilles Grille Style Ext/Int Color (All n. i;mc3,.:dra w;xh lupilxs,.indo„�um1 r TY Luhw iter,:Will t�-si`„itlr,u r;Ei:;I��_ ADDITIONAL WORK DETAILS: No Contractor will wrap exterior casings with coil stock color of Owner is aware that Contractor does not do any painting/staining or removal/installation of alarm system or window treatments/hardware.It is the responsibility of the homeowner to have the alarm system and window tealinertslhardware emoved p for to installation. We make no guar-Itee as to whetheralam;s or window ., treatmentslhardware 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, windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 1 Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)Is included in the total contract price. 5 Yes All discounts have been applied to this agreement. li ” Y', No Owner agrees to be present on the final day of installation for final Inspection and to deliver final payment/finance form(s). i �h i;a nxYl and nndt nu r(1 hN•will bcm,-vii lire pari,,that thi,S(xrili,htion Shecl,alotig r,ith dtc CUSTOM 1A71NDOW AND DOOR REMOTPELING AGREi:.AIE\C mnaiwws lite emire �undencuulin(lx;t,c<ern the parir�-,and therr,an+no wd);J nndrnt:ur<tini,�r-h:in:linf;or m,xlifiin,G:nry„f tit.,urrnts. This Stxv ificatiat Short only 11"I be chaltgol or its form,m,xliAed orsc,ri,'<I ill am'„tv uuits:.ntlr h.ut s are in„T tin :❑til si n.d 6y Will the Birt;,)wind Conuactne Buyrn,l hcn-br:tekno„lrrl e that tiulrn's)heli marl lhii sp-61i,atioll Sh,Ct. (Renewal by Andersen Corporation Buyeui) llupcnsj 011/11 /I/ l Signature of Consultant L Signature Signature DUNCAN FIELDS JOHN HASSETT Print Name of Consultant Print Name Print Name WiNDows-DOORS Andersen. Andersen' NFRC Certified Total Unit Performance (continued) : I Andersen•Product Glass Type U-Factor' SHGCz ! Vf na Andersen'Product Glass Type I U-Factor SHGC �' Architectural 400 Series - HP Luw-E4 032 028 0.47 HP Loy+E4. 0.27 0.35 0.60 HP Law-E4 with Grilles 0.32 025 0.42- IN tip Law-E4 with Grilles 0.28 0.31 0.54 r" .'�` HP lux-E4 Sun 0.32 0.17 0.26 Circle Top HP tow-E4 Sun 0.27 0.21 0.33 s i Casement♦endow HP Lwr{4 Sun with Galles 0.32 0.16 0.23 FH in Casement Window HP tux-E4 Sun with Grilles 0.29 0.19 0.30 i M Hp Lurr-E4 SmartSun 0.31 0.18 0.42 ' f HP Lax-E4 SmanSun 0.26 023 0.54 ' ' HP Lmr-E4 SmartSun w/Grilles 0.31 0.17 0.38 `"f'1 111 HP L0,1-E4 Smartsun w/Grilles 0.28 0.21 0.49 HP larr-E4 0.32 028 0.47 ­19 HP Low-E4 0.27 035 0.60 (1 HP Low-E4 with Galles 0.32 025 0.42 HP Low-E4 with Grilles 0.28 031 0.54 F HP lux-E4 Sun 0.32 0.17 0.26 ' HP Lovr-E4 Sun 0.27 021 0.33 F French Casement - Circle&Oval Window�, ryp Low E4 Sun with Grilles 0.29 019 0.30 f; Window HP low-E4 Sun with Grilles 0.32 0.16 0.23 -? HP Lax-E4 SmartSun 0.31 0.18 0.42 HP Low-E4 SmadSun 0.26 023 0.54 Fq HP Lax-E4 SmartSun rr/Galles 0.31 0.17 0.36 }''l HP Lax-E4 Smart$UO yr/Grilles 0.28 0.21 0.49 I? Hp Lux-E4 0.32 028 0.47 F1 HP law-E4 0.28 0.33 0.581 - Hp low_E4 with Galles 0.32 025 HP Law-E4 with Grilles 0.29 030 0.52 HP Low-E4 Sun 0.32 0.17 0.26 HP Lax-E4 Sun 0.28 0.20 0.31 Awning Window Arch Window - - n HP lax-E4 Sun with Grilles 0.32 0.16 0.23 HP Low-E4 Sun with Grilles 0.29 0.18 0.28 HP Lav-E4 SmartSun 0.27 023 0.52 C,i H .18 0.42 P Law-E4 SmartSun 0.31 0 021 0.46 L( HP Iow-E4 SmartSun w/Grilles 0.31 0.17 0.38 HP Lox-E4 SmartSun w/Grilles 0.28 HP Lux-E4 0.31 032 0.55 HP Low-E4 0.27 033 0.58 1 HP Low-E4 vrNt Grilles 0.31 029 0.49 HP lux-E4 with Grilles 0.28 0.30 0.52 HP Luw-E4 Sun 0.31 010 0.31 F7 I HP law-E4 Sun 0.27 020 0.31 ql Casement/Awning Flexifrome'Window Up Low-E4 Sun with Galles 0.29 0.18 0.28 ` Picture Window HPL HPL Sun with Galles 0.31 0.18 0.28 HP Lax-E4 SmartSun 0.31 021 0.50 I HP Low-E4 SmarlSun 0.26 023 0.52 Hp Lmv-E4 SmartSun w/Grilles 0.31 0.19 0.44 f HP Lox-E4 Smartsun w/Grilles 0.28 021 0.46 F 3 " ' HP Lav-E4 0.30 037 0.64 'r••'.k HP Lax-E4 0.31 033 0.58 HP Low-E4 with Grilles 0.30 033 0.57 HP Low-E4 with Grilles 0.32 030 0.52 HP Lo,v{q Sun 0.31 022 0.36 F'?_ HP Low E4 Sun 0.31 0.20 031 ® Specialty Window Hp w{4 Sun vrith Grilles 0.31 020 0.32 f Springtime Window Hp Low-174 24 0 4 Sun with Grilles 0.33 0.18 0.28 Ps HP lux-E4 SmartSun 0.30 0 .58 IM HP Low-E4 SmartSun 0.30 023 0.52r� t-?£ HP Lax-E4 SmartSun vi/Grilles 0.32 021 0.46 -d HP Luff-E4 Smartsun w/Galles 0.3 0-2 0.52 HP law-E4 0.322 022 0.37 Eq HP Lax-E4 0.30 027 0.45 )+' - Hp Lax-E4 with Grilles 0.33 020 0.33 - HP Low-E4 with Grilles 0.32 0.23 0.39 HP torr-E4 Sun 0.33 0.14 0.21 - Frenchwood' HP Low-E4 Sun 0.31 0.16 0.25 Hinged Inswing, _ rilles 0.34 0.13 0.18 French Door HP lrnr{4 Sun with G Gilding Patio Door HP Low-E4 Sun vrith Grilles 0.32 0.14 0.22 Y HP Law-E4 SmartSun 0.32 0.15 0.33 E-1 Hp Lax-E4 Smartsun 0.30 0.18 0.41 ) - - )-� � ryPLow-E4SmanSunw/Galles 0.33 0.14 0.30 ( Hp Lax{4 SmartSun w/Gnlles 0.31 0.16 0.35 , HP Lmv-E4 0.33 025 0.41 HP Lor{4 0.31 0.24 0.41 i _ lip lux-E4 with Grilles 0.34 0-22 0.36 c Hp lax-E4 with Grilles 0.32 021 0.35 HP Lour{4 Sun 0.33 0.16 0.23 at HP low-E4 Sun 0.31 0.15 0.23 Hinged Outsving _ Frenchwood'Hinged o m French Door HP Low-E4 sun with Galles 0.35 0.14 0.20 :•a. Inswing Patio Door ! HP Lmi{4 Sun with Galles 0.32 0.13 0.19 '� HP Lox-E4 SmartSun 0.32 0.17 0.37 NP Lux-E4 Smarts 0.30 0.16 0.37 1 k"i HP Law{4 Smartsun yr/Grilles 0.31 0.14 0.31 91 ' 0.38 HP Lax-E4 Smartsun w/Grilles 0.34 0.15 0.32 - o HP lar+{4 0.31 025 0.41 t:< ` HP Law-E4 0.33 023 Hp Lax-E4 with Grilles 0.33 021 0.34 HP Lax-E4 with Grilles 0.32 021 0.35 F•" lip Low-E4 Sun 0.33 0.14 0.21 - HP Lor-E4 Sun 0.31 0.15 0.23 �.Y Fued French Door- _ Frenchwood'Hinged Sidelight HP Lox-E4 Sun with Grilles 0.34 0.13 0.19 Outsving Patio Door HP Lux14 Sun with Grilles 0.32 0.13 0.19 =-i lip Lurr-E4 SmartSun 0.32 0.15 0.34 - HP lax-E4 SmartSun 0.30 0.17 0.37 11, "f Hp torr-E4 SmartSun w/GiBles 0.33 0.14 0.30 - HP love-E4 Smartsun w/Grilles 0.31 0.15 0.31 4 HP Low-E4 0.32 025 0.41 - HP Low 1`4 0.31 022 0.37 .. r i HP lax-E4 with Grilles 0.33 022 0.37 - i. HP Lor-E4 with Galles 0.32 020 0.33 Fl t , HP tax-E4 Sun 0.32 0.15 0.23 - Frenchwood' HP Lax-E4 Sun 0.32 0.14 0.21 1 ;Fued Transom _ - k French Door HP low-E4 Sun with Grilles 0.33 0.14 0.20 Patio Door Sideiighi IIP Ln r-E4 Sun with Grilles 0.32 0.13 0.18 t - Hp Low-E4 SmanSum 0.32 0.16 0.37 - I Hp Lour-E4 SmartSun 0.31 0.15 0.33 s pal HP lax-E4 SmartSun yr/Grilles 0.32 0.15 0.33 - Hp Low-E4 SmartSun w/Grilles 0.32 0.14 0.29 HP Low-E4 0.35 026 0.44 - HP Lax{4 0.30 024 0.40 r� HP Low-174 with Grilles 0.36 023 0.38 - HP Low-E4 with Grilles 0.30 021 0.35 , Hp Lox.{4 Sun 0.35 0.16 0.24 - Frenchwood' HP low-E4 Sun 0.30 0.15 022 Folding Door HP Lary-E4 Sun with Grilles 0.36 0.14 0.21 0.13 0.20 !4_ 'F9 Patio Door Transom � HP Low-E4 Sun wish Grilles 0.31 tip Low-Ext SmartSun 0.34 0.17 0.39 HP Low-E4 SmartSun 0.29 0.16 0.36 !` HP Lour-E4 SmaitSun"/Grilles 0.36 0.15 0.34 - HP Low-E4 SmadSun w/Uncles 0.30 014 0.32 continued an next page •For NFHC certified total unit perfomnance on units with capillary a,E4,Smars for high altitudes,pleasen)andnderseperfo ancem. •'High-Performance"Low_F,t(HP Low-E4) -Performance'Low-E4'Smartsun"(HPLow-E4 Smartsun)and'High-Performance'Low-E4'sun'(HP Low-E4 Sun)are Andersen hadem ereFks glass.Use glass. ' 'High-U-FacPerformance" es the amount of heat loss through the total union BTU/hr sq_ft°E The lower the value,the less heat is lost through the entire product Wmdow values represent non-tempered glass.Use of tempered glass can increase U-Factor ratings.See andersenwindows.com for specific performance values.Domrvaiues represent glass. 'Solar Heat Gain Coefficient(SHGC)defines the fraction of solar rai iation admitted through the glass both directly transmitted and absorbed and subsequently released inward.The lower the value,the less heat is transmitted through the product ' s how much light comes through a product(glass and frame).The higher the value,from 0 to 1,the more daylight the product lets in over the product's total unit area.Visible Transmittance Visible Transmittance(VI)measure is measured over the 380 to 760 nanometer portion of the solar spectrum. •NFRC ratings are based on modeling by a third party agency as validated by an independenttest lab in compliance with NFRC program and procedural requirements. •This data is accurate as of ma ember2010.Due[o ongoing product changes,updated lest results or new industry standards or requirements,this data may change overtime.Ratings are for sizes specified by NFRC for testing and certification.Ratings may vary depending on use of tempered glass,different grille options,glass for high altitudes,etc. •PassiveSun-glass values are available online at andersenwindows.com. 277 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Kashington,street Boston,MA 02111 www.mass.govldia "Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieiansfplumbers A licant Information Please Print Legibly Name(Business/organization/Individual): RENEWAL BY ANDERSEN Address: 30 FORBES ROAD City/State/Zip: NORTHBORONA 01532 Phone #: 508-351-2200 Are,.you an employer?Check the appropriate box: Type of project(required): I'm I am a employer with 30 4. ❑ I am a general contractor and 1 6. E New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.+ 7. JZ Remodeling ship and have no employees 'These sub-contractors have $. El Demolition workingfor me in an capacity. workers'comp.insurance. 9 y P ty• El Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 i.El Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]r employees. [No workers" comp, insurance required.] 13.n Other "Any applicant that checks box##1 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 their workers'comp.policy information. 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.Lie.#:__MULIC3Q543_7.QQ._____ Expiration Date: 110_0,1-16 Job Site Address: ,'/y /?d s eInv^//- DR City/State/Lip: �"U /y/j nwep, 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 DTA for insurance coverage verification. I do hereby certify#dthe pains and penalties of perjury that the information:provided above is true and correct Si nature: Date: Phone#: 6045'1-2 2 0 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 M ANDECOR-01 YADAVYO DAMM/DDYYY, 01YCERTIFICATE LIABILITY INSURANCE 10/1/25 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(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 CONTACT NAME: Willis Certificate Center Willis of Minnesota,Inc. P"G (877)945-7378 FAX No; (888)467-2378 c/o 26 Century Blvd A/c No Ext P.O.Box 305191 a UREss:Certificates@willis.com Nashville,TN 37230-5191 INSURERS)AFFORDING COVERAGE NAIC# INsuRERA:OId Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC INSURER C: 30 Forbes Road INSURER D: Northborough,MA 01532 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR MWZY 305440 10/01/2015 10/01/2016 PREMISES Ea occurrence M$ 4,000,000 MED EXP(Any one person) PERSONAL&ADV INJURY GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE X POLICY❑ PRO ❑ PRODUCTS-COMP/OP AGG JECT LOCOTHER:AUTOMOBILE LIABILITY EOMBIINdEeDtSINGLE LIMIT $ 5,000,000 A X ANY AUTO MWTB 305438 10/01/2015 10/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X SLITETATEERER 0TH A ANY OFFICER/MEMBERPROPRIETOR/PARTNER/EXECUTIVE rN ] N/A MWC30543700 10/01/2015 10/01/2016 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in and I E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more 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 WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of InsuranceG�_ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD d 1) Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS-090125 i JAME L MORINS` 86 GARDINER S LYNN MA 019(Y r � Expiration Commissioner 10/06/2016 I � c-Tl� "Ite of Consumer Affairs&Business Rquiation (' pME IMi'R4171=fiANf G.QN7RACTR t l�egietrtu 1 ► 10 E�cpitatibft .1 ; b Supplement r RENEWAL BY ANORATION , JAIME MORIN z 104 OTIS STREET NORTHBOROUGH,MA 01532 _ Undersecretary t