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HomeMy WebLinkAboutBuilding Permit # 10/15/2015 NORTH 4 BUILDING PERMIT 32 a`T�no,°•'•°�°L ,\ TOWN OF NORTH ANDOVER ° F APPLICATION FOR PLAN EXAMINATION - - n � Permit NO: Date Received / �9SSCNU ���y Date Issued: T- rf NS IMPORTANT:Applicant must complete all items on this page LOC T( 250 Btue R d e Rd North Ando�rer MA 01845 PROPERTY OWNER Sonya Terra Pant MAP,NQS065 0 �,,,P,�4RCEL01$3: ZO;NIhCG DISTRfCT, R1 Historic District ds no ` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q`Septc DWell ❑ Floodplain q 1Neflantls UUate�sh'etl Distract; d Water/Sewer ;, Replacing 8 windows, no structural change Identification Please Type or Print Clearly) OWNER: Name: Sonya Terra Phone: 860-460-8506 Address: Jaim `Martr „ COI�TFtACTOR Name Phone`508 351 2214= Address 30,Forbes Ri " thb ostruc ion;LicensehM9NQNag eu or" 0153 f25 Exp ;Date. 10 6.16" ; Dome Ir�prau�ment,Ltcerise 120810,;�~> :�� '.� �� ��p ,aafa 12:2315 �� = 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: $ 20,056.00 FEE: $ a q I --- Check No.: Receipt No.: NOTE: Person contracting with unregistered contractors do not have a" ss t guaranty fund \ I Signature of-Agent/Q. Signature of contractor o®i?'l H Town of ndover ® ";: 0% No. 414--- 0 ^� S° LAKE h ti ver, Mass, � /6 COC NICMEWICK V1• �•9 °"Areo S U BOARD OF HEALTH Food/Kitchen PERMIT �T� D Septic System THIS CERTIFIES THAT ......... .. ....*",,,,, BUILDING INSPECTOR has permission to erect buildings on .. .. ......'4�.4S1.C..... �G Foundation Rough tobe occupied as .............S)........... . . ... ........v....................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS C TRCT ARTS Rough Service ............ ...... ..... ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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. e1 �W�� MA Home Improvement Contractor .�' ' License N170810(Expires 12!23!2015) byAndersen Renewal by Andersen Corporation Federal Tax ID#41.1818413 WInUO\e al.rLhCl:MI'NI 30 Forbes Rd. Northborough,MA 01532 (508)351.2200 Fax(508)-886.7072 I CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT j i I I ;Buyer(s)Name Date; SONYA TERRA - AUGUST 21, 2015 Buyer(s)Street Address City State Zip Cade 250 BLUE RIDGE ROAD NORTH ANDOVER MA 01845 Email Address Home Telephone Number Work/Cell Telephone Number SSTERRA74©GMAIL.COM 1 1 8604608506 '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. st,_Start Date, Method of Payrnont Total Job Amount $ 0 mount financed S 4 Deposit Received(33".)$ 0.00 Deposit at signing S 0.00 Check/Cash 8-10 weeks Balance Start of Job(331,6)$ 0.00 Chock# Balance on SubstantialAl Subs(antlal Est.Install fiinlo Credit Card Completion of Job(3311.)$ 0.00 Completloo S 0.00 2-3 days if credit card is selected,please No tins) a Em shall be demanded arta all arises are aatsf�d see Credit Card Payment form Buyers)agrees and understands that thls Agroemont constitutes the entire understanding between talo parties,and that there are no vorbal 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 sof both Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyor(s)1)has road 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. I Renewal by Anderson CorporationBuyor(s) Buyer(s) J i rill ur =` ,'_ Signature Signature of Consultant g _ x KEVIN MONAHAN SONYA TERRA Printed Namo of Consultant Printed Name Printed Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY 11ME PRIOR TO MIDNIG14T OF THE THIRD BUSINESS DAY AFTER THE DATE Of THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. ------------------------------------I------ -------------------------NOTICE OF CANCEId.\TION NOTICE OF CANCELLATION Hale of Trunsucitl 1'nun,ay canrrl fid. I llntr of•Fr:utwaetiou 11P;l/Ifl . You llllly L':lnCel lldw jtran.rwtlan,wlti,am any penalty er obligation,within three bn,41mrss day's From,lite t—asacUnn,without any penalty or obllgadou,within Utree business days front lite iy "der der I above date.If you cancel,any property traded in,any pay,uents tuade by you under above date.if you cancel,say property traded in,any paymeut_c:wade by the Contract of Sale,and any negotiable instrument executed by you will be I the Contract of Sale,and any negotiable instrument executed by you willbe returned within 10 days following receipt by the Contractor("Seller") of your I returned within 10 day%following recelpt by die Contractor("Seller") of your cancellatlou notice,and at,security Interest arisimg out of lite transaction will be 1 —reellation notice,and any security interest arising out of tine transaction will be +canceled, If}'ou caner!,you must mule+avnlluble to Ibe Seller nl your rrsidencr,ba 1 canceled• if you cancel,you nnlst muhe available to Ute Seller at your rr%idenco,lit ;subNlathdly n%good cnndltlon tis when reaeivrJ,any goads dalivrretl fo you uudrr 1 %ubslauliully u%glntd conttidvu us when rrceAsxl,ally gomlw delivered In you uudrr ifhls Contract or Saler or you maay,If you wash,coutply%vitt the Instructions of live I this Contract or Sale; or you lady,if you wish,comply with the instructions of the Seller regarding the return NhIpment of the goods at the Seller's expense and risk. I Seller regarding the return Nblpn,ent of the goods at the Seller's expense and risk. If you do make the goods available to the Seller and the Seller does not pick thein up 1 If you do snake the goods available to die Seller and the Seller does mot pick the..up =within 20 days or the date of your Notice of Cancellation,you stay retain or dispose 1 within 70 days of the date of your Notice of Cancellation,you%nay retain or dispose 'of the goods without any forthrr obligation, If you fail to make the Roods available of lire goods without any furtbrr obllgntlnn. If yon fail to make live good.available 'm the Seller,nr if you agnea u!return the goods to d!e Seller and fail to do so,Iben , Io the Seller,or If you agree to rrlu•n ale goods to tae Seller and fall to do so,then ,you rtuunin liable for performance of all obligations Hader the,Contract, 'lit cancel , you renndn liable for performauee of all obligations under she Contract. 'Ib cancel %lids trau,.acdon,mail or deliver a signed sad Jnled copy of this cancellation nollec , this transaction,mail or deliver a signed and dated copy of this cancellation notice or any other written notice,or send a telegrmn to Contractor:Renewal by Andersen,I or any other written notice,or send a telegrams to Contractor: Renewal by Andersen, d30 Forbes Rd. Northborough,NIA 01532. 1 30 Forbes Rd.Northborough,AL2 01532. i I HEREBY CANCEL THIS TRANSACTION. i I HEREBY CANCEL THIS TRANSACTION. I _ _ __ ei•,n'S.7,enm Print flans IL,ta I ....._ Ile IY.L;:yc,9no r�,GH llnerM Ix.� -..� rn I enewal , r Renewal by Andersen Corporation MA Home Improvement Contractor �' ��• byi°lndersen. 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12/2312015) WINDOW REPLACEMENT (508)351-2200 Fax:(508)-986-7072 Federal ID#41-1918413 Window Specification Sheet �Buwr,'sj-Name Date of_Agrecment SONYA TERRA FRI, AUG 21, 2015 17he buys tis,listed above herebyjoindy and severally agree to purchase the+goods and/or services Ikted below,in accordance tcith the prices and terms described �on the Specification Sheet and the lbont and the reverse of the accompanying CUSTOXI WINDOW 21\D DOOR REMODELING AGREEMENT,of which !the Specification Sheet is part. WINDOW&DOOR DETAILS App. Arra. F;pz ExImorAnterior Color Hardwa Hxd.—e Lo,,E4/ C Ile 00e Glass Room C M= Wght W. Windovr/DOOt Style Detail Casings Ext-Int Color Style Sa— Smart-n Grilles S-h Sri Sash2 Lifts Options Kitchen 100 :59 40 99 CD full frame Int/Ext MF 908 wHVH White Standard FFG SmarlSur N«� 0 0 No No .Family 101 32 60 92 DB sq tail equal insert sloped sill L-Trim NHAVH White Standard FFG smortsur ne- 4/3 0 No No Family 102 32 60 92 DB sq rail equal insert sloped sill L-Trim WKWH White Standard FFG SmarlSur Nr-i 4/3 0 No No Sunroom 103 58 58 116 GW full frame lafo Int/Ext MF 908 JWWH White Standard FFG lsmartsuN_ 0 0 No No Sunroom 104 :511 58 116 GW full frame Isfo InUExt MF 908 Nt+wH White Standard FFG sm3risur u.— 0 0 No No Sunroom 105 :58 58 116 GW full frame lafo InUExt MF 908 WH.NVH White Standard FFG smarisur 0 0 No No Sunroom 106 :iia :515 116 GW fust frame lafo InUExt MF 908 VJWWH White Standard FFG saiartsun tion= 0 0 No No Total a BAY,BOW&BUILD OUT DETAILS Styi4Dotail! viith/ Approx. Numbor Frame Window End CenlerLowE/ Roof/ Hard,var0 Room Count Style Flankers het ht a rugs Anglo Lite-3 Interior F_xVint Color Gri_os sashes sashes Screens Smansun SofQ Color Family Illi Bay 1:2:1 DB.PW.DB sq 107119 Int/Ext 31-35 3 Birch WHAIIH GEG 2/2 7/4 FFG SmanSun Root White SPECIALTY WINDOW DETAILS Full/ Approx. Lai-E/ Specialty BAY/BOWADDITIO.NALWORK NOTES Room Count Styes Insert W_ Srrvrtsun Grilles CnIle Style FxtAnt Cdor Icu,au red_ iuh my/tH t d.,:.,u z inrir�� 11-e:.ill I.- ADDITIONAL WORK DETAILS: Customer is aware they will have to paint or stain interior casings on frame changes I 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 treatmentsihardware,it is the responsibility of the homeowner to have the alarm system and window treatments/hardware removed prior to installation. 14e make ro guarantea as to v:hetheralarnis or window treatments/hardware will fit after replacement. Customer is also aware in some cases there will be glass loss. 11 there is,the amount will be dependent on the type of existing windows,type of installation and window slyte.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 s 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. 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. a ✓ Y" Nr, Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). �It i.agreed and und'-1—d ill-and brusecn the panics that alis Spiflydion Sltii 1,:ihne t:ith the CUSTOM WI\WAV AND DOOR RF\IOARt.I\G AGRI-TATE\T,mnaimw,di,vwiw �undenlanding Ilel""en the p trtir.:.and there;nr nn cabal under'tandin ry ch mt,in or nt bfcin4;mq of the u•nu..This Sl dation Shirt m:q not h eh ngp.o or its wrnu twillified or varicd in �:ut}'x.t�unlr'ss vu it eburim anx in tlritins,.nuf si_�,ned Irk•bulb for}Sutrdsi:uttl t�, tet n Bul en,i brrelsr acku nd,dtie that Bulrrsl h L u.ui th Spt azDcauon Shcvlt Renewal by Andersen Corporation Iluty u ) / Ifuyrr'. Signature of Consultant Signature Signature KEVIN MONAHAN SONYA TERRA Print Name of Consultant Print Name Print Name Renewa Renewal by Andersen Corporation bf rCAV ',fid os "! 1) s „9_+.1:� t, = I ,i+4'i 1 1 i _i L,�+��n�i i � l __Ll_`a Fax y�Il�,� ?,�i5.,tl�_ Nm=Ammmw LCti tllti`al ti .tt I ."ti:1a iid l tt, l.;L)Ol CLIS1"rM.1'47NT)OV,.',>M',)POOR L6 L'�oils xcilcwill t_otl'oraHcI 'at ar,d i,',�' 't t l . 1`1 ants-.r°;I_ i2oon-ac:ct ik,10 Lta,etly+1,,eribR t.tzi [L)ut.[LO'O Laid rr'�tkllfv tl 2 tr. 41.L h;"'I ib.�1�'�til��d44ltIx41E�1 ,�a•�!i, .( 'a �,�. �, A ��,(!�, fL 1•a.I I nMb�i€t�ti 1 tt�.'d 1114'�4kg1` i 'I�lit 'bll. 1-vil`l.��l's.+[114JI1 I.`+Ilti1_itixt_�LLtii- [ll:i. $1MLlatP15=Ell Ilk-,L3`r _i_t,;1i�'ltil_,Y+1'ival'Ll'1�.1��U_,.1i117._ 1=Y.c°CLlurc4��I,:,11111{a[j�.?Lil.L N..iP_ui ,��l'�.GL-Holy '.. 1.5 11111 di _i sL" iu_-Liu'6 111)€7t�t�1'c tt L4ei;,iiL1i1 cs-it%a5 done ea hae It shiaws thL8 custonter Is nived S_�_l diallars;which Changes theJob uniount to 20056.9 malice:arnnunt ra III slut ttceA to lar chan->Ld to 20056_ 1IL,L tlflS[I yz'_°t, t L,� 16 lxY+h lLt°:; 1x'•fll i of fhb wA J*L--i_icrit ::+1` Ll:4:1 L-11.1 t.ytl"s 4l II;�C'Z 1.+ ?1.:) LGi iti::�L'`,Lri JPem will L-.. L3'i blalik 0,, 4 1 110,cl1;11 IkEWToLi., IoI:I Awr%tax: _20,076.0,0 Payment 10thad, 'w Cr3Lra_, jt'Yr<u7 of lob: ', .vViL_i v,-ti Gi4`al''a}'r` "IMSlI` :4` ,!, gn i hl L v�zZtT: t, �_6 t(xlb: It is Ap=d Md unkrstood by and ldwzm the-pjaiies that tis Amendment and;the crigbuf Agmvmt1t o+mstituto the entive undrs a mel b - twom the per,mid tt=AM no veabol WL4 ', 'YAW 4v4ing or wdifyin 4rW*f the tam.of ft AA�nmid cert, ) = - cd Mitt T�aayneals)I= this Amcn4>t=vt said hu r s c plcted,aiy�ncd,said dn:'cd axfr c(alis Auwnidrai .t on 44c xrral m bclats, Renewal by-Ax4mmun Corporsti BUM((O E-Siqued : 05E`'711?:5E�1 CST �I ;ti:l?111'1't11 e't'6hltu 'd 6'1 i'.l,x_t t' Sondra Terra 1F.21-.147,116.:=!r - - - - - 15 • cu UJIL CIL �DY�r9�/ ®a 4urdrlr+eYrAen+itaible Renewal ice. .m■...aw �r...ueefMe.•: .nn�rnce..yw,r ANO-N-$7 Vinyl/WOO!COMPOSJtEs M$t-risl Dual Arran Low-E4 SmorlSun Product Type; Picture ENERGY PERFORMANCE RATINGS U-1=2�ator 501ar Heat GaiinCoefflolent 027 1 . 53 0 . 22 U.�.n-P MekicJ3l ADDITIONAL PERFORMANCE AATINC;8 Vitalble Tranernittanoo 0 . 51 Mwreesuv�snpaneeae mesa�u.ne'Wa cantannm apPdaaele NFi2C praraewaf rar wtemdnYp�■+e.+.peeewc wmnounae.WRC mwx a ere amearminm mr a rmo eaO or w"arndeito mnmau*m==27'apeeae pm 27' NFRO mar nac rewnmem airyprvductand dogs r,elxltNeXma f�oiaerya enfr Pnacctor erhrepeodld uce. 090.4 aexr ea,e.r■=-.b—mr a~At"Padorwnm k*wmedwL • wwrnto.orp Aild r=,• en o ora 4n:RbA Pich-a Wndow enu er Skendard RaTln9 KAMW erMMAMOAMMA ifl i sXUd0A9 DR psf F-050 VMS Wm—tenbom Oman SEWS 4eY wwkwmemd gvvp*— e�R ,k yar W "A:°� antam ft n. e� r, ..rt.ee.me■■m IL i� m d rai�. owafter aou 100-OQ59 t00B-0�'I erteem armmm� .,cra,a�.eze.wr unveoon regeemnerowaw.wswex roar� } ^� a Donut remove unt➢3n>i code Inspedien.SNe labd hlriulurz tefetr'nce t 3 o rr Im a Lm Wim" t c a a C �G�laJ U W O . .a '0.5.7 ILII._' '� '�� • Renewal. j � MNvpM vvueFMEl1i as MderlC�yaq AND-N-35 WoodMnylCamPosl�FF Dual At, Lov Ed SmartSun i PtaduotType: Gilder ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient b.-29 ,1 1.65 0.21 ADDITIONAL PERFORMANCE RATINGS Vlslbie.TransmDiance 0.49 MrfYtnafr!/.�aRnrf raaq�rnYrn�af/yff NfNORsamr RfasnYaNf�[� Fr..vTRira,K110 tipaan�nrtWRall.v.��/uMswsva�ttaAfaraeNmC� �fpOfaYlfflfmmMlJf1I/NYfCst.ffYltfarRRela�iY�r�aA/�vRIIr/��vlN aLL . CtI.MINtuYL.ta PtY.RN/NsCrN�IrIa YMt�l _ Illicit] amen tl oraeom naw ' r appfimvpf np Standard RaMg aeamvnw�wawvwnapus:.ewfa ••DPPSFHS•G35- SeAt ,mR.fwfWs asna..n 1�U-00517D35--015 y.a arsa..+rea, ,a rowh�raoe.n>dinwne. j i . f® d a Do not remove until final code Inspedtion. Save label for tture reference, ` r r • I • m Caeadf � Yfoo afT-fafa ' O- anarfyaMnOe.rtA .. N • C m d tu 2 u ' UO y UATEA ac - Renewal byAndersen, HlNCCW fFPLACEMENT an�nda0C1(3laparR. sNaaa;rw, +t• AND-NA02 •I Ltctq�e: Wood/VlnylComposite — —._... Due( Argon Low-E4, Product Type: Casement ENERGY PERFORMANCE RATINGS U-Factor Solar.Heat Gain Ceef iclent 0'.29. 1 1 .65 0 .28. U.S.A-P Metric/51 ADDITIONAL PERFORMANCE RATINGS VIsIble Transmittance • ' - • - -• 0 .48 . ." . . ' M.mdaeMceepd.m RnRbaaa raNga mldvlmbaCP/cam.NFilC Prvuau"mrd.trmMpatlala prodst SII Pam•RPNe nan0a an dahnNnad bra M aatar enMvmerW evndebm aMaapeax pmmaiatr� IFpC tlou notrammvind arty pmductand tloea mxnmrcas aubMRy aran/Pmdudbr>rrj apamk uaa, umm' Camarmamnmmh NraAae br omarpmaepefarm.n Mvm.daM1 rS Co ora on: A Caseme now ' Retlng usvtiuo-os DPpsrDP36 - ����.4� 7tt+pmdudmam ' 'lV 6taei Each - �bRe Rene acal aaah • - - � iDD-0b513972-0D1 • 1lrtb arweWf MEo„CEC,4IE".IY RaaEadan regltrmafda WOAVIMabam CefCaCul PmQrea. renewal rkc byAndersene WINDOW, REPLACEMENT anAndetaMC0MRA0q Wood/Vinyl Composite IF Dual Argon Low E4 SmartSun tsc::ilCt:•r:c"`' Double Hung 100-00473518-010 ENERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient 00- 29 Onlg_ Y ADDITIONAL PERFORMANCE RATINGS Visible Transmittance OA2 funufacturar mowates that these ratings conform to appF=able NFRC procedures for detarmi6in9 whole product padomanc6.NFRC ratings era determined for a fixed set of environmental conditions and a specirc product site. NFRC does not recommend any product and does not warrant the suitabfsy of any product for any specif use. consult manufacturer's Raraturs for othar product performance information. www.nfm.otg This product meets Green ' Sears environmental aeeear +^ r" •T t-ice. 1 standards governing energy �,�„„;q°,e1. t>:,•` ( ��.,,.w < v•.' t afficiancy,heavy metals in /"`1 :ry;,i+f'• 7 Y..S� the frame and sash ,} r:. lar . f„3+.mater'e4 Paclagin9.and >.::•.<:: 'zz/•",'-�' '. consumer educational c iS. M3Ief01a. .Nrrunar o �.•,e..aw.'w..,u.ae» DESIGN PRESSURE(PSF) t. r w dowuidfwa ' N MCI G� r htywlacWvrt�AAsmebtbn H �V �Sl�oped ma.S® RbA DB Sill DH IN Tested tollAfS 02efW4M''0tANSA701ASfAWK htandaUVH st oo TO rn a ScahlB standards. deets or exceeds hLE.C.,C.E.C,&I.E.C.C.Air Infharation requirements WINdA Rahntark Certification Program. } The ComwitweaUh of jdanechrtsetis Departmeat of Indaestrid Accidents w Cyriceof-Invesag adons 600 Washington S:reet Basten,JA 02111 www wess,gov/dia Workers' Com- pengation Ilnsulrmace Af#rr avh-: .Builtdersfwontractors/Electricia-ns/�'inmbers Ap hean¢ f'ormajq 1 asd 'tint�, ib' Name(Busine.-s/organizationlitidividual): RENEWAL.BY ANDERSEN Address: 30 FORBES ROAD City/State/Zip: NORTHBORO,MA 01532 Phone 4: 508-351-2200 Are You an employer?Check the appropriate box: Type of project(required): 1. I sift a omployer with 30_ 4. ❑ 1 ata a general contractor and 1 6. ❑New wristruction employees(full and/or pant-time)* have hired the sub-contractors 3. 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# 7. ` J Remodeling ship and have no employees These sub-c:ontraclors have 8. ❑Demolition working for mein any capacity. workers'comp insurance. % ❑Building addition [Ivo workers'comp.insurance 5. ❑ We are a corporation anti its 10:❑Flectrical repairs or additions required.) officers lave exercised their 3.© 1 am a homeouner doing all work right of 011.e11uption per M4 FL 11.LI Plumbing repairs or additions myself.[No workers'comp. c. 152,$1(4),and we have no I10 Roof repairs insurance required.]t employees.[No Workers' 13❑Other comp.insurance required.] ---�----~ 4n lu,ant that checks box#I must a,st fill out the section stow show' their workers com ration li4 in "- Y aPP mK P� P6 Y formation. t;•lomeowners Who subn>it this affidavit indimin ihe4 are doin all work and then hire outside contrautors must stthrai a nettaffidwit indit:ating such Conbactots that cneck this box must atta Thea an additional snect showing the name of the sub contractor and their workers`comp policy intimation. lam an employer that is providing workers'compensation insurance for my employees Below&air policy and,job site information Insurance Company Name: OLD REPUBLIC INS. CO. Policy#or Self-ins.Lic.#: MWC 30543�QQ Expiration Late:_10-01-16 Job Site Address:250 Blue Ridge Rd City/State,'2ip:North AndoverLMA 01845 .Attach a copy of the workers'compensation policy declaration page(showing the pol cy number and expiration date). Faihlre 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 ce under pains and penalties of perjury that the information provided above is tate and correct, Phon : 8-351-2200 Official use orgy. leo not write in this area,to be completed by ci#or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.I ity/Yown Clerk 4.Electrical Inspector S..Plumbing Inspector 6.Mer Contact Person: Phone M ANDECOR-01 YADAVYO CERTWICATE OF UTY }M j DATE(MMIDDNM) 10/112015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANAME:CT Willis Certificate Centel' Willis of Minnesota,Inc. PHONE $77 945-7378 c/o 26 Century Blvd AIC No Ext):( ) At No):(888)467-2878 P.O.Box 305191 An�aL :Certificates Willis.com Nashville,TN 37230.5191 INSURER 8 AFFORDING COVERAGE MAIC# INSURER A:Old Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC INSURER G; 30 Forbes Road INSURER D. Northborough,MA 01632 INSURERS: _ 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. NOTVNTHSTANDING 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 ADDLTYPE OF INSURANCE SUOR POLICY EFF POLICY EXP LTR INSD WW POLICYNUMBER MM/DD MMIDDlYYYY umn's A X COMMERCIAL GENERAL LIABIDTY EACH OCCURRENCE g 1,000,000 CLAIMS-MADE �OCCUR .64W,LY 305"0 10/01/2015 1010112016 PREMISES(Es RENTED nce $ 500,000 _ '.. MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ 4,000,00 X POLICY F-]JEC- LOC PRODUCTS-COMPIOP AGG S 410001000 OTHER g AUTOMOBILE LIABILITY Ea accidentSINuLE DMIT $ 5,000,000 A X ANY AUTO MWTB 308438 10/01/2015 10/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED P OPER DAMA HIRED AUTOS AUTOS Peraecldent $ a UMBRELI.4UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEP I I RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY YIN X STATUTE ERH A ANY PROFFICERIMEM ER EXCLUDED?ECOTIVE I N� NIA MWC30643700 10/01/2095 1010112016 E.L.EACH ACCIDENT $ 1,000,00 (Mandatory in ndnd E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe auer I. DESCRIPTION OF OPERATIONS belmv E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached U 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 insurance 5�1- � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD ty Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-iwr License: CS490125 JAIME L MORIN 06 GARDINER ST LYNN MA 0190 x 'i 1 4kjExpiration Commissioner 10/06/2016 ,p� C/fte�pasrr7J2oozuieacc�L a�C�:l�[a�dC7cftiGla�l ', �\ ffice of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration: 170810 Type. Expiration: 12/2312015 Supplement 5, RENEWAL BY ANDERSON CORPORATION JAIME MORIN 104 OTIS STREET NORTHBOROUGH,MA 01532 Undersecretary