HomeMy WebLinkAboutBuilding Permit # 12/2/2015 00RTF9
BUILDING PERMIT
TOWN OF NORTH ANDOVER ® �
7 APPLICATION FOR PLAN EXAMINATION * - -
,
Permit NO: 1 Y0 Date Received
SgcHus�`��y
Date Issued:
IMPORTANT:Applicant must complete all items on this page
'LQCATIO�t �f51� /EA�STREET,:NORTH ANDOVER,;,M� 01845
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ne family
❑Addition 11 Two or more family El Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
7777777-777
Septic ❑Well
3""'r-laodplain ❑`It/etlands l Watershed Drstrict
',[�Wafier/Sewer,
REPLACE 18 WINDOWS AND 1 DOOR- NO STRUCTURAL CHANGE
Identification Please Type or Print Clearly)
OWNER: Name: JIM HAJJAR Phone: 508-878-8266
Address: 510 REA STREET NORTH ANDOVER, MA 01845
O�CTR/�CTO , C Fhone 50� 351214
rREi�fEWA48Y/INDERSEN,
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Addres 30 FORBf�S ROAD NQRTHBOROUGH, MA 01532
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�s�p�,�r�"r�grf's,�ar�strucf��r�a�fcerise r Exp
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Horne (mpro�remarit�lrc�nser
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.
31,71-1.00 FEE:
Total Projec�71)c�
t: $ $
1
Check No.: R Receipt No.: --?-'1-1 y`j
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner,_5e_v_'Q-f!k, Signature 6f`cohtract6r
Town olF NORTH
nclover
® -
h ver, Mas o�a lCj
O
�,95 R�►reo �Pa���S
L) BOARD OF HEALTH
Food/Kitchen
PERMI Septic System
c�
THIS CERTIFIES THAT ...................... BUILDING INSPECTOR
...$.Vcq.f..................... Foundation
has permission to erect .......................... buildings on ...5A0........ ....
��II ...... Rough
to be occupied as ..P. .... . .... .. .. . ... .�lS ..l W................. 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
J�+ Final
PERMIT EXPIRES IN 6 M HS ELECTRICAL INSPECTOR
UNLESS CONSTRUrNV4
RTS Rough
Service
........ .... .&Awoon........................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Islay 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.
Renewall� MA Home Improvement Contractor'.
�� Renewal b Andersen Corporation License 11 decal (Expires 121918 1 3
�'ACtCfeCsetl y � Federal Tax ID,-41-1918413
WIMDOnk REPLACEMENT ��;1+ ,. , '
30 Forbes Rd. Northborough,MA 01532
(508)351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
'Bu er(s)Name Date:
JIM HAJJAR NOVEMBER 12, 2015
,Buyer(s)Street Address City State Zip Code
510 REA ST NORTH ANDOVER MA 01845
Email Address Home Telephone Number Work/Cell Telephone Number
JIM.HAJJARe1NTEL.COM 508-878-8266
.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,Stara Date Method of Payment
Total Job Amount S 31,711 kmount Financed$ 31,711
Deposit Received(33 s)S 0.00 D pP it at ssgr:;a S 15,855.50 10-12 Check/Cash
weeks
Balance Start of Job(334'x)S 0.00 Check 4
Balance on SubstantialAl Est.Install Time Credit Card
Sirs_t �! �.
Completion of Job(3346)S 0.00 Camp?tet;_$ 15,855.50
5+days If credit card is su_9=>cted,please '.
No final a•mer,.sea€{to ,i a7 palt.ere sacst tl sew Credit Card Payment form
'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 Buyers)and Contractor. Buyer(s)hereby acknowledges that Buyers)1)has read this Agreement,understands the terms of this Agreement,and has
received a completed,signed and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was',
orally informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation Buyer(s) Buyer(s)
Y
Signature of Consultant Signature Signature
X GREGORY TAUTKUS JIM HAJJAR
Printed Name of Consultant Printed Name Printed Name
YOU,THE BUYER(S),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 OFCANCELLATION ronms FOR AN EXPLANATION OF THIS RIGHT.
---------------------------------------------------------------------------
I
NOTICE OF CANCELLATION NOTICE OF CANCELLATION I
I
Date of Tr .cU.. I]z 13!I IS You nmy vaueel this I Date.of Transaction I I i I2/! .Y....'y cancel tlds
'ira;tsactboti,,vithout any penalty or obligation,i:ith:n thr ec buslnc:dw,.fr-m the :r stcactsm,vviihnut aay penalty or obligation,rvithln ore h-lurss days Lrom the
above date.If you--I,any property traded in,any payments made by you under i above date.If you cancel,any property traded in,any payments made by you under
the Contract oC Sale,and any negotiable instruuent executed by you will be I the Contractor Sale,and any negotiable instrument executed by you vvill be
returned withht 10 days following receipt by the Contractor("Seller') of your i returned vvidtin 10 days following receipt by the Contractor("Seller") of your
cancellation notice,and any security interest arlsing out of the transaction will be t cancellation notice,and any security interest arising out of the transaction vvill be
canceled. If you cancel,you trust make available to the Seller at your residence,in I canceled. If you cancel,you must make available to the Seller at your residence,In
'substantially as good condition as when received,any goods delivered to you under 1 substanlIaily as good tnndithru a_s when received,anv goads delivered m you under
this Contract or Sale:or you inay,if you wish,comply with the instructions of the I this Contract or Sale;or you rnay,if you wish,comply with the Instructions of the
Seller rega-ling the-turu sI,lp.,-t of the good at the Seller's expense add risk. I Seller regardhng the return shipment of the goods at the Sellers expense and risk.
If you do stake the goods available to the Seller and the Seller does not pick thein up I if you du make the goods available to the Seller and the Seller dors sol pick there up
�avlthin 20 days of the date of your Notice of Cancellation,you may retain or dispose I within 20 days of the date of your Notice of Cancellation,you tray retain or dispose
of the goods without any further obligation. If you"B to snake the goods available of the goods without any further obligation. If you fail to make the goods available
to the Seller,or if you agree to return the goods to the Seller and rail to do so,then to the Seller,or if you agree to return the goods to the Seller and fail to do so,then I.
;you remain Dable for performance of all obligations under the Contract.To cancel you reatain Rabb,for performance of all obligations under the Contract.'1'o cancel
this transaction,mall or deliver a signed and dated copy of thls canrcllation notice I this transaction,.nail or deliver a signed and dated copy of this cancetlatinn notice
.,any other written notice,or.send a telegram to Contractor: Renewal by Andersen,I or any other written notice,or send a telegram to Contractor: Renewal by Andersen.
30 Forbes Rd. Northborough,NIA01532. I 30 Forbes Rd.Northborough,lltA 01532.
1 HEREBY CANCEL THIS TRANSACTION. I I HEREBY CANCEL THIS TR\:\SACTION.
eu•,�rs S:fa,c.•_-se Prue.N,_,,,,. Cr._ I ❑, _r_ Fenn N.r-m
I
Renewal tM. Renewal by Andersen Corporation MA Home Improvement Contractor
$ .
x
t�� - 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 12/23/2015)
byAndersen-, �
WINDOW REPLACEMENT .�,.,�,.1:�.:,;c.,�,� (508)351-2200 Fax:(508)-986.7072 Federal ID#41.1918413
Window Specification Sheet
l3u�cris'I Dame llatc of:Agiccuionl
JIM HAJJAft THU, Nov 12, 2015
I'lle huver:,l listed above herebyjointly and neaer fly agrec to purchase rhe goods and/or service,listed holo%%.in Ilcrurdauce with flic priers and terms described
oil rhe Specification Sher't and rhe li'ont and the rctrr,c of Iheaecnmpau}Ing' (il!S'I'ONI WINDOW AND DOOR RFNY)DI>LING ,(;t7.l.:MENT.of whit It
rthe Specification Sheet is part.
WINDOW&DOOR DE'T'AILS _
, ,,, --- Extedar/Imedor Calar HanlWare rL�,iwnn� 1.",F,A C,n1lc Grit, Gll s a
Room yr r -t u I. 4VindoydDoor Style Detail Casings Ext-Int Color st le Sere. 4 n,ni_un Grilles sash 1/3 Safi 2 Lifts Options
Office 201 32 61 93 DB sq rail Nual Insert sloped sill Ext,MF Flat H/WH White IStanewdl FAL ,arlartSw cBG 3/2 312 No No
202 I 12 61 9.3 DB s rail tial insert sloped sill Ext.MF Flat WHMH White Istandardl FAL SmarlSur GeG 3/2 3/2 No No
Bed 1 20.3 :32 61 93 DB sq rail equal Insert sloped sill Ext.MF Flat NHrWH White StandardVFAL
smartsur Gee 3/2 312 _No No
'201 32� til 93 DB s rail equal Insert sloped sill Ext.MF Flat H/WH While Standard -marts. GBG_ �3/2 _ 3/2 No No
Den 206 1 32 6 1 9:3 1 DB sq rail equal Insert sloped sill Ext.MF Flat NHNVH White Standard FAL Smartsuil GBG 3/2 3/2 No No
2117) 32 61 93 DB sq rail equal insert sloped sill Ext.MF Flat NH/WH White Standard I FAL SmadSur GBG 3/2 3/2 No No
Dining l O l 32 61 93 DB sq rail equal insert sloped sill Ext.MF Flat NHrWH _White Standard FAL mans. GBG 3/2 3/2 No No
102 32 til 93 DI3 s rail ual Insert sloped sill Ext.MF Flat NHrWH While Standard FAL mansur c>ee 312 312 No No
Family 103 ;2 61 93 DB sq rail equal insert sloped sill Ext.MF Flat NHMIH White Standard FAL mart Su Gac 3/2 312 No No
101 32 61 9.3 DB sq rail equal Insert sloped sill Ext.MF Flat NHM/H White _ Standard FAL _marts. G5G. I 3/2 I 312 No No
103 3$ Ii 1 93 DB sq rail equal Insert sloped sill Ext.MF Flat NHNVH White Standard FAL marts._ GBG 312 312o No
lot-) :32 131 9:3 DB sq rail equal Insert slope sill Ext.MF Flat NHAVH White Standard FAL 'mariSur GBG 3I2 3/2 No No
111, 32 fit 93 DB sq rad tial insert sloped sill Ext.MF Flat NHNVH White Standard FAL ko"arlsur GBG 3/2 3/2 No No
[Olt 32 6l 93 DB sq rail equal insert sloped sill Ext.MF Flat VVH/WH White Standard FAL ma,tSur GBG _ 3/2 3l2 No No
Kitchen 100 G!7 79 118 ND C rale Ext.MF Flat WH/PN�Sat.Nickl Newbury FFG Smart&Jr GaG 315 No tern er
Office III :32 61 93 DB sq rail equal insert sloped sill Ext.MF Flat HNVH White Standard FAL >mailsur GBG 3/2 312 No Na
Parlor 112 32 61 93 1 DB sq rail equal Insert sl ed sill Ext.MF Flat NH/WH White Standard FAL s.adsu GeG 312 312 No No
113 32 (11 93 DB sq rail equal insert sloped sill Ext.MF FlatNH/WH White Standard FAL martSu GEG 3/2 312 No No
1 1 d 32 ill 9:3 DB sci rail equal Insert sl ed sill Ext.MF Flat NHNIH White Standard FAL firnartfitn GBG 3/2 312 No No
Total 19 BAY,BOW&BUILD OUT DETAILS
Approx
Style Detail/ wdth/ Approx- Number Frame i Window End Center LOvrE/ Roof/ 1lardware
Room Count Style rlankars Ito. ht Cvrinis Anglo Lites Interior ExVInt Color Gnflfr3 sashes sc.slws t;:croons Saradsen Soffit Color
SPECIALTY WINDOW DETAILS
Full/ Approx. L—E/ Specialty BAY/BOWADDITIONALWORK NOTES
Room Count Style Insert u.l, Smarts..' Grillo- Grillo Style Ext/Ini Color
duIc nia L,,i,fluilu.rw nLi.I L.«•_
ADDITIONAL WORK DETAILS:
Customer will be installing Ir the north of March
DO NOT 7101101 INTERIOR CASINGS _
I No Contractor will wrap exterior casings with coil stock color of
Owner is aware that Contractordoes not do any painting/staining or removal/installation of alarm system or window treatments/hardware,it is the responsibility of
lite homeowner to have the alarm system and window treatments/hardware removed prior to installation, We make no guarantee as to whether alan»s or window
treatments/hardware will fit after replacement. Customer is also aware in some cases there will be glass loss. It 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 aconin,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 lull,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.
r ✓ 1'es \r, (honer agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s).
�Ih I,uu"'d nOd undrrstnnd In mid heturvn the partici dor Illi.Spvrilirauuu SLrei.Amu,t6th flit CCSI O\I 11`INM AV AND IN)Olt I(I;AIODI:J,IAG:AG121I:AIf V'1',t oo.tinur"dIr engin,
auulcr.t uxhnq hruvrrn
it,,,p:urirs,and Ibvn on"I" undr.uwdmg..ch.."''ginl;nr n,diftin„:u y of Ihr Iran. chi,Sp I da'ennu Shrvu may not In•vh:utgrd or ns Irrnx Inddn•d.nvnrird in
j:my u:tt unlrr,v rh vhauvr,an•7)u eIiliuG urtd,igncd hp both tin liup Ito,nut 1:OIIII:OIUL Ihnl r',;,1 hru•Lp a.luuntlrller Thu.Luo r,�'hui rrad Ilia hprrilil-utiun tihrrt.
Renewal by Aundersen Corporation IAlccr;',i liu�rrs)
r
Signature of Consultant Signature Signature
GREGORY TAUTKUS JIM HAJJAR
Print Name of Consultant Print Name Print Name
Renewal
WInDOW' REPLACEMENT mMderferCOMr;tny
WoodNinyi Composite IF
Dual Argon Low E4 SmartSun
Double Hung
100-00473518-010
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)/I-P Solar Heat Cain Coefficient
0
a 2 9�, r, v
1" 9..........
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0 ,. 42
manufacturer stipuN[os that thaw ratings conform to apprTbla NFAC procedures for data rma�ing whot)product
performance.NFRC ralingsam datennined for armed sat of environmental cond U...and a epacifq produce sea.
NFRC does not recommend any product and does nol Itarr'ant the suhabMy of any product for a,ty specific use.
Consuh manufaelu(at's rearatwe forothor product pedomtance information.
is vA%w.nfrc.ow
'Q& las product moats Crean
Searsanveonmeotal
3 standards gavarnin9 anergy 1..t".:�.a - t; ..•i •''� '�<Y:�'
fps. aH'c:ancy,heavy ma late > �
the frame and sash r, + t
f:matarial,packaging,and �` '3i�r .5•
Y, consumer educational
materkets.
DESIGN PRESSURE(PSF) `1'
w coa aew mor
r M1ttmeget, nAas:chlbn I]
RbA DB Sloped Sill DH IN
Tadd lelUfSQ2aUt1l4M1'AtSA'CSAt01.iSrA6140i I.IanrtacarCr srl Iatnc wMutmanco to tma [ao±aswwards.
4oets or exceeds hi.E.C.,C.E.C,&LE.C.G.Ah Infldtration requvoments WCh1A ffalhnark Cud'6r:a0m program.
Tiy„„_.":,:M
PRODUCT PERFORMANCE
An.derses'NFgC Certified Total tlni-IL Performance (conrioued)
Andersen'Product
Glass Type U-Factor' SHGCrr
200 Series ."_- -- -----. VT' ---_
Clear Dual Pane 0.45 060 _
C!ear Dual Pane with Gillies0.63
lilt-Wash tm0,,5 0.64 0.56v-E 0.30
Double-Hung Window 032 0.55 "j
Lmy-E wiih Gdllas 0.30
029 0.49
HP Low-E4 SalanSon 0.30 021 0.49 _
HP lrnv-E?SmanSun sv/Gnlles 0.31
0.19 0.43
_ Ciaar Dual Fane 15 9.61 0.64
NacroOne' C'.rDual Pane with Gillies 045 -- _ -
Dauble-Hung Wind .
Mellow 0.5'1 0.57
Low-E 0.30 0-32 0.56 "7
(ort-EvAth Grilles 0.31 029 0.50
Clear Dual Pane 0.44 0.63 0.66
Hemline' Cicar Dual Pane Mill GdOes 0,44 -
Transom Window ----- -- _ 0-57 0.59
Lnw-E 0.27 0.34 0.58 -
Lmv-EwithGnlles 027 030 052
ClearOual Parra 0,45 0.60 0.63 _
Ctesr Ouai Pana eAth Grdiet 0.45 0.54
0.56 -
GildingWiadow Low-E 0.30 mi
- -_-__lnw-E- Gripes 0.30 029 0.49 ;
_ Lmv-E SmBosun 0.30 021 0,49
lnw-E SmanSun wlth Gnlles 0.31J
019 0.43
Gear Dual pane 0,43 0.61 0.65 _
Clear Dual Pane mb Gnlles 0,43 0.55
Fund,Transom,
Low- 6 0.33 0.56 ''
Circle Top'Window E 0-2LW-E With Gdllas
,- 0.178 030 0.50 .J _
Lmy E SmadSun 027 022 0.51
Law-E SmartSur,with GdOes 0.27 D20 GAS
Clear Dual Pane 0.44 0.61 0,84
Clear Dual Pane tvM,Grilie, 0.45 _
0.53 0.56
Narmitne' -
Low-E029 032 0.56 _
tnw-EwithGriiles 0.30
Gilding Pa0__," ,29 ._ 0,49 ,g
Patio Doom Lmv-E Sun 029
020 0.31
Low{Sun wiDr Grilles 0.31 0.18
021
Lmv-E SmanSun 018 021 0.50 _�
LorfE SmanSun_Mill G611_r3 0.30 0.19 DA4
Clear Dual Pane
0.43 0.61 0.64 _
Clear Dual Pane with Grilles 0.43
'------._-�___ 0...c4 0.56
Lmv-E 0.28 0.32 0.56
Parma-Shleld' Low-E t'rith Grilles
Gilding Palle boom 0.30 029 0.49 a;] 'q '....
Low"Esun 0.29 0.19 0.30 .�
LOW-E Sun with Grilles 0.30 0.17 0.27
lmv-ESmartSun 027 0.22 0.50
lnw-E-owu un with Gdllas 029 0.19 '..
0.44
Cle>r.-I lane 0.43 0.=45 0.47
Ctaar Dual Pane tit Grilles 0.43
-'-----�. 039 0.40
M,I
4
Hinged inswing Lew-EM Gdlles 0.33 032 024 i 0.41
Patio Doors 02] 0.35 _
Low-E Sun 0.32 0.15 023 "o
tnw-E Sun with Grilles 0.34U3 0.19 •�' _
Lnw-E Sma!_0.32 0.16 0.37
Loiv-ESman5un with Gnlles 0.33 0.14 0.31
I
The Commonwealth v,��; assn cfar s
Depmme tt of Indrfstrdal Accidents
Cjrice ofInvesd9ad"s
600 Washington Sirreet
Boston,MA 8,2.1.11
www..wrss gov/did
Workers' Co mpenAafion Insura.tce Affidavit:3uilders/contractors/Electricians/K'lumbers
AqBean*'glormzrr'on Plew, Print ib'
Na1118(Busine.3/01ganizationllndividual): RENEWAL.BY ANDERSEN
Address: 30 FORBES ROAD
City/State/Zip: NORTWBORO,MA 01532 - Phone 4: 508-3512200
Are you an employer`:Check the appropriate box: Tyne of project(;required):
l.� I win a cmn Io er with 30 4. ❑ 1 am a general contractor and T
p Y _.._. 6. �1_New construction
employees(full and/or part-time).* have/tired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet,t 7. Remodeling
ship and have no employees These sub-contractors have &. ❑Demolition
'com
working forme in any capacity. workersP insurance. 4. ❑Building addition
[No workers'camp,insurance 5• ❑ We are a corporation and its 10. FlertriE-al repairs or additions
required.] officers have exercised their
3.❑ i am a homeowner doing all work right of G'temption per MOL I l.[]Plumbing repairs or additions
myself[No workers'comp. c. 152,§1(4),and we have no 12.[]Roof repairs
insurv.ce required.]t employees.[No workers' i3[:1 Other
:pomp.insurance required.] -------*Any appltwnt that checks box#1 must also fill out the section oelow showing their workers compensation poli,;y information,
t Hotneowners who submit this affidavit indicting dreg are doing all work and then hire outside coanrataors roust submit a new affidavit WliTtr'ng such
�i ontractom that cneA this box must atto heti an additional ineet Mowing the name of the sub rontraetorA and their wotkers`Comp policy inf xmafron.
I am an employer that is provk Ung workers'compensation insurance for alae employees Below is the policy and job sista
information.
Insurance Company Name: OLD REPUBLIC INS. CO.
Policy#or Self-ins.Lie.#: MWG 30543jQO_ _ Expiration Date:_10-01-16
Job Site Address: 510 REA STREET _ __C'i /State,,Zi : N. ANDOVER, MA 01845
.Attach a copy of the workers'compensation policy declaration page(showing the polacy 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
fine up w$1,500.00 and/or one-year imprisonment,as well as ci,ilpenalties in the Corm 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:orwarded to the Office of
Investigations of the DIA for insurance:coverage verification.
I do hereby and r the pains and penalises of perjury that the information provided above is tMe andcorrect,
t,
Signature. f•�— 1-— �—
one : -351-2200
Official use only. Do not write M this area,to be completed by cl#or town official
City or 'own: PermittLicense#
Issuing;Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Ot cer
Contact Person: Phone M
` y ANDECOR-01 YADAVYO
Al s. CE
m 9� � -I �d
LI1 TDATE(MMMDNYYY)
90/112015
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 WANED,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 NAME:CT Willis Certificate Center
Willis of Minnesota,Inc. PHONE 877 945-7376FAX
c/o 26 Century Blvd AIC No,Etj:( ) WE No).-(88-8)467-2378
P.O.Box 305191 F-IL
Nashville,TN 372305191 Certifcates@—Willis.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A;Old 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,
ILTR TYPE OF INSURANCE SUOR -P-0-LI- Y EFF POLICY EXP
INSD WVD POLICYNUMBER MMlbb MM/DDlYYYY LIMITS
A X COMMERCIAL GENERAL LIABUJTY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE aOCCUR MWZY306440 10/01/2015 10/01/2016 pREMISESEaoccurrence $ 500,000
MED EXP(Any one Person) $ 10,00
PERSONAL&ADV INJURY $ 1,000,000
GENL AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 4,000,00
X POLICY E]JECT= LOC PRODUCTS-COMPIOP AGG $ 4,000,000
OTHER: $
AUTOMOBILE LIABILITYf�MBINdeDISINiiLE LIMIT $ 5'000,000
A X ANY AUTO MWTB 305438 10/01/2015 10/01/2016 BODILY INJURY(Per person) It
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
HIRED AUTOS NON-OWNED OPE DAMA
AUTOS Peraccldent $
$
UMBRELLA LLAB OCCUR EACH OCCURRENCE $
EXCESS LIARHCLAIMS-MADE AGGREGATE $
DEC) RETENTION$ $
WORKERS COMPENSATION _
ANDEMPLOYER&LIABILITY YIN X STATUTE ERH
A ANY PROPRIETORIPARTNERIEXECUTIVE I eT! NIA MWC30543700 10/01/2015 10101!2016 E.L.FJICHACCIDENT $ 1,000,00
OFFICERIMEMBER EXCLUDED? 1�
(Mandatory in
If yes,describe uander E.L.DISEASE-EA EMPLOYEE $ 1,000,000
under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00
DESCRIPTION OF OPERATIONS I 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 � �
071988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
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Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
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LYNN MA ®1
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1114 OTIS STREETt
NORTHGOROUGH,MA 01532
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