23 MOFFATT RD - BUILDING INSPECTION (4) The Commonwealth 0t'MaSsarhUSelts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7'edition OF SALEM
Revised Jmnnrry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. MAY
One-or rwo-Family Dwelling
This Section F Official Use Only/
Building Permit Number: If Oale Applied: //--
Signature: "* lW
Building Commissioned Inspects of Buildings to
SECTION 1:S E NFORMATION
1.1 a 22 M f �� Q-A. 1 �`aors Map di Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Informal bn: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
Jj'1 `Owne1rt1of`R�ecyPrd:
IOGIP P0< 710 ✓ Q(AbG. > 1)3JO
Nome(Print) Address for Service:
Signature TelephoneSECTION 3: DESCRIPTION OF PROPOSED WORK (check stillthat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Additio
Demolition ❑ Accessory Bldg.❑ Number of Unit_ Other Specify: \
Brief Description of Proposed Work':
r—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1, Building S 10t g57$.c,a 1 1. Building Permit Fee:S Indicate how tee is determined:
O Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Feel: S
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S J 0 1 SS Ud 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 101950 —l9—la
�1 License Number Fxpiraiion Date
Name ul'CSI.• I folder List CSL Type tree below)
t
QI 1Xs ion
ss t U llnrestricteJ u to 73.000 Cu.Ft.
R Restricted Jai F,—dy Uwellin
Signamre M M' only--
�TZ C(I� 'Ort�i� RC Residential Routing Coverin
I depinme WS Residential Windowand Siding
SF Residential Solid Fuel Burning Appliance Installation
D Rrsidrntid Demolilion
3�([j Reglsterad ortte 1 rov`\mQe�ntt C�onntractor(HIC) I cf 9 Go
'`p n eW \ WOW e c ' — Reg
istrvion Number
I IIC Compqny Name or FIIC Re istrant An
( rrV C11
.Y�'�I -1 �4G Expiration Date
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ....... No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
signature of Owner Dote
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1. d n C cow` as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my nowledge and
behalf.
Print N
l l r b lr
Signature of(honer or Authorized Agent Date
71. An
nder the ains and hies of 'u
NOTES:
Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration
ram or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program andstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS, respectively.
n substantial work is planned,provide the information below:
ors area(Sq. Ft.) (including garage, finished basemen✓attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Tidal Project Cost" 1 O 3 S� .Utl_
y
DEBRIS FOB
This form is to be sabmitted with ,;l=ig permit applications whI n ver there is debris to be
disposed of
PropwtyAddress:
. Ia�ccordaac.nth the grovisioas of MGL c.40,§54,:a condition of�BuiL�ia;Permit
Number is that fhe debris rcmhing from.this wxl shall be disposed of is a properly licensed
solid wasta disposal facility as dz5=d by-10L c. Ill §'150-A.
\\• This debris wMbe disposed ofirr 1
ezaA �m QVM - LOLi 1L 6ru, WAG
(L;ocatim of Facility)
. Simafise OTPemnit Appllrant
11 IlJ ILO
Date
I (I,i;KI.,Nil 1l6u-ntth. (11"i{2 ,)c@ .Wi nnlcn,Im:..a/Is/t ,AAA IIOI11e In1prpVenlnit Coulrnctelt
:.dqf '!IP.114nn•I':IV'.771 JIS'.-4U 1'i Renewal tic, ,,,#I44N01 fF'spircx 1/24/2012)
byAndemn. acr;ll rasu,#bs-o4oazol
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Dare nt ty oome>„
6,1412- F d- G&-orte tj;ka(You lcp�_!.°-18`co
—�
Ry„l•I FIn fAdd ,cry.Stul endZio Cod.
y3 Mof-P _+-� R9 54. ICVV .Tinn 76
LM61 Addro, � 7 Nomhm ilk feephcne Number
11.me letp hone _ -_
__.. . _V5-?0 _S4 Sy7—)S _..�
Ilew,W hardly jai nl ly it d severu l ly;I[;lies In purehaxc Ihe pnxl Lit!.<;tI Id/JI'surviL of I k 1.Windows.Ina d/h/a Renewal by Atldo,wu
I"c'aubvlcloi"),in accord:uue wll It Iho Iorn,s lmd any:ilium dcsc rib,d OIl IIA.inml:md the rive rR'of IIIi,;l,�lwnlcnl and 011 Ihe td l:lehcd
+port Wi lfintl p'haelG)(NhdCIIVCIV,111,"AI�rMIIC 11 •).Bu yc r(s)Ile retry LI,`l vc,to si•Qn a nn.lpletion L-01 il'igdc after Coulruclor has Covgildcd
aI l wuI'k ender Iles A;ylee111aIli,
�/'� p e Method of Pyrrrro:J Cash V Check 'J Mosteraorel J VISA
Total Job Amount WO Sa Fsnmrnel Slna'mp Date: Method
pp E
Deposit Reeived(33%)
Nam¢on Credit Card:
6o1once of$tart of Job 133 6,1'. r
Estimated Completion Dale. Credit Cord r:
Ralnncc on Subsmnliol /-r a si c oK f
Completion of Job 1337): CC Eap. Date, CC Security Code:
Ifi'imu hII>,I r u 1 An l Irl4i tII,I Ih, B.11 leas (Still,I&lid III BA"It uSlih,l-rut I(,..uplL li'rn
Buyer Initials dJolatintitb 11 - Lrn 'II,.url and lutisth I, Ls p,la ud rb.:k leak -h -k,mreal
Buyers) 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 bath Buyer(s) and Contractor. Buyer(s) hereby
acknowledges that Buyer(s) I) has read tbis Agreement, understands thr. terms of this Agreement, and has received a
completed,s:goad,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
(HERE ARE ANY BLANK SPACES.
J A,L Windows,Inc.d/b/a Re by Andersen Buyers) Ruycn s)
.ti' alnlo r,f 1'n du A-I- atirc hi uf1111I • Fimlurr
L- /_ _./y1Gl LC it
I'rinl It.inl S:nn.. Prim Nam,
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,SEETHE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
,< _ _ - - _ _ _ _ ._ . .. _ _ _,t. - _ _ _ _ _ 1 . _ _ _ _ - .`,- ._ _ _ _ _ _ _ _ _. . .<
NOTICE OF CANCELLATION h NOTICE OF CANCELLATION
Date of Transaction /D-( /r,.(U You may cancel Date of Transaction i 0 0 You may camel
this transaction,without any penalty or obligation,within I this transaction,without any penahy or obligation,within
three business days from the above If you cancel,any three business days from the above delete.If you cannel,any
property traded in,any payments made by you udder the property traded in,any payments made by you under the
Contract of Sale,and any"atiable instrument executed Contract of Sole,and any negotiable instrument¢waned
by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice, by the Contractor ("Seller") of your cancellation milke,
and any security interest arising out of the transaction will and any security interest arising out of the transaction will
be canceled.H you cancel,you must make available to the be canceled.IF you
you camel,you must intake available to the
Seller at your residents,in substantially as good condition Seller at your residence,in substantially as good condition
as when received, any goods delivered to you under as when reserved,any goods delivered to you under this
this Contract or Sale; or you may, if you wish, comply Contract or Sale;or you may,if you with,comply with the
with the instructions OF the Seller regarding the return instructions of the Seller regarding the return shipment of
shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.H you de make
If you do make the goods available to the Seller and the the goods available to the Seller and the Seller does rim
Seller does not pick them up within 20 days of the date 1 pick them up within 20 days of the date of our Notice
of your Notice of Cancellation,you may retain or dispose of Cancellaton,you may retain or dispose of the goods
oaf the pact without any further obligation. If you foil to without anyy further obfrgation. H you fall ro make the
make the goads available to the Seller, or if you agree goods available to the Seller,cur if you agree to return the
to return (fie goods ro the Seller and fail ro do so, then goods to Hw Seller and fail ro do so,then you remain liable
you remain liable for performance of all obligations under for performance of all obligations under the Contract.
the Contract.To cancel this transaction, mail or deliver a I To camel this transaction, mad or deliver a signed and
anand dated copy of this cancellation notice or any dared copy of this cancellation notice or any other written
other written notice, or send a lelegrom to Contractor. J notice,or send a telegram to Contractor.J&L Windows,
&L Windows,Inc.d/b/o Renewal by Andersen, 104 Olis Inc. d/b/a Renewal by Andersen, 104 Otis Sheet,
Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MIA 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OF /D -Z£'-rii .(Dale) OF-,till.__—.(Date)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION.
Buyer's signmure Dore.—........ . Buyer's signurvre —_._._.. cob
B/Zd EleEL8641L1 « 04oEZ 81-0I-0IeZ
a L Winnows,Ine.d/b/A
1040tis 51 red,NOnhlnrouph,Aap Utsn2 Renewal MA IIIl Wccnsee,.11 jo 1cxpirc>V24r12I
t'hon.r•0�?Ip.OVlhiLs]91.nnZ301.a K IfAl9a1'f:181Dy %a-040.1L01
bvAndersen.
M R[[LRC[NFMI till Arnkmn(�•m{amv
OF Gmirk M,os...RTI')ANLI NEW HAMRHIFL
WINDOW SFECIFICAIION SHELF
Iluyrr(s)Nemc Date ni Agf¢enant
l E a�o
'1'ha puverlA listed almvc hereby jointly slsd w.vcr:+lly ngn'a Pis patch': the gaols and/or services listed aLlOW,in acmriancc with the prices and IcrmY
described till the Specincudon Street and L the imnt And the revers of the+aroolparying C176'I'OAa WINDOW AND D C7 DOOR REMDELIN('.AGBEEMr.,
at which this xlnuifie;Ahrn xlmet is'n pan.
WINDOW DETARS
I. Conlrad",will Install a total of (U windows in Owner's home,Using the following individual 1111Mlilics:
10 Dollhlr hunk([ni) [ hlual sash ❑ Colfax,sash(i/3 tor,21S bononll ❑ Otael sash(2/3 lop.1/3 111ttow)
Casement WW) ❑ hinge I ghl ❑ Hillge left(as viewed honl extet'Iorl: ❑ Standard handle ❑ Moro herdic
Double.Casement(C'.DW) ❑ Standard handle ❑ Metro hin,,W
CaSemCId/Pletrn'e/CESORIertl Q'I'W) ❑ 1:1:1 or ❑ 1:2:I ❑ Slart handle❑ Marro handle
2 Lite Glidin,(Window(GW)
_ Glldcr/Picture/Cdidcr(GFW) ❑ I:I:t or ❑ 1:2:1
Awning Window LAW)
_ hOUIT Window(VW)
Bay Or now Window
Panic,Dnrox(.,ice separate Door Sivoiicalion Sheet)
2. 43�Vcs ❑ No Qty of Windows to Ix Cn%nnt fit Rcplaccmcnt: 10
i1. ❑ Pose �J�N��O Qly of Sills to Ix rcpinacd by Contractor:
4. ❑ Yes Ly No Qly of Windows to Lv New Consll'llition full frame(includes new into,for S,exterior easings)
Exletiol rasing, ❑ I'mc ❑ Maiulennrvcr.-tine material ❑ Factory applied 908 1511rex brickmold
3. Gk1,.in;(tolx^.:jR1111'IDw-lAi SllartStill- (7'aTCYv&tHtgrb1e) ❑ Olher Ifolhcr•plcawspecify: .,
G. Ilxloior colartolx: &-white ❑ Solid ❑ Canvas ❑ '11crratonc ❑ Ci,coa Bcau
T. ❑ncrioreolor lote:W'Wlflle ❑ .Sand ❑ Canvas ❑ '1'mrntnnc ❑ Pine. ❑ Maplc ❑ Oak
Note: Inyteriorcolor can(tidy lx white,wO(xi or,rune enter as exterior. Wood inlci iors uecti to finished by Owner.
S. Ilalstwaly: Ly White ❑ Stone ❑ lNnvuS ❑ Brass ❑ "-state hard-1- Style:
n. ❑ VOSR�No Install Lifts Will'
Double Hung W111110 s
Ill, lereenr. Windom tolleveh1 Half n/' ❑ Full screens Screcos to lee�il7t`tI lase ❑ Alumitln111 ❑'PrLi.kvoc
GRILLE DEPABS
1 I.Windows have gr No It yes:tirurills nctween Gho,a:wa❑ Rcnwvable Inlnior wed(!xn'w)❑ full Divided 1•ighl A io
LtY �-13 Qty' Qty: Qty: Qty: Qty: Loy'
11
on on nH pn cw.Pmwre Ll
UCFWo,.'Ilse additional sliecl if needed Owncre ed
I h:iw grille patterns nlxevC. ppfoy
ADDITIONAL WORK DEFAHS
12.❑ 1'cs PR-No Conlfaclen will remove.mctrll Irdnlcs of windows. Qty of I lints:
IS.❑ Ycs �,NO Contractor will install new pa inl-rcadyo. stain-readycasings-
interior'casing qly of olrcnings:_-„ Exio iot'casings Lilly of openings:_ ❑ nine ❑ Maintenance-free material
1.1.❑ Ves EQ-No Contractor will install new paint,reedy 01 stain-react inside or uutsidc slope qly of oprnings:
heh:rior stops qty of Opcniy;s; Y.xterier qty of oprniny.. ❑ pint ❑ Muinlenanec-Ircc matctial
. Owner is aware that Contractor does not do any pain g r a' tials -
I6i [] Yes a No Contractor will wrap exterior casingsw -�stock of color.
Note: Wrapping may In Icgstired with Stoll III window r,nieval;removal of storm windows will leave sc'mw holes in c all Itg.
17. Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water'and air infiltration
18,aj-Yen ❑ No A funned warranty shall I,issued to Owner up(nt completion of lhejob and payment in full.
1 B.&I Ycs ❑ No Bulldln%Fer*nit Contractor will secure any and all necessary ixrrins. 'Iha fee Iitr the permitCl iv not
included in file Contract Price and A sepal'ale Check is mquinsl at tl'le link of sale for Ibis fee
20. Additional01.1details: .._. ••
21. m.3cs ❑ No Owner agmes to be present on the final day of installation for final inspection and to deliver final payment.
NO 1%/Lll LLiV//ia'nLt'/l.d/Lt'd�mxrtdM urllil l)etl COnbne(ie['anrL,/'hxf hl//1C.41lidaetinn a1 n/1)tvrbf9.
It is Agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING
AGREF.MF.NF,constitutes the entire undersnndulg between the Partin,And there are no verbal understandings changing or modifying Any of the
terms. 'Iles Specification Sheet may not he changed or fill terms modified or varied in any way udess such chatil are in writing and Apted by both
the Buyer(x)and Contractor. Buyers)hereby wknawlcdgc that Buyer(s)has read this Specification Sheet.
Renew r of Greater MA end lVFi Buyer( �)7') Buyer(s)
Signature of t Manager Signature Signature
l�n � aL [e NiKcccfu
Print Name of Product Manager Print Name Print Name
Shd E10EL86OLL1 cc 6E:E281-01-01o2
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance davit: l udders/Contractors/Electricias/Plumbers
.kpp icmnt Information Please Print Ledbly
Name(Bwinms/Organizadon/individnan: �[�n p w�' �J y Hnr�E.l—S e.ti .
Address: /0fl Qir S
City/Sfate/Zip: /VOf � borot /�A 1 95 — Phone#:
Are you an employer? Check the appropriate box: Type of project(requtired):
1.E'l am a employer with J D 4• I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t �• odeling
ship and have no employees These sub-contractors have 6. Demolition
working for me in any capacity. workers' comp.insurance. 9. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its ME]Electrical repairs or additions
required-] officers have exercised their
I El am a homeowner doing all work right of exemption per MCiL 11.❑Plumbing repairs or additions
myself [No workers' comp. c. 152, k1(4),and we have no ]2•�Roof repairs
insurance required.]t employees.[No workers' 13.E Other
comp.insurance required.]
`Any applicant that checks box#I mist also fM out the sectionbtlow showing their workers'compensation policy mfom'asrion.
t Homeowners wbo submit this affidavit indicating they es doing aU work and then hire outside conhactom must submit a new affidavit indicating such
;Coahattos that check this box most anaehed an additional sbed showing the moue of the snb-oontractoxs and their wod='comp.policy infurmatinn.
I ant an employer that is providing workers'compensation insurance for my employees. Below,is the policy and fob site
information Insurance Company Name: I A(` �P__o» -- /f'1 —,r, ✓/'rl C �
Policy,#or Self-ins.Lic. 3� ln1 ����'/�{i/ Expiration Date: 2—!
/�
Job Site Address;��J �n��,� `tL.a. City/State/Zip: S r p VtA .
Attacli a copy of the workers' comapensatlou policy declaration page(showing the policy nmo ber 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 DIA for insurance coverage verification.
Ida hereby c r )/nb��
er the pains andpena.Ides.ofperfury that the informationprovided above is true and correctSimatnre• Date: [ I 16 it l)
Phone#' Z �
Official use only. Igo not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuimg'Amthority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMMDNYYY)
02/10/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC#
INSURED Renewal by Andersen INSURER A: Hartford Insurance Com an
J and L Windows, Inc. INSURERS: Nautilus
1 O4 Otis St , INSURER C:
Northborough, MA_ 01532 INSURER D:
INSURER E:
COVERAGES -
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 CONDrrIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
TR POLICY NUMBER LIMITS
B- GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 EACH OCCURRENCE $ 1,000,000
! COMMERCIAL GENERAL LIABILITY Ea PREMISES Pmurence - $ 100 000
CLAIMS MADE O OCCUR MED EXP(Any one Person) Is 5,000
I PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,0000
POLICY PRO-o- LOC
A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT $ 1,000,000
: ANY AUTO (Ea acCMenp
X'. ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY.
NON-OWNED AUTOS (Per aaddenq $
PROPERTYAGE $
(Par ecddendeni)U
GARAGE.LIABILITY -. AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AEG $
EXCESSAJMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
a
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/2011 WCSTATU- OTH-
EMPLOYERS'LIABILITY
L EACH ACCIDENT $ 50O
ANY PROPRIETpR? E 000
ARTNER/E%ECUTNE - -
OFFICEWMEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE $ 500000
11 yes,describe under
SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE,CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVECl
ACORD 25(2001/08) 0 ACORD CORPORATION 1988
tF
•'=• Niassachusetts - Department of Puhlic Safct)
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 101952
Restricted to: 00
DAVID BANCROFT
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01588
Expiration: 3/192012
� .
_ ('ummisauna'r Tr#: 101952 -
,per ✓Lea-�aaavmno=«ealUz of••/I/LaeearfiueelA .'
�—\ office of Consumer Affairs&Business Revelation -
R VoOME IMPROVEMENT CONTRACTOR
Expiration g9RM-
ExpiraWpr y[t ai�P12
�e SsU=}Ieuert[ent Card
RENEWAL BY.AroC3EE5'O,h,+
DAVE BANCROF R9
104 OTIS STREET" `� ,f g
NORTHBOROUGHMi�Ll�32 Undersecretary
r
6
Renewal
rg� byAndersen. -%
WINDOW REPLACEMENT =Mdtt (h - lmy
jz"at a!Fq�re.M wood/ inyl Composite IF
'6Ccx t Dual Argon Low E4 SinartSun
Double Hung
100-00473618-010
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)A-P Solar Heat Gain Coefficient
. 2 9 . 1
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
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wINHFow REFLkcEMENT aaAnderr=Campsr.F
'o Whom It May Concern,
_nclosed is a permit application package for a project we have been
:antracted to do in your town. Thank you In advance for receiving this
sackage by mail. As we work In every town In the state, It greatly helps us In
)our process.
We have also enclosed a self addressed and postage paid envelope and
would request that when the permst application has been processed, that you
€irculd mall it back to us.
Enclosed for you review In this package is:
❑ Permit Application
❑ Home improvement Contractor License
❑ Construction Supervisor License
❑ Proof of Insurance
❑ Proof of Energy Efficiency Rating
❑ Signed Contract from customer
❑ Permit Fee (if accepted at time of applying)
If you have any question regarding this application please call me at (503)
9 P9-F,y992.
Best regards,
Kelley Donahue
Permit Coordinator
104 offs sheet 1
Northbaro AMA,01532
Phone(508)919-0900
Fax(506)919-0903
Website:www.=ewalbyande:sen.com