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31 MOONEY RD - BUILDING INSPECTION (5) The Commonwealth of Massachusetts ' Board of Building Regulations and Standards FOR ITY Massachusetts State'Building Code,780 CMR, 7 s edition MUNICIPAL E. Building Permit Application To Construct,Repair, Renovate Or.Demolish a RevfsedJarruary. - one-or 1`wD-Family Dwelling 7, 3008 - This'Section For Official Use only' . �J 1 gPerinkNumber Date Applied: ISignature: Building Commissioner/Inspector of Buildings Date SECTION I:SITE INFORMATION IJ Property Address: 1.2 Assessors Map &Parcel Numbers �I YVlwine.�t jY: 19.-.0011-:b 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number. 1.3 ogInformafion: �1 1.4 Property Dimensions: . G ne Zoning District Proposed Use Lot Area(sq ft) Frontage I.S.Building Setbacks (ft). Front Yard Side Yards - Rear Yard: Required . Provided : . Requimd Provided- Required Provided - I:6 Water Supply: (M.G_L c.40, §54) 1.7 Flood,Zone Information:._.. 1.8 Sewage Disposal System: -- -- Public❑' Private El Zone _ Ousidp Flood Zone? Municipal❑ On site disposal system -❑ Check if-yrsli SECTION 2: .PROPERTY OWNERSHIP' 2.I Own e('of RppcorrY J 1I Ph l l �! bo lost�e KH l�ti&-.� 1 V�lcont. �� �c d� , u1nGl 01 k' o Na me(Print) — Address for Smrvicr-A.- Signature .. - Telephone .. - SECTION 3;D'ESCRIPTION OF PROPOSED WORKS(check'all that applY) ;;ez'Ccaa uct cu ❑ E ist o Suitliftg.� Ov;aer-^ccupied ❑ .°epa s(sj''.❑ "lte�ticn(s) L' Additica 0. - _. _ Denitilition ❑ Accessory Bide:❑ Numberofllnits Other Grief llesctiption of Proposed Work'': - ce-- SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item - Official Use Only (Labor and Materials) T,Building $ :,ta q m . o 1. Building Permit Fee:S Indicate how fee is determined: 2 Electrical g ❑Standard City Town Application Fee .❑Total Project Cost?(Item 6)x multiplier x . . 3.Plumbinv $ 2. Other Fees: $ " 4.Mechanical (HVAC) S List 5.Mechanical. (Fire $ Su pression) ' Total All Fees:S r Check No. Check Amount Cash Amount 6,Total Project Cost S. ).a, �,Gq,oo 0 Paid hi Full 0 Outstanding Balance Due: _ SECTION 5: CONSTRUCTPAr'SER';i>3CEs 5.1 Licensed Con5tuction Supervisor(CSL) ( t ^ L Sc3il License Number I xpitation Date. Name jCSL-HDlder List CSL Type(sec-below) !�" Add ' � - _ " U Unrr_thicYed(o to 35,000 Css.Fc) .Signature - - - - R P=trictcd 1&2 Fanuly Dwelling" .. . Telephone. X �S,�'o�b'S - RC 'Residential Rgofm CovCTM' Cov - - - WS Residential Armdow and Sidin . SF Residential Sol' rut ]LB 'urnm Ap pliance Installatio n I3 .Residrntiel Demolition 5 Registered' one i provement Contractor(MC) enewc l : �ct r io �I o Hl('C Coru yName HIC R gistrant ame - Registration.Number 3 a Address l oa-a L'aaU0 Expiration Date . Stgnazure" Telephone SECTION 6:WOPMAMS' COTYIiENSAitONMU1RANCE AFFIDAVIT(M.G-L.r-152_:§ 35C(6)) . Workers Compensation Instvarice 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 Attach6d-� _. _ Yes :...---:.. ` No...-... -_ SECTION UI O'F-.t2iM *UT$0RIZATIpN TO BE-C.O FT. E O�Sr13ER'S:SGIIa1'�9It C0N'�ACT'A1R APPLdES F03:�I7IL;p 'P�3R11'aT'- " 4" `.�( 0. 5�r I t as Owner of the subject property herrby authorize ( �ar� rinl S c�^ " to act on b. my eb:al£in all matters relative to work authorized by this building Permit application Signature of Owner T' � Date .:�1^, Mrt'Y'.if�% ,'1S- �hl ._ x-rOuver,o fctith_6zed Agent irettbv tdaclait , that tl t stLic'nents and info m ration en the i�Ye'in application aretrut::and accivair to the b— esT t o k oNrledge and bebal 6 .Print Name Signature of Owner 6-r-AuthWH-#Agent Date ' (Signed underthe pains and penalties of - 'u - -- - " NOTES: 1. " An Owner who obtains a btulding.permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(MC)Program),will nor liave access to the.arbitration program or guaranty fund under hLG.L c..142A_Other important information on the HIC Program and -Construction Supervisor Licensing(CSL) can be found in 780`CMR Regulations 110-R6 and 1103t5,respectively. 2 When substantial work is planned,provide the information below Total floors area(Sq.Ft.). (including garage,finished basement/attica, decks orporch) Gross living area(Sq.Ft) Habitable room count Number of fireplaces Ntmtber ofbedrooms Number oflrathrooms Number of-half/baths Type of heating system Number of decks/porches Type of cooling system" Enclosed Open 3- "Total Project Square Footage"may be sabstimted'for"Total Project Cosy' � q� DEBRIS FOB ; Tbis form is to be submitted apth br i i permit appficafions wh�wver thm is debris m be disposed o£ Prbpesty�.dd=ess: �j � YVlpe7/LeN R�. . ' In accordance wj&t3r.:.provisioaS of I�iGL c,40,§54„a candi ion of th^Br,+1 =n o Pe=it Nnmbw is that rl e aeb=r-omItin;from Ibis wmk shah be disposed of in a properly Hceased solid c�rst✓disposal r'act�y as deim.:d by h�iCrL a 11i§i50 A. . Thisdebrist!,Mbedisposedofin: / f (Locaanmofraclity) Si-mat=of Permit applicant o�10Ail(a Datz , ' 1 F Renewal NIA Itonie hnpruvcmcnI Cunh'uclor Liccnnc u 170810(F.x pi nee 12/'L:VA)13) byAndersen.w Renewal by Andersen Corporation Fcdera Tax ip#41-1 51 84 C5 WINDOW aPLaOrnFai un A,A—,Cl —, " I014his3] Nn]il]iv.... h.AIA 1116'i7 ' 6DN:O I Fl-I I!)Iln•Pea:;i 7d t!IR7-ill l3 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Paycrlsl Nama D.I.al Agreemem FMm Addm.. Hom J-1,f WA T.,1.. N.mbe, p 0dy Gwsn . co� p7g�y5L4 Iiuyrr(.$)herehy jointly and,wvcratly agrees Io pumha.aa the Imxluels and/or Aeviwl 01 ReIlCwnl by Anderxlt Corpora lion ("Contrachtr"),in ucmrdauCC will]the Icrms atilt conlhhom described oa the from and the reverse of Ihis ggreenlenl and on(lie:I nachcd I),r.i Iicnliwr.alleel(S) (COIIcClively,this"jNVCeumnI").lloyiv(s)hereb)r]Brans to sign;I eomplelion cerkfiutlo]lifer Contractor has conlplClcd . :III work ender Ihis Agrocmm�l. Total Job Amount. 121 f // E,tlmated Starting Date: Method of Payment:OCheck OCash inonced Deposit Received 133%1: Z -Z O -f 2- Balance at Start of lab 33%). Credit Cards are accepted for deposit Esrmared CDmple6an one: only- maximum 1/3 of the project cost- Balance on Svbttantiol ��' 6-� ,K f Please see Credit Card Payment Form. Corrplelion of Job(33%): By signing this agreement,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion of]ob cannot he made by credit card and must be made by personal check,bank check,or cash. 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 win be valid without the signed, written consent of both Buyers)and Contractor. Buyers)hereby acknowledges that Buyer(s) I) 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. R.newal byA dersen Corporation Buyer(s) / Buyrr(s) tiigna rcr of Pruden Alalulgrr Rigu:uun• �Ty „t";]'`],'''� I'u Dior,l Radar]Afnnaxrr Print Saner Priul V:uue 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 OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. NCITICE F CANCELLATION X NOTICE Of,CANCEL]A11M Data of Transaction U-2 0-I Z- . You may cancel Date of Transaction 2-'Ld-1 Z- You may cancel this transaction,without any penally or obligation,within 1 this transaction,without any penalty or obligation,within three business days from the obew:date.ff you cancel,any 1 three business days from the above date If you cancel,any property Traded in,any payments made by you under the 1 eroperty traded in,any payments made by you under the Contract of Sale,and any ne$plobk instrument ex«urod entnext of sale,and arty rhegottable instrument executed by you will be returned within 10 days following receipt t by you will be returned within 10 days following receipt by the Contractor ("Seller") of yaw cancellation notice, I by the Contractor ("Seller") of your-concelicAM notice, and any securby interest arising at*of the transaction will and any security interest arising out of the transaction will be contekd.if you cancel,you must make available to the be canceled.If you Cancel,you must make available to the Seller at your residence,in substantially as good condition 1 Seller at your residence,in substantially as good condition as when received, any goods delivered to you under 1 as when received,any goods delivered to you under this this Contract or Sale, or you may, if you wish, comply 1 Contract or Saki or you may,if you wish,tumour with the with the instructions of the Seller regarding the return imhvetians of the Sdkr regarding the return sMpmem of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make N you do make the goods available to the Sdier and the 1 the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the dote pick them ufs within 20 days of hhe date of r Notice of your Notice of Cancellation,you may retain or dispose 1 of Cancellation, you may retain or dispose of the goods of the Bands without any further obligation.If you fail to willauf arty further obi'q�atien. If you fail to make the make the $Z. available ro the Seller, or if you agree 1 goods available to the Seller,or if you agree to return the ro return the goods to the Seller and fail ro do so, Then 1 a to the Seiler and fail to do so,then you remain liable you remain liable for performance of all obllaahlians under pe.Fcs once of all obligations under the Contract. the Contract.To cancel this fronsoceion, mail or deliver a I To cancel this transaction, mad or deliver a signed and sigrmd and dated copy of this cancellation notice or any doted copy of this cancellation notice or any other written other written notice,or send a telegram to Contractor: matte,or send a telegram to Contractor: Reuel by Andersen Corporation, 104 Ors 11 Renewal by Andersen Corporation, 104 Otis Street, Sheet, NtiAhborou 01532, BY NOT LATER THAN Northborough MA01532 SYNOTLATERTHANMIDNIGHT MIDNIGHT of L-L =E-__ .(Date) OF �33-_�.(�k) I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL THIS TRANSACTION. I rnyoi aigna rc him N.m. Date Buyer iSirnoNro Lin]Name Dele chn I"'.— whil., nnv,.r I'nnv-N5,Ilnw Iluvrr('env-Pink 015ur20»A9A46 11 8/Zd flafL869LL1 « Bt:Ll 022o-ZIOZ Renewal Renewal by Andersen Corporation MA Nona httprovcmenl Contractor I0l()dx w,Norlhhun,n h.h4A 01532 License#170810(Expires 12/23/2013) byAndersen• 511tb 0194a400•lax::77F19873013 Fcacrnrrnx lD N41-1018413 _ WIn00W REPLACEMENT 'gym A,xnrnrn m , WINDOW SPECIFICATION SHEET lhprr(s)Nnmc• Mule of ASNernrnl d Or<i pll Z. '1'Ia•BuycrlJ IistrJ nM+vc Imn'hy ieinlly nuJ a:verully ag 'to pachn.w the ga+dx:uW/.r Actvieen listed below,in smorddnee with the prices and forms, dessrihcd Oil the Slectfic:Oinn Sheet still the It'onl:old Ills Nverw of the nerongn;lnying la;Cll>.b1 WI.VI)OW ANI)1100R RI; lOIIEI.I.YC ACRI!Emi:Nr, Of will, the,%Iwcifiaaion Shot isa pa']. - WINDOW DFTAII4 I. Contractor will lnSllll O lulalol jLwinflowx in Owner:sholncuning the l'allowirlglndividuul quantities: IknlLrlr I Itd)g(D171�'I'elual clsh ❑ COlhrge n:rsh(I/3 top,2/3lxdtortl) ❑ Oriel.ansh(2/3(ap. I/:s hottom) Clscnsnl(C W) ❑ hinge ri;(hl ❑ I lingo lull laA viewed lisvn emerinr): ❑ Stnndurd Handle ❑ Mcw handle Llollble C:asemmill(CI1W) ❑ Slanaard handle U Mclro handle —_- Casement/Plc'tarc/Casement(CI'W) ❑ 1:1:1 or ❑ 1:2:1 ❑ Nandurd handle ❑ Metro handle -_. 7 Hie GHIIHI g Wi ltiow((:W) Glider/picture/Glider(GPW) ❑ 1:1;1 or❑ 1:2:1 _ . AwWng WiudOw CAW) -._—Picture Window Owl Ikp'Or lbw Window Ialio IAsys(ace ac'lmr:de Llwr Spcxiftcatton SlIeel) 'I. , . .�/Tis NO QIV Of Windows to Ix CUMonI Fit RcpluccmenC 3. ❑ 1'ex�l/5t�ryNs�� t, QIV of Sills to be replaced by Contractor: 4. ❑ Yol]jrNo Qly of Windows to be New Construction Fit ll thuno(Ulrluden new interior Ne exterior cuvinc'):uul nrond Exlenor easing.: ❑ fine ❑ Mai tnena nh•.Ilco ln:ueral ❑ 1'aelorynppic`d!Y108 Fibre:x 1, mold 3. Gluriu;(to lie; ❑ III'Iwrw-Il4 ^I 4wlrol I' tfolher,Please specify: rf uln_ r,. Exteri..r calorlolx:JRwlfle ❑ Sand ❑ Claims ❑ 'feratone ❑ CoL."a]lean - 7. hucriorcalortolx: 'White ❑ Sand ❑ Canvas ❑ 'relt'alone ❑ fine ❑ maplc ❑ Oak Note: Interior color c:m only lY white,wood orsnn[coloru,v Cxln'ior. Woxl iWcriors need to 11111.4led I+y OWllef. K Ihu'dwmc:'WWhite. ❑ Slone❑ l:mvax ❑ Brass ❑ t'statc l lnniwam: Style: 1) )$<Ys U No 111,11 III I.Iftd Wllh UOLnble Ihlll,'(Wllldt+W.0 10. 4'reeus: wind".10have: ❑ Half ✓r 3(ullscm¢ns \'1'eetlntOLV;Hill—the, ❑ Aluminum ❑ 'Iruticen, GRILU DETAILS I 1.Windows huvc,grillCs: ❑ Pas No II yes❑ 6rillc 6ebvao Glass sAMY❑ Seunwstnc Interior Waxl ua'f\VI❑ fall Llivided Liglil InrU QN; QIy:....__ QIV: QIy: QIy: QIV: QIy: nN nu L. ILJ 1 ,w,j1 coon c..r straw,sml le panCL'us:duvc• -Ilse'uddili.null shed il'bcuattf Owner applovod(iTnitisls),f ) ADDITIONAL WORK DEFAM 17.❑ Yes aNNo C'onlradln'w it l remove alcial lia tiles of Windows. Qly of l lni l s: Cs.❑ 1'C"tJa rvo Conlradur will I nl:dl new p:lIIil-n`ady or satin-malty cash;vv. Interior casing Lily ofolviiin:(s: Est C I'ior Casiq¢s ell y Of ON11i ngs: ❑ tine ❑ Ma ilacn:mce-free material IS.❑ )'csjE No Controller will inshtll new poinl-wodyor Alain.lc_ :-side Oranlsideslopsgtyol'orrnliMi: Interior slops Lily of npc'niggs:.,,,-, I''SI(I lyF Mainlcnuncefree material 10. Owner is aware that Contracor does not do Bay fing. f Y 1� ) Initials Ili. 'Cs n No Cornracor will wnlpeNeriorcain..g. Ih:duration . ockof A)Y,If.color. Note: Wrapping Italy IV nguircd Mill slorpl window mnloval;removal of slorm windows will lolve SCIWw holes in cueing. 17. S ❑ No COntrnetor will insuhde,caulk and seat windows with s lVint system to prevent walerand air infiltration. I!t,W1'Cv 1 1\n 0vall op all Inll r'r'Iia'sl IIr'Ini,nu'hiding o d OuldIIwY oill In o-Illon, I,k:Irnurn Ilighily 1y. 1Ls ❑ No A bellied Willa-Only shall Ix issued lu Owner upon completion Lit Illejob and payment in full. 411.( 'es ❑ PILL Building Permit Contractor will at'urc any;md all necessary perinils. The fee I'or the permit(d)is not included in the Contract Prior and a sepnnde stack is nalulnxl Ill the lime OI'dslc for this f T 2LJ'Jlos ❑Nu All diaemlm.h:nr bran applird In this u4rrrumm p'a :!'!. Additional job dctnil.v: Y3.W(Cs [ 1 No Owner ugnrs to he preso n cal the liunl dsy of invlallatiou for linnl inspect inn and Io dCliver 1'tn:a raymem. ,NO lino/rnaueul.+•/�alllR',li/1CIl/[ILYI al/l11(tic'LYUIl1:'/e'/l.�<UOf(IAYaSI IJ ll4'R9/l+'l:I('/%JAI O/':fII11.'fr/lCa. It is Agreed and understood by and between the parries that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING u AGREEMENT,constitutes the entire nderstanding between the patties,and there are no verbal underslmldings Changing or modifying any of the terms. This Spatificatsm Sheet may not be changed or its terms modirvd or varied in any way unlem such chRaW are in writing and signed by both the Buyer(s).and COntreL:tOr. B )hereby achwwleQge that Buyu(s)has reed this Specification Shed. Ran ration Buyer(s) ) / 0 Buyer(s) Signature f�I� pf Manager Sfsnatum $rpmture Print Name of Product Manager Print Name -Print Name Oil CIDEL86PLLI « Lr310Z-ZO-ZIOZ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/Individual): {� ? (\e V C \ Y)t a i� S CC ✓� Address: City/State/Zip: �� r ���n��Aa Ci1S37,,, Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with C� 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 7.remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building addition o workers' comp. insurance 5. ❑ We are a corporation and its [N P• 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'My 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. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. \ Insurance Company Name:_ �/`' � p 6\ Policy#or Self-ins.Lie. #: W C- Expiration Date: ] - ` - l - Job Site Address: . �3\ 1 r `OnnP , 104 S a�w nA 4VNA 4-6 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 DIA for insurance coverage verification. n I do hereby cerhfy err the pa' and penalties ofperjury that the information provided above is true and correct. Signatur L6 Datei L Phone#• 5-o 3 i 1 -ao�U D 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#: Q - - ATE D c _ CERTIFICATE OF LIABILITY INSURANCE 01/11/2(MWDDD12/YYYY) 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 1-612-333-3323 CONTACT Jonelle Hargrove or Katie Psimos NAME: Rays Companiee - - tPAI 612-333-3323 FAX 612-373-7270 AX No E-MAIL 80 South Bth Street ADDRESS: Suite 700 "PRODUCER Minneapolis, MN 55402 cu O D ^ INSURER 5 AFFORDING COVERAGE NAIL Ir INSURED - INSURER A: OLD REPUBLIC INS CO 24147 . Renewal By Andersen Corporation INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 104 Otis Street INSURER C: Northborough, MA 01532 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 25114267 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 ADUTYPE OF INSURANCE NqR SUER POLICY NUMBER MMI POLICY P LC VTR D EFF MMIDD D(P LIMITS A GENERAL LIABILITY MNZY 59313 10/01/1 10/01/12 EACHOCCURRENCE $ 11000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES ED Dccurrencel $ 500,000 CLAIMS-MADE I JOCCUR MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENERALAGGREGATE $ 4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 3,000,000 X I POLICY D PRO- 71 LOC $ A AUTOMOBILE LIABILITY MWTB 21377 10/01/1 10/01/12 COMBINED SINGLE LIMIT $ 3.000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALLOWNEDAUTOS BODILY INJURY(Per accitlent) $ SCHEDULED AUTOS PROPERTY DAMAGE X (Pereccident) $ HIRED AUTOS - X NON-OWNED AUTOS - $ $ B X UMBRELLA UAB X OCCUR 25030519 10/01/1 10/01/12 EACH OCCURRENCE $ 25,001,000 EXCESS UAB CLAIMS-MADE AGGREGATE $ 25,000,000 DEDUCTIBLE $ X RETENTION $ 25,000 $ A WORKERS COMPENSATION MWC 117140 00 10/01 11 10/01/12 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTNE YIN E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDEDi NIA _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If,at,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks schedule,if more space is metered) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE . —udl�euvl�er94.a.. kpsimOB - ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD 25114267 �. �la�sachusctt. Dcp: rtmcnt nl' Public �,afm . f Board of, Buildin_ Rc'Rllatio s and Standards Construction Supervisor License License: CS 95707 BRIAN DENNISON _ 86 CREST CIRCLE - WORCESTER,MA 01603 - ��—L s/=� •`' Expiration: 918=12 - - (Lnmii..i,ner TrT: 2679 !' ✓ n�4P� oy✓liCo4opc�zr�delC Office of Consumer Affairs&B siness RegulaHan VHOME IMPROVEMENT CONTRACTOR - Registration: 170810 -Type: Expiration 12/2312013 Corporation RKWAL BY ANDERSEN CORPORATION BRIAN DENNISOt,,Ly L _ _- 104 OTISTHB ST _ 4 NORTHBOROUGH, MA,01532 : Undersecretary ewa[. WaudRf[n41 Lbnpn�ite[F Dual Ngoo Low R Smart'lnn i ' Double Nang ' EKE.RGY'PERFDRl CE RArMRS Factor ( 1.S)f-P SDIa[ Heafaain CDeffiC;ient j aft :I . a ADEUDDNAL PERFDRFTANDE RAif�fDS" Visible I ransttvttance u 42' ' • Gh.uk=m.r¢ivufuc A.:A:a Ninp«oknn revPPI�YNFAC Pm-.am..A•-e.runlvwwnu Pmac� . ._, NRW tloernm rv.�m.vtl wYP�veu=�neao.coevn..=m AcalmhSry ay.nYP�^a twvnl'T,.a'�"� • . a=sset muvh�enu�hlwmvn for ml.vrP"tlu¢p.dmmm+Nlmmvela. ' ' ' wweslvnry . I r 6e.lxm��nvYm�mN 1 A�t't,� D6 RPGkI DESIGN (PSG �y4- h�DB_alcLpa S DH IN i�amius�ru+ure¢sustemwnar� rw.arR=u�cmmmo,�m -.wit.=u�� .. Fa¢cR��sGcfLfS�.G=li 4LSfil1'IUON�at6e rt9rtinmvnt WOAfAHaCmcf�GeM1R'�1L�P+4=- 4 11 Renewal byAndersen� WINDOW REPLACEMENT an Andersen Company To Whom It May Concern: Enclosed is a permit application package for a project we have been contracted to do in your town. Thank you in advance for receiving this package 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 permit application has been processed, that you would mail 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 questions regarding this application lease call me at: 508-351-2200 X 55285 q g g PP P Regards,. Kelley Donahue Permit Coordinator 104 Otis Street Northborough,MA,01532 - Phone(508)351-2200 X 55285 - Fax(508)774-987-3013 Website: www.renewalbyandersen.com -