15 NIGHTINGALE LN - BUILDING INSPECTION (2) ga The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards
Massachusetts State USE.
Building Code, 780 CMR, 7" edition I rUN1SE. TY
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
This Section For Of5cial Use Only .
Building Permit Number- ate Applied:
Signature:
Building Commissioner/In 6eto-r of Buillings"IX 2
ate
SECTIO : TE INFORMATION
1.1 Pro nDerty Address: ( / 1.2 Assessors Map &Parcel Numbers
I � t 1lC.�T�1n CG1L' l,Ci ri G.
1.1 a Is this an accepte street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions-
Zoning District Proposed Use Lot Area(sq ft) Frontage(fi)
1.5 Building Setbacks (ft)
Fr6ntYard - Side Yards - - Rear Yard
Required Provided - Required - Provided Required - Provided
L6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?.
Public❑' Private O — ' Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o Record:
OFF ��\�_P.f i� �(1�,�lk lP iA gulwtt . mc, 0m:�-b
Name(Print) Address for r Servic&:
Signature - - Telephone
SECTION 3-.DESCRIPTION OF PROPOSED WORK�:(check all that apply)'
t;'� 'Coast--- ❑ Ezis' u [d^i^❑ O^ -�'^ pied ❑ Fepairs(s) .❑ " tica(s) :dd ❑
n c
Denr?litinn V ❑ Accessory Bldg. ❑ Number of Units Oilier SA- 11ccify:__.
Brief Description of Proposed Woric: e
G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
].Building $ ��. �� I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ rLl (o_G0 0Paid in Full ❑ Outstandino,BalanceDue-
SECT—IONS: CONSTRUCTIOI`ISERVICES
5.1 Licensed Construction Supervisor(CSL)
�(A,•�L� �C•Alan` ; - License Number Expiration Date.
Name of CSL-Holder o ,ll 1 II A, List'CSL Type(see below) \�
a IS$ Descii lion
U Unrestricted(i to 35,000 Cu.Ft.
Signature - R Restricted 1&2 Family Dwelling -
�(�� � M MasonryOnly
RC Residential Roofing Covert n -
Telephone. WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
F—IDF—TResidential Demolition -
�5//( Red stered 1'7}ome Imp ovem`ent Contractor(MC)
-1'CL'Y�r-VG� �134 A-Cf•Lc:n
HIC Company Name(�I^rr- lC R��ggi�strant.Npnr a Registration Number
1l`yl �)�is �T.: tVl %-O- OISJ-X I—o`ZLi — C-�)r L p
Expiration Date -
ignature Telephone
SECTION 6:WORKERS- COIviPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152_ g 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...........❑
SECTION 7a: OWNER AUTHORIZATION To BKCONMETED-
OWNER'S AGENT;OR CONTRACTOR APPLIES TORBUILD VG PER1YIiT
as Owner of the subject property hereby
authorize 1 ��,, r V- ��r �t y n (ram to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si griature of0wner Date -
1 rSEECTSON 7b:nOW_NER'OR ALTTHORiZED A EN3 DELI AR4?iON
nr.Autltctrized Argent lierkbv rteSlaze„= '• :�:
that the statements and utforniation oil Lie foyeLo ue application a e True mid accivate, to'tlie best of niy lmow ledge aiid
belt
Print Name
1 p
Signatur o wner or Authorized Agent _ Date -(Signed under the pains and penalties of perjury) -
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the home Improvement Contractor(HIC)Program),will not liave access to the arbitration
program or guaranty fund under M.G.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 I ID.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft). (including garage,finished basement/attics, decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf7baths
Type of heating system Number of decks/porches '
Type of cooling system Enclosed Open
3. "Total Project Square Footage" maybe substituted for"Total Project Cost" 4
II`
DEBRIS FORM ;
This form is to be submitted vitli building permit applications whenever theme is debris to be
disposed of.
Property4dmss.-' .� k if tin ����ea 1NlLt
in accordan:�,with the pro-,visions of MGL c.40,§54,:a condition of tht Builiing Peffiit
Number is that the debris restM=from this wort:shall b disposed of in a properly licensed
solid waste disposal faulty as deiimd by MGL c. I11 §150A.
This debris v,Mbe disposed of=
1"in(YP fir)Ar
(Location of Facility)
Signa of Permit-AppliCaA
I_
Date to
!Ibl ntis$t.•�:nrthko;o•.tCh.h1.411Li3? ,J\I.FS•1\'Dflt\'S,fVC,.,O/Rio\ NLk llomz pnprov.,vncid Contractor
,g0U1919-040U•Fac iii4l9U7�i01'4 Renewal Licen.e414"KI (llipins /2•t/201")
bn,ArWersen, l-aderal'rax It>>x,s-odeasnt
CUSTOM WINDOW AND DOOR REMODELING AGREMIENT
Buyeal,l Nam Dote d Agreemerl
Bvryr(A Stem Addmv,Cry,Smm,oral ZIP Code
E.vn:l wjjrev H°rte Td°rbm Numlur 'Nook ielWM1anc N.mter
Yolcrrc;lf+7l rxrm.,•-1 ,G_M -
Bayvrfs)Iterelty jointly and s%orally agrees to ptimh=the products and/or services of 1&L Windows,In:.d/b/a ftrnztval b 4ndersen I 1'Ccnlraapr"1,iu error d:once eith the'arms and cpndihuns dtxrilxd on the ironf and Ikte ra'trse of tF.is agrecmc7R and on aII:101I
syeeilicn ihm shags)(collea6'02l �IMc`.%SreerncnP7.0...i 60 heeeby:Gr<c,to sign i rnmplerinn ccrtificaec aR.,ConaaeNt hers eo,nplet:d
.it cos under this Agreement
melked of pymnt J Cash eck J Atosbce,d J VISA
bml)ah Amount: 7_rJ�(r v Edmotcd finning Nis .-�Dueaver J Fronsed,Asp#: _
Deposit Re-ci.ed f33%I: Ze{yrL �4-1L Lr.<�7CS.
Nacre on Creels Cord:
Balance of Starr of Jab(33°,I:-�y�y__
Esnmomd Complet,oe Dam: Credit Lord T:
ealence an svbs:on,iol i -Z DI 5__._.
Completion of Job(?3%I:_z'{'s(•tY -- CC Exp,Dom CC Securiy Code:
Rr uitialinq here,,at,oelnma ed,m that dic Balance at Sinnoffob and the 8;...r,.or,SnMranti:d Copt,on
Buyer In:dals ofJtdre:n,:ant ix:nadir In-credit<4od raid must be nmdr.by petcon:d thee.-hank dlrtic,or ni,,.
Buyer(s) agrees d understands that this A erecuhent constitutes the entire understanding between the pardes,and Mat
therearcnoverbalurWer. dinss changingor modiiI anyof the mrr.woftlus Agreement.No alteration to or deviation
E.dris Arc.—.,..tilt 6e valid "dI Me signed,wr:rteo consent of both Buy.+r(s) and Coorrsetor.Bnyer(eJ hereby
acknowledges that Boyet(s) 1)has head this Agre®coy anderstands the terms of this Agreement,and has received a
Completed,signed,and dated copy of this Agreement,ineluding the two attached Notices of Cancellation,on the date fiest
wrinee above and 2)was trolly informed of Bhtyerss right to cancel this Agreeoheat.DO NOT SIGN THIS CONTRACT IF
TTIERE ARE ANY BLANK SPACES.
Jx LWivdowc,Inc d/b/n Renewal by Aodarseu a.yat{s) Buyar(s;
Sigpanuc o(Yroducr\Lmaorr 'r Sigpeatm Sisnoui e.
Prim\;un,.1,Norlrret:N nna"er I nt Name 1'iinl Naar,
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 BIGHT. t
x_ _ _ _ _ _ _ _ _ _ _ _ _ _ -;.e_ _ _ _ - _ _ _ _ _ _ _ _ _ ;.e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _„ti
NOTICE OF CANCELLATION % NOTICE OF CANCEl1ATZIN
Onto of Trartsatsion You may cancel Dote of Transaction You may cancel
this transaction,wiHtotritartyperict orobrgotion,within Brig tmrssacfion,wipeout any pens[y or obligation,wbhin
three business days framtheabove debt Ifyeuwncel,arry Bvicebusiness daysfrom4ho above date.ffyou cancel any
property traded in,any paymertn mo by you urderihe property traded in,airy payments made by you under the
Comincar of Sale,and any rte$otiable rraarhnrhent executed Cemsraet of Sale,and any,netjotiable Instrument executed
by you will be returned within 10 days following receipt I by you will be resumed within 10 days following receipt
by the Contractor ( SellI of your cancellation notice, by the Cor rreclor ("SeOW) of your cancellation runiee,
and any security interest arising out of the transaction will and any security interest arising out of the tr artsaclion will
berunceled.if you cancel,you must mdce available to the becanceled.IF year cancel,you must make available to the
Seller at your resdimm,in substantially as good condition I Seller at your residence,in subaftntiully as goad condition
as when received, any goods delivered to you under t as when received,any goods delivered to you under this
this Coronet or Sale; ar nosy, if yourwish,comply t Cantroht ar Sale;or yea may,if you wish,comply with the
with the instructions of the Seger regarding the r.dum instructions of the Seller regarding the radium shipmeret of
shipment of the goods of the Seller's expense and risk. I the goods at the Seller's expense and risk.t you do make
If you do thmke tFe goods wmlable b the Seller and the
. a the goods available to the Boller and the SoRer,does not
Seller does not 'ck them up within 20 days of the date t pick*teat up within 20 days of the dote 4A r Ndice
of your Notice of Carue9alim,yw may retain or dispose I of Cancellation,you may retain or ditpase of the goods
OF tto gnods without any further obliggation.H you III to withocR any further ob6galivt IF you fail to make the
nook.fire goods available to Mho SeLer,car if yyour ooice I Bonds oat b e M the Sellller,or if yen agree re,relom the
to rehhm the goods to the S.Ilet and fail m do so,then I sratherSelleracd fail to do so,Hhen your remain liable
you remain liable far perfomhanced all oblgahons under I (or p:las once of ail obligations under the Cantraa.
the Contrad.To cancel this transaction, ni or deliver o To concel this transaction, mail cr deliver a signed and
sihggned and dated cagy of this cancellation notice or any dated copy of this cancellation notice w any other writtenotter written notice, or send a"rem to Contractor.J notice,or send a RI rant to Contractor.J&L Windows,
8 L Windows,Ix d/b/a Renewed by Andersen,104 Otis 1. d/b/a Renewal by Andersen, 104 Ofs Street,
Street, Northborought, MA 01532, BY NOT LATER THAN Northborough,MAO 1532,0YNOT LATERTHANMIDNIGHT
MIDNIGHT OF .(Date) OF .(Date)
I HEREBY CANCEL THIS TRANSACTION. i HEREBY CANCEL THIS TRANSACTION.
Buyer[Signature slate ! 9nyCr1 sigrgarm Dk
ebA Copy- While Raycr Ccpy-Y--H. Ruyer,Copy-note
9'd ZOM70C809 Apild 1100S dvq lL OL l0 100
1&L Windevn,lu.d!b/a
Itli(+nc5lma.Nshlzmc,i119:1 11932 IahtYl[::Cx ill l-O:hb'I'YC i]i.nx:.:V[:1 196]t( lRenewal RdLrll'fn1ILW ,e:.lO/dl0i1/2I11?1)byAndersen.
N[an rMl,.si,timw.
Or QUM MwecmrstTrs nap ntw 1d,teteslnu
W2=W SPECIFICATION s=
Curycr(s)Hama Dal,of Agrmncnl
at,,.Puyer(<I bard above Ixre�y'p:ntiyand xrerallr uxrec ro yvmlux the goods aM!or aerv:c-es)stet Fao.v in acrordmce with<he pda..mtl terns
daatihd on fhe Sperificanat SlheA and tFe fora!mid elm rovalx ai the uanmpanyutg CIfSIVffi WINDOW ANp DOOR RFJr10DF.IJNG AGtJiFMFN'I.
of which this Sprcjficalion titan is a pert.
WNDOW DETAILS
1. Canoctcr will InNnlla mist of_( windowsNUwmr's hoa'e,utinS tilt following irdlmdlml goanhtO,:
Dnub:c Iluug 11?B) ❑ F.qual sash !] Coeeg sasF p B rop,Z/3 bottorN �] Orha sasEt i2/3 fcp.1/3 Wthunl
'. Czsc;netn IClSq ❑ Higge right ❑ Hi[ugc kR las ricwcd ftrnn cxtcrioH: ] Standard lumdlc❑htetra handle
_I)m;bk C:ucmcnt(COI)O ❑ SlatldmH handic❑ Mcim handic
Casonwnl/Nct[ne!Ca.¢nsenl(CPW) ❑ 1;1:3 or[' 1:2:1 I] Standard hurdle❑ Mslr�hatdle
- 21.ite G.idw,,Window(CN)
—Crider/I'ictuac!Glide'(Gl-V) Ell:,!: or o 1:3:1
Mwnu(q%Vindow(A W)
lvinrnw TWI
Puy or now Window
Falic Doors ucc separate Ugnrspecificatfon Sheyi
2. s n .y,+ Cn•Of Windows 10 be Gvstom Fit Aaphte tnen..
I El Yes Qty of Sills to be replaccd W Contractor.
i. QI--, Xo Qrol`Windows to be Nast Coluh utlixt FlhV foot Gncludu ncw'interier&exferis'enxings)
F.cicris,"Isisings: C Pine [:Nvutlennnce-1'rtt nmlerlal ❑ Fav1o:}applied 90S F'ibrex brickmnld
5. GLvingtohe: rJ HF,—laa�w-Fs�'SnlaliSwl^' (Tao LTiHrf Qigr61G Q Qdw, Ifollxr,pleasespecify.
li. Exterior color m b ffo: Wltfm❑ Sand Q Canvas ❑Tmalonc❑co-,
Y_ Inlc,EorcNormbc: Q l hku❑Sand❑C;nv:n ❑'Itrratonm ❑ Pine❑ Maple❑Oak
Note intelior color can only be wine.word _or sent color as cmer'ior. Wood inter iw5 ne::d to finished by Owner.
N. Wlyd.re:Q�WFitc Ej Slone ] Canvas:] nrxss❑ emate Narttwar¢ StS•le:
:). Q yes L�NO tns'all Lals with DouNu thing Windows �/
ID. Sc iris: windawslohavr. ❑ H.Y or [TFull scorns 9crmratnbc: ❑Filxrgisss ❑ :dwahnom L�'1'ruscnrc
ry CAMIP DEfAIIS
I L Windows lunvc solios: ❑ 1'es tJ No ti ves:0 GNk Iletwemr Gla.a towel Q Vemuvablc Inmrior Woof non❑Full Divided Cg!d mru
Qly: Qly: Qtr. Qly: Qty: Qty: Qtr:
IL I I III oa ux'.sne Gann CM nrrn�
Dmw grill.patterns above 'Use Additional slat ifnttded Owheraplrzw.&(udtieU):l 1
ADDITIONAL WOE&DMAILS
l?.Q 1'c< �jD Con r.t:lor will rcnmve metal frames of windows. Qly of Units:
13.❑ Yes ffz\o Contractor will install nrvpaiul-rudy orstain-readycasinay.
Ielerka�.t�u(Y gtvofopenings: Esedorcasings qty ofepenin¢s: Q rlrsc Q Mvimemmm-fore material
l a.❑vcy [J'Cro Conlraclor will install non paint-;ea•,iy er>tain-mrzdy inside or outside stops gp of opntityg5:
ltim'rtrstepsgdyofopeniags: Ell".or stops yofopenings, ❑ FSne ❑ Majntenance-hea material
.v. Owner is aw thltt CanVactordarsnotdoanypa-b3lg- Owser blitials
!G,❑ you Mrvrac for wlla'rap exterior casings wi th al plum mil stock,( color.
Note: Wapping may L•e ryuhtd with s4A'Ct svndow removal;rcmeval of storm windows will leave SCnw heirs in c.+sih�e
1 L 's❑ No Con tmetor will insulale,'.a:dk nndseal windows with 3-potnl syst mt to proven:walcr and air h:fillmlion.
t8.j�'-s❑No ,Rimed warranty ehnB ho issue:]Ia Owvcrupon completion orIhejoband pnyrnsm in fWL
1 J. )'.s❑ No ftdjdbu Permit—Cen4alzor will s:cvrc any and all n¢asar}pernitc. The fee for the pernlsit(st is nM
included in the C'ea.,k Fria and a separal0 clock is regvi red at the lion of sslc for this fee.
zc. Additim.iljebdctad _ zN
21. L/I 1'es Q No Owner.%rmcs to he J'�'it on Iha fim l day of i etilktium fort:d inspectiwl mud todetivtr fi d payment.
AU final paprrcnt.Meal/Lr rkntamkJ rmlil/laemiarm/is completed fo dx srrisirfion ni s!!{rrrh'ee.
u is agreod aM anderdood I!J and bGween the patties that this SRclicados Sheet,abng with the CUSTOM WINDOW AND 000E EFMODEIJNG
AGEFFMCMrp mintitmes the entire undershndigq Lenvcmn the patties,And these e W verbal understandings chingh i;M e,odiftiiM any of the
terms Yhu Sleeffi'-rl Sheet army nor he char'Scd oats knro math isd er Va[led in duly way anbu sneh cluggm are.ut writing and signed by both
the Buycr(s)and Contractor. Buyer(s)hereby acknowledge Net BuverCs)has read this Stepiflcatlan Sheet,
RenmA byAndersen oFGM NH Buyers) Dvyer(a)
By: Lli a
Stsmattra of Prloducf Manager Siganbae Sg „in«•
['
olvv—
Print Name ofprodua Manage, Print Name Frint Name
Z'd ZOZ£t0£809 Ap)!d ADDS d69 LL OL LO Too
The Commonwealth of Mzzssachusetts
Department of Industrial Accidents
Office of Invesagqtions
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Sudders/CoFrtaactors/FIectriciam/Plu-mbers
APIDUcant Information Please Print LeeibIy
Name (Business/oreanizedonandividnat): wen p o a J y N911de)73 a.n
Address: -n//0/>'f �i S Ll�Yec�
City/state/Zip: /�/ fl JS 3az- Phone#: C�1�� Jl1�' 0/oo
Are you an employer? Check the appropriate box: Type of project(required):
1.E-I 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 sob-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet �'• deling
ship and have no employees These sob-contractors have 8. Demolition
working forme in any capacity. workers' comp.insurance. g. ❑Building addition
[No workers' comp,insurance S. E.] We are a corporation and its
required.] officers have exercised their - 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGM ILL]Plnunbing repairs or additions
myselL [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.]
;Any applicant that checks box Rl most also fM out the section below showing their workers'compensation policy information.
t Homeowaeea who submit this affidavit indicating they are dome all work and then hire outside con tact=must sabmit a new affidavit indicating such.
tCoahacmr:that check this bat must atomhed an additional sheet showing the name of the sub,-oatcaetan and their wades'comp.policy information.
I am an employer that isproviding workers'compensadox insurance for my employees. Below.is the policy aced fob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.1 I 3'J LU�(��� /�{i J Expiration Date: I 1-71,1L
Job Site Address: In E I v, e Wl� City/State/zip:_`y\ r n Ms, ![9 -710
Attach a copy of the workers'compensation policy declaration page(showing the policy nr amber 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. -
I do hereby c artder the pains and penalties.ofperfury that die information provided above ' true and correct
Simature• l l DatE'
Phone#
fJ)Icial use only. Do not write in this area, to be completed by city or town offeciaL
City or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2.Bmildin Department 3. City/Town Clerk 4.F3ectaical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
F
>= N1assachuscttN - Department of Public Safct'
Board of Building Regulations and Standards
Construction Supervisor License
License 0. CS t 1952
Restricted to: 00'
DAVID BANCROFT
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01588 -
Expiration: 3/192012
('unnni.+u^ncr Tr#: 101952
a
✓/xe {iiomvmwow�e¢/.dz of•./LlaaearfureeCta _'
Office of Consumer Affairs&Business Regulation -
19 OME IMPROVEMENT CONTRACTOR
Registratio !1L 601 �.
Explra.ipr - •12
7 leEnt Card
RENEWAL 8Y 11EE_q,
RAVE BANCRO 1 rJ
104 OTIS STIRE �� ;•s
NORTHBOROUGH,INA(fJ1�a2 Undersecretary
'F
6
ACORD. CERTIFICATE OF LIABILITY INSURANCE D02 I10/2010
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
P.O. Box 333 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC#
INSURED Renewal by Andersen INSURER A: Hartford Ins r nce ODm an
J and L Windows, Inc. INSURER B: Nautilus
104 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 CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
T POLICY NUMBEq
MDiTY DATE D LIMITS
B GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 EACH OCCURRENCE $ 1000000
COMMERCIAL GENERAL LIABILITY DAMA D
PREMISES Ea amuren� $ iQQ QQQ
CLAIMS MADE OCCUR MED EXP(Any one Pusan) $ 5,000
PERSONAL&ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 20000000
POLICY JE
PA0. LOC
A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO (Ea mdent)
X ALL OWNED AUTOS
BODILY INJURY $
_I� SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY. $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Peraccident)
GARAGE LIABILITY _ .. AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
' AUTO ONLY: qGG E
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $ $
A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/2011 W2YSTATJ-
LIMITS OTH-
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 500,000
OFFICERIMEMBER EXCLUDED? SL DISEASE-EA EMPLOYEE S 500000
If Y describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/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 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(20D1/08) 0 ACORD CORPORATION 1988
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ENERGY PERFORMANCE RATINGS
U-Factor(U.S)A-P Solar Heat Gain coefficient-
034 0 .30
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
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DESIGN PRESSURE(PSF)
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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
eF, wind request that when the permit application has been processed, that you
would mail it back to cis.
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 €tee at (503)
.919-09-92.
Best Regards,
Kelley Donahue �
Permit Coordinator
104 Otis Street 1
Northborough,MA, 01532
Phone(508)919-0900
Fax(509)919-0903
Website:wwwxenewalbvandersen.com