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15 NIGHTINGALE LN - BUILDING INSPECTION The Commonwealth of Massachusetts U 1 Board of Building Regulations and Standards FOR Massachusetts Stale Building Code,7.go CMR, 7a'edition 1vfUNIC1 ALITY Building Permit Application To Construct,Repair,Renovate Or Demolish a Revfsed January. One-or Two-Family Dwelling 7, 2008 Tins-Seatim For Official Use Only' . Building Permit Number. Date Applied: (311 Signature: — aZ Building Commissioner/Inspector of uildings Date SECTION 1:SITE INFORMATION 1.1 Prop"A dress: 1.2 Assessors Map&Parcel Numbers TlIt tT1h64uIf ( �1 �.a I�-Ck1G�- ByN 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number. 13 ZoningInformati 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) - Frontage(A) - 1.5 Building Setbacks (ft). Front Yard Side Yairds Rear Yard - Required Provided - Required - Provided Required - - Provided - - 1:6 Water Supply: (M.G.L a 40,§54) 1.7 Flood Zone Information:-. 1.8 Sewage Disposal.System- Public -.-. Zone Outside Flood Zone?-. ❑' Private❑ — Municipiil❑ On site disposal system ❑ ' Check if.yes❑ SECTION 2: PROPERTY OWNEILSHIP' 2.1 Owner]ofFtnrdt � ( C e I S I�11C � C tnr 1-(r Lh � lY M Vk! -t 014 6 r Name(Print) Address for Service: L Signature - Telephone SECTION 3:.DESCRIPTION OF PR"CPOSED WORK=(cheek all that apply) :;ew'Cous� �onC ExistirrgB'uilduig.O Oc:ner-occupied C .Repais(s)'.0 ;;1:w cn(s) ddtio C Demolition ❑ AccessoryBldg. 0 Number or Units_ Other�ccify: _, E4Ctx Cee.� Grief Description of Proposed Work'': -SI' . - K)0 C TaJ r-CA I CE L.e SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) �{�n:ua I. Building Permit Fee:$ Indicate how fee is determined: I.Building $ .� 1 2.Electrical $ ❑ Standard Cityfrown Application Fee ❑Total Project.Costs(Item 6)x multiplier - x 3.Phumbin. $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Su ression) Total All Fees:$ Check No. Check Amount Cash Amount. 6,Total Project Cost: $.G 0 Paid in Full ❑ Outstanding Balance Due: 1 SECTION 5: CONSTRUC'IWN-S�S 5.1 Licensed Construction Supervisor(CSL) . !a ` t/1^t_'SCYY1 License Number Expiration Dam. eof L-Holder Nc-s1� t_ .�.lfOrL vki�' List'CSL Type(sxbelow) .0 restricted .. .-D U Unrestricted( m 35,OD0 Cu.Ft) Smgnatvre T .. R Restricted 1&7 Family Dwellm . M -MEsonry Only Telephone. - RC - Residential Roofing Coverin - WS' Residential Wmdow and Siding, SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition •- - 5,.3 Registered time mprigvetnetnt Contractor(HIC) 4 �6 rtnr,.a U�yldreon HIC Company Name or H C RF istrant N - Registration Number - 11. s ST A n•�- 4 1VIP T _i s �a . Expiration Date Signaflure� V Telephone SECTION 6:WORiMR$' COIYli ENSATION INSURANCE AFF DAVIT(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 2a:.O R IJTdI©1;i- IlON TO BE•CpMP) E2E3)RISEN'. . ' ©�VNEI2'S`AGENT RCONTRACT'DR APPLIES:FOR8IIti3? P''1,Gr as Owner of the subject property hereby authorize k u^.c ,4 n to act on my be half,in all matters relative to work authorized by this building permit application . Signature of Owner .. Date - - - - SEC3�OAf�Jb O'PirlaE$':OR A�]'PHORI�,E�"AOE15i�D; �ITTOm N' :" 1r ^_' `t ._ rl azbnvet nr fcttthotned Agent#tettbv deelAre_ dial the siatentenLs and info— on Lhe.f!+:e_aetu" applicatmun'are.'trtme and accurate, to the best of my hhowledgc and f. behalf. : ,Jew, nC cAn .Prim Name . . . Signature of Owner or Authorize gent Date - - (Signed under the pains and penalties of a 'u - 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 NLG.L. c. 142L Other important.information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and 110.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 ofbedrooms Number of bathrooms Number ofhalf/baths Type of heating system Number of decks/porches ' Type of cooling system Enclosed Open 3. 'Total Project Square Footage"may be substituted for"Total Project Cost" Apr 19 11 08:20p Marc Festa 5083726518 p.1 lo•I Out,Ri..\orthbnrou¢h.\J:1')1 3n J&L SVisDcn•;s.LVC...D/x/n ,llA Horne I'nprwancn l cernndor !SPIN'^I E'-pr.ICIU-Fax:[?i 1 9;;7-30I3 Renewal Lixns der l T 01 fttrres t0?211 12) byAndersen. dcrul Tar m Cti3-DdJ42D 1 xm..x nrusnxenr ..,.w...um... CUSTOM WINDOW AND DOOR REMODMNG AGREEMENT ayxi.l x"xm. Dct cur Po�aa+nw. 6, bl S-al Ad*—,C. ,eok,x,d Ze C.& 15 N{''%a'f:.nr,p/e Goner Sr E.tSia W,i,cu Wne Te�erlv�Numbm Wak bL.ht,c 4onle, 13 r—-) 4n.-.i. 4742 57y r3-5icz peyvr(s)Iterel)ioinlly and scvn.dly•LSfees to Ivrdiasc the Pr X11cIS andlor service+of 1&1.\:'indows,wc.&Wa Renewal by Andersen ('Crnnsclor'),in amcomanee with thr tents and auditions J.crltcd on the f%cal and elm avnse of this:r;Ccemenl +md on the:utadrui yrcifical inn'heel(h)(coll c heel,this'A;ra'sent"I.Rnyerls)hereby As et io siyti a completion ca titillate after Cenlraclur has.'nplcted a11 ,wL under this A<raonnrl. (y)`/G 6emorcd stoning Dace: Method of Poyment:WChock ❑Credit Card Cash Total Job Aneenl.. OFtnonced D.posit Rece'vad03%1'. 2-04_y._ 6-v '--er1_l Bolonce s Start oilob(33%):_zo 34..— Eslm wd Cemplascr Dac If payment is by Credit Card, please fill out Snlnnce an Sub,ttmtml _)_g wy_ the Credit Card Receipt of Deposit Farm Comp etiar of lib(33%1:2 c_{y it,'ianing this aF1'r.mrn,wu ackvo inEen drat A,,Bala...Y al Sam of Job lnal the&ilmvt,an Stuemu l i Cr:mpktiml ofJolr nmi br mairbraxAi'rent'.and must urmar,byp.rsnn:d cK-- k.bawlr b'rk,nrcash. Snyer(s)agree and understands that this Agreement constitutes the ends undcxstandiag bee. ...the parties,and that there atv no verbal mderstaodlne changing or modifying any of the terms or t1asAgreement.No altcrationeo or deviation from this Agreement vAU be valid without the signed,wrin en eottsent of both thrycrls)and Connector.Buyer(s)hereby achnowkdges that Buyer(s) I)has read this Agreement,o tderstwds the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two anhcbed Notices of Cancellation,on the chat,first written ab ne and 2)was orally informed of➢uyer's right to canal this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. J&L W:al.,Inc.d/b/x Rexewal by Mdersm Buycgsl Buyer's) ti ignn¢im of 1'mducr\i:mager t -tom ejrrn�:m`.—rc-- tiignam¢ �9df irs1C -1 C'--• f-C liter' P.im Stet rd 1Sadacr Aian:grr l'nm\:mar Prim Nam' YOU, THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF TESL THIRD BUSINESS DAY AFTER THE DATE OFTHIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. :.e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _F. - _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ - _ _ NOTICE OF CANCELLATION ^ NOME OF CANCELLATION Dote of Transaction U-it,-I I .You may cancel Dare of Transaction .You may cancel this transoclim,without any per�aHy orobligarim,within this fiansoclinn,wdhovr any ponolryx ebligatian,wilflin three business daysfrom the abtrve duce.Ifynu cancel,any three businessdays from the abovedmi.lfyou cancel,any property traded in,any payments made by you under the property traded ill any payments made by you under the Contras of Sale,and any negotiable imtru nem a om utod Contras of Sole,and any negotiable brst.ammr u«cared by you will be relumed within 10 days following receipt by You will be retunnod within 10 days follo..Ang eisoe;pt by the Contractor("Seller") of your cancellation notice, by the Contractor I-Selleel of your cancellation notice, and any security interest arising out oflhe transaction will and any security interest wising out of the tronsaaian will be cwnceleci.Ifyou cancel,you must make available to the betometed.if you caned,you must make available to the Seller at your residence,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 received,any goods delivered to you under this this Contract w Saint w yyou may,if you with, comply Contract or Sale;or you may,of You wizh,mmplY with the with the inaruaims of lftis Seller regarding the retain instructions of the Seller regarding the return shipmem of shipment of the g00 cur the Seller'sexpenseaml risk. the goods m dire Sellor'S expense and risk.IF you do make If You do make the goods avaioble ro 11ie Seller and the the goods available to the Seller and the Seger ones not Seller does not pick them up within 20 days of the date pick them up within 20 days of the dare of your Notice of your Notice of Cancellation,you may retain or dispose of Cancellation,you may relom or dispose of the gtrods of the goods without any further obligation.If you fail to without an further obligation. d you fail ro make the make the s available to the Seller,ar if you agrce s ovolble to the Seller,or if you agree to return the ro return the�ggd0000ds to the Seler and fail ro do so,then and to the Seller and fail rode so,than you remain liable you remain liablefor performance of all obligations under far peronmance of all obligations .ratter the Contact. the Conrad.To cancel this transaction,mad or deliver a To caned this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any dated copy of this cancellation native or any other written other written notice,cur send a telegram to Contractor J notice,or send a telegram to Contractor.J&L hKndows, &L Windows,Inc.d/b/a Renewal by Andersen,104 Otis Ine, d/b/a Renewal by Anderson, 104 Otis Street, Sheet, Norddwrough,MA 01532, BY NOT LATER THAN Norrhborough,MA 01532,BY NOT LATERTNAN MIDNIGHT MIDNIGHT OF -(Date) Of .(Date) I HEREBY CANCEL THIS TRANSACTCN. I HEREBY CANCEL THIS TRANSACDON. e.w..ss.r.� em�Nomn onn en.n se•ox. r,w ue,o as, Rha Copy- MliG: Juyer Copy-Tdlow Bl:ycr Copy-pink Apr 19 11 08:14p Marc Festa 5083726518 p.5 J§L Winduwa,lee.d:W v Renewal Clu:ns[:Icr.dTk IVft eEl/YVL) H evx Sati.VIJ090°-I'a..'.t naT.;YI^, f Pdar:d Tas�K Sy.cyCV2Cl L-Andemen. ' _ OE Garwrooaueactn,,ma.•cla Ntw Ha aku¢ WLNDOW SPECIt(CSTION SI-= F:rv'eri.)R:nnc Datcof:a3manaiy1 FF F 1-rr Y—i4'tf 11m;1u)erfs)LWd nWm I�,nby,iei N]y and saWnily q;ree to punha.r the goads and/or wsrices hind Ixlmv,in mmnt im:c n•i:b dW pncco and CMIS dc¢rited an II IC b(xrihC.nicn Shml nm1 the tmul and the rl Oot Of Ile CU,7Oh1 WINDOW AND DOOR XIMODLTSNG AGKEFNtENL Of wlliaB tlli.1 Speei liPdimt Slucl b n Part. WINDOW DMILS 1. 0111011d,will Wall a loml of b xi:NomsinO,a,vrlR hcmq,uing Ire iak.riq¢individuat-lluniicies: Dooblo F.c,S(DrI ❑ fgnal wish ❑ Collage jc1l(i/,1t l213 Ualem) ❑Oriel ash lV3 or.1/3"tou,) Cusnncnl(Cl" ❑ H insa light[ Hier'e lall tea w""frank tstai n'1: ❑slandud itw,db❑ AM."handle Dotd,le Lestul(CDW) Q SLindard h;uldle❑kkVn bundle C:ocmmnit/I'idare i(:;'-nu.1 UYAk') ❑ 1:1:! er❑ 1:2c1 ❑Maednnl handle❑6i9ro tumAlc 2 tin GIui 19uu1Oa cW) Glider/Ilduln/Ctidar(GI'lV1 ❑ 1:1:1 °r Q I?:I —_Awning Wfi,d°w JAW) Ficlu:c Wind",(11v) F.,cr I0.w Winkle', cello LAtnx fwe xp:unk Dmr Slvritim&.n Sbmp ❑,�/NO Qty of W1mtLMS le be Cal"n fit ILpL1CmkaiL L,. ❑ Yns No QN IfSillo to he o,plOcd by Canlraclor a, 0Ye' lallo QtY of Windrays to be Nesr CPII$INIti".full fume linclu:h>ucw i".ter A cxlc,ier clsi'W') niJ nra:ul So"wr'.,linge: ❑ mkt ❑bLlnt_tunce-fret mael'iA Q fldwr appliN t4ln ribres bricklthdd n. Cdaxing to be:❑ 111'L.w Ii 0"� []�Olhr!' li other.please sp¢iiyi,�'+'1+/ITSVN f., rveriore Artabe:[Q\lllne ❑scold Q Comas❑TerrW°ne ❑ C,con]4-an 7. Iwerier.OLW IL,1%, ❑ Sand ❑C:Lll.❑T.rnl°ue❑ ilne❑ALIpIC(] Oak Noll': In larich 6;1: r cut W1 x J inleriory teed lO inislud b)'Chvncl'. s. Itand\ram: [7rWlde❑Sto"a p Can.'a<❑ bran❑tea:a.:n:,rm.-a,>±: styli: D. ❑ Yl'a[7 No h,.a:dl Lir...vdh Damle H:my W,,JO ra 10. Sumacs: '.rircdnw•s to ll ❑ H;df or iJ✓ ull scrcuv s ,,ut!c Lv. ❑ llhrgl:tw ❑ Aluntinuut Tn EIc GRttrP DLfAIIS I I.W ind,nva lane grmen ❑ 1's ICJr.y-y NO li yea:❑Grdlc Ecnve'n GL[.Y u.I W,❑ F:vin-aUk Ildubr\vao t nn-nn❑ ruu Diddrd l{Jxl m,'., Qly: Qty: 111';' l'4y: lYr: QT: 1?raw Nrillc p:rticnu uh..v 'lle a,4lilioval erect ifnndc?l Owner approved Unitia1971( ) ADDr1TONAl WORK DerNLS 12.❑ 1'a�y��No COM, clOr wilt mtnovr m,.isl forma du e l� i.,dov ':i LS:ils: 13.[I Fey[y„cl Can4:mlur\rill install ne,,Iliol-lt_tdr cy st v Ilk —dv casing,. Ind .Icr cnnhg.py of opcnin s: Equierraeitics gly of O{Wnin;;r ❑m,. a Mtinlcnanee-li'm aut,rlal IJ.❑ Ccc *0 C'One'-+club will ivaall nau•luint-MO,yW vl:,in-wady nside or cuisine elolu qly ofo4'a:nimce I'lanorslopsgty ofaµniggs: ItlerioraWlx4yLf Opening, 0rice❑Mainlccancc-inti mactial I d. Owner is aware that Contractor does not do any painhtlg. ( Owner L)ilials 16.E Y,,I?rNo Conlra lor,ili lvrtp-IanOI cacioV ll'IPI al nlhmal wit slOck of mlorl /Note: Wrxl!pil;e)nay be 101uind lri:b ueml W'ind°w ronovnl;ramen-ni of storm winr.'Ivs lV li leave a"w holcv in ulxh Sg. I7.CI fa❑ No Cattrxtondll ins'J latc,Caulk and s:nl xindews uitll lO prn'elt.eater and airniullw Lion. I IL�]"vc❑\n (:h;In up ulljob mated drblis inducting oW r:induas,8l br rcmmr[L lacuunutLh'J.: ' ;n.[]-)'r3❑No .V imilCd[vanan:ysh;Al bC iwwdfo Onner upm<ompldu.n[,(Ihc lob and p:[rnmlllin lull u 5^. ]1ai1dm 't--GCnll'kLl°I'W'lll a.Tmeaa'afd all 11mcau.y Runic. Tle Ice for Me pCrtml(s)Isle' ite9mtol in the COnlraCl Fri t:wd a separalC dns:k is re,iuired al the time M c�R:i.xi tY.Ls der. YI.rr Yes❑No Ail discounts lcrv[Iwrn algdiI7 In ll,is:uRranem-16CI ?'L.Additiannl job details: 'a3.[rlba Q No Owner e,,.t,L¢: on ll,c fi"Ol day at installation for fivul inalzcliNl antl to deliver thud pnpnenl. :4,liun/ry�ymtnl tba!ll+e,k+noouiii 1110,78W nxvex!iv r;wRn'tl.:f Ln INe.rviu:it'd Jl..!'sl.'perGn'. It is agmed and underalood by and behexn the prim that Ous Specification Sited,almg with Vic CUFFOM WINDOW AND DOOR REMODELING AGREEMENT,mEutilu=the entire endentandlgg between the parties,and Noe nee no raebd vndneaandigga etwu gbtg or nwdifying vey d the Penns This$pecibeotion Sheet maY>�lx Changed or ila krms modifid or varied n,ury way uNrss such ehvges v[c is Writvlg mtl aylM by both tl+c RxLrerls)wMCar:ngebr.Fu)srl9 hereby rc]mowlrLge that 6uyeeW has reed Ills bu�mdon Slpxt. Fcncwal by Aadeven o?G liked W baym-W ti}: CIS---7,7 .,tl. )IP ��1 Signature of Product M=ag°r / 1"Siptai,ve Signature 4!24,?: FLSTA Print Name of Pr'olud Manager Print Nave print Nam. From. Phil Sherman [mailto.psherman@crowninShield com] Sent: Monday, May 02, 2011 3:25 PM To: Shannon Lacy Subject: RE: Approval Request - 15 Nightingale Lane Salem, MA 01970 The Board approves the same type and style. Phil Sherman From: Shannon Lacy [mailto:SLacy@renewalboston.com] Sent: Monday, April 25, 2011 2:02 PM To: Phil Sherman Subject: RE: Approval Request - 15 Nightingale Lane Salem, MA 01970 Hi Phil, Yes. The window order was based on what was existing. Thanks, lci'�'.Q/rt/1Z1JO7 —(Vay Sales Administrator Renewal By Andersen 104 Otis Street Northborough,MA 015.32 (508) 919-0911- Direct Line (774) 987-3013- Fax From Phil Sherman [mailto:psherman@crowninshield com] Sent: Friday, April 22, 2011 4:28 PM To: Shannon Lacy Subject: RE: Approval Request - 15 Nightingale Lane Salem, MA 01970 Shannon: Is this the same type and style of window that currently exists at Hamlet? Phil Sherman From: Shannon Lacy [mailto:SLacy@renewalboston.com] Sent: Thursday, April 21, 2011 4:31 PM To: psherman@crowninshield.com Subject: Approval Request - 15 Nightingale Lane Salem, MA 01970 Importance: High Good Afternoon Phil, I am contacting you in regards to an existing customer Of Ours, Jeff Folger, looking to replace additional windows. He has had prior approval before for window replacements. I have attached a copy of the approval request, our Certificate of Insurance, as well as door specifications pertaining to his order. The order details for this order are as follows: (5) Gliding windows — white interior / white exterior, no grilles If you need any additional information, please let me know. If you could please confirm receipt of this information and fax or email the signed approval request to me at your earliest convenience that would be great. Thanks and have a great day, Sales Administrator Renewal By Andersen 104 Otis Street Northborough,MA 01532 (508) 919-0911 - Direct Line (774) 987-3013 - Fax This email and any attached files are confidential and intended solely for the intended recipient(s). If you are not the named recipient you should not read, distribute, copy or alter this email. Any views or opinions expressed in this email are those of the author and do not represent those of the company. Warning: Although precautions have been taken to make sure no viruses are present in this email, the company cannot accept responsibility for any loss or damage that arise from the use of this email or attachments. No virus found in this incoming message. Checked by AVG -www.avg.com Version: 9.0.894/Virus Database: 271.1.1/3590- Release Date: 04/22/11 02:34:00 This email and any attached files are confidential and intended solely for the intended recipient(s). If you are not the named recipient you should not read, distribute, copy or alter this email. Any views or opinions expressed in this email are those of the author and do not represent those of the company. Warning: Although precautions have been taken to make sure no viruses are present in this email, the company cannot accept responsibility for any loss or damage that arise from the use of this email or attachments. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �j Please Print Leeibly Nagle (Business/Organization/Individual): T ne r ' 4A d&r,5&n Address: p f/b/ A�,�l`S Ti rC if IL / \ City/State/Zip: /l/o rA p 6 re, , 1,1� Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.NI am a employer with �90 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.I ?• X Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.❑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' . comp. insurance required.] 13.❑ Other "Any applicant that checks box#1 most 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 sub-contractors and their workers'comp,policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �J /'!C>��.Ly)�/,�14,3(j 1-G/7 C e_- y / / ' q / Policy#or Self-ins. Lic. #: I�:7 W�(' �� Expiration Date: Job Site Address: 1% l� ;/,i lY' LA City/State/Zips 1 e [jd , AA& 0 1 Ci `d 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 a 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 rt' under th pal and penaties o rr.ury that the information provided above is true and correct Si ature: Date: ✓ t L � e Phone#: 0 Q 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#: ©' GERTII ECATE OF LIABILITY. INSURANGE avas j FrIG -E B ISSUED AS A MATTER CIF ➢FClF3L'MC7N DMLT Alm'COWEP5-111D E;JE'a'dT5 UPON TEE CEACEF-IGiTE HPLllH3.'Tfi6 rE Dms NCrr AR:m& TrvM Y.-DR PSa&TrVSLT AM3411, aaaV-OR ALTER THE DDVE VOE AFF MED 13T 7iE PDLIMS 'H S aEKTE=ICSTE CIF VMMhNM lDCf[3 WT.RDISRTULE A CONTRACT SETYF!E£N THE.EL-�WH Qsq [S'y.AUTrID[� TAFR c DR PEiDAUC2p.AM THE•C'3MICAT F HODD M i:. m If them mcSss¢-�hoida it an ;4ODRIDNAL .crc¢cn,gQ Pom-IIC� m�s[hF®doh H SClSEiDE.ATON S WA IS:Il sr>bj�m lid=madras cc fl0 PoBnS c�Pow MET�°M®d=BMMI. A sly Bdc dos cacm3 to �e In da m Fm ct sorb rndort;Som1(rry': r R maph t lrcKaane 734-SM-BS CID P hAaKevne irsurance Agan y, inr- p _a. Box 3m A�mvee,� xas� .nn Arbar, BN 481 CIS-Mm msa��:.liartford Ynscuars� . EL WrxjoW Itr- Renal by Andersen osu�e:NaurLus D4 C fs SL dorfFlbDrnugh, MA. m sm - urac�ie: S CEK=-XTE hTLIM&.FA REVl9ION MummR - CEFn-pf -kj THE PCL09I OF INSUR�4NCE L E as DM' WKVE F�q DD T1g INSIJF® NAIu� A�7VE FOR THE POL�1'FB�IDD N6 VATHSTAhMlM ANY RgIl16EaJENr.TERM.OR =NDRION OF ANY 07NTR4Gi OR 07HER DDMIWE X7 WT7H FAT TD WHICH THE TE WlY 9E PSUM Di MdY 1'=AW,T-E ovSURANUE AF�rUE'D 3Y THE POL MES DESCR® HHiEIJ 15 --LMJ2�T TD ALL THE TSWS NS Alm MNXMI S OF M=H p,�L"Tr%�iDWN MAY WIVE BEEN REiUaM SY PAD O-NMS PmJLT B� ro�¢Z'F� YTPE OFN�+A� r'O[.LT ra[I�A i�emmnY ,, c 1 DD CID „e.�.: uAs¢trr' N,CP5644e1 5DN5fID10 Tatvvml.I 0 SDn DO t mp rAcrym¢P� C �iDDD ra�NALEADV wnniYc s_DDnADD �aALAr�cre c 2.DDC DDD ODo. 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M rigs rESEr al 25 (2D-F altg) The AODICD tffi»e a<rd Iogc are +% u»i, Cd ACS7RD . ?lass:achuscttn - Department of Public SafctN -Boardlof Buildim_ Rc_ulatiuns and Standards Construction Supervisor License License: CS 95707 BRIAN DENNISON 86 CREST CIRCLE WORCESTER, MA 01603 - Expiration: 9/8/2012 ('.n..... �nu•r Tr#: 2622 ��ie totenea�/ o�./�aaaar�umet7a .';j Office of Consumer Affairs&Business Regulation r - HOME IMPROVEMENT CONTRACTOR t RegistratiorF� 801 ExPIra§—.FF 2 1 1"p pTgnt Card RENEWAL 8Y BRIAN DENNISrh�� - 104 OTIS STREET_,\ _�-�--,o/ g '=-w�•� _ . 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