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16 NURSERY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts �r Board of Building Regulations and Standards I N SP E C I(. Cn Y OF ` " Massachusetts State Building Code, 780 CMR SALEM Revised Mar 20n Building Permit Application To Construct,Repair,Renovate Or Demolisti'95 �' ` One-or Two-Family Dwelling This Section For Official Use "t 00 OAS Building Permit Number=;w _ = Date A i Building Official(Print Neme) L s . , +r -___ ., . S illm 'bE Ay s s a{3 r Date Cn ,'�49 SECTION 1:SITE INFORMATION— :: y, ' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 16 NURSERY STREET 27 27-0136-0 l.la Is this an accepted street?yes_ no� Map Number Parcel Number } ^ 1.3 Zoning Information: 1.4 Property Dimensions: R2 SINGLE FAMILY Zoning District Proposed Use Lot Area(sq R) Frontage(ft) 1.5 Building Setbacks(11) 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: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Checkifyes❑ - "i E i"wtr SECTION 2 '•PROPERTY OWNERSHIPt m t , 2.1 Owner'of Record: THOMAS KRISTOPH SALEM, MA 01970 Name(Print) City,State,ZIP 16 NURSERY ST 978-745-6043 No.and Strut Telephone Email Address StitlSIQN 3:DESCRIPTION OP PROMSEt1,WORK=(cheek all that apply) New Construction❑ 1 Existing Building Owner-Occupied.( Repairs(s) Alterations) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ I Number of Units Other Specify: R p A . MENT Brief Description of Proposed Work : REPLACE 17 WINDOWS - NO STRUCTURAL CHANGE IL SECTION 4:ESTIMATED CONSTRUCRON COSTS,, 5. S p 1..c. . ffir Item Estimated Costs: 06 Of}ictal Use Onlyg � .F %, and Materials 1.Building $.22-00000 1 Building Permit Fee $ Indicate how fee is determined.ti ❑Standard CityiTown Application Fee • J r-i # '. , '< 2.Electrical $. ❑Total Project Coats(Item 6)xmnitiplier 3.Plumbing $ s 2 Othei Feec $, - - - 4.Mechanical (INAC) $ List: h 5.Mechanical (Fire t suppression) $ Total All Fees.$ Check No. Check Amount: Cash AmounE` 6. Total Project Cost: $ 22,000.00 ❑Paid in Full ;- ,:'j❑Outstanding Balance Due: :.. S:Q� s .:C:- 10t?-(- Z SECTION St.CONSTRUCTION SERVICES'_ Ta 5.1 Construction Supervisor License(CSL) 90125 10-06-16 JAIMEMORIN License Number on Date Namc of CSL Holder List CSL Type(see below) D 86 GARDINER ST No.and Street IYpe � Description, 5. LYNN, MA 01905 U Unrestricted (Buildings up to 35.000 cu.ft. R Restricted 1&2 Family Dwelling CityiTown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 617-966-0412 1 1 Insulation Tele hone - Email address D Demolition 5.2 Registered Home Improvement Contractor(LUC) 170810 12-23-15 oFNFIA/Ai RY ANDFR EN HIC Registration Number Expiration Date BIC Company Name or HIC Registrant Name 30 FORBES ROAD No,and Street Finail address NORTHBORO.MA 01532 508-351-2214 City/Town, State,ZIP Telephone SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L c:152.$ 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...... ❑ d SECTION 7a:OWNERAUTHORIMATION TO BE COMPLETED WHEN �0 ` o "OWNER'S AGENT OR CONTRACTOR"APPLIES FOR BUILDING PERMIT as "' I,as Owner of the subject property,hereby authorize JAIM E MORIN to act on my behalf;in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) _ Date SECTION 7bi OWNER';OR AUTHORIZED AGENT DECLARATION,. .. , n? By entering my name below,I by st under the pains and penalties of perjury that all of the information contained in this applicant s true accurate to the best of my knowledge and understanding. 10/19/15 Print Owner's or Au 's Namc(Electronic Signature) Date -.1 OTES. ' a �,- --., . =I , 1. An Owner obtains a building permit to do his/her own work,or an owner who hires an unregistered contractorm (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass�ov/oca Information on the Construction Supervisor License can be found at w .mass.eov/dos 2. When substantial work is plamted,provide the information below; Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. fQ Habitable room count_ Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 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" i CITY OF &U.& 1, NMASSACHUSETTS Bun tNG DPP jtnoNT 120 WASHiNGTON STREET,3'FLooR TBL. (978)745-9595 FAx(978)740-48" iCI�J3ERLEY DRISCOLL MAYOR THobw ST.Pm.RRB DIREMIL OF PLOUC PROPERTY/Bt:MMG CO3N0,a5S10:4ER Construction Debris Disposal Affidavit (requited for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,780 CMR section 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111.S 150A. The debris will be transported by: RENEWAL BY ANDERSEN (name of hauler) The debris will be disposed of in : RENEWAL BY ANDERSEN (name of facility) 30 FORBES RD NORTHBORO,MA 01532 (address of facility) sipaturc of permit applicant 10/19/15 data d6rinf.dm Renewal MA Home Improvement Contractor byAndersen. Renewal b Andersen Corporation License Federal(Expires 1.191 01 3 Y g'P Federal Tax ID F41.1918413 na.ew eraaermr.. .e.,.1,.w.ao,^". 30 Forbes Rd. Northborough,MA 01532 (508)351-2200 Fax(508)-988.7072 CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name Date: THOMAS KRISTOPH - AUGUST 28, 2015 eu er s Street address city State Zip Code 16 NURSERY STREET SALEM MA 1 01970 (Email Address Home Telephone Number Work/Cell Telephone Number TKRISTOPH06g_L,.COM 9787456043 9785940687 IBuyer(s)hereby jointly and severally agrees to purchase the goods andfor services of Renewal by Andersen Corporation("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"AgreemenT). Buyer(s)hereby agrees to sign a Completion certificate after Contractor has completed all work under this Agreement Total Job Amount 8 22,000 mount FlnoxedS 22,000 Est.Start Date Method of Payment Deposit Received(33%)S 0.00 0eneanots mar,S 11,000.00 10-12 weeks U Check/Cash Balance Sinn of Job(33%)g 0.00 Chock A Balarwoon Substanbel Est.Install Time " , Credit Card Completion of Job 33% $ 0.00 AID fiinuM p ( ) pleuon S 11,000.00 3-4 days If aerie ta>d Is svlee[ad,please No noel dal.demaded,nuno mrtuttu.memfin, I sea Crotla Card Paymentfwm Buyar(s)agrees and undofstands that this Agreement constitutes the entire undamtanding between the parties,and that them am no verbal understandings changing or modifying any of the forms of this Agreement No oltomtion to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s)and Contractor. Bula r(s)hereby acknowiedgns that Buyer(s)1)has road this Agreement,understands the torms of this Agreement and has received a completed,signed and dated copy of this Agreement including the two allached Notions of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Renewal by Anderson Corporation Suyer(s) Buyer(s) BY. Dv,:473,,'171 Signature of Consultant (.mod'"" Signature If DAVID BARRY THOMAS KRISTOPH Printed Nam of Consultant PMted Name Printed Nam YOU,THE BUYERfa),MAY CANCEL THIS TRANSACTION AT ANYTIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE ME ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. ____________________________________r ____________________________________ I NOTICEOFCANCELIATION NOTICEOFCANCFJ.IATTON I Dote of Tb..sonlon a/hilt . You......eel this 1 Datt.w}anaacd.n 11/211/1.4 Yommnyeomcllhih, tr•+ezoedoq without any penalty oe.ug.d.¢,within lbree boom..doyz rm.u,he I Granada, above date.V you esmeet any prapery traded W,any payments mode by yam under , above date.If you eamet my pmperry traded im,any psymana made by you under the Cmtraemf Sale,and any oegatimbh but.,uemud by yo,....m be ; theCwtrartof3ale,and anyneg.tisblebmwmeaa oecured by"..,[lbe teturaed withal 10 days re"..iog teceipt by the Coetma.e("Sen.e)of'ur 1 ueoc.l within 10 days mmwivg receipt 1'y .Co...,("Seacr^) of your tommeeUndan modiste,and any semdty merest arMiog out a the tranavedon will be I eoemU¢don nodev,and any secwlty:utrest.Aving out of the trvmmeIlOt wen be eu¢celed. I moeelM. Iryouemttl,you muat.vo4a owilvble to the Seller¢gour msidroce,Ina aubam.dnllymgaodmndition,wwbco mroivM,.eygoods dellverodto you under I sulwmnd.fyuagmd madidm ns whey mcciveJ,..y goals dcUv.mimyou under IAL Co¢vnet or Sde;or you any,V you vWah,romply with tba laawedom of the I this Ca.uott ar Salei or you may,V you wish,complywitb the Wstemdom of the Siam regu.dieg We.etum shipment of rise goads mt the Seller's expense avd rich. I Seacr.egmrding the eetar laipmeal of the g.ada at the Seaer'e expeme ovd cisk. V you do make thegroda nvallablemthe 6eaer andthe Seller rime mtp:eh them upl Vyoudomahe,he gaodamWlahlemthe Seaee nett We SeRee does mot pid,them up within 20 days of d,e date.[your Nedee ofCmrelladeq you any retain me dlepoe< ' or the Sam" dateofyour WS"o. If You Run meaket ematnA ble ,.,he gads wbhemtaslb to made..o Dym rmutammadme goads,Ilun ' In be gmau.wit Tom ymnh remarn he m. . a rStUarad the gad.available, he. m the SeOrtn eNryou ogmm mmmmtbegmds to the Seller mad fail ado eo,thna ' aneSstaen.rif ble re, erent.ramm the g.odatothst Sdo,M. onitado se,then you remvinllsble for perlbrmmttof all obligadamunderNl.e.una.Tommel you....olon,moulpo,daIN ,..1,dl andobli dated under Ohi Convene'.To caned tbiatmm.edoe.mdl or deliveea Wgoed and JmeJ ropy of tMeemsellvdw mdce ; thlstmnsoednn,mdl mr deliver.visaed and doted mpy of this eaoceaadouvs anyotber wAUm mdce,ar sevdatdegram to Cootrsnon Renatmiby Aadetsea,; any other wrium mike,oremda ulegram to Contmetor. Iie¢ewd 6y Aederderaeq 30 Fortee.Rd. Narthborough,btt01332. I 90 Tarbes Rd.NoMbomugh,h1A m532. 11�11EBY CANCII.TID9lmAN3ACT10N. ' t11EnEBY CA.NCELTtUS 11UNSACf10N. I I OyeM1aewae PAn Nvm Pb i nua,h,:ywra PaW N. pee Renewal Renewal by Andersen Corporation M rdta A Home Improvement CaCtor by,N Nelsen. 30 Forbes of Northbarough,MA 01532 License 9170810 (Expires 12/23/2015) IWINaow seereeemeNt (508)351-2200 Fax:(508)-986-7072 Federal ID#41.1918413 Window Specification Sheet Buyer(s)Name Date of A,greeinent THOMAS KRISTOPH FRI, AUG 28, 2015 The hutrel{s)listed above hereby jobtdv and se%vmlly agree to purchase the goods and/or servic s fisted helmr,in accordance eith time prices and terms desorilled on the Specification Sheet and the fmnt and the m•erse of rim amompam)ing CUSTOM N`L\DONn tV\D DOOR REMODELING AGREE-NIEN7,of whidi the Specification Sheet.is Pan. WINDOW&DOOR DETAUS AOP App. Appa 6xbriarnmerior Cob, Hardware IimNtwa lgaGt/ ore, Glad Glass RNrtI p vkn� neYJ11t ILL wmmw/DaO, a Defall f:btirg5 FJa-m (:Ole Style $Cvac srtart9m Gf N5 SE419 S rt2 LIMB opums twin1 101 1 31 157 1 Sit De so rail ecual risen sloped sea L-Trim TFAVH White stnddl FFG manse Nan x x No No UAcg 102 31 157 1 88 DS so rail equal been sloped set L-Trim rrAVH White Standard FFG nuetSu, w— x x No No LvIrg 103 31 157 1 88 oe su roll equal been sloped sm L-Trim Tr1WH White Standard FFG rise Nan x x No No Living 104 31 57 1 88 DR sg rail equal hest sloped sa L-Trim TrAVH White Standard FFG scorsur Nora x x No No play Rm 105 31 57 1 SB De so rat equa isent sloped set L-Trim TT/'N Stone Standard FFG tree xoo x x No No Bed 1 201 31 .52 93 DR so rail equal Insert sloped din L-Trim TrAVH White standard FFG rttanSur Nwn x x No No Bed 1 202 31 52 113 DR so roll equal kused sloped sa L-Trim TTAVH White Standard FFG xoro x z I No I No Had 203 25 39 64 DR so roll equal heart sloped sill L-Trim TTMH White Standard FFG uoo x z No No Had 204 25 39 64 DR so red euni hest sloped sa L-Trim Tr/WH White Standard FFG ans,4 Nee x x No No Hall 905 25 39 64 DR tic,rail ectual insert sloped sa L-Trim TT/WH White standard FFG n xons x x No No Refit 206 22 38 60 ML insert L-Trim TTANH White Standard FFG et— x x No No Office 207 25 39 64 D8 comil equalhsed sloped Sol L-Trim Tf/PN Stone Standard FFG umm x x No No OSbe 208 25 39 1 64 DR w rail moal keen sloped sin L-Trim Tr1PN Stone Standard FFG nuetser Nan x x No No office 209 25 39 1 64 OB so mil Nual beet Mooed set L-Trim Trnsi Stone Standad FFG No. x x No No Bed 2 210 25 39 1 64 DR w rail equal Insert sloped sill L-Trim Tr/PN Stone Standard FFG vrar Non x x No No Bed 211 25 39 64 OB sq mil equal Inset sloped set L-Trim Tr/PN Stone Standard FFG N. x x No No Bed 2 212 25 39 1 64 DR W mil equal k1sM sloped sill L-Trim Tr/PN Stone IStardard FFG nenSi, N. x x No No Total 17 BA BOW&BUEEM OUT DETAIIS styles Dot �iCW Appox Number Frome Wndow Feud Cenaa tmvE/ ROW/ Hardware POarn Count Style Flarukers In Caves Argo Utes Weds Fx 1Odor Raw sashOs sash Streets Smarten Soffit Colo SPECIALTY WINDOW DETADS —1 Appmk. ImvEy spedaty BAY/BOWADDCI70NALWORKNOTES Room Cwmt Styli Meet Ul Grille Grlae we F_xrMt Cdor (Smo•mua..xea wirA dr/ixlaw;nM1+uaunS.r P2 im4ee ADDYITONAL WORKDETADS: Peplaee sill rinse on all triplet mindores I No Contractor will wrap exterior casings,vAh coil stock color of Owner is aware that Contractor does not do any painting/staining ormmaval/installation of alarr system Or window freafinenGs/naNware.It is fie responsibility of the homeowner 0 have da alarm system and window i eaNrents/haNvsre removedprior to installation. We make no guarntoe as tic whA.ttleralams Or window fmatmenk/IarNva2 wN Rt ahPl repbcenent. Custorrta is aka aware in some rases there wSl be glassloss ituM ismaamountwNbedepsldrntmthe4-pe 21 of wising wmdovn type of Installation and window s yre.We make no guarantee alto the amourn ofgfaSs bss Cratanteris aware andundersdands any and all unsean rot is not Included in this Contact.Shouldam rof be found them will be an additional a arge for lime and aHferWis unless SO Statad in AWS COne2cf. 3 Yes Contractor will Insulate•caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris, windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 4 Yes Budding Pem-A--Contractor will secure any and all necessary permits. The fee for the permit(s)is included in me total contract price Yes All discounts have been applied to this agreement. 6 ✓ lees -No Owner agrees to be present on the final clay of installation for final inspection and to defiver final Payment/fumartce fmm(S). It is agnxd and mrcknlOokl hr and Ixncecn the Ionicsdw tM1is Spncifrtr'nm Shop.Wing with the CUSPONIA ND(AVAM3 DOOR RENIODRILING AGM-NIE\T.ronaimtes therntice und,m,,.Kng Inuwven the rymlie;and where arc no rerhW umlerstandinys rhmtging or madif ins aw N the arms.TAis SI>nifxmimn SM1ea rimy rim Ix dlvugrd rx iu unm modilietl nr varied in arc warp unlace wrh dvvtgrs are in..Thing and.�tol M•Mth the Surer(e}onA Cmmtraaor. Bwer(s)hembe arkmn.ledge tha BtpvY,.c)hoc rM Jtis Spvitimtion Shreu. Renewal by Andersen Corporation Btmcr(c) Smer(s) ON. .Dal'[�Qitrry _ Signature of Consultant Signature Signature DAVID 13ARRY THOMAS KRISTOPH Prim Name of Consultant Print Name Prim Name e 1�W�1', Renewal by Andersen Corporation �„ �^ 30 Foibm Road•NorthbowLngh, Massoeht'wtts 0�1!532' ti1,t etsn�CmFovvglem ctr of byA dersen. . Phone 509 35L-`MO•Fait(503 98C.-70?,7. nthtiee��six,O2)Z -20Lrs ) ) lwA:.SJ:dLtl3D anaotaar awaaeeaerten ,e.ta:��c�,t tb•3'erat.iMt'lbrt 4L49:IN443 COl'P1RACT AMlitaDAd&+1T i TI05 AMeendinelti 4`.AtnL01dmeel*I is 10 E I W CUSTOM 1dIT'OOW XL%'V DOOlt.,FIA'IG'ttDEl.l-xG hTKUItt--,T€ mv"'t_FLn' y,and L aween.Renewal by,Vtteb mft Cogvrrst"t mad Meryl KrIstoph Obtegen"). a"_ontracWrand Eu%w(s)hereby jpvvtoyantenduisl modify the. A ntenl as Ind Ltkxl Mow. ®ttwe t.h to as speactllevlty 111dieaEed lb--IOW,110 the[arsos of the Ati%mantent MR rattim n in Pull kree and effect TbEs AanLendnae/Lt ie sukfoa tar 19ee wnns amd comdleions ad the Ag4.MMh—IaL. Aw lolluwht.S additluats,s3wal?omq,or deLLdonLs L the,preAwts and%e raly.6"aver(s),ardim,2d,ive heing ntsde- %Wndoses,numbered:101-103 and.20-.POT%I l become Oat sill replscemeals.The archer wh3dows-will',rennin alth a.sloped sM. No addlilonal charges necessary. No other changes to the original eoutrart. Asa eesuG.oP these clL�ama,,�,-taw fullowin;g hertns&L6L i�viceineok..ire also charm q6 r {'If tiiorer.iv on1 change;.any Mean.xI1l be left!htank or nt: A&das'�.N/A.".,Endkaklaagthatnoeh:tny;eal4A= 1V2:'W Total_loh Anxuuu: S22;OMOO Payment L4lMhod: N&w NTmsit V=hvi:SI 1..D.N, '..GeeenSky Firtance Nw%Lin at Start ofjub:.S i'4twlbExs rm GrmaS'ky Finame suisinv hl.Ca Fkion offab $11.ZOOO-00 It Is gVeed and.mtd=tiod by and bchm=the portlra Heat this Ammdtand.emd the mtdgkmol.AV=menl oaretltvto_the endm undev� bc- sweat the put=,tmd*=a m no verbal w4miWadirp cbsrAg tg-ar,meaibftkg any of Hx tams of thtt A;n=ln n WJMvwl- OM 9Loat Buy=4p)box r=d tlas Ame:rwA=:mt amd figs rva:tr aed a a awnplekd,Apta4 and daled="cf W3 Amm da=t wL the drle wrift bdow. 0aewa1 by And=m Corpmatoom DMP=(* By: E-Signed, a')tE,htlS-04r56 SNt ST sL�autturaael�i2 t!9at�;ae Cheryl P. Krist3ph vs6e clrrita oh@aol.wm ]P:�3a�96.2+t.2Y3 Davld.Ha2xY a a a 9;+'1.7f'±ahi5 Print Nanx of Froduct ManaXe Sjgnattthe D9Fc. stk The COrtnn UMMalth Of irlassachasetts Depertwnt of IndesMW Accidents O,lice Ofinvestigatio is 9 600 Plaskinglon S.teet Boston,MA 02111 www.ei mgovldta Workers' Compent4ation IusWrruce Affidavit: r3uildera/Contractors/Electricians/Plumbers Auolican#;oformiction P10482 Print I.,eeiblY Name(Busines/Orgmizatiowindividual): RENEWAL BY ANDERSEN Address: 30 FORBES ROAD City/State/%ip: NORTHBORO tlMA 01532 Phone F: 508-351-2200 Are you an employer?Check the appropriate box: Type of Project(required): I. 1 ain a enhployer with 30„ - d. ❑ I am a general oonuaetor and I 6. New construction employees(fwl and/or part-time).* have hired the vub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t ?• J Remodeling ship and have no employees `hese sub-contractors have 8. Ej Demolition working for me in any capacity workers'comp;insurance. 9. []llaildidg addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10. ectr Fli al requited.] officers have exercised their hairs or additions 3.❑ I am a homeowner doing all work right of otemption per MOL 11.0 Plumbing repairs or additions myself,[No workers' comp, c. 152,61(a),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 110 Other comp:insurance required.] — •.My applicant that clmdcs box#I must aisn fill um the section Do"showing their workers`compensation p lky ndormetim . t Homeowners who subrait thin affidavit indicating dw�are doing all work and than hits outride antrautms must subraea hew afdwt i"ojng such. -'i mttractots that creak this box must shta;heb an additional shot chowing the nm w of the sub conttactorc mid that workers'tamp:policy ia6:rmation. I act an em ployer that is providing workers'compensation hcsurence far oW emplayees. Below is the pasty and job site informadom Insurance Company Name: OLD REPUBLIC INS, CO. Policy#or Self-ins.Lie.# MWC 3 0 5 4 37412__---- 1xpiraton Pate:_ 10-01-16 16 NURSERY ST SALEM, MA 01970 Job Site Address: _._City/StateZip:_� Attach a copy of the workers'compensation policy declaration page(showing the poi* 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,n well as cis it penalties Mi the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do he by a palm and penalties oJperjury that the rnformadon provided above is true and correct. 10/19/15 Sianatu Phone': 508-351-2200 t?,(/icial use only. Do net write in this area,to be completed by c4 or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk A.Electrical Inspector &Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts -Department of Public Safety S Board of Building Regulations and Standards y Construction Supervisor - License:C84=1245 „tar. dADU L MORIN f. w.- 86 CAADUa R Si s j LYM MA 019K J.+4».,.11 'rlu'a Expiration Commissioner 10100=16 i cA��u g��fa�eaer{ua� ' e of t,secamer AQf3rs d BvMateA>�h6eo u�. k; rit CONTIV T" .; t ,�s supplemt+, I'�idESA!AI.BY !'t'>RATIQht q' A i JAi .I — t0A 9TI$STPLET t4MTHROR©WH AAAdtff32 �s a k } Do not renwe mN 5nd ode Insped um. Save land for Mare reference. ' P IPIOffi-CEm two . d m ry g .Lm a n � Renewal byMdersen _ ww w .aueeaaxi mdd.m,�awn AND-N-102 WwdfVInYI ComPmfts 4, Ouel Mean , Pmduet Type: Casement ENERG( pERFOMAANCE RATING .U-Factor Solar.Heat Gain CaeFiclent 0.29 1 .65 0..28 . .: U.6.443 Metrlal9l AOOMONAL PERFOPMMCE RATINCa Vislhle TmmmltbBnce 0 .48 0 ersen on; same n wmeimnm w .- Raang xHamww�wnntwvxmusa+�xas OP Ps(OP36 .r -------------- ' ' , 'QFRt�� gym. 10o-0a513W2-ant • - MmvIMCC.C£C.l12CC./Y[l��Rx�'•��MYPo�m�+emrm9�'. -- Renewal byAndersene WINDOW REPLACEMENT aaMJ"=Compnny WoodNinyl Composite IF ?;ts,,:a;f;n?,Ira " Dual Argon Low E4 SmarlSun FEss.gCsa"�"` Double Hung 100-00473518-010 ENERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient 029 0m19 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance OA2 Manuft.—mW..-IM,I.—raingee+nlerm beppfceaY NFPC prae0urea br Eer rminiapwaeY proEec perbrmanca. NFPC ruemm ve aelarmioeE bra l#eU we elem'v+nmen�alcenEilbna ene aepecit preCwlehe. 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