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10 OUTLOOK HL - BUILDING INSPECTION (2) Department of Industrial Accidents Office oflnvestigations 17/_a a 600 Washington Street O O Boston, MA 02111 ' www.mass.zovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): NEWPRO Address: 26 CEDAR STREET City/State/Zip: WOBURN,MA 01801 Phone #: 781-932-8300 Ext. 251 Are you an employer? Check the appropriate box: Type of project(required): 1.X I am a employer with 50+ 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. 1 7. 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 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.] + employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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 is providing workers'compensation Insurance for my employees.Below is the policy and job site information. Insurance Company Name: ARBELLA PROTECTION INSURANCE Policy#or Self-ins. Lic. #- 90967005 Expiration Date: 05/01/2008 Job Site Address: L© C�,G l /�!( City/State/Zip: XgA&,t �� 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. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:nol��GF5/ FOR NEWPRO Date: l Phone 4: 781-953-8146 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 . Bui ding De par 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Crry OF SAmm +' PUBLIC PROPERTY ` DEPARTMENT �����.saarrxwa.oawanasraas ��.�,�...ems eosa.r►+w Cunsbvcdaa Debris Dbpa4at A NIVIt (eagrr "6 at daoo wm and aeovado- wee 4 In awohme with dw abrdt son ddw Stm HuildtaS CWI%790 CUR seatiea Ill.! Debris.d dr.p mvwam a(14CL a 406•34 13UMMS l OMN 0 is brad vA&do ssnddm dwi*9 debris nwrides Aostt � dlep wwt"ba ew d Otis s peopwll►tloaoaad Mu/e�aPear Aailitlt:r dsQuad by 1,(R8.s r,addwiswig be waVoMd by: t•••e dtd.rl Z'lra debris will be dispoad of in: (same o(t'+eility) ° i� �• �tf U�ll� / UC WQB Ue_N (aJdesse a<he�lUy) �isaasue of paratir silk era 9�9 0� CT Reg:06052 9 �® ® 52207 CT Reg. #0605216 RI Reg. #26463 THEREPLACEMENTWINDOwPEOPfE J Federal ID #20-2625129 Corporate Headquarters:26fCedar St.,P.O.Box 2696 Wabu/m,MA 01888 (781)933.4100 1-800-342-2211 THIS C NTRACT MAD THE. j/. . . day Of.. �! ,/� 2007 . between . . . . . . . . . . . . . . . l"i4u, . . . . rr- . tie . . . . t7F- _ Y- 47�8 78 - . .F.(-o�� 3 . (Horn ners) (Home Phone) (Bus./Cell Phone) (Mr./Mrs.) of. . . �. . . � W.�C .V1 .1 12� . . . . . � - ut. . . . . ..�4. . . . . . . . . .©.1.4 7v. (Address) (State) (Zip Coda) the "Owner' and NEWPRO Operating, LLC, "NEWPRO". NEWPRO hereby agrees that it will for the consideration hereinafter mentioned, furnish all labor and material necessary to install the following described work at the premises located at (Job address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(E-Mail Address) . TOTAL 2 NEWPRO Additional S le TOTAL CASH Windows Purchased t ✓ Work tY OtY PRICE Window Color S eci ( % Slift Glass Door DEPOSIT Capping Color Specify - Qty Steel Securi oor WITH ORDER 5 Double Hun (N Picture Window Obscure Glass TOP BOTTOM BALANCE Stationary Casement Screens ALF FULL DUE AT Casement - Model# INSTALLATION 2 Lite/3 Lite Slider NEWPRO" does not do any painting or Bay/ Bow Frame staining. CASH Garden Window NEWPRO° is not responsible for condition Balance Paid to or circumstances beyond Its control including Installer at Installation Awning condensation resulting from or due to pre- Other existtn conditions. IF±B FINANCE Bank Completion GRIDS Colonial Diamond 1 For Signed at Installation DESCRIBE WO d fsAT� �n `D Out, n . P 4AJ ail dK ao t d rr,c(u 1 t� ha All steel security doors will h e a 3/4"aluminum threshold installed over exist i g threshold.-0 Customer Initials Est. Start Date: o Est. Comp. Date: ( j j , It shall be the obligation of NEVYIPRO to obtain any and all permits necessary under this agreement, as the Owner's Agent. The Owners who secure their own construction-related permits, or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. All Home Improvement Contractors and Subcontractors shall be registered by the Director and any inquiries about a Contractor or Subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108,(617)727-8598. If the Owner is obtaining financing by way of a Retail Installment Sales Agreement, such Agreement shall include a time schedule of payments to be made under said contract and the amount of each payment stated in dollars, including all finance charges. The Retail Installment Sales Agreement shall be incorporated herein by reference. If the Owner is obtaining a revolving credit line to pay, in whole or in part, for the contract amount herein, the terms of the revolving line of credit including interest rate and payment terms, shall be clearly set out on the credit application. The portion of the credit application referencing a time schedule of payment,to be made under this contract,and the amount of each payment stated in dollars, including all finance charges, shall be incorporated herein by reference. NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of$100,000-$300,000. If the Owner refuses to permit NEWPRO to proceed with the work herein,or in the event of any breach of the Owner of this agreement,for any reason whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid,as fixed, liquidated and ascertained damages, and not as a penalty, without further proof of loss or damage. NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control. Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners to enter into this agreement. This contract represents that entire agreement between the Owner and NEWPRO and cannot be changed except by a writing signed by both the Owner and NEWPRO. You are entitled to a copy of the Contract at the time you sign. Keep it to protect your legal rights. We, the aforesaid owners, certify that immediately after the signing of the aforesaid agreement, a copy was furnished to us. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office, or branch thereof, provided you notify seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. (Saturday is a legal business day). See the attached notice of cancellation form for an explanation of this right. DO N N THIS CONTRACT IF THERE ARE ANY BLANK SPACES. The Owne seen "Sam warran 'as that will be provided by NEWPRO upon installation. Sam warrantiWprovided wrier.IN WIT WHEREave hereunto signed their names this C day oil 200-7 IN# Signe Marketin epresentative Prints e ;wner Accepts . NEWPRO Operating, LC By Signed Marketing Representative Signature Owner WOBURN BRANCH OFFICE SHREWSBURY BRANCH OFFICE WARWICK BRANCH OFFICE 26 Cedar Street 151-153 Memorial Drive Businew Park 45 Gilboa Street Woburn,MA 01801 Suite B-C Warwick,RI 02886 TEL:781-932-8300/EXT:330 Shrewsbury,MA 01545 TEL:401-732-2407 800-242-9974(FROM NE) TEL:508-B42.6876 NO-356.3312(FROM NE) FAX:781-933-0717 800456-M5(FROM NE) FAX:401-732-1371 FAX:508.042-9248 WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy US-15 100/PKG. 11/05 SAMPLE COPY . ®.110011aed in all zones �.EVCO PRODUCTS, INC. Nmrc NewierolDenati 2000 Picture Window V:nyl frame, Triple glazed, Ne ro aatra9m Low ,-coating (a-0.034, S2 &5). Retl�c d Kr.rpton/Argon/alr filled ® E94•DEV01&o0' ENERGY PERFORMANCE RATINGS U-Factor(U.S.A-P) Solar Heat Gain Coefficient 0, 17 0e29 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air Leakage (U.S.A-P) 0e42 0e1 Condensation Resistance 74 Manulachwdl alftuet dsse sdngscadamtoopplic"NFAC pn>cedures la de0rmanNgwhale produdpertormallca mmcrogsamdetam nw for araedsdateovimmdalcoadmolc and a swificprAct size.Cosuftffwvft mesliialahae(oratlsrpodudpmVmanceidomsgon. www.Mrc.org ACORD„ CERTIFICATE OF LIABILITY INSURANCE CBR TH DATE(Mrvvppnvvv) Nam:L 05/01/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE American First Ins Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 122 Quincy Shore Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ':. North Quincy NA 02171 Phones: 617-770-9000 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A, Arbella Protection Ins. Co INSURER 8: NeW�ro Operating LLC INSURER IT POE 2696 INSURER D: Woburn NA 01801 INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED OY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI-THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS, POLICY NUMBEfl P E OLC PI I LIMITS LTR NEL TYPEOFINSURANCE DATE MNJDOIY DATE MWDD/YY GENERAL LIABILITY EACH OCCURRENCE $1,000,000 ' A X COMMERCIAL GENERAL LIABILITY 850000010649 01/01/07 01/01/OB PREMISESEII cc, once) i50,000 CLAIMS MADE X❑OCCUR MED EXP(my nna person) $ 5,000 PERSONAL A ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY % LOG JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO 81037400001 12/31/06 12/31/07 (Ea acuaem) $1,000,000 ALL OWNED AUTOS BODILYINJURY $- X SOHEOULEDAUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Ppr acddonq PROPERTY DAMAGE $ (Per aedtlanl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ I EXCESSIUMSHELLA LIABILITY EACH OCCURRENCE A X OCCUR �CLAIMSMADE 4600010709 01/01/07 01/01/08 AGGREGATE $5,000,000 g DEDUCTIBLE $ I RETENTION $ $ �O WORKERS COMPENSATION AND - X TORN LIMITS ER f A EMPLOYERS'LIABILITY 90967005 05/01/07 05/01/06 ELEACHACO)ENT i500,000 ANY PROPRIETORATARTNERIEXECUTIVE {{ OFPICERWEMBER EXCLUDED? EL DISEASE-BA EMPLOYEE S$00,000 f U Yes, Seed Ad PR descnba antlOVISIONS below er E.L.DISEASE-POLICY LIMIT IS500,000 1 OTHER DESCRIPTION OF OPERATIDNS I LOCATIONS I VEHICLES/E%CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS OPERATIONS OF INSURED CERTIFICATE HOLDER CANCELLATION SPECIME SHOULDANY OFTHE'ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE E%PIRA' r DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYSWRITTI NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DOSO SHI SPECIMEN IMPOS 0 IPATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REP SENT IVEB, ANTS RIZE EPRESE A E ACORq 26(2u0170@) Q ACORD CORPORATION 1 J ) �7 p"�{h, "v7 �,ze fo�rr�,rro�mu�au�� o�...f�naaar,�utaeCGi ✓/ie -(000xnnoauueal/.li o�'✓�dac,<eudrlla `4+ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR __ Board of Building Regulations and Standards Number: CS 029090 I HOME IMPROVEMENT CONTRACTOR Birthdate: 11/19/1953 Registration: ,'1:46589 Expires: 11/19/2007 Tr,no: 9879.0 i Expiration: 5/5/2009 Type: Supplement Card nacm914.JPG Restricted:�00 THOMAS P FOXON- _ NEWPRO OPERATING, LLC. 230 WALNUT ST G— �, ,ram THOMAS FOXON READING, MA 01867 26 CEDAR ST. Commissioner �.y.MGl•-•••�.. WOBURN, MA 01801 Administrator CITY-OP-SALE . --- PUBLIC PROPERTY DEPARTMENT KI�QIEIO.EY DRISI'ULL MAYOR i?0 W&SIJINGTON 51REEr•SALEK MASSACHLSM-IS 01970 T-.L-978-745-9595 0 FAX 978-740-9846 APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: /O 0U7-LOOA� N l L L A2,a Property is located in a; Conservation Area Y/N Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: p,9 Lr� PAU.L El ELL) Address: le) O U Z-U0/`I I-1/LL Telephone: 9 _ — 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation New of existing building Brief Description of Proposed Work: 4EP&Ae�E l 3 wi/V a a w s DL /nl-I-o E?os7-1/J6 Mail Permit to. Ty _ What is the current use of the Bwlding? Matenal.of Building?; " If dwelling,,how many_unds? h Will the Build�ri Conform.to Law? a �y:. "' Asbestos? 9 Architect's Name .. An/sa'AA0p—O t'7f��/ Address and.Phone4dgGl2 1 - � 7 MechanlCs"Name Address and Phone o?6' %a/� 'S 7` c�ss i?�//� Ask A„ Oh3irUCtiOn $ lf (r UeNISOfa L.ICe `rRTr z * •' *`xvx a..:pt ,n+ ,.> p License# " Da?9�` HIC Registration# 99 vrn � ,» R ''' " Estimated COst P ct$--���t Peflillt Fee(`ialCU�tl00 rc ''" �''h '` ' ,1 i s f ` _ t ?aft a ,trY8 u' r, +y. % r' P P.ennd Fee$ Estimated Cost X$71 1000 Residential , ? " ' 38 + ;,XT .3. 2ktfy,^4 »�u s:r; '. •� 1^X�pr�ttr x, t$.�N; aI r'".`.Ia _ -d, Esbmated Cost X$1`1/$1000Commerci x' {' b+ r ) a k Additional $5 00 is-a-d w tled as an <x �h ¢y wr Administrative charge q Make sure that all fields are properly and legibly written to avoid delays in processing. mit to build to the ' The undersigned does hereby apply for Building Pere above stated '2 specification Signed under penalty of peryury � � I Date 9 / . 2 %r :4. < � v4' is �{ r p 4 w +•= '. x, r .�{ 11 on w4 > r m E V � � e � � 7r �n; sr, —� — '_ ' 'o- „ . "Cis- ,z. Nr r77,77 - m