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4 PARKER CT - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of k" Massachusetts State Building Code, 780 CMR, 71h edition Building pep' Building Permit Application To Construct, Repair, Renovate Or Demolish a ! '1--0n ar Two-Family Dwelling �t This S ton For Official Use Only Building Permit Num Date Applied: 2. 1a - Signature: IeL L o oy Bodying Commissi n r/Inspector of Buildings Date SECTION 1: SITE INFORMATION I.I Property dress: 1.2 Assessors Map& Parcel Numbers t¢ am ,.- 2.. �v27• L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions:r--------:.-_- (-+- Zoning District Proposed Use Lot Area(sq n) Frontage(R) 1.5 Building Setbacks(ft) 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?Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) Address for Service: sC-V'I.re e z = y�/� y.4 y i Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) )0 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': 714 f/-11 X 47 SECTION 4: ESTIMA ED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ g-doD, I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:S DaO �_ Check No. Check Amount: Cash Amount: 6. Total Project Cos[: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) L oz9o9�__ �� �f ff6/YI A3 YD X/Mo License Number Expiran n Dal N,4mc of CSrL1- HgWner �J/� List CSL Type(sec below) / QNit.�l Type Descri Lion cow Address O/apo U Unrestricted u to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling Signature�p 'T �P��/�, M Mason Onl 7��• T����y6 RC Residential Roofin Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel ing Appliance Installation D I Residential Demolition 5.2 R istered Hoop Improvement Contractor(HIC) HIC Company Name or HIC Registrant N me Registration Number AddressLgs����® E�icpiration Date z - sigAafore Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... ly No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �} � . as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authoo9rized by this building permit application. Signature of Owner - Dale SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I /�J � „(»jJ`7 � �y/�jr /���('D�/,as(finer or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf yy/ O Print Nagle tg ature of Owner orifflutrioriz Agent Date (S igned ned under the pains an d p alties of r'u NOTES: I. 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 have 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 I I O.R6 and 110.115, 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 of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Foolage"may be substituted for"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 12, A IN SIRIA T # SA I I M, N IA li\t dI ,,_Il Construction Debi-is Disposal Allidavit (t'CLIL[ired lbr all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section If 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit t - - is issued with the condition that the debris resulting from in this work shall be disposed of a properly licensed waste disposal flacility as defined by MGL c 111, S 150A. The debris will be transported by: ez 6) 6 Le-/ (riamle ot'llauler) 'I he debris will be disposed of in L (name of facility) 6 CZIW� .IS r (address ol'l'acilityi S i6i latul c of,J)':fill it applicant 'late' J#146589 From Out HametoIma... Federal ID#20-2625129 ;g#0605216RJEWPING 57830 +9g#26463 Windan Siding and More Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com HIS CONTRACT MADE THE-H day of 20 between _ J 264fa-/C ll1 GGry d rg CL - 12rF_�G� (Home Owners) ' (Home Phone) (Bus/Cell Phone) of 6 S4 &C — J � " (Address) (City) (State) (zip) the"Owner"and NEWPRO Operating, LLC, "NEWPRO". The job address is a condominium. 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 Jcb Address) (E-Maill r proprietary use only TOTAL Additional Model TOTAL Windows Purchased NEWPRO Work Number Qty CASH Window Color In: WK Out: Sliding Glass Door PRICE Rab Capping Color Steel Security Door Door Color In: Out: DEPOSIT Model Name Model Numbers Oty Sidelites WITH a coaC fd� Double Hung New Construction Unit ORDER J Picture Window Storm Door BALANCE Casement /" Obscure Glass B M DUE AT 2 Lite/3 Lite Slider ,/ Screens HALF INSTALL Bay/Bow Frame Please Initial: Roof.' ❑ Soffit: ❑ Customer understands that ROR does not CASH Garden Window / do any painting or staining. (ie:when removing Balance paid to installer at installation Awning or replacing interior stops or trim) Hopper _ NEWPROO is not responsible for conditions or Shaped circumstances beyond its control including con- INANCE_. densation resulting from or due to pre-existing Bank completion fo at installation RID Colonial SDL Euro conditions. DESCRIBE WORK: y 4, t a 4 GL ri..r J[,., A, / N 4 Est.Start Date: -1 y-rl� Customer understands this is an"estimated date" Est.Comp. Date: IJL V Initials Customer understands all steel security doors will have a 314"aluminum threshold installed over existing threshold. It shall be the obligation of NEWPRO 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 PI,Room 1301,Boston,MA 02108,(617)727-8598. 1f 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 the entire agreement between Owner and NEWPRO and cannot be changed except in 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 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Th/onerhas "sample"warranties that will be provided by NEWPRO uponn installation. Sample warranties provided to Owner. IN WOF,the parties have hereunto signed their names tthis/. ) day of y� 20EIN# _M Signed lAMark Printed Name Owner Accepted: NEWPRO Operating,LLC By Signed Owner PORATE OFFICE SHREWSBURY BRANCH OFFICE WARWICK BRANCH OFFICE - 26 Cedar St 151-153 Memorial Drive Business-Pk 24 Minnesota Ave Woburn,MA 01801 Suite B-C Warwick,RI 02888 (P)800-242-9974(From NE) Shrewsbury,MA 01545 (P)800-356-3312(From NE) (F)781-933-0717 (P)800-456-0555(From NE) (F)401-732-1371 (F)508-842-9248 WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy US-15 R0508 „fG✓yl 'TOTAL#OF � - #OF DOORS WINDOW COLOR WINDOWS #OF BOW/BAYIGARDEN Storm,steel,Patio J + InsidelO JMiae CAP COLOR OPENING SIZE STOPS NO. STYLE W x H U.I. LOCATION GRIDE SCR IN OUT • ADDITIONS OPENING 'j�, CUT Zc� �75 3 GZ 6 ✓✓� x✓' `Za J D x 3 2vL ��SS 2 MAsIJ ��o ✓ x lj 3 l x 37 z�3 ats! 2�x3 �Inskr 4l� x ` � 3,/ x3'7 Z 2�ss 2r (3 t P�.� nm �/� Y s x33 Z05 ��5s zs-><� 4?Z t3��I�un ��� 5 ' x'3 z x33 ZO zT5 Z& X3L, x x33 x x x x x x x x x x x x x x x x x x x x Measurema a.v v In r l✓� �' tl i ate Crew Time Frame to omplete job Capping Type Special Installation Instructions: � t i r Directions to site: j Revised 1101 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTEROFINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE A3DBiicaa-First Zis Agency inc =- ""-' "HOLDERFTHISCERTIFICAT-E��DOES'NOTAMENO,IEXTEND-0R -- 18T�2uincy Shore Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ,5 Noz-bh Quincy NA 02171 1 Phonll617-770-9000 -- INSURERS AFFORDING COVERAGE __ NAICp_ _ INSURED INSURER A' Arbeiia Protection IAB. CO INSURER 8: Ne r0 Operating LLC INSURER C: Wobuurn MA 01801 INSURER M. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT 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 LIMIT$SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5H Row PCY EFFECTIVELTA NSR TYPEOFINSURANCE POLICY NUMBER DATE MMIDO/YY DATE MWOWYY - LIMITS GENERAL LIABILITY - - EACH OCCURRENCE S 1y000,000 A X COMMERCIALGENERALUABILT' 050000010649 01/01/08 01/01/09. PREMISES Ea=urehll) S 50,000 CLAIMS MADE OCCUR MEO EXP(Any one person) 3 5,000 PERSONAL A ADV INJURY S 1,000,090 GENERAL AGGREGATE S2,000,000 GEN'L AGGREGATELIMIT APPLIES PER: PRODUCT$-COMP/OPAGG s2,000,000 1 POLICY 7 PLOT ED LOC AUTOMOBILE UABOTY COMBINED SINGLE LIMIT S 2,000,000 A` ANY AUTO 81037400001 12/31/07 12/31/00 (Ea=d1ml) ALLOWNEDAUTOS BODILY INJURY $ (Per person) X SCHEDULED AUTOS - X HIRED AUTOS DODILYINJURY S (Per xcdeenl) X NON-OWNED AUTOS PROPERTY DAMAGE _ -$ - _ - (PeramiCenQ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHERAUTOO HAN ONLY: EAACC S AUTO ONLY: ADO S ' 6CESSIUMBRELLA LIABILITY EACH OCCURRENCE S 5,000,000 A X• OCCUR �mAimsMADE 4600010709 01/02/08 01/01/09 AGGREGATE 55,000,000 s DEDUCTIBLE S 1. RETENTION S S ( 'WORKERS COMPENSATIONAND X TOPYLIMITB I I ER A i EMPi0YEWLIABILITY 90967005 05/01/08 05/01/09 E.L EACH ACCIDENT s500,000 -I ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED9 E.LOISEA$E-EAEMPIDVE $ SOD,000 II yyee9'dowdlia under E.L.DIS EASE-POLICY LIMIT $ 500,000 SPEGIIAL PROVISIONS below OTHER , I DESCRIPTION OF OPERATIONS LLOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISION$ OPERATIONS OF INSURED CERTIFICATE HOLDER CANCELLATION - sPECINE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE THE EX%RATIO 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 SO:SHALL y SPEI;IMEN - IMPOSE NO OBLIGATION OR IUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR .S. {(. SENTA ES. �; AUTNORREDR AESEN ATI - O ACORD CORPORATION 190 � - ENERGY STAR'Qualified, Highlightedin Regions 'WQ ®•Oualllled In all zones NEWPRO MANUFACTURING tMil 3000 PICTURE WINDOW r Cellular PVC frame,Triple glazed, ( NedmmlFenwha9on netlapt:awc0®, law E coating (e=0,fy94,S2&6), I ® - Argon/alrfilled j REV-K-22-0000 t ENERGY PERFORMANCE R TINGS U-Factor(U.s,A-P) solar Heat Gain Coefficient. ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Cdndensatlon Resistance feanufaslurer stipulates that fesmmangscanmrm toapppaable NFNOpracedurea fordetermfNngWnule product performance. a sped"T'umduatelm.NFROtlsas not recommend any? domnatyrenantNe suaeNlily of any pmductfarenyapecitlouae.Cansudmanufaalurefa lltenmreforolhorpmduct performance Ndnrmatlan. mvw.n ro,or 600 Washington Street y www.mass.gov/dia r Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busihess/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/orpart-time).* have hired the sub-contractors listed on the attached sheet. �• X Remodeling 2. ❑ I am a sole proprietor or partner- # These sub-contractors have S. ❑ Demolition ship and have no employees 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 l 1.❑ 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#1 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. l am an employer that is providing wodcers'compensat/on insurance for my employees.Below is the policy andjob site Information.. Insurance Company Name:, ARBELLA PROTECTION INSURANCE Policy#or Self-ins..Lic.#- 90967005 _ Expiration Date: 05/01/2008 Job Site Address. 4 City/State/Zip: /Z/VO D� Attach a copy of the workers' compensation po cy 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. I do hereby certify under t e pains and penalties o erjury that the information provided above is true and correct. Signature: FOR NEWPRO Date: l� S Phone#: 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 .Buildin De airmen 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Phone#: Contact Person: t '( $u8rtl of$updng Regulations and Standards i GPnStrucfitrn�Stlpen+iser:LrGense CS 29090 - i 1 MINE1 /20.08 Tr# 8131 IMES - THONIASP 230 WALNUT ST - j READING MA:91867 Commissioner lTr, - � - �/re "�osnnnan o�.�apar./ureelk Board of Building Regulations and Standards HOMEiMPROVEMENT CONTRACTOR - � Registfii�-IT�j 6589 v acf>lratJao , /7009 8 lementCard." ' NEWPRO OPER'Ai. THOMAS 'FOXON - r�- . . � 26 CEDAR ST. WOBURN,MA 01801 Adris4,gtErC S THIS CERTIFIUAI k IS ISSUEU AS A Null ten Nr mrunIMAOLIN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ` ' 'HOIDER.THISGERTIflGATE=DOES NOT--'AMEND,E%TENDOR -�=- .C-pine Ageacy inC = '=- nore Drive ALTER THE COVERAGE AFFORDED SV THE POLICIES BELOW. / MA 02171 /70-9000 - - -- INSURERS AFFORDING COVERAGE, -- -- NAIC III INSURER A. Arbeila Protection Ins. Co INSURER B: Iletaprar Operating LLC INSURER C: PO Box 2696 INSURER D. V70bllrn MA 01601 INSURER E: AGES OLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN A SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH JLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'R NSq TYPE OFINSURANCE POLICY NUMBER DATE MPOLICY FFECTI DATE MM/OD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE 81y OOO.00O A X COMMERCIAL GENERAL LIABILITY 850000010649 01/01/08 01/01/09, PREMISES(EEaox 10m) S 50.000 CLAIMS MADE ®OCCUR MED EXP(Any one person) 'S9,000 PERSONAL d AOV INJURY S 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'LAGGREGATELIMIT APPLIES PER PRODUCTS-COMP/OP AGO s2,000.000 >.• POLICY PERGT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO 01037400001 12/31/07 12/31/08 (Ee accdent) ALLOWNEDAUTOS BODILYINJURY $ X SCHEDULED AUTOS (Par person) X HIREDAUTOS BODILYINJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE .S (Per mIdanq GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 8 ANY AUTO OTHERTHAN EA ACC S AUTO ONLY: AGG S E%CESSA)MBRELLALIABILITY EACH OCCURRENCE S 51000,000 A X OCCUR �CLAIMSMADE 4600010709 01/01/08 02/01/09 AGGREGATE $ 5,000,000 8 DEDUCTIBLE S I, RETENTION S - S t 'WORKERS COMPENSATION AND X I TORVLIM S I 1 ER A S EMPLOYERS'LIABILITY ' 90967005 09/01/08 05/01/09 E.E.L.EACH ACCIDENT s500s OOO -II ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER,EXCLUOEDT E.L.DISEASE-EA EMPLOYEE-$ 500,000 Ilyy SPEGIes tlesddDaIALPROVISunderIONS Delaw E.LDISEASE-POLICY LIMB $ $00t000 OTHER DESCRIPTION OF OPERATIONS LLOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT r SPECIAL PROVISIONS OPERATIONS OF INSURED CERTIFICATE HOLDER - CANCELLATION SPECIME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO 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 SO%SHALL SPECIMEN IMPOSE NO OBLIGATION OR ILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR '.I. EBENTA EB. x� AUTHORIIEDR RESEN ATI J r n O ACORD CORPORATION T98 L ENERGY STAR'in Highlighted r, ®�Qualified In all zone, CNMjNEWPRO MANUFACTURING BC 3000 PICTURE WINDOW r Cellular PVC frame,Triple glazed, i Nedating neamdbn�1C - ey� � pm Low E coating (a=OR94,82 8 5), I a Argon/elr filled DEV-K-22-00006. r ENERGY PERFORMANCE R TINGS U-Factor(U.SJI-P) Solar Heat Gain Coefficient. ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Condensation Resistance MmufeNurra@ratlpuiatmthettlmsa retlnpacoMarm to Bpppce0le NFACprocedures ardetazmininB whale pmduet padormence.NyaCmdnpa vetlemrmined lore laedaetof enulranmentel candltloreand e apedBc praductalm NFitCdom product arany epaci(louea Canenuatttmmcerommfmaaetnuraeerna a rather mefna www.n pnmatdwuaont peanAtMoremaeunialeel NlyGdyor omfa atnloyn h 600 Washington Street www.mass.gwyldia Worters';Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Ihformation Please Print Legibly Name(Business/Organizationandividual): 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 listed on the attached sheet. 7. X Remodeling 2. ❑ I am a sale proprietor or partner- # These sub-contractors have 8. ❑ Demolition ship and have no employees working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp: insurance S. ❑ We are a corporation and its M❑ 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 110 Roof repairs insurance required.]+ employees. [No workers' 13.❑ Other' comp. insurance required.] *Any applicant that checks box#1 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: City/State/Zip: 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. I do hereby certify underlhepains andpenalties ofperjury that the informationprovided above is true and correct. Signature: FOR NEWPRO Date: Phone#: 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 .Buildin De artmen 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: -- _- Board of Bn(Iding,Regulahons and Standardt L Const oYlunSruPetVisArtLicense ,�-'_.. • Is`y CS 29090 :k—�. - aF 1p/2009 Trfl 8131 THOMAS P FOXC � � i> 230 WALNUT ST _ READING M_A 91867V '} Commissioner 71m 1°io9rw�a�✓ apac/aeelta UBoard of Building Regulations and Standards t m HOMEI Ff. VEMENT CONTRACTOR Regisiia l�r� 116589 f acPitibd 5/ 009 i,f element Card. ^%:A , NEWPRO OPER,4'f '�;=LLG THOMAS FOXON�'\^ti jjf- 26 CEDAR ST. WOBURN,MA 01801 - - ,..