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CTTY OF SALEM
PUBLIC PROPERTY
` DEPARTMPNT
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Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
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
[No workers' comp. insurance 5. ❑ We are a corporation and its ❑ Building addition
required.] officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ 1 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.
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. Lgic. #- 90967005 Expiration Date: (05/01/2008
pI Job Site Address: g �L/7/✓J L ST- City/State/Zip: V PrL j �T7 )9:: 6
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 under the pains andpenalties ofperjury that the information provided above is true and correct.
a�
Signature: %r FORNEWPRO 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 .—Building De artmen 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone M
l
ACORD CERTIFICATE OF LIABILITY INSURANCE OSR T3 °gTE(MM°°""""'
NEWPR-1 05/01/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
.1 I 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 MA 02171
Phone-. 617-770-9000 INSURERS AFFORDING COVERAGE NAIC It
INSURED INSURERA Arbella Protection Ins. Cc
INSURER U.
NeWpro Opperating LLC INSURER C;
PO SOX 2696 INSURER D:
Woburn MA 01801
NSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT W ITHSTANOING
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 SHOW N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTq INSRL TYPE OF INSURANCE POLICY NUMBER DATE MMIDBP/ �PTE MMID�NY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,DOO
A X COMMEROIALGENERALLIARLITY 650000010649 01/01/07 01/01/08 PREMISEBErt.cOIence) i90,000
T—ICLAIMS MADE aOCCUR MED EXP(My one person) $5,000
PERSONAL A ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GENE AGGREGATE LIMIT"PLIES PER: PRODUCTS-COMPIOP AGG $2,000,000
POLICY PECT RO LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A ANY AUTO 81037400001 12/31/06 12/31/07 (Ea accmeml $1,000,060
ALLOWNEDAUTOS BODILY INJURY $'
X $CHEOULEOAUTOG (Per pelsan)
X HIREDAUTOS BODILY INJURY $
X NON-OWNED AUTOS (Par eccldpnq
PROPERTY DAMAGE $
(Per rOcIdanl)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHERTHAN EA ACC S
AUTO ONLY: AGO S I
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $5,000,000
A X7 OCCUR FICLAIMSMADE 41600010709 01/01/07 01/01/08 AGGREGATE $5,000,000
$
DeoucrlaLE $
RETENTION $ $
WORKERS COMPENSATION AND X TORY LIMITS Efl
A EMPLOYERS•LIABILITY 90967005 05/01./07 05/01/08 E.L.EACH ACCIDENT $500,000
.ANY PROPRIETORPARTNEPoEXECURVE
OWICE"EMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE B 5 D O,0 00
It Y..d.c,nbe under E.L.DISEASE POLICY LIMIT $500,000 I
SPECIAL PROVISIONS UeIOW
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
OPERATIONS OF INSURED
CERTIFICATE HOLDER CANCELLATION
SPECIM6 9HPULDANV OFTHE'ABOVE DESCRIBED POLICIES BE CANCELLED SEFORETNE EXP.IIU s DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTI
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHI
SPECIMEN IMPOS P IGATION OR LIABILITY OF ANY KIND UPON THE INSURER,US AGENTS OR
REP t0litives.
MT. RUDE. PRESE A E
ACO,R¢25(2001/08) _,. OACORD CORPORATION 1
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR - Board of Building Regulations and Standards
Number: CS 029090 HOME IMPROVEMENT CONTRACTOR
Birthdate: 11/19/1953 Registration: 146589
Expiration: 5/5/2009
Expires: 11/19/2007 Tr, no: 9879.0 i
Type: Supplement Card
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Restricted:'�00
THOMAS P FOXON' - NEWPRO OPERATING,LLC... -
230 WALNUT ST G— ,ram THOMAS FOXON
READING, MA 01867 26 CEDAR ST. -
Commissioner
WOBURN, MA 01801 Administrator
ENERGY STAR Oualified
in Highlighted Regions
DEVCO PRODUCTS, INC.
� C Newpro/Denall 2000 Double Hung
9 Vinyl framejrl le lazed,
Low E coating(e-0.074,52 d,5(,
w '
ag ISryptonfArponlalr filled,Olvld"
ENERGY PERFORMANCE RATINGS
LI-Factor(U.S.A P) Solar Heat Gain Coefficient'
0.19 0.25
ADDITIONAL PERFORMANCE RATINGS
L
ransmittance Air Leakage(U.SA-P)
.36 0.1
tion Resistance
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. - Spea(KplOdetl Stia C06W1e1hhtLLwww rillabfOCllrPa
www.nlrc.com -
MA Reg. S06 89 ( O 5 4 0 3 2
CT
CT Reg. #060505216 L
RI Reg. #26463 7MREPIacEMENrwlNowvPEOPLE Federal ID #20-2625129
Corporate Headquarters:26/Cedar St.,P.O.Box 2696 Woburn,MA 01868 (781)933-4100 1-800-342-2211
THIS CONTRACT MADE THE . . . . . . <. e. . . : day of. 200'/. . between. . . . . . . . . . . .
J. �»i33
(Home Owners) ( ome Phone) (Bu ./Cell hone) (Mr./Mrs.)
of
(Address) (State) (>jp Code)
the "Owner' and NEWPRO Operating, LLC, "NEWPRO". � try
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 NEWPRO Additional S le O TOTAL CASH
Windows Purchased �� iZ Work ty ty PRICE / ,s(��
Window Color Specify iTZ= Sliding Glass Door DEPOSIT
Capping Color Specify ; Qty Steel Security Door WITH ORDER 3g
Double Hun I
Picture Window Obscure Glass TOP BOTTOM BALANCE
Stationary Casement Screens HALF FULL DUE AT
Casement - Model # I INSTALLATION
2 Lite 13 Lite Slider NEWPRO* does not do any painting or (�
Bay/ Bow Frame staining CASH
Garden Window NEWPRW is not responsible for conditions Balance Paid to
or circumstances beyond Its control Including Installer at Installation
Awning condensation resulting from or due to pre-
Other existing conditions FINANCE I Bank Completion
GRIDS (7 Colonial Diamond & ,J Form Signed at Installation
DESCRIBE WORK:
' 1%>g G i a e i 5CLU i 41 4u� .:.:.:I.r�l.t�✓
7,4Ct UAJ 5 f 0 CO.Cte m&NJ `2z YL l 2 C s cL-cE,y,.n
All steel security doors will have a 3/4"aluminum threshold installed over existing threshold.F_� Customer Initials
Est. Start Date: - y Est. Comp. Date: —i Lr-6
It shall be the obligation of NEWPR 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 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
The O ne as seen "sample" warranties that will be provided by NEWPRO upon installation.
Sample warranties provided to Owner.
WITNESS WHER QF,the parties have hereunto signed their names thi 9�Own
200
— EIN# Signed
Marke ' g Re esentatii
rint a e
Accepte PRO C
BY Signed Marketing Rep en
tative Signature
WOBURN BRANCH OFFICE SHREWSBURY BRANCH OFFICE WARWICK BRANCH OFFICE
26 Cedar Street 151-153 Memorial Drive Business Park 45 Giibane 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:508-842-6876 800356-3312(FROM NE)
FAX:781-933-0717 800-456.0555(FROM NE) FAX:401-732-1371
FAX:508-842.9248
WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy
US-15 1001PKG. 11/05
EI'�O��AL
PUBLIC PROPERTY
DEPARTMENT
I:ImHERI.EY DRISCOLL
MAYOR t30 WASHINGTON STREET•SALkd/,,%t.\SSACHLSL TIS 01970
'ML,978-745-9595• FAX:978-740-98"
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: P( ft/f /d'T. Building:
Property Address:
Property is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: SI H-I ,GCSE G20CK /
Address: a q PLRA17i --X-9 cS 77
Telephone:
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:
RC)OC,R-CC // W I1 )ROWS. / nOT0 EY IS T1 M 6
Q PE>\d l ti1 C� S
Mail Permit to:
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What is the current use of the Building?
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Material gf.BwldingT,. `" � If dwelling;how many units s' �
Wiil the Building Conform to Law? Asbestm
fI TV;
Architects NarAIa /U
s nV k 1
,Address and Phone _ ] "
' Mechanic's Name f
K
`Qi Address and Phone "? c%t sT^^�GU /'y/�
ao
4 Construction Supervisors License#"" c y` f T HIC Registration#
Estimated Cost ro ed$ l ) Permd Fee Calculatlon
"Rermd Fee Estimated Cost X$7/$1000 Residential,
Estlmate.d�Cost X$11/$'1000.Commercial . a,t
An Additional $5.004s added as an
y. Administrative charge
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it
Make
Make sure'that all fields are properly and legibly written to avoid delays'in processing. '
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The undersigned does hereby apply fora Building.Permit to build to the above stated
speafications Signed under penalty of peryury
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