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3 SEEMORE ST - BUILDING INSPECTION The Commonwealth of Massachusetts - Board of Buildin;Regulations and Standards MIJFOR Massachusetts State building Code, 780 CMR, 7`a edition USE. Building Permit Application To Cons7uct,Repair, Ren ate Or Demolish a RevisedJanuory One-or Two-Family Dwelling I, 2008 This Sec on or Official Us= fly' '\. 1 Building Pem if Numb r: *DateAppli Signature• Building Commission=/Insp- or of Build Date d 1 SECTION 1:SM INFORMATION 1.] Property Address: 1.2 Assessors Map &:Parcel Numbers ' ' re C-e. ST• 1.1 a 1s this an accepted stz eet?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4' Property Dimensions: Zoning District Proposed Use Lot Area(sq fi) Frontage(h) - 1.5 Building,Setbacls (ft) From Yard Side Yards - Rtu Yard Required Provided Required - Provided I Required Provided . I - L6 Water Supply: (M.G.L c.40, g 54) 1.7 Flood Zone Information: 1 1.8 Sewage Disposal System: Public❑' Private❑ Zones _ Outside Flood Zone? municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY GIVNTERSHIPt 2.1 Owner'of Record- \'�dLre,n MV Vr'.t 35' e_emf,re S- . eNA C-)I.Ci O Name(Print) - Address for Service Signature - Te-itphone SECTION 3-.DESCRIPTION OF PROPOSED WORK 2`(check all that apply) I4e.: Cca> ^t c:: ❑ Ens uti n^❑ O.; ^ upi d ^ Repa s;s)'.❑ ^' tian1,sl ^ 3 C Demolitinnyy ❑ AccessorpBldo ❑ 1 NumberofUnits. Otlier Brief Description of Proposed Work': l-'i z Tl r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building S (o o�/uo 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee o.Electrical S ❑Total Project Cos? (Item 6)x mulfinlier x 3.Plumbing I $ 2. Other Fees: $ "'' 4.1viechanical (HVAC) I S List: S.Mechanical (Fire $ Su*�ression) Total All Fels: d Checkl:o. Check Amount: Cash Amount: 6.TotaI Project Cost: , Oust_ndin�o a alance Du- 1:3 Paid in Full SECTIONS: CONS:::: CTIQI\T SERVICES 5.1 Licensed Construction Supervisor(CSL) License Atumber Expiration Date. Name ofCSL-Holder p \ 1 List CSL Type(see below) NJ z �,.Ih�� n�� ��P J°"1 T e - � �Description . . - . c�1 see U Unrestricted(dti to 35,OD0 Cu.Ft.) - R Plestricted 1&2 Fainily Dwelling Signature g-C11�-059{C( � Covering NI. Mzsanry On] O RC Residential Roof Telephone. - WS" Residential wmdDw and Siding' SF Residential Solid Fuel Bumin Appliance Installation - - D Residential Demolition �2 Registered Home Itt�prov merit Contractor(HIC) G(�l Y�c� e2:0vT HIC Compan an-or lC Reg ant NaRegistration R g`istr tionN'mb� C \ 1\ h4. - 66g- ck(C-(.{) el Expiration DateUL - Signature" Telephone " SECTION 6:WORKERS' COIvirENSA—IION INSURANCE AFFIDAVIT(AI.G.L.c.152_ § 2SC(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 7x;:OWNERAU. 110=kTION TO EE CO?1MPT ETEIi OWNER'S AGEN'TO i1l R CONTR4C.TOR APPLIES EORBUILD] "G PERl1'�FT . I, I`In ire.v� v v tp <� J\ as Owncr of the subject property hereby authorize_ r. . e� ���rJ71 '\ to act on my behalf,in all matters relative to work authorized by this building permit application. . . Signature of Owner - Date - ff SECTION FS:O NFRt:0;2UTH€}R1ZEI3 A€�EI> £.LFC?4i 4 0Ia } L1 JLC1 (`1c pe Ouvnet,nr At`*nize 1 A e r by rf tics' thatch ..1ctC*1-.'2]I>alld llSJ171Lt10n OR L�� ���" Jln apph�atl6n 21'C 1'.rpC 31iCI�CClli alE t0 the bt'<_t of and belialL (\J 4Cl .FrinrNarne - lb Signature of Owner or Authorized Agent , Date (Signed under the pains and penalties of perjury) 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)Pro;am);will not liave 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 790`CMR Regulations 110.R6 and 11 D.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 of bedrooms Number of bathrooms Number ofhalffbaths Type of heating system Number of deckles/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" (0113 a-aa DEBRIS FOB ; This form is to be submitted with bvil°+g gait appIlcations v'h*aever ih= is debris o be disposed of Propti' iddmss: 3 Stomof C St. . c�e m !"�� D\9 C� Ea accordaacr with the prm isions of MGL a40,§54,:a canditi=of the Bu!img Pemit Numb=is that tfie d bris remldn�izam.this wmk shah bo disposed of is a properly Iic=sed solid zst~disposal facility as defied by MGL c. 111 §150_A This debris winbe di,.-posed ofia lbA (\'v vim. (Location of Famay) Sipatam of P=ait Spplic Bate Oct 22 10 07.37a Microsoft (978)957-4666 p.12 104 Otis St;,\brdhbcnP ugh,]VL',G 153'2 J&L WINDOWt,ING: ohs/A ,MA Honie Improvement Contractor ;308)919-e900•Fax:(774)987-3013 Renewal License ft149601 (Expires 1/24/2012) byA dell Federal Tax 1D#83-0404201 waoxw eo...ernrnr .e.a...mc,,..., CUSTOM WINDOW AND DOOR REMODELING AGREEMENT B (,(Nome Dcre of A,rmmen, {moo f wj s�yar(.I sneer Add—,n.. s,w,e,a„d n Cade 13 SC eT—or,e 5 FMail Adcrasa Nome le -Number Wank Tell Number Suycr(s) hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc d/b!a Renewal by Andersen ('`Contractor'),in accordance with the terms and conditions described on the£runt and the reverse of this agreement and on the attached sxciRcation sheet(s) (collectively,this°Agreement"). ttuyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. // Method of Pymn[O Gash ❑Check ❑Mastercard ❑VISA Total lob Amount_lo _3 Estimated Srarrng pate: l')o ODiscover GFinanccd,AppV,: Deposit Received 133%): +��`_— '(9 ��GS,. Name on Credit Card: W _ I'. Balance of Start of Job 33°' ' �4....__ 1 ) Eshmoled Compl\ehon Dote. Credit Cord c: Balance on SibsonlialJ— Completion of Job(3396(: v'1"I —�(�- CC Exp_ Date: CC Security Coda: By initialinghere,you acknowledge thatthe Balance at Start ofJob and the Balance on Subs$nhal Carnpletion Buyer Initials cf Job eaanor be made by cox is card and must be made by personal cheek,beak cav,k,or cash. Ruyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation Boom this Agreement will be valid without the signed,written consent of both Buyce(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, vaderstands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,iaclud ng the two attached Notices 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. J&-L Windows,Inc h/a Renewal by Andersen Buyers) Buyers) i BT; Signature of Productl`lbfanager Si Signature i" Puler"') Prmt Nance of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIVfE PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. x NOTICE C_EL{ATION X — — — — — — — — — — —NOTK O CAN ELIA13QN Date of Transaction O y=}Jr' J, You may cancel Date of Transaction . You may cancel this transaction,% -our any pen,y or obligation,within this transaction,without any perw11 or obligation,within h three business days from the ove da nc te.If you camel,any three business days from the above date.lfyoueancel,any properly traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sala,and any negotiable instrument executed Contract of Sale,and any nesotiable instrument executed by you will be returned wit tm 10 days following receipt by you will be returned within 10 days following receipt by the Contractor ("SelkWl) of your cancellation notice, by the Contractor ("Sell of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residents,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 or Sale; or you may, if you wish, comply Contract or Sale,or you may,if you wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make tree goods available to the Soper aMl the d+a goods available to the Seller and the Seller does not Seller does not p'ndc them up within 20 days of the date pick them up within 20 days of the date of r Notice of your Notice of CanteRotion,you may retain or dispose of Cancellation, you m retain or dispose of the goods Of the g+�rods without an further obliggation. If you fail to without arty further obIgation. ff you fah to make the make the Dods available to the Stdler w ill agree goods available to the Seller,or if you agree to relum the to ,alum the �ood� to the Seller and fail to da so,then yoads lathe Sellerand fail to do so,then you remain liable you remain list Ib a for performance of all obl'gah'inns under for performance of all obligations under the Contract. the Contract. To cancel this transaction, mail w deliver a I To cancel this transaction, mal or deliver a signed and srgg,red and dated copy of this cancellation notice or any I dated copy of this wrtoellation nalice or any other written Mher wrtten notice, or send a telegram to Contractor. J notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/o Renewal by Andersen, 104 Otis I Inc. all Renewal b Anderson, 104 Otis Street, Sheet, OF oroug to 001 s9 (Date) )NOT LATER THAN NO en (Bede) 9D e),JOT LATER THAN MIDNIGHT IHEREBY MIDNIGHT OF J�(RA.[ I HEREBY CANCEL THIS TRANSACTION. � I HEREBY ANGEL THIS TRANSACTION. Buyer'Sign—W Date I eiyrl sig.wNre Dab KLA Copy- White Buyer Copy-Yello,v suycr Copy-Pink Oct 22 10 07:37a Microsoft (978)957-4666 p,13 J&LWirldows,Ine.d/b/a MA HIC License 49631 (cpirrs 1/24/12) 1.401W Strc„I,Northboro rh,MA 01 a9Z Renewal redcrm Pax 1OX 83-0404201 Phone 608.919,o9o)-Fax 774.987.3013 byAndersen. XIR11. REPL....%a' Jr GaLAa1S MMSAcmusE .WO NEW H.4MPS115E WINDOW SPECIFICATION SHEET Date of Agreement Buyer(sl Name with the prices and terms T.ae Buyer(s)listed abovr.hereinL'y artd severally agree to purchase the good..and/of services listed below,in accordance desenbed on the Specification Sheet and the front and the revels"of the accompanying ChSTOM w1rvDJW AND DOOR REMODELING AGREEMENT, of which this SpeHKcatiou sheet is a part WINDOW DEIAIIS 1. Contractor will install a total C. wmo,,va(n Owner's home,using the following individual quantities: Double Hul,g(DR) ❑ Equ sash ❑ Cottage sash(I/3 top,2/3 bottom) ❑ Oricl sash(P/3 top. I/3 bottent) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Mahn handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/frcturc/Casenent(CPW') ❑ 11:1 orLe : [Standard handle ❑ MetrohaMie 2 Lite Gliding Window(OW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2d Awning Window(AW) Picture Window(PW) Bay or Bcw Window Patio Doors(see separate Deer Specification Sheet) Z. yea ❑ No Qty of Whldows to be Custom Fit Replaeomene 3. ❑ Yes tom`No Qty of Sills to he replaced by Contractor: 4. ❑ Fej&�No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Prue ❑ ,Mainlenance-free material ❑ Factory applied 90g Fibrex brickmold 5, Glazing to blo� HPL(ow-£C SmaltSunDs (Tex CYaGD)Ipble) ❑ Other If other,please specify: 6, Exterior color'to lx:cPL White ❑ Send ❑ Carrvas ❑ Terratone ❑Cocoa Bean 7. Interior color to be: white ❑ Sand ❑ Canvas ❑ Terralonc ❑ Pine [IMaple ❑ Oak Note: Into rl0 eo or can only he white,,voed or aame color as exterior. Wood interiors need to finished by Owner. 8. Hardware:rfq while ❑ Stonc ❑ Canvas ❑ Brass❑ Fstate Hardware: Style: 9, ❑ Ycs�No nstall lifts with Double Huull Windows - IL. Screens: windowstollave: ❑ Half in Fullscreens ScrecnOobe:IlY Fiberglass ❑ Aluminum ❑ ?7u5cene �-y GRIL SS LEDE£AII l l.Windows have grilles: ❑ 1'tc.�oV No if yes:❑ Grille lletween Class;mua❑ Removable Interior Wood nmwr❑ Full Divided light nnU Q1y: Qfy: QH Qty: Qty: Qty: Qty: eN on eR en WJ!GI:Ne stile CPN O! Draw grille p nt"lls abnve 'Use additional sheet if needed Owner aFvmo d(imta tw ADDITIONAL WORK DEPAQS 1 es ❑ No Contractor will remove metal frames of windows. Qty of Units: �.l•^ s 13.❑ Yes&NO Contractor will install new paint-ready or stain-ready casings. interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Mainicnance�free material 14.❑ Yerg-No Contractor will install new paint-ready or stain-ready inside or outside stops qly of openings: Interior stops qty of openings. Exterior stopsq Corp, +ings: ❑ Pine ❑ Maintenance-free material 15. Owner is are that Contractor does not do any penning. t:�--t Owner Initials 16.❑ 1'ea e Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window remc,al;removal of storm windows will leave screw holes:n casing. 17 Ye- ❑ No Contracter will insulate,caulk and sal windows with 3-point sysxm to prevent water and ale infiltration. I Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. I. Yes ❑ No Bwild' perm't-Contractor'will secure any and all necessary permits. The fee for the permits)isnot included hr the Contract Pr a an a se le check ie xe uised the time of e for t �s fee. r 1 zo. Add;iiclu jabndicCails: =� = V �.� e St k G r 21�j`es ❑NO Owner agrees to be present On the final day of installation for final inspection and to deliver final payment. No ima/payment shall be demanded un(If Jle contract is coeuplekd to the"ahs/w4ion stall parties. It is agreed and understood by and between the parties that this Specification Shed,along with the CUSTOM WINDOW AND DOOR REMOD©JNG AGREEMENT,eonsdtutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the mars. This Specification Sheet may neF be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyers)and CO ins r, Buycr(s)herelry aclmowledge that Bvyer(s)has marl this Spcci6cakion Street. P.rnewel by Andersen Greater MA mtd NPI Buyer( uyer(s) By: Signature of uct Manager SiglatUe Signal K� Print Name of Product Manager Print Name Print Name Oct 22 10 07:39a Microsoft (978)957-4666 p.15 Renewal RENEWAL. BY ANDERSEN Naxtc ues lasso) (ex�1,24;121 bAndersen Or GREATER 11ASSACHUSMS AND NEW HAMPSHw,, FCC rel TanlDk 63-0404201 WINaon REPLACEMENT 104 Otis Street•NDribborough,Massachusetts Ot532 Phone 503.919.0900•Fax 505.919.0903 sPECBTCATION SHEET Buyer(s)Name Date of Agreement -Oren ('Y�rgrJ I L) t� I'r) T She Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed below in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW .AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. PATIO DOOR DETAILS 1. Ins I total of: 63 rt=asllfeld Glidu Patio Door ^'10"x G'8" ❑ Other(not available in 8068) Op,panel s left ❑ right(as viewed from exterior) Intcnor and Exterior Color ro White ❑ Canvas ❑ sandsmne ❑ Terratone (Color same inside and out on PS) Hardwaac: h-gpn Vitite Stone ❑ Bright Brass ❑ Other—Specify Ye o G- Patio Door to have sidelight? Size: [ 1'e o Grilles? ff yes: GBG ❑ INPW ❑ FDL(Pattern is standards vic ved in book for all doors) 2. Install t tal of: _ Narrowline GG Patio Daodsl ❑ 6'0"x G'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sarsthme ❑ Terratone (Interior is WOOD and customer must paint or stain) Hardware: Metro: ❑ White ❑ Canvas ❑ Stone ❑ Bright Brass ❑ Other—specify: Yes ❑ No Gliding Patio door to have sidelight? Size: yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 3. Install total of: Frenchwood GEditlq Patio Door(s) ❑ TO"x 6'8" ❑ r. Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood: ❑ Pine ❑ Oak ❑ Maple Interior Finish: ❑ Prefinished White(Available oniv with white exterior) ❑ Unfatished(Paint/stain done try customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Braes ❑ Satin Nickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ Na Grilles? jja�yy�s�. GBG ElINTW ❑ FDL (Fun Divided Light) 4. Install total of: French yood Hinged Patio DaeT(5) ❑ 6'0"x 6'8" ❑ er: _ ❑ Yes ❑ No Active/Passive Panel?: ❑ ].rail ❑ Right(viewed from ext.which is ectivc) OR ❑ Yes ❑ No Active/Stationary Ferrell: ❑ Left ❑ Right ` Door swinsr: ❑ Inswing ❑ Outswiag Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone anterior Wood: ❑ Pine ❑ Oak ❑ Maple Interior Paush• ❑ Frefinished While ❑ Unfinished(Faint 1 stain done W customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel •NOTE: Canvas hinged screen frame N/A—must choose white or stone if exterior is canvas` ❑ Yes ❑ No Hinged Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INFW :j FDL (lull Divided Light) STORM DOOR DETAILS S. Install total of: storm Door(S) C. ❑ Full),iew❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Samdtone ❑BaenFe ❑ Forest Goren 8. sine to be. ❑ 32" ❑ 34"(Whfteonly) ❑ 36" ❑ Custom(10 weeklead time) Sire: 9. Hardware to be: ❑ Bright Brass ❑ Nickel 10. Additional job details: I I Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. r hat payment,ehnll be demanded until the eontrectis completed to the satisiacbon ol allparties, It is agreed and tutderstood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no venal understandings charetang or modifying any of the teens. This Specification Sheet may not be changed or its terms modified cr varied in any way unless such changes are in writing and signed by both the Buyer(s)end Contractor. Buyer(s)hereby acknowledge that Buyer(s)has mad this Specification Sheet. Renewal Fry Ande/rs�en of Greakr MA and NH Buyer(, ) Buyer(s) By: _ 0,�� Signatvue of Product Manager 54gia sisr attire �1�,�Q�1- P�j f-eA-rerY �')Uratf� Print Name of Product Manager Print Name Print Name The Commonwealth of Massachusetts Department oflndustr'ialAccidents Office of Investigoons 600 Washington Street Boston,M.A 02111 rwww.mass gov/dia Workers' Compensatdrun Insurance Affidavit: Bunders/Contracters/Electricaans/Plnrsabers Amlicant Information Please Print Lep-ibly NaMe (Business/Ore=anization/Individua): ,gene—..)J ZV �nG/Er3 f_�n Address: n/0Fl Q�r S City/State/Zip: /�/i2r4 bo !o , Phone#: Are you an employer? Check the appropriate box: Type of project (required): 1.al sm a employer with 00 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).= have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• odeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. workers' comp.insurance. g• ❑Building addition [No workers' comp.insurance 5. Q We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 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] t employees. [No workers' 13.0 Other comp.insurance required.] °Any applicant that checks box Rl must also fin out the section blew showing theh worlcas'compensation policy infmmatiaa. t Flom who submit this affidavit indicating they are doing an wort:and then hire outside comracturs must submit a new affidavit indicating such =Conhaetoa that check this box must attached an additional sheet showing the uame of the sul>—outreeton:and then wed='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: �' (' /��o-n /f'1 CrI rr nC i; Policy#or Self-ins.7Lic.n Lai —?? f_1YU Expiration Date: i�����f1. Job Site Address: 7 <Se tl itA_c1,f P S 1 City/State/Lip: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veriacation. I do hereby c u �er the pains and penalties.ofperjury that the information provided above iis'true and correct Simature: Date: y pp Phone#: Official use only. Ito not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3. City/Tewn Cleric 4.Electrical hispector 5.Plumbing Inspector 6.Other Contact Person: Phone# jF • JiassachusettN - Department of Puhlic Safeh Board of Building Regulations and Standards Construction Supervisor License License: CS 101952 Restricted to: 00' DAVID BANCROFT 5 JOHNSTON AVENUE WHITINSVILLE, MA 01588 Expiration: 3/192012 ('u nunissimtet. a Trb'; 101952 " ✓/ee -foo�u�.a�su�eaLlh of'./12amarf.ueeC� "' Office of Consumer Affairs&Business Regulation - OME IMPROVEMENT CONTRACTOR Registratio (n�gg601 Ezpirafi —0f2 112 r.— n ler:TLEflt Card - RENEWAL BY �[1E-Q,F - r DAVE BANCROF$� 104 OTIS STREEi'•CC:;�, 32 NORTHBOROUGH,M Undersecretary - F ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE `MMMDmm 02/10/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 333 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Ann Arbor, MI 48105-0333 INSURERS AFFORDING COVERAGE NAIC# - INSURED Renewal by Andersen INSURERA: Hafford Insurance Company J and L Windows, Inc. INSURERS: Nautilus 104 Otis St INSURER C: Northborough, MA� 01532 INSURER D: NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IRSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR IN POLICY NUMBER LIMITS B GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY AMA T OR occurence PREMISES Ea $ 100,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,000 i PERSONAL B ADV INJURY $ 1000000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPnP AGO $ 20000000 POLICY PRo- LOC A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ee eP d.rd) X II. ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY. $ , NON-OWNED AUTOS (Per accitlenQ PROPERTY DAMAGE $ (Per accident) GARAGE.LIABILITY - r AUTO ONLY-EA ACCIDENT $ ANYAUTO - OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ b DEDUCTIBLE $ RETENTION $ $ W C STAT J OTH- A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 M17/2011 EMPLOYERS'LIABILITY ANYCERNEETORIEXCLUDRrXECUTNE El-EACH ACCIDENT $ 5QQ Q00 It as des'ene under EXCLUDED? EL DISEASE-EA EMPLOYEE $ SDO QQQ Syes ILL PROVISIONS ISIO GPECIAL PROVISIONS below EL DISEASE-POLICY LIMB $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THECERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) C.`�©ACORD CORPORATION 1988 i ram,—ids-=,sCcr 1• � 'WoodAIinyl CcT;CsIL n'am,W E. DualPan� . • i Ptr�Cae:l Casement ESc7 . . . R • a • .= �� ® '�C:ii o MAN�rC RATINGS. [b-Factor (�•$3�`P So tar K_3L'Gain Cosff cisnt' • PEPJ Vlsitile'T+�s aitt'anc • 0 � u�1oS•BahlTWni.t:hofn f ' sllPV.�1=`I'dplip AlltseoPlodjod ippA f� -.AERC Pf'�ad,�.. an6lucm mdr • pledudl pertcrmand,l�e pdnpc aR dlprt�IMd faP=feed,:nL ,'spsillr Ploe'udshe.bosdk miwholuier4l�;tctufa.—`�rv�:r prndu'Piff t t. . NE..1 ` ! f .•Y _ to 1 -• r ' S •.� •M L � Ln •f wv[Ns5-Wc .Nagel • I 1' rkrr'c n„•+Im! �� �MLr.w.Irre.rw • � ® FsO. .rrr.ur..tyul..0 yf'Ir��'s••_P7 NN lka0merk GeNnillnn°rwAm • Moils or:-,.:ad:kE4��t 61:S�arInI1lPaLon 9:GWrciomt: M . • f I •..f1 . . Elm w�- _ r d V s, H � a � a _ @':�• x'Y�y'4 , �_ .�,•�,� 3 , [i. �@ — SSG + _ � 1 tp z� 1 9 ,� - ,� 6 $ • -• Re in e- wa I ��Aifdersemi [F+r6NnDOW REFL&GEMENT aaAredcrEmCamp€ir.Y To Whom It May Concern, - Enclosed is a permit application package for a project we have been contracted to do in your town. Thank you In advance for receiving this package by mall. As we work in every town in the state,. It greatly helps us in our process. We have also enclosed a self addressed and postage paid envelope and when wo.udd request that hen the permit a.pplicatEon has been processed, that you virouEd mail it back to us. Enclosed for you review In this package ls- ❑ Permit Application ❑ Home Improvement Contractor License ❑ Construction Supervisor License ❑ Proof of Insurance ❑ Proof of Energy Efficiency Rating ❑ Signed Contract from customer ❑ Permit Fee (if accepted at time of applying) If you have any question regarding this application Tease call €sae at (SOB) .919-09-92. Pest Regards, i Kelley Donahue Permit Coordinator 104 Otis Street 1 Northborough,MA,01532 Phone(509)919-0900 Fa (509)919-0903 Wcbsitc:www.renewalb�decsen.com