10 SETTLERS WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
'Board of Building Regulations and Standards FOR
Massachusetts State Building Code,7.80 CMR 7a' edition M-UNILIIPEALITY..
Building Permit Application To Construct, p Renovate Or Demolish a' ' Revised January. "
1 O f One-or Two-FalniLv Lr we ling 1, 2008
�1 This"Section For Official Use
Building Permit Number.
Signature:
Building Commissioner/InspectorofBuild gs I Date _
SECTION 1:STfE ORMATION
1.1 Propeyty Address: 1.2 Assessors Map&Parcel Numbers
1I/4 t4 + �a yI -.(304) 0
1.1 a Is this an accepted street?yes_ no Map Number Panel Number.
13 ZoningInformatio 1.4 Property Dimensions:
� J
Zoning District - Proposed Use, Lot Area(sq it) Frontage(11) '
1.5 Building Setbacks (ft).
Front Yard Side Yards Rear Yard-
Required Provided Required - Provided - Required Provided -
1.6 Water.Supply: (M.G.L e.40,§54) 1.7"Flood Zone Information: 1.8 Sewage Disposal"System:
public❑' " Private❑ Zone _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if"yes❑
SECTION 2. PROPMTY OVVATEi28 "
2.1 nert of cord: I
U X n �c)rtCLn I O S�� e�s C J4 �n le_Hn. V�fa
Name(Print) Address for Service "
Li pow 014�
Signature - Telephone
SEcn-ON 3:DF-SCRIPTION OF PROPOSED WORK2`(check all that apply)
.. ..r: 'R.>.:. i+. �:.:- ri..: 'n. .Rti
1,es'C osCu o ❑ t ..g utt.mg.❑ , r-o--e4pied ❑ epa:s s, .G c ) di iun"❑
Demolition ❑ •Accessory Bld_e. ❑ Number of 1 hits Other RUpccify:_._ L Zl9�Ln
Erief Gesetiption of Fropo�ed Work=: l2, IQ k;>, t - Loc/k
� Ib T-Jrul
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee "
❑"Total Project.Cose(Item 6)xmulfipliarl. x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount
6.Total Project Cost: $.( 1"t ❑Paid in Full ❑ Outstanding BalanceDue:
o
C
SECTION5: CONSTRUCi?ON.RRVICES
5.1 Licensed''Construction Supervisor(CSL)
�h✓1 N A l l0•/1 License.Number Expiration Date. ,
Name of CSL Holder
�L.\ List CSLType(smbelow) A
-
T'. nestCID
U Unrestricted( ' to 35 ouu Cu.Ft
Signature - .: R Restricted 1&7 Familly Dwelling .
-5 F4 I9-bri Z JY Masonry Only
Telephone. RC Residential Roofing Covenn -
WS- Residential WmdDw and Sidin
SF Residential Solid Fuel Bunaing A ]iance Installation
Residential Demolition -
5gRegistere Home lmprnovegtent Contractor(MC)
d1 P�.�:.w
H]C Co anv Name or C R gistrantName Registration Number
Ki- i Expiration Date
Stgffetrure' - - Telephone
SECTION 6:WORIu+"'R$' COMPENSATION t!TSURANCE AFiIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation lnsuremce 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 Atacbed? 'Yes :.:....:.. No..........❑
SECTION7a:OR Tf�Ry1IIT�ORi�A.3TOI$TORE•CFAMP ET N...
OVi'iZElI2'S A\G_ENTDR/--CO1V'FB k6WR APPLIES FO�LBIIII ii P S211'¢iT .
I• v"� r�J ��^ as Owner of the subject property hereby
authorize _ . "I n L tiu ) to act on
my b ehal�in all matters
re tiVe la to work
authorized by this building permit application. .
Signature of Owner - Date
. -SEC�tiII�7b:AVJNER'QR Ai]TH�Rh;E}Y _ ;; `
} . `1 �1���.✓F i it"2 v 7 - _'az pwnet nY fctithntized Agen[fieteby{taSllre ;• ::.•: ' :.'-,.'
d ai the statements arid inSoruiation'en the fpre-eina'applica4on are u�:.ai� scciirafe,toil In best of>ny kttowledgt and
.Print Name
`J
I I /
Si afar co f Owner o
gn r Authorized Agent
(Signed underthe pains and penalties of a -u -
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)Program),will not liave access to the arbitration
program or guaranty fund under IA G.L. c. 142A.Other important information.on the MC Program and
Construction Supervisor Licensing(CSL) can be found in 7B0`CMR Regulations 110.R6 and 110JU,respectively.
2. When substantial work is planned,provide the information below.ri
Total floors area(Sq.Ft). (including garage,finished basementlattics, decks orporch)
Gross living area(Sq.Ft) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhaMaths
Type of heating system Number of decks/porches '
Type of cooling system Enclosed " Open
l "Total Project Square Footage"may be substituted for"Total Project Cost" I t �ot6 "06
� J
SUN-24-2011 01 :42 AM P.01
104 psis St.,Northbnmugh,MA 01.5,92 J&.L WiNDOws,INC,,D/s/,A MA Home Improvement Contractor
(308)919-0900•Fax:(774)987 3013 rlewa� License#149601 (Expires I/24/2012)
by dersen. Federal Tax ID#53.0404201
wrneew xnn.taexr .,,�,;,,.r.c.+wm
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(,(Nome Dole of A ,".rat
-�'70 /v
Brgv1.)sneer Addnn,Pry smn,end Zip Cod.
9 J 0
tAWI Add,n, Nam.Tel. hone Ncrts r Work Telephone Number
Fuycr(s) hereby jointly and severally sgrees to purchase the products and/or services of J&1.Window.,Inc,d/b/a Renewal by Andersen
l"l'ontrnctur"),h1 uccordanoc waft the lerinv anti conditions described at the front and the revcru of this Rggmen cat and on the attached
spcc:if"ation slico 0) (col lectivcly,this"Agrccuentr').Fuyar(s)hn'cby agrees to sign a completion certificate after Contractor has Completed
all work under this IkSIVCntent.
Total Job Amount:.
1/319& Estimated stor Method of Payment:pCheck ❑Credit Card Wash
,99 'no Da LIFinanced
D.pasif Received(33%I',3�7p --- C
Balanc.at Stan of 1oh 133 e)c3 .1�_".. Fslimated Date:
If payment is by Credit Card, please fill out
Complefon
Bolance on substantial 9� L�,�g the Credit Card Receipt of Deposit Form
mpl Cosllon of lob(33%(. "
Hy initiating here,you acknowledge that the Balance at Stnrl.of foh end the.Hahmcr on Substantial Completion
Buyer Initials ) nt l e niadt.by credit card and must.be made,by pmonal check,bank check,or[ash.
_......._ .... of ob coon _. . ....
Buyer(s) agree.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
from this Agreement will be valid without the signed,written consent of both Buyer(.) and Contractor. Buyer(.) hereby
acknowledges that Buyer(") 1) has read this Agreement, understands the terms of this Agreement, and has received a
completed,signed,and dated copy of this Agreement,Including the two attached Notices of Cancellation,on the date Bret
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.
.I&L W1ndr, d/b/ fon .cowl by Andersen Buyer(s) Buyer(s)
.'inn:wu 4Pm net . err Signnnue Sigrmwre
Print N;unc of Pindno. anager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEETHE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT,
- - - - - - - - - - - - - - -�- - _ - - - -- - - _ _ - " ` X- - - - - - - ->•r
NOTICE OF CANCELLATION X1 NOTICE OF CANCELLATION
Date of Transaction _."..,..,__,- You may cancel Date of Transaction You may cancel
this honsactien,without any penalty or obligation,within 1 this transaction,without any penalty w obligation,within
three am business days h the above date.If you cancel,any l three business days from the obe ve dote,if you cancel,arty
prop'traded in,any payments made by you under the I property traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed I Contract of Sole,and any negotiable Instrument executed
by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice, l by the Contractor ("Seller") of your cancellation notice,
and any security interest arising out of the transaction will and any security interest arising out of the transoaion will
be canceled.If you cancel,you must make available to she 1 be canceled.If you cancel,you must make available to the
Seller at your residence,in substomially as good condition Seller at your residence,in substantially as good condition
as when received, any goods delivered to you under 1 as when received,any goods delivered to you under this
this Contract or Sale; or you may, if you wish, comply Coo it 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 the goods available to the Seller and the the goods avalktble to the Seller and Ole Seiler does not
Seller deer not pick them up within 20 days of the date pick them upp within 20 days of the date of your Notice
of your Notice of Cancellation,you may retain cr dispose of CarRallaHon,you may retain or dispose of the goods
of the qnods without anyy further cbl' n.If you fail to wbhom any further obisgaOen. O you fail to make the
make me Beds cvaieble to the Seller, er if you agree 1 goods available to the Seller,or if you agree ro return the
to return the goods to the Seller and ail to do 6o, Then 1 goods to the Seller and fail to do se,then you remain liable
you remain liable for performance of all obligations under 1 for performance of all obligations under the Contract.
the Contract.To concel this hansaction, mail w deliver a I To cancel this transaction, mail or deliver o signed and
signed and dated copy of this cancellation mice or any dated copy of this cancellation notice or any other written
other written notice, or send a telegram to Contractor! J l notice,or send a telegram to Contractor.J&L Windows,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis l Inc. d/b/a Renewer by Andersen, 104 Otis Street,
Sheet, Northboreugh, MA 01532, BY NOT LATER THAN Northborough,MA 01532 BY NOTLATERTHAN MIDNIGHT
MIDNIGHT OF.. .(Dare) OF .(Date)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION.
Boy.M1 atBnemn prim Nam D.I. auywY FBnNrr. Irin,Nom. D.I.
RbA Copy• White Buyer Copy-Ychow Buyer Copy-Pink
SUN-24-2011 01 :43 AM P.02
104 Otis StrMt,Nonhboreugll,MA 01352 Renewal
'� )k L Windows
,Inc.d/b/a
Flsune 509.919.0900•Fux 774A87.SOl;i I\)rnewa I MA HIC I,ianse a 149CAl I(exrlros 1/24/12)
Federal Tax IIhY 83-0404201
brAndersen.
YINOap RLPUQKYeN7 MMdvrtnrm,pny
OF GRudix MAF&U]IuaPl'1'g AtII,New HAasasenea
WINDOW SPECIFICATION SHM
Buyer(s)Name
Date of Agreement
NAALI I 1
The Buyer(s)limed uMve hendLyiointly and severally agree to purchase the g w
oods anA/pr services listed belo ,In uccordanet With the priors and terms
described nn the SpeciBeation Shxi and the front and dte reverse 01 file accompanying CI!$1'OM WLN1sOW AND DOOR REMODELING AGREEMENT,
of which Ibis Spwihcaurn,sheet is a part.
WINDOW DETAILS
I. C'oatrach+r will Install a lotul of windows in Owner's humq using the following individual quantities:
__. Pouble Hung(DB) glad Sash ❑ Q+ttsge sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top. 1/3 ironer)
Casement Cm ❑ Hinge right ❑ Hinge tell(aS viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement(CDW) ❑ Standard handle ❑ Metro handle
—__Casement/Picture/Casement(CFW) ❑ I-1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Mctro handle
_-_2 Lite Gliding,Window(CAI)
Glider/PICnme/Gilder(GPW) ❑ I:1:1 or ❑ h:2:1
Awning Window(AM) ttichme Window(PW)
,s-,�Bay or Bow Window Fano Doors(see separate Door Specification Sheet)
ft?2. yes ❑ No Qly of Window,,to bo Lustom Fit Repinocmc it: _
3. ❑ Yes ❑ No `ty of Sills to be replaced by Contractor:
4. ❑ Yes ❑ No Oty of Windows tc be New Construclion Full frame(includes new interior k exterior casings)and actual
Exterior I%, ❑ fine ❑ Maintenance-free material ❑ Factory applied 908 Fibrcx brickmold
B. Glnaing N be' ow-R-4 TM ❑ Other If other,please specify:
6. Exterior color to be: White ❑ Send ❑ Canvas ❑ Tcnatone❑ Cocoa Bean
7. Interior color to be: gewhitc ❑ Sand ❑ Canvas ❑ Tcreatonc ❑ Pine ❑ Maple ❑ Oak
Not: Inter' eolnr Can only Lw white,wood or same color as cxlerler. Wood inferiors need to finished by Owmcr.
B. Hardware: YWhitc ❑ Skne ❑ Canvas ❑ Brass ❑ Estate Hardware: style:
9. ❑ Ycs o Install Lifts with Double Hung kndows .
10. Screens: windows M hn te: ❑ Half nr II screens Screens to be: ❑ Fiberglass ❑ Aluminum ❑ 'I'ruScene
GRILLE DETAILS
11,Windows have,gnIles: ❑ Yes ❑ No If yes:❑ Grille Retw•ten Glass man Frt.bla Interior Wcx d al❑ PoII Divided light ono
Qty:All QtV: Qty: Qty: Q(y Qty: Qtv:
J ,1
DX DH CW/Piulury OIdM LIA
Draw grille patterns above 'Use additional sheet if needed Owner approved(initiaLs):( ]
ADDITIONAL WORK DETAILS
12.❑ Yes o Contractor will remove metal it--of windows, l y of Iln its:
13.❑ Yes 9�<o Contractor will install new paint realy or stain-txady,casings.
Interior casing city of openings: Exteriorcastil gtyofopenings: ❑ line ❑ Maintenance,free material
14.❑ Yes [P'K-o Contractor will install new point-ready or stain-ready inside or outside stops qry of openings:
Interior stops city of openings: Exterior stops qty of openings: ❑ Pine❑ Maintenance-free materal
IS. Owner Il
is4vrar s that Contractor does net do arty pair lg. ( )Owner hdtiels
1G.❑ Yes ,Y�•...Contractorwill wrap exterior endings with aluminum coil stock of color.
RV
.INote: Wrapping may be required with skam window removal;removal of storm windows will leave screw holes in casing.
17.hy-,es ❑ No Contractor will insulate,caulk and seal windows with 3•point system to prevent water and air infiltration.
I H.[2?'9ca ❑No Clean up nlljob related debris including old winduws will he remnved.Vacuum nightly.
19.[R�' ❑ No A limited warranty shall be issued to Owner upon completion of thejob and payment in full.
20. cs ❑ No Raul inst Permit t—Contractor will seeure any and all necessary permits. The fee for the permits)n not
mcl sd in the Contract Price and a separate Cheek is required at the time of sac for this fee.
2 L es ❑No All discounts have been applied to this agreement pane.
22. Additional Jobdin ils:
!, fTit� r
/ 1
23. ❑ Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No thial Aelymeare shall lK densnndsrf anti!/!te mnnact fs cnrnplew h,the sntislmolion p!'ali'myr iiw,
It is agreed and understood 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 ere no verbal understandings changing or modifying any of the
terms. T16 Specification Sheet may not be changed or its terms modmed or vaned In myy wttY tudess such changes and in writing and signed by both
the Buycr(s)and Contractor. Buyerls)hereby acknowledge that Buyer(s)has read this Specification Sheet.
Renewal rit a r NH Buyer(s) Buyer(s)
S store of product Signature Signature
.TON/✓ T. \ b/V/a ti
Print Name of Product Manager Print Name Print Name
From: Jeff Conley [mailto:s-jconley@comcast.net]
Sent: Tuesday, June 28, 2011 6:55 PM
To: Shannon Lacy
Subject: RE: Approval Request -John Ronan 10 Settlers Way Salem, MA 01970
Shannon —
You are good to go with the Ronan's`windows.
From: Shannon Lacy [mailto:SLacy@renewalboston.com]
Sent: Friday, June 24, 2011 2:23 PM
To: Jeff Conley
Subject: RE: Approval Request - John Ronan 10 Settlers Way Salem, MA 01970
Hi Jeff,
Thanks for the prompt response. I look forward to hearing from you. If you could please just fax me
the signed approval request upon Trustee approval that would be great.
Have a great weekend!
Shannon Lacy
Sales Administration &
Residential Development Relations
Renewal by Andersen
too Otis Street
Northborough, MA 01532
Office: 5o8-919-o9n Fax: 774-987-3013
slacy@renewalboston.com
From: Jeff Conley [mailto:s-jconley@comcast.net]
Sent: Friday, June 24, 2011 2:21 PM
To: Shannon Lacy
Subject: RE: Approval Request -John Ronan 10 Settlers Way Salem, MA 01970
Shannon,
I will circulate this request to my fellow Trustees and get back to you soon. Where your company
has already installed the same window in the complex I don't anticipate any problems.
From: Shannon Lacy [mailto:SLacy@renewalboston.com]
Sent: Friday, June 24, 2011 11:47 AM
To: s-jconley@comcast.net
Subject: Approval Request - John Ronan 10 Settlers Way Salem, MA 01970
Importance: High
,�.r.yas��. �,.y�,p.,y�.r,.4+�.mwea3rahrad ki:�4�a.t�f+v�4�4a+aP9*sa�a•ua dga vxa�.,�s-r�-aa,�as s�?-:w�+bm�2a+r�a t
Good Afternoon Jeff,
I am contacting you in regards to window replacement approval for John Ronan at the
address listed above. I have attached PDF files of our Certificate of Insurance, the
window specifications, and an approval request which upon approval must be signed and
dated and faxed back to me at the fax # listed below.
The window order for the above property is as follows:
(8) Double Hung windows -white interior /white exterior-grilles to
match existing
If you need any further information, please let me know. If you could also confirm
receipt of this information and let me know when a decision can be expected that would
be great.
Thanks and have a great day!
Shannon Lacy
Sales Administration R
Residential Development Relations
Renewal by Andersen
104 Otis Street
Northborougb, MA 01532
Office: 508-919-o9n Fax: 774-987-3013
slacy@renewalboston.com
This email and any attached files are confidential and intended solely for the intended
recipient(s). If you are not the named recipient you should not read, distribute, copy or alter
this email. Any views or opinions expressed in this email are those of the author and do not
represent those of the company. Warning: Although precautions have been taken to make sure
no viruses are present in this email, the company cannot accept responsibility for any loss or k.
damage that arise from the use of this email or attachments.
This email and any attached files are confidential and intended solely for the intended
recipient(s). If you are not the named recipient you should not read, distribute, copy or alter
this email. Any views or opinions expressed in this email are those of the author and do not
represent those of the company. Warning: Although precautions have been taken to make sure
no viruses are present in this email, the company cannot accept responsibility for any loss or
damage that arise from the use of this email or attachments.
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
k1ri 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n Please Print Legibly
Name(Business/Organization/Individual): °n e Ua ' ) //l�C t' s' 9/
Address: p I �6'7 r7i S W r(feL
I
City/State/Zip: LJ rA p b r6 Phone #: (U� 1F\J ��/`' 9 4)(9
Are you an employer? Check the appropriate box: Type of project(required):
LMI am a employer with �9 o 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. t �• 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
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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#l must also fill out the section below showing thew workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContmetors that check this box must attached an additional sheet showing the time of the subcontractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
o2, r
Policy#or Self-ins. Lic. #: i\,j:7 �,�� � �'/�� Expiration Date:__ �_
Job Site Address: I h SP N\ef� nu City/State/Zip: Ste.,e,vt [Aih DVR
Attach a copy of the workers'compensation policy Jectaration 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 c rt' under th pai and penalties o dury that the information provided above is true and correct
Signature: Date: tt c
Phone#: )
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 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
® CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD YYYY
ACORO
`�• 02/09/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER - CONTAC
Joseph McKeone P owe FAX
E , 734-662-8100 ac No:
JP McKeone Insurance Agency, Inc. E-MAIL
ADDRESS:
P.O. Box 333 INSURERS AFFORDING COVERAGE NAICIt
Ann Arbor, MI 48106-0333 INSURER A: Hartford Insurance Company
INSURED J&L Windows, Inc. Renewal by Andersen INSURER B:Nautilus
104 Otis St. INSURER C
Northborough, MA 01532 INSURER D:
INSUflEfl E
NSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE I L BUBR POLICY EFF POLICY EXP LIMBS
LTR POLICY NUMBER MMIDD/YYVY MM/DO/YYYY
B GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
COMMERCIAL GENERALLIABILITY NC958461 10/01/2010 10/01/2011 PREMISES Ea Pc cur adnce $ 100000
CLAIMS-MADE 121 OCCUR MED EXP(Any one person) $ 5,000
PERSONAL&AM INJURY If 1.000.000
GENERAL AGGREGATE $ 2.000.000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2000000
POLICY PRO. LOC $
A ROMOBILE LIABILITY 35MGCXD6390 10/01/2010 10/01/2011 Gomel 0SINGLE LIMIT 1,000,000
ANY AUTO BODILY INJURY(Par person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS $
HIRED AUTOS q
ANON-OWNED FeOac tl�DAMAGE
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS DAB CLAIMS-MADE AGGREGATE $
DE I I RETENTION$ $
WORKERS COMPENSATION 35WECPP1444 02/17/2011 02/17/20121� we STATUS OTH-
A AND EMPLOYERS LIABILITYLIM
ANY PROPRIETORPARTNER/EXECUTIVE F7 N/A EL EACH ACCIDENT $ 500000
OFFICERM.EMBER EXCLUDED?
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below ! E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Mail Remarks Schedule,if more span is required)
CERTIFICATE HOLDER CANCELLATION
INSURED COPY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
C 19BB-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
?lassachusetts - Department of Public Safer
Board(of Buildim, Rceulatiuns anti Stand:a-ds -
Construction Supervisor License
License: CS 95707
BRIAN DENNISON _
86 CREST CIRCLE -
WORCESTER, MA 01603
Expiration: 9/8/2012
('uunuisi unrr Tr+: 2622
�,A.. � ..�t7ee lJo-,=vrs�o�ruiealC�i o�./N.amac%uae�b "ICI
Office of Consumer Affairs&Business Regulation
I;IOMEIMPROVg�MENT CONTRACTOR
-
Regfstratwrt: g9g01 -
.Expi t�i 4F 12
i t Card
RENEWAL BY
.-BRIAN DENNIS- /�+ -
104 OTIS STRE 'F=��`.
3
NORTHBOROUGH Ms',O'1T332 Undersecretary
.� �
1 �
) A 11-
.44
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WINDOW REPLACEMENT an Andersen Company
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 mail. As we work in emery town in the state, it greatly helps us in
our process.
We have also enclosed a self addressed and postage paid envelope and
would request that when the permit application has been processed, that you
would mail it back to us.
Enclosed for you review in this package is:
❑ 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 please call me at (508)
919-0992.
Best Regards,
Kelley Donahue
Permit Coordinator
104 Otis Street 1
Northborough,MA,01532
Phone(508)919-0900 -
Fax(508)919-0903
Website: www.renewalbvandersenxom