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15 SETTLERS WAY - BUILDING INSPECTION (3) The Commonwealth of Massachusetts- Board of Building Regulations and Standards FOR Massachusetts State'Building Code,7.80 CMR,7'� Mtn`' edition ICIPAL= � Building Permit Application To Construct,Repair,Renovate Or Demolish a RevisedJarruary. ' _ 1 One-or Pwo-FmnilyDwelling' 7, 2008 7 Tlris'Sectionl: 'al'Use nly . . " B1rildingPetmitNumber. 'D Ap ed: Signature: ` uilding Coaunission ectorofB ild'mp Date SEC!A2gj&g INFORMATION 14 Pro ert-ttyy`,nA,ddress: 1.2 Assessors Map&Parcel Numbers _ts �S�4� IzrS Wa . Wa n003" GIs. 1.1 a 1s this as accepted street?yes_ no Map Number Pareel Number. . 1.3 Zoning Information: ., 1.4 Property Dimensions: n Zoning District Proposed Use.' Lot Area(sq ft) Frpatage(4) 1.5 Building.Setbacks (ft). - Fronl Yard ,; Side Yards ' Rear Xard- - Required . Provided -Required Provided Required Provided - - L:6.W ater.Supply: (bLG.L c 40,§54) 1.7 Flood.Zone Information:. 1.8 Sewage Disposal.System: .:-.-_ Zone outside Flood Zone?-'. Publie❑' Private❑ — Municipal❑ On site disposal system ❑ Check iSyesO SECTION 2: PROPERTY I Oi7,*2,7ERSHIPt 2.1 O nerlofRec° d 2 C I 61 P P,tn lJ �J( I e✓� i S S G��I C( � I.)n t &A Name(Print) Address for Service �T - - r �IRa-a Signature .. .- Telephone -- - -SECTION 3±IJEBCRIPTION OF PROPOSED Vi ORle-(check all that gpp7y)- ls�eu''GcR�C'nction ❑ 'F:::isti:to E'u kh Ej�. O• 'O^ up _ _ .Sepais(s`)''.� -41(^�ticn(s) ❑' Addilicr C .. - - i ::ner- c Fcd.l�_ Deriitlilinn ❑ •AccessnryBldg: ❑ TJurnherofUnits OtherL4spCcifg:_ tc� Grief Description of Proposed Work=: t 7 110 - St vycTJr� G�a�c SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I.Building $ 1. Building Permit Fee:S Indicate how fee is determined: � . -�(Ji.p•uo 2.Electrical g. ❑Standard City/Town Application Fee . .❑Total Project Cost'(Item 6)x multiplier ... x . 3.Plumbin, S 2. Other Fees: S 4.Mechanical.(HVAC) t S List 5.Mechanical, (Fire S Suppression) Total All Fees:S CheckNo. Check Amount Casb Amount 6,TotalProjectCost: S.,O.3 W(o-d- 0Paid in Full ❑Outstanding Bala nceDue: SECT.—IONS.— CONSI 'SER';i s S_1 Licensed Congbruction Supervisor(CSL) . . 1 ,fA�i � . b1/�\•� -Oh �LicrnseNuuibrQ Expiration Date. _ Name of//j��Ir g(� l Lee' ,t et( . O 03 LuCCSL Type(serbelow) . 1`.. . Address ..,T. 'e - ,'�, :. . Des • tion -' U Unres4rcted(UP to 35,000 Cu.Ft R Restricted 1&z Famil Dweliin ..Signature !]��''\\ .. . RC Residential RooSn Covering Telephone. WS Resiammii Wmdow end Sidin SF Residential Solid Put)Burning A fiabcelnstallation . . . . D Residential Demolition 516 Registered,,'Ho a Imp FRvemynt Contractor(HIC)' U/a l-i.,., l'�/I r-4 rrr✓� - W710 .. MIL;Comp�y Name or HPC Regt Registration.Number 1 t's Address - d - 7tG� ,ST7$'3�'t—r7�Cyo `Expiration Date . S�.gnamrq' Telephone SECTION 6.WORiUM, C0TVh NSA110NINSURANCE AFFID:4vIT(M.GS,,c:152_g YSC(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 AffrdayitAftchrb Yes ......... No SECTCQN 7a:,QF�NERr4IITQ011:iATION TO BE•Cp&JPI EII}D,WIEta' OWNER'S AGENT I i;C9NTl?P CTOR APPLIES FQ8BI7IL3t p�BRt]i[iT.. . t ✓n as Owner of the subject propeity hereby authorize t rkk \�J✓1 to act on my be half,in all matters relative to work authorized by this building permit application. signature of owner .. Date -. .. sECT1m1# �b oIZ':oR f� ITs©.RSFd D£,;Cl ©ItT7777 . } ::'x?f2na ernr fcythtar zed Agent tiert b%":decloe dia(time statcnie 6 and mformahon en Lhc fir gotne- atiun'a appitcrtfitie aiaJ accurne;to therbest of ni;LioqTedgc and . .beb'ali . PrintNanic Signature of Owner nr Cuthorized Agcnt . Date _ (Signed underthe pains and penalties of '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 CHIC)Program),will not liave access to the.arbitration program or guaranty fund under hLGJ-c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 7g0`C2VR Regulations 110.116 and 1102,5,respectively. 2. When substantial work is planned,provide the information below Total floors area(Sq.Ft). (including garage,finished basemmt/attics, decks orpomch) Gross living area(Sq.Ft.)_ Habitable room count Number of fneplaces Number ofbedrooms Number ofbathrooms Number ofhalf/baths Type ofheating system Number of decks!porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted'for"Total Project Cost" r2 3 eo DEBTS FORM ; This f=is to he mbmitted with�"1�+�;permit applicafics whi rover th e is debris to be disposed a£ Progc ty�sddress: a;,ei 1`t I e W0.Nt In accm emci wir7� the pmvigms of MOL cA0,g54,:a candi£on of th:Bt il' Pest N=ber is that tie acbii s rcm Ming from this wxk shall be disposed of in a properly liccnscd solid wasta disposal fscili!y as Lffn.d by'-MGL c. 111§150_A. This delxis vtU be disposed of in: . IS3 (Location of Paml#) Sipe=of Pemut Applirant Date • Renewal � PdA Home Improvement Contractor �YAf1C�2152I1. License#170810 (Bspires 12/23/2013) Renewal b{� Andersen COrpOCdilOri Federal Tax ID#41-1 9 7 84 1`3 byA REPLACEMENT pan Mdenen Grmpany J 104 Otis St.;Northborough,hLA 01532 (508)351-2200•Fax:(651)351-4810 CUSTOM N'INTDOW AND DOOR REMODELING AGREEMENT Bvyerls)Name - Dole of AO,eemem Kh%lq5iy A ko '/��ziE�J 1 ��;/-? auyerlsl Slreci Address,Clry.9me,oad zip Code "Moil Address Ha[m/e T�eleph7one N—bb.rr Work Telephone Number Buyers) hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen Corporation ("Contractor'),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectiveiy,this"Agreement').Buyer(s)hereby sivees to sign a completion certificate after Contractor has contracted all work under this Agreement Total lob AmountA 1?06 E ri/mated Starting Date: Meihnd of Payment _/ Deposit Received(33%): _1 rr/—�wK S ❑I heck ❑Cash �25,i .oced Balance at Start of Job 133%): pZ 21so/MC ❑Discover ❑AMEX Eshmafed Completion Date: Balance on Substantial If credit card is selected, please see Credit Card . Completion of Job(33%) D -- Payment Form. Beryer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that there are no verbs]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 Buyers) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 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 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. Banawa7!y ersen Corporation Buyers) Buyers) S�- ct Sio tamre ' ' ' -- - Signature Pdm.Name of Produ6t Manager 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.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF TI3IS RIGHT. s<- x- - - - - - - - - - - - - x- - - - - - x NOTICE OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction . You may cancel Date of Transaction _ . You may cancelthis transaction,with any penaly or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the 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 by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, 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 transaction will be cancled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the e Seller at your residece,in substantially as good condition Seller at your residence,in substantially as good condition n as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sole; or you may, if you wish, comply Contract or Sole;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 ou do make the goods available to the Seller and the the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date pick them up within 20 days of the date of your Notice of your Notice of Cancellation,you may retain or dispose of Cancellation, you may retain or dispose of the goods of the goods without any further obligation. If you fail to without any further obligation. If you fail to make the make the goods available to the Seller, or if you,a e goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so, threen goods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under Cps of all obligations under the Contract. the Contract. To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and siggned and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written niher written notice, or send a telegram to Contractor. notice,or send a telegram to Contractor. Renewal by Andersen Corporation, 104 Otis Renewal by Andersen Corporation, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF .(Date) OF .(Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyer's Slgnawe Prml Nome pole 2vyer's SignoNre Prim Nome Dare RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink ®18LLPI009sa Pn a,ANH Renewal R^-wa) by Andersen Corporation MA Home Improvement Contractor b)Andersen. 104 Otis St.,Nortbborough,MA 01532 License#170S 10(Expires 12/23/2o 13) WINDOW REPLACEMENT'tar,Mdersenepmpany (508)351-2200•Fax:(651)351-4810 Federal Tax ID#41-1918413 WINDOW SPECIFICATION SHEET Buyer(s)Name Date of Agreement I be Buyer(s)hsted above herebylomily 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 revere of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specification Sheet is s part. WINDOW DETAILS 1. Contractor will Install a total of � windows in Owner's home,using the following individual quantities: Double Hung(DR) ❑ Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle _ 2 Lite Gliding Window(GWq Glider/Picture/Glider(GPW) ❑-1:1:1 or ❑ 1:2:1 Awning Window(AVr) Picture Window(PW) Ba�or Bow Window Patio Doors(see separate Door Specificafion Sheet) 2. ( _S ❑ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes ❑ No Qty m Sills to be replaced by Contractor: 4, 1 Yes ❑ No Qty of Windows to be N w Construction Full frame(includes new interior&exterior casings)and actual Exterior craassin�gs: ❑ Pine aintenanee-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: t_I nP Low-E-4 I- ❑ Other If other,please specify: 6. Exterior color to be: 'te ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: - White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. S. Hardware: hire ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ 1'es o install Lifts with Double Hung WiAdows 10. Screens: windows to have: ❑ Half or u1l screens Screens to be: Fiberglass ❑ Aluminum ❑ TruScene GRILLE DETAILS _ 1,1.Windows have grilles: ❑ Yes ' I o If yes:❑ Grille Between Glass anc)❑ Removable Interior Wood mrlwl❑ Full Divided Light(roo QlR Qty— Qb' Qty Qb" Qty: Qty: JILor L on on ewrvm Jcwu o�apu, Draw grille patterns above `Use additional sheet if needed Owner approved(intfials): I (] ADDITIONAL WORK DETAILS 12.❑ Yes V No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes E No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Yes Dy o Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings Interior stops qty of openings: Exterior stops qty of openings ❑ Fine ❑ Maintenance-free material 15. —Ownener is aware that Contractor does not do any painting. ( `t I /) 1 owner Initials 16.ig-res ❑ No Contractor will wrap exterior casings with aluminum coil stock of color. ote: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in easing. 17 V �s ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18.LL_rves ❑No Clean up all job related debris including old windows Will be removed.Vacuum nightly. 'i 9.[9'Yes No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 20. � es ❑ No Building Permit—Contractor will secure any and all necessary permits. The fee for the perrin(s)is not Included in the Contract Price and a separate check is required at the time of sale for this fee. 21.❑ Y"es ❑No Ab discounts have been applied to dais agreement price. 22. Additionaljob details: 23, L Y"es ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. ,No final papmettf shall be demanded until the contract is completed to the satisfacfion ofall parties. It is agreed and understood by and between the parties that the;Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. Phis Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyers)and Contractor. Buver(s)hereby acknowledge flat Buyer(s)has read this Specification Sheet. Renewal nder xs-Y�P orati n Buyer s) _ Buyer(s) b �/ afore of P/roduegret Signature Signature G� Jr�/C�/L Ml D I-641EF j Print Name of Product Manager Print Name Print Name ' Renewal MA Home Improvement Contractor IS�,/\�,..Iersen� ���,•' tieense#170810(Eaxpses 12/23/2013) !'lull Federal Tax ID#41-19184IS wiaouw REPLGCEMEar Renewal by Andersen Corporation 104 Ods St.,Northborough,MA O1532 (508)351-2200•Fax:(651)351-4810 _ SPECIFICATION SHEET Buyer(s)Name - Date of Agreement The Buyer(s)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 par. PATIO DOOR DETAILS I. Install total of: I, Permashield Gliding Patio Doors) L '10"x 6'8" ❑ Other(not availab��e in 8068) Op.panel is left right(as viewed from exterior) Interior and Exterior Color to be: Q—Whine ❑ Canvas ❑ Sandstone ❑ Terramne (Color same inside and out on FS) (lard : Metro: ❑ White tone ❑ Bright Brass ❑ Other—Specify es E❑� Nam�'' Gliding Patio Door to have sidelight? Size: -� ❑ Yes S-No Grilles? If yes: GBG ❑ INTW ❑ FDL(Pattern is standard as viewed in book for all doors) 2. Install total of: Narrowline Gliding Patio Doors) ❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ 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 ❑ INT'W ❑ FDL (Full Divided Light). 3. Install total of: Frenchwood Gliding Patio Door(s) ❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Saidtone ❑ Terratone Interior Wood ❑Pine ❑ Oak ❑ Maple Interior Finish: ❑ Prefrnished White(Available only with white exterior) ❑ Unfinished(Paint/stain done by customer) 3ardwere: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? lives: GBG ❑ ENT'W ❑ FDL (Full Divided Light) Install total of: Frenchwood Hinged Patio Door(s) ❑ 00"x OS" ❑ Other: ❑ Yes ❑ No Active/Passive Panel?: ❑ Left ❑ Right(viewed from ext.which is active) OR ❑ Yes ❑ No Active/Stationary Panel?: ❑ Left ❑ Right Door Swing ❑ inswing ❑ Outswing Exterior Color. ❑ White ❑ Canvas ❑ Sandtone, ❑ Terratone - Interior Wood ❑ Pine ❑ Oak ❑ Maple Interior Finish: ❑ Prefirdshed White ❑ Unfinished(Paint/stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel "[:OTE: Canvas hinged screen frame N/A—must choose white or stone if exterior is canvas" ❑ Ycs ❑ No Hinged Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If ycs: GBG ❑ ixrw ❑ ML (Full Divided light) - _ STORM DOOR DETAILS 5. Install total of: Siorm Doors) ❑ Prd]View❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Sandtone ❑ Bronze ❑ Forest Green S. - Size to be: ❑ 32" ❑ 34"(White only) ❑ S6" ❑ Custom(10 week lead time) Size: 9. Hardware to be: ❑ Bright Brass ❑ Nickel 1.0. Additional job details: 11. Yes ❑ No Owner agrees to be present on the final day of installation for final inspecfion and to deliver final payment. No fmal payment shall be demanded until the contract Is completed to the satisfaction otall parties. 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 are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in Writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet ' Renewal by dersen Co oration Buyer s) Buver(s) 2jj 6 { gnature of Product Manger Signature Signature _ &int Name of Prod ct Manager Print Name Print Name Page 1 of 1 Lacy, Shannon From: Jeff Conley [s-jconley@comcast.net] Sent: Sunday, May 13, 2012 8:10 PM To: Lacy, Shannon Subject: RE: Approval Request- Karen O'Brien 15 Settlers Way Salem, MA 01970 - Response Requested Please Shannon, i Sorry for the delay—the request is approved by the Collins Cove trustees. From: Lacy, Shannon [mailto:Shannon.Lacy@andersencorp.comj Sent., Wednesday, May 02, 2012 1:04 PM To: Jeff Conley Subject: Approval Request - Karen O'Brien 15 Settlers Way Salem, MA 01970 - Response Requested Please Importance; High Good Afternoon Jeff, I am contacting you in regards to the replacement project for Karen O'Brien at the address listed above. I have included all necessary door and window specifications, our certificate of insurance and our approval request which requires a signature upon approval as attachments. The order for this address is as follows: (2) Gliding windows—white interior/exterior—no grilles (4) Permashield Gliding Patio doors—white interior/exterior—no grilles If you could please confirm that you have received this information and when a decision can be expected that would be great. If you need any further information,please let me j know. I look forward to hearing from you. Thanks and have a great day, Jfxll�l?Oy/.Cl.IG� Sales Administration & Residential Development Relations Renewal by Andersen Corporation 104 Otis Street Northborough,MA 01532 Office:508-351-2200 X55300 Fax: 651-351-4810 Shannon.Lacy@andersencorp.com I 5/14/2012 i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' 'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Lelzihly Bus Name( iness/Organization/Individual): \t J�A d 5 r Address: 1 y D-� City/State/Zip: �)c ���4 o U 4\v, CAS 3D Phone #: Are you an employer? Check the appropriate boy: Type of project(required): 1.[L I am a employer with -3 D 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors i 1 El am a sole proprietor or partner- listed on the attached sheet. I [�]Remode ng ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10:❑ Electrical repairs or additions required.] of 3.❑ I am a homeowner doing all work right of exemption per MGL l 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#1 must also fill out the section below showing their work=&'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. *Contactors that check this box most attached an additional sheet showing the name of the sub-comractors 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 —formation. Insurance Insurance Company Name:_ V lY p `b\ \ C r1 S C-0 Policy#or Self-ins.Lic. #: �ec� Il I- Fxpiration Date: Job Site Address: J e-- le fit 1Q City/State/Zip:�A`� �!A V(� 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. n I do hereby.certify urzle—r.,the pain sa penalties ofperjury that the information provided above is true and correct. - f Sienature: //( / Date: S-r f ( a Phone# �� - 35 f - a�➢) Official use only. Do not write in this area, to be completed by city or town offaciaL 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 P A6� CERTIFICATE OF LIABILITY INSURANCE 02_/11/2012 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 - 1-612-333-3323 CONTACT Jonelle Hargrove or Katie Psimos NAME; Hays Companies PHONE 612-333-3323 AX.No 612-373-7270 A/L Nock E-MAIL 80 South Bth Street ADDRESS: Suite .7D0 PRODUCER - Minneapolis, MN 55402 USiD =_RID It INSURERS AFFORDING COVERAGE NAIL N INSURED INSURERA: OLD RBPuBLIC INS CO - 24147 Renewal By Andersen Corporation INSURERS: NATIONAL =ON FIRE INS CO OF PITTS 19445 104 Otis Street INSURER C: INSURER D: Narthborough, MA 01532 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 25114267 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 INDR-Q POLICY NUMBER MWIPOLIDY EF'r MMIDDPOLICY�P LIMITS R A GENERAL UABILFT MWSY 593i3 LO/01/1 10/01/12 EACH OCCURRENCE Is 1,000,000 DAMAG-TORE TED X COMMERCIALGENERALUABILITY PREMISES Ea pccunenca $ 500,000 CLAIMS-MADE I JOCCUR MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY S 1,000,000 GENERALAGGREGATE S 4,0D0,DOD GEN'L AGGREGATE UMITAPPLIES PER: - PRODUCTS-COMPIOP AGO S 3,000,DOD X POLICY PRO- LDC $ A AUTOMOBILE LIABILITY MFTB 2L377 10/01/1 LO/01/12 COMBINED SINGLE LIMIT $ 3,000,000 - (Ea accitl,int) X ANY AUTO BODILY INJURY(Par person) S ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS - PROPERTY DAMAGE X HIRED AUTOS (Peraccident) S X NON-OWNED AUTOS $ S H X UMBRELLA LI4B X OCCUR 25030519 - i0/01/1 10/01/12 EACH OCCURRENCE S 25,000,000 EXCESS Like CLAIMS-MADE - AGGREGATE S 25,000,000 DEDUCTIBLE S X RETENTION S 25,000 $ A WORKERS COMP ENSATION MPlC 117140 00 10/01/1 10/Ol/12 X CRY".U- OEE TH- AND EMPLOYERS'LIABILITY ANY PROPRIEOH ARTNER/EXECU➢VE� NIA EL EACH ACCIDENT S 1,DDO,DDD OFFICERIMEMBER.EXC W DEl (Mandatory in NH) EL DISEASE-EA EMPLOYE S L,000,OOD Ifyes,describe under EL DISEASE POLICY LIMB S 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 1111,Additional Remarks Schedule,it more space Is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Bvidenca of Insurance - THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN - ACCORDANCE WITH THE POLICY PROVISIONS. AUTHDRIZED REPRESENTATNE 1."Simae 1968.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name andlogo are registered marks of ACORD 2511£267 �= 11 assachusett. - Department of Public S:dctN ? Board of Buildin_ Rceulations and Standards - Construction Supervisor License _ License: CS 95707 0 BRIAN DENNISON - Y 86 CREST CIRCLE WORCESTER, NA 01603 - - Expiration: 9182012 (-inuvni"mn'r Tr: 2622 Office of Consumer Affairs&Btisiness Regulation HOME IMPROVEMENT CONTRACTOR Registration: �y]p810 Type: Expiration: 112013 Corporation L_ � TRWALBYA NLI€R 3EN -- --RPORATION �„.� '.' BRIAN DENNISON;y�„_;�;,�_; --) loaorlssr. �X„��_� , NORTHBOROUGH M�09532, - � �, Undersecretary y� J - m sta[9pv " p_o,�reataar�E.mix Renewal 3 FF Arta-rasa WoodMnYl ComPwke IF _ Dual Argon LmLE4 Smarbun Product Typa;.GUdar _ ENERGY PEP.FC)VMANCE RATINGS . U-Factor Solar Hit Gain ant O19 ,Sh-P Meticts ADDTTIONAL'PERFORM"C� RATINGS Visible Tr r smttfanee P4 - msm-s:r�nc-mmmmm nppn�ax NFNcprv:®vm:1m°@^^xdnpx+mtP�v°"° . LwmM� iv=dP"'� N eMmnmmal mnm0ury ena e:{mnK Pr°°"�=� - pe°omivnc�Nr�ntlnVc are o-rnnNea b-slrJ ec . - M'FAC ournmt�mxmxnneMPmou¢ann ins nm'Wnra¢m=valv°v�'�aR'PImu�lm'alp""PxxR u� . L'—�..r..i4�.—scl�nemFa tl4Tf—�em.PMgfoa".s�rhmi ' _ w.MlAlcnR . Vnnva�anc9mr I Andersen Co arabort' RtA G6dm "Window " snutc fim9 c°N°imsnc[ IwMD s n°sue cwruf�pu . Standard. -Frn9 .. NhFc�@ mhnuavmsars,lDU.F:J4+ar�ns DP psF HS-C35 - . .'.'' SE��„gym.•- - . � pwemND en4ID' ' - ahcL-n9.ImY1'mmc . Qlo mEhvn_am sID .' L ma¢°aP�pNyi apo . �' mumirmumtl°mY. - loo-oa514aoa-vaz " . - yEt;rF;,ctECL:tmf�m%d°nr=Wr VAkt''mmuRCelm¢�DG FfuDr�. 6:! I z: PRODUCT PERFORMANCE y Andersen' NF3C Cal tined Total Unit Perform ance (.fined) Andersen'Product" GlassType 0-FeA01' SHGC' VP - 200 Series - _ aear Dual Pane :e 045 0.50 0.63 - ClearOualPene:vhaGA. OAS 0.54 0.56 - V,il[WazM1 Inn, 0.30 ax 055 :-0 hl Hudgerindow-'- LO"E wM Grills 0.30 029 0.49 c HP tarE4 SmartSnn 030 021 OA94y a HP lav{43mar5un w/Galls 031 019 0.43 -19 Clear Dual Pane 0.45 O61 0.64 :N 1 FIT ,D.]Pane idhl Grilles 0.45 054 0.57 - n hl N Wmtlo ! We 030 032 0.56 - !uw-E rlh GAIs 0.31 029 0.50 Clear Dual Pane 0.44 0.63 066 ' N I - Clear Dual Panew Gnlls 0.44 DS] 0.59 T wndnw _ mr,-c 027 034 0.58 Dn.E+rm:Gales 027 030 0.52 :2 _ ,. cl.,Oual Para 0.45 0.60 GIB - .1. me=r Dual PaO,Mdn Unlls 0.45 054 0.56 - Gliding Vienne - - Wn 0.30 032 055 aa - Imv{•-.ft Grilles 030 029 049 _ Ldn- SOMR.n 030 0.21 OAP id,- Saartunw Grin. 0.31 019 0A3 y _-'j• Llaar Dual Pane 0A3 061 D.65 Clear Dual PanevdN Galles 0.43 0. 5 = 058 - f F d,Trasom, W-E 028 033 056 5 ClM1 Tav W dhw. - tav-E whh 6nlls US 030 0.50 _ Imv{Smar6un 027 D22 0.51 � W -E SmahSun win Galles 027 020 0.45 d - Clar Dual Para 0A4 0.61 0.64 ' Clear Oual Pane wNh Grill. 0A5 0.- 0.56 - Wv{ 019 022 056 - - �'.Nanohne , tuw£ rilh Galles MG 029 0.49 � Gliding P.26D Dams 1; Imr{Sun 029 020 0.31 � Ww-E Sun wNn Gnlls 0.31 0-18 027r _ w.E smarcsur D28 GM as0 7 - W11E&rrMnSunwiNGalles 0.30 0-19 OA4 Llear Dual Pane 0.43 0.5i 0.64 Clear Dual Pene%M Gallas 0.43 0.54 056 - - - - InwE 030 032 U.56 - Penner BN eld Isv-E.ft6nl1s 030 029 049 '.Gd gPah Daum IDw{Sun 029 0.19 030 mw<sun wan Ganes 030 017 027 aIId / W:rEsmartSun 027 D22 0.50 a Imr-E Smarton wlu Glls 029 0-19 au '- ClearOualPnne 0.43 GAS 0.47 ❑sr Dud PanewfO Galls 0.43 039 040 Im+f 032 014 0.41 aau � EN gdinswng Imo-E wnh Gnus 033 021 0.35 Pah 0 - D,w S.n 032 015 023 a � lan- S.unh Grills 034 013 0.19 I ESnahSun 032 0.16 037 un,{Snrrt wN6Galles 033 014 031 ibt Mdersen. Andersen NFRC Certified Total Unit Performance famfur9ed) - - Anderrelf Product Glass Type U Facmr' SNGC VP Andersen Product! Glass Type I U Factor' SHGC VP - r Architectural _ _ r•' '" 4005ena _6 '_ � ' ' - " HP ton-E4 -32 0113 1A HP Lox-E4. 0.27 035 O.pu HP Low-E4 with Gala 0.32 025 - 047 I'tl�t�® HP Lui-Elf whin Grilles 0.28 031 0.54 F9 UP Low-E4 Sun 027 021 0.33 F1 ':I® - HP Low-E4Sun 0.32 0-7 0.26F ® clmleTp Dazemen6Yn. UPS-E45un whh Grilles 032 0.16 023 e ® Oaseemalat ntlon xP lux-E4 Sun GGfflb. 0.29 0.19 030 �U® XP Iwv-E45man5un 0.31 0.18 0.42 L IfI® HP Iex-E4 Smarse. 0.26 OZ3 0.54 F^l® '• ,III HP lnvr-E45maR5un w/Galles 0.28 011 0.49 HP inrv-E4 Smmaime w/Galles 0.31 0.17 0.38 '•® . -�l OMI�. HP l HP law-E4 0.32 018 UAI HP Ww{4 0.27 035 0 11 'I UP ton-E4 wdth Galles 0.28 0.31 054 wr-E4 whin Grilles 0.32 025 0.42 !+�® HP Iron-E4 sun 0.27 01l 033 U4 :'1® F ch Case t HP Lmv-E4 sun 03z O.11 0.26 f +. IBM Gmee&o I W Low{I HP lax-E4 Sun vath Grilles D.29 0.19 0.30 1 ['":® W tlow HP tun-E4 Sun whin Galles 0.32 0.1fi 023 HP4 Sun AmanSun 0.26 023 054 R k.'`+® UP UawE4 Smonlli 031 0.,m 0.42 11I NP Low-EUSmehSnow/6aes 0.28 023 0.54 k5 ,:9® 'I HPWx-E SSmmc9un-/Gales 031 0-17 0.38 HP lwv-E4 018 OA3 0.58 - HP law-E4 0.32 02B 0.47 t UP low-E4 rvpA G lies Q29 030 OM .hFa' 5 H HP ton{4 with G.11. 0.32 025 0.42 3 xP lox-Et5un 0.28 0.20 031 � '?® HP tan-E45un 0.32 0.1 016 :f41® Amh Wi tlow Awning Wntl HP lax-E4 Sun whin Imes 0.32 0.16 0.23 .nN® NP Iwi-E45un wM Gnllrs 029 0.18 028 ryp ton-E45maRsun 031 018 0.42 .: IN HP lam-E4 Sner Sum 021 OZ3 0.52 H� ,'i® F5 a �'! HP law-E46man5un w/Gtllles 0.28 021 046 I<il® a HP tsv-E4 SmartSun w/Grilles 131 O1T ' 038 ,I ® HP lux-E4 0.31 0.32 0.55 HP Uuw Ed U.21 0 33 0.58 is UP law-E4 with Gana 028 O30 OM [5 T?G i HP law-E4 with Gr01es 0.31 OZ9 0.99 HP tox-E4Sun 017 0.20 0.31 � ".� Caement/Awn g HP lax-E45un 031 010 0.31 l7® Flesltm W tlow _ HP IwrE4 Sun with Gnlla 0.29 0-18 028 1191 Place Wood.. HP tor.-E4 Sun wall Galles 0.31 0.18 0 28 R. HP tax-E4 GmaRSun 0.2fi 013 0.52 f� !7® HP Lax-E4 SmarGSun 031 02l 0.50 :! xP lux-Ea SmarlSun n/Grilles 028 021 0.46 1-iaj HP lmv-E4 Sma25un w/GaOes 0.31 0.19 0.44 'I_'fit® xP lun-E4 0.31 033 059 UP Imv-E4 D30 037 O.64 '3]!' .j HP HP lax-E4 with GXlles 0.30 033 06 IwnE4 with Galles 0.32 0.30 0.52 US h <i law-E45un 0.31 010 0.31 ?j0 UP tau-E45un 0.31 HP 012 033 H0 Spnngll W tlow SpedalryW tlmv HP Law E4 Sunman Grain0.31 020 0.322 tiJ® HP lmv-Ea Sun with Gape 0.33 018 0.28 '® UP Iwv-E45mml5un 0.30 024 055 Fit yrTl HP Iwr-E4 SmntSm. 0.30 023 0.52 1 I"® tn{43martim w/Grilles 0.32 021 046 F' >.`:'� NP lvx-E4 SmaR5un w/Grilles 0.30 OZZ 0.52 M M 11 HP o HP Iwv-E4 0.30 027 0.45 �'� �:"l HP tun-E4 0.32 022 ®0 3T i l! } HP lox-E4 niN Galles 0.32 023 039 Fq lip® HP Wi with Galles 0.33 020 0.33 NP I,,AG Sun 0.31 0016 0 25 99 F 1® Hmged tnsmng HP Lerv-E45un 0.33 0.14 0.21 Fail Inw d French Ooo UP Lave-E45unwM Grilles 0.34 0.13 0.18 - 3 Gliding P4 D , , j HP tun-E4Sun man Grilles 0.32 014 022 ^.4] .A98 HP lmv-E45maR5un 0.30 0.18 041 H� F7® HP luw{4 Scansion 032 0-15 013 ®-_"'•::•l9 ! pu HP lax-E45mm5un w/Gales 0.31 0.16 035 1� ":'® ! HP tun-E45marl5unw/Galles 0.33 0.14 0.41 �e xP twv-E4 0.31 024 0 41 I �l® wo HP Lorr-E4 0.33 025 0.41 - HPIax-E4 we,Galles 032 02l 035 ri:i� HP Luw-Ell with Grille 0.30 022 0.36 mE i NP Iwr-E4 Sun 0.33 0.16 0.23 e French a..a'N ingcd HP tun-E4 Sun 0.31 0.t5 0 23 rni Ili® H nged Dulsvang e m ]timingPa Door :! HP law-E4 Sun with Galles 032 0.13 019 '� ';+® French Dhr HP IamE43un whin Galles U35 014 010 no wo HP IwrE45mar6un 0.30 0-Ifi 037 o® HP Lax-E4 Smarm. 0.32 0.17 0.37 © 'i'[?;® o� 031 0.14 ��I HPLwv-E4SmmlSunw/Galles 031 @9 '^® HP tmv-E4 Smarlsun w/Galles 0.34 015 032 - E2 HP Iwv-E4 0.31 025 041 Fa F'� HPlws-E4 033 013 0.38 - r'v ri ,{ HP tan-E4 with Gales 032 021 035 {� [I!® f4 HP derv{4 chin Grilles 033021 D.34 = HP left-E45un 0.31 0.15 023 [h. !'2® F tlFren M1Door HP law-E4 Sun G33 0.14 0.21 Freilmod Hiroo pij Starlight' UP Iwv-E4 Sun with Galles 0.34 0.13 0.19 - Outsm g P. boD r HPIux-E45un won Gdoes 032 0.13 019 Hp le, -rise- HP 0.32 0.15 0.34 - HPIax-E4 SeWaSon 030 0.17 037 1�4 t;� _ UP Iwr{46ma25un w/Galles 0.31 0.15 031 F� HP lax-E4 SemLal w/Galles 0.33 0.14 0.30 HP law-E4 0.31 022 037 l� ll HP lax-E4 0.32 G25 OAl _ HP Iwr-E4 with Galles 0.32 OZO 033 `:I HP lax-E4wM Galles 033 022 437 HP lwnE43un 0.32 'F.di pam m -.I HP lux-E45un 032 015 023 = Frei hwo d F n M1Door NP lux-E45unwith Galles 0.33 014 0.20 Pati Oo 6 tlel ghf y HP taw-E4 Sun whin Galles 0.32 0.13 018 11 I'i® Hp lax-E4 Surmise. 0.32 0.16 0.37 - NPWw-E45man5un 0.31 0.15 033 PH F'!9� _ HP l,x 4Smalrsun vi/Gale 0.32 Ot4 029 R1 !'j� _1 UP tun-E4 SmarlSun yr/Galles 0.32 026 0 033 0.44 - HP tun-E4 0.35 HP Wx-E4 0.30 024 0 a0 i' ® UP Ian-E4 with Gnllx 0.36 023 038 - NPIumEE who Galles GIG 021 035 f� .I"® _ HP lmv-E45un 0.30 0.15 022 A7 4fii� UP ley{43un 0.35 0.16 024 Fen h otl Falling Door 36 0.14 021 - Patl D T HP low E45un with Galles 0.31 0.13 020 IPA '.11'i® NP tux-E45unvain Galles 0. HP Iwv-E45marlSun 0.29 Olfi 036 �'--'in HP lmv-Ea SmateSun 0.34 O.li 0.39 - Luw-E4 D 0.14 5mar6un w/Grilles 03 032 ER'.r.-I ® HP lax-E4 Smar5un w/Galles 11.36 0.15 0.34 '! HP - cardsmed4nnatpage •For NFHC counted total unit performance me units wild capillary berathertubes for high subarea,please visit andemenwindows.com. n'IHP Low-E45un)are Andersen lndemarks for'Law-ITglass. •'High-Ped 4`onnance'Low-E (HP Low-E4),-High-Performance Law-E4'SumnSun"IHPLow-E4 Simonson)aoi'High-Performance Law-E4-Su ' D-Facer define the amountaf hea[lass through Ne total unit in BID/arse-ft'EThe lowerlhevslue the less heatis lost through the entire pmbrul Window-hays monism-On-remained glass.Use oflempered glass can increase U-Factor mOngi.See anderseowindows.cum for specific performance values.Door values represent tempered glass. 'Solar Heat Gain Coefficient(SHGQ comes the fraction of solar md!adon admitted through We glass both directly loam rim!and absorbed sad subsequently released inward Thelower We value,We less heat is bansmiumd through the product 'Visible Tmnsmiturem(Yr)measures how much light comes through a product(glass and frame)The higher the wall,(rpm 0 a 1,We more dayligM1[Ne pmduc[lets in overall,pmducCs fatal unit area.Visible Transmittance is measured overthe 390 a 760 nanometerponfgn mane said spectrum, •NFRC mtings are based on modeling by a third may agency as validated by an independenitesl lab in compliance with NFBC program and procedural requirements. •this data is accurate as of December 2010.Due to ongoing Paul changes.updated test results or new industry standards or requirements,Nis data may change overtime.Ratings are for sins specified by NFRC for testing and cenificaaon.Bahngs may vary depending on use Of tempered glass,different gmle options.glass for high ourades,etc •Passi mSun-glass values are available online at andemenwindows.com. 277 Renewal - nde . WINDOW REPLACEMENT anAnndtrsenC=My 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 every 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 ❑ Rome 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 questions regarding this application please call me at: 508-351-2200 X 55285 Regards,. Kelley Donahue Permit Coordinator 104 Otis Street _ Northborough,MA,01532 - Phoae(508)351-2200%55285 Fax(508)774-987-3013 - Vdebsite: www.renewaIbymdersen.com -