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17 SUMNER RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF SA EM Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 9 Building Official(Prin Name) , Signa / Date y rye- SECTION 1:SITE INFORMATIO i 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers l� .S , „ � D, ill' as dn 'aa L` 0100 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 ning Information:c� 1.4 Property Dimensions: 4l . SG me 63aC7 Zoning District Proposed Use .Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards - Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: r^iP. -l-�Ql 1 Name(Pr nt) City,State,ZIP i'1 Rol, A, - 3 C) No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': --I— SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials) .. . - 1. Building $ + _ O o 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ 3 - ❑Total Project Cost (Item 6)z multiplier x ' 3. Plumbing $ - ''.2. Other Fees: $ 4. Mechanical (HVAC) $ List: ' 5. Mechanical (Fire $ Suppression) Total A11 Fees:$ a Check No. Check Amount: Cash Amount: 5 j)6.Total Project Cost: $ 16 ry, '❑paid in Full Cl Outstanding Balance Due: ._. .i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) tt ba�9� 0\i) r� t 'Fnye)r) License Number Expiration Date Name of CSL Holder /� C� List CSL Type(see below) G U :J S+ No.and Street Type Description p 1�. l� U Unrestricted(Buildings u to 35,000 cu.ft.) W[7 w(n3 II G I-r�l ��L71 R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ` ✓�5 � ��"1]OC� T17f*��Okt�6��f'Yti)�7,Cl�oh I Insulation Tele hone Email address I D Demolition 5.2 Registered Home Improvement Contractor(HIC) ile-1 Lr G.rn l� d� n I'�658q S - al( HIC Registration Number Expiration Date HIC Co any Name br HIC RegisUant Name f ,Q(,_cc4ar S-t Tbr�,Foxo�Ca� roc r6. U. rn 1and Street mail addre s b�rn, h-,a 0 18a1 � -G3� 1� City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......r# No...........❑ SECTION 7a: OWNER'AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize C �-, -� to act on my behalf, in all matters relative to work authorized y this buil ing permit Wplication. rna r I e. 4A61 I] Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION.. By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. i7 Print Owner's or Authorized Agent's Name(Electronic Signature) ��,.Ba Date z ;: ..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 have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.pov/dpss 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) �a9j (including garage,finished basementiattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms a. Number of bathrooms ] Number of halfibaths 0 Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" MA Reg#146589 our Ham 0yours rmm ... CT Reg#0605216 ift lbe Contract# RI Reg erg#26463 Energy Saving Name Improwmeno Federal ID#20-2625129 Corporate Headquarters,,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com 66109 I THIS CONTRACT MADE THE k day of 20 1'• between At vit. )J ld- ,- (Home Owners) (Home Phone) (BuslCell Phone) of r t .r r1 . � c 9 z f , ,fJ n r }1 (Address) (City) (State) (zip) the"Owner"and NEWPRO Operating, LLC, "NEWPRO". (E-Ma16 %I) for proprietary use only NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessaryto install the r> following described work at the premises located at: The job address is a condominium. E (Job Address) 79TAL# ---!I INEWPIRF WINDOW OPTIONS •,� ` x'r ' WINDOWS -Al ) .J SERIES# .-. -r 11 'r Grids: YES ',NO CONTOUR LJSDL EURO LJ DIAMOND Window Color CITY Window Color QTY O S 7MP: (Location) dy t ATOP QBOTTOM Int: 1 ` ..� Int ©. Screens:(Exterior color Full Screen Standard) [L MLF []FULLExt: „,' Ext: Vent Latches: - ❑YES L❑W Capping Color: ;, _ I . I DOORS e* .��'.E.ti�•:,-' '*;;?MODEU":CITY Please initial: ' PVC A Smooth NoMar No Capping Sliding Glass Door ^-vl I MODEL NAME 1, 01A r 4 MODEL# CITY Color In: " Out: Customer understands lRal-NEWPRbi Double Hung 5755 )Qj,. Active: Left Center Right does not do any painting or staining. 2 Lite Slider 757 HDWR: SN BB WH BGE (ie:when removing or replacing interior 3 Lite Slider rA,1/2.114) 753 Entry Door Style - stops or trim). NEWPRO®is not respon- 3 Lite Slider (1/3,113,113) 756 - Color In: Out: Bible for conditions or circumstances be- Casement(Hinged Right) 851 Fiberglass Steel yond'its control including condensation result- Casement(Hinged Left) 852 HDWR: SN Be AGB AB ORB ing from or due to pre-existing conditions. Twin Casement S 853 1 Sidelite S y le ,, y T:a , (circle one): _ Stationary Casement 856 Color In: Out: CASH Triple Casement (1/4,v2,v4) a-;; " P 859 $tOrm ODOr Style 1 Balance paid to installer at completion Triple Casement (1/3,1/3,1/3) 860 - Color \ Picture Window 751 HDWR: SN Be AGB', AB FINANCE Sash Only 752 Left Hinge ! Right Hinge- Bank completion form signed at installation Hopper - 491 Entry Door Style 1,4 1, ; Awning 351 color In: % out: �. 1TOTAL71 Garden Window 798 Fiberglass steel CASH Bay Window(Roof/Soffit) HDWR: SN ` BB AGB AB ORB 'PRICE Bow Window(Roof/soft) Other Door C4 r 1. I DEPOSIT Other Color Irr Out: -WITH ul� Other HDWR: ';.ORDER DESCRIBE WORK&PROMOTIONS APPLIED: ,TOTAI: 7 DUE AT INSTALL Est. Start Date: + Est. Comp. Date: 11 1 ),12- Customer understands this is an"estimated date" 'El Owner has read and agrees to the terms and conditions on the front and the reverse of this Agreement. Owner specifically agrees to the (1)Total Cash Price; (2)work being performed; and (3)work not being performed. Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two(2)copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. ; (Rhode Island Sales Only): Notice to buyer: (1) Do not sign this'Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank. (2)You are entitled to a copy of this Agreement at the time you sign it. (3)You may at any time pay off the full unpaid balance due under this Agreement, and in so doing you may be entitled to receive a partial rebatekof the finance and insurance charges. (4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement. 5 You may cancel this Agreement if it has not been at the main office or branch office of 9 O Y 9 the seller in the Agreement by registered or certified mail,which shall be posted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement, excluding Sunday and any holiday on which regular mail deliveries are not made. See the accompanying notice of cancellation form for an explanation of buyer's rights. (Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education materials. Owner's initials I{ tt< f By: I 'l r 1 tt 6' { J(o EIN# t Signed: 6, Product specialist(Printed Name) Owner BY Signed: NEWPRO Operating;LLC_(Signature) Owner ,} WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy /// R1012 ADDITIONAL TERMS AND CONDITIONS " C') n� ' Wa anrtieP s;.'A�y product warranties are provided by the manufacturers of the products that Owner is purchasing. NEWPRO is also providing Owner with a labor warranty, which covers NEWPRO's labor. Owner understands that Owner should read all the written warranties for complete details of warranty coverage and that warranties are available for complete review before signing this Agreement. Late Cancellation: Owner understands that Owner has three (3) business days to cancel this Agreement. Owner understands that if Owner wants to cancel this Agreement after those three (3) days, NEWPRO does not have to allow that. Owner understands that if NEWPRO does let Owner cancel, however, that Owner will have to pay to NEWPRO a late cancellation fee equal to 33.3% of the purchase price in order to cover NEWPRO's labor,administrative,and material costs, so long as that is legally allowed. Delay/Unknown Conditions/Damages: Owner understands that if NEWPRO determines within thirty(30)days of the date of this Agreement that it cannot perform the work according to NEWPRO's professional standards,NEWPRO can cancel this Agreement,notify Owner of cancellation,and promptly return Owner's money. Owner understands that issues that may cause NEWPRO to cancel this Agreement include incorrect pricing or unknown pre-existing conditions to the property. Owner understands that NEWPRO is not responsible for structural or other defects in the property,and that NEWPRO's products do not cure these problems.Owner understands that the work could be delayed by events that NEWPRO does not control. Owner understands that NEWPRO is not responsible for(a) damages due to causes beyond NEWPRO's control,(b)damages arising from a delay in NEWPRO performing under this Agreemcm,.or (c)unintentional damage to Owner's personal property,it being understood that it is Owner's responsibility to remove/secure his personal property prior to commencement of work. When Money is Due: Owner agrees that when the work is"substantially complete", Owner will pay the balance due on this Agreement. Owner understands that "substantially complete" means the work has been materially finished, functional as intended, and a final inspection,permit, or occupancy certificate, if required, has been obtained. Owner agrees that once Owner has paid the purchase price, if Owner believes any of the work performed by NEWPRO is defective or incomplete, NEWPRO will inspect the work and perform any service Owner is entitled to under this Agreement and/or any warranty. Owner agrees that if Owner does not pay any of the money when it is due, Owner can be charged a late fee of 1.5%on the amount owed for each month the money is not paid. Owner agrees that if Owner defaults on any promises under this Agreement,and NEWPRO hires an attorney to enforce this Agreement,Owner will pay NEWPRO its reasonable legal fees and related costs or expenses,as long as it is legal for Owner to do that. Other Understandings: Owner agrees that Owner will assert a dispute,claim,or controversy(hereafter referred to as a "Claim") arising tinder or relating to this Agreement only on behalf of Owner's own self and that Owner will not assert a Claim on behalf of,or as a member of,a class or group in either an arbitration proceeding,a private attorney general action or in any other forum or action. If a court determines that this specific paragraph is not fully enforceable, the court's determination shall be subject to appeal. This paragraph does not apply to any lawsuit or administrative proceeding tiled against NEWPRO by a state or federal government agency even when such agency is seeking relief on behalf of a class of buyers. Owner agrees and understand that if Owner finances the work, Owner's separately provided financing documents will include the number of monthly payments and the amount of each payment, including any finance charge. Owner promises that he will provide NEWPRO with access to the work area, including access to electrical outlets. Owner understands that this Agreement and any attachments make up the entire understanding between the parties. Owner agrees that any change to this Agreement must be in writing and signed by both parties. (,Massachusetts Sales Only):All contractors and subcontractors must be registered by the administrator of the Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza, Suite 5170, Boston,Massachusetts 02116 Telephone: (617)973-8700. It shall be the obligation of NEWPRO to obtain any and all pernuts necessary under this agreement,as the Owner's Agent.NEWPRO shall advise Owner of any necessary permits. The Owners who secure their own construction-related permits or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. Any deposit required under this Agreement to be paid in advance of the commencement of work shall not exceed the greater of one-third of the total contract price or the actual cost of any materials or equipment of a special order or custom-made nature,which must be ordered in advance of the commencement of work,in order to assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of the patties. (Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE.During the term of this Agreement.NEWPRO shall maintain public liability and property damage insurance covering the work of not less than $500,000 combined single limit, bodily injury and property damage and workers' compensation insurance as required under chapter 29 of title 28. NEWPRO and/or subcontractors or material persons may file a lien in accordance with Rhode Island Mechanics Lien Act,chapter 28 of title 34. (Maine Sales Only): Consumers are strongly advised to visit the Attorney General's publicly accessible website (www.maine.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their homes. The Attorney General can be contacted by telephone at 207-626-8800. Any alteration or deviation from the above contractual specifications that results in a revision of the contract price will be executed only upon the parties entering into a written change order. In addition to any additional warranties agreed to by the parties, NEWPRO warrants that the work will be free from faulty materials, constructed according to the standards of the building code applicable for this location, constructed in a skillful manner, and fit for habitation or appropriate use. The warranty rights and set forth in the Maine Unifor-rn Commercial Code apply to this Agreement. If a dispute arises concerning the provisions of this contract or the performance by the parties that may not be resolved through a small claims action, then the parties agree to settle this dispute by jointly paying for one of the following: ❑ Binding arbitration as regulated by the Maine Uniform Arbitration Act, with the parties agreeing to accept as final the arbitrator's decision; O Nonbinding arbitration, with the parties free to not accept the arbitrator's decision and to seek satisfaction through other means, including a lawsuit; or Z Mediation, with the parties agreeing to enter into good faith negotiations through a neutral mediator in order to attempt to resolve their differences. (Connecticut Sales Only): THIS INSTRUMENT IS BASED UPON A HOME SOLICITATION SALE, WHICH SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT.THIS INSTRUMENT IS NOT NEGOTIABLE. The, owner(s) of NEWPRO is or has been a shareholder, member, partner, or owner of the following corporations, limited liability companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous five years:NONE F(to1h.01(rHdgretoYotrrs JOB#: LEAD PAINT STATUS 562171 Yr Built: 1951 LSWP: _v ONE MUST Wtntlb Page of EXEMPT: BE SELECTED CUSTOMER HALL /�wvC E E-MAIL DATE 1 11 6 12 HOME PHONE 978-745-3860 ADDRESS 17 SUMNER RD WORKICELL PHONE CITY,STATE,ZIP SALEM MASS BEST DAY TO INSTALL: M T W TH F (circle one) JAMES KASSIOTIS 11-30-12 PRODUCT SPECIALIST ESTIMATED START DATE TOTAL#OF #OF BOW/BAY/ GRID COLOR 9/L,',k' WINDOWS GARDEN #OF DOORS (Inssi-idd--elrom0,fleiddell) VCAPCOLORBe -- Stonn �SDL FG: NAPCC-f1q= dee Gamen�sh.1 Steep Contourthem Roof or SOW Patio Praine (circle ane) Diamonds&Keepers(circle one): Whi Almond Bronze Brass (Uncle one) .(Z( Handles&Night Latches(circle all that apply): CSC Almond Bronze No Bottom Handles Night Latches(Night Larches are NOT standard feature) Inside Color(circle one): hite Natural Oak London Walnut Colonial Cherry Muskoka Oak Banister Oak Outside Color(circle one): . hite Univ.Brown Wicker Forest Green Wedge Blue Sandstone Burgandy Bronze Custom OPENING SIZE STOPS NO. STYLE W x H U.I. LOCATION GRID SCR IN OUT CONV ADDITIONS OPENINrrG�1 CUT 1 8755 21X52 73 LIV H / x J-dr x 2 8755 39X52 - ` 91 LIV H /y xs�`^�'`j' x 3 8755 21X52 r 73 LIV H / x,,7vry%` x 4 8755 21X52 73 LIV2 H x��` '-� x 5 8755 39X52 91 LIV2 H 3�3y xSo''X/ x 6 8755 21X52 73 LIV2 H x 3 7 8755 29X52 81 BAS STAIR H 03 J }( x x 8 8853 38X38 76 KIT F ^ ,\ x 3,,//& t y x 9 8755 3OX43 a 73 BATH H OBS TOP AND T C x(1 3 x 10 8755 30X52 r 82 OFF N 3D: X'5R 3 x 1501x 5 3 x 11 8755 3OX52 82 OFF H 1/ 12 8755 30X52 82 BED H �0% x q/ x 13 8755 30X52 82 BED H �y x•{�. y x x x x x ---+ x x Measureman: - Jr-'pZ�c.G,-�(!�(w+✓ t Initials Date Crew Size Needed Time Frame to complete job Capping Type O Special Installation Instructions: NOT DOING WINDOW DH IN KIT — 1 Revised 12/10 ACORL , CERTIFICATE OF LIABILITY INSURANCE I DATE(MWDD/YYPQ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 01/03/2013 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 endorsemerrt(s). PRODUCER ' Ma'CR`7Fit'ire Insurance'A enc' .;`Inc NAME g y PHONE S08.366.6161 FAX 11 West Main Street Eacw� Ed' ac No:S08.366.5202 ADDRESS: Westborough, MA 01S81-1931 PRODUCER p0013793 i%TO ,RID INSURER(S)AFFORDING COVERAGE NILICp INSURED INSURER A: Peerless Insurance Co. 24198 Newpro Operating LLC INSURERS: Acadia Insurance Co. 26 Cedar St. NSURER C: Woburn, MA 01801 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 12-13 Master 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 CONTRACTOR 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, UCED BY PAID CLAIMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RED . IN TYPE OF INSURANCE ADOLSUBR POLIC EFF LIC EXP LTA INSR MO POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY CBP SS89S7 12/31/2012 12/31/2013 EACH OCCURRENCE $ 1,000.00 X COMMERCIAL GENERAL LIABILITY DAMAGE N PREMISE Eno Ere $ ZOO,OOO CLAIMS,MAOEFX]OCCUR MD EXP(Any one parser) $ 5,.11DO PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ I,OOO,OOO POLICY JECT JECT LOC $ AUTOMOBILE LIABILITY BA 8S8417 12/31/2012 12/31/2013 COMBINED SINGLE LIMIT ANY AUTO (Eaaccidant) $ 1,000,000 ALL OWNED AUTOS BODILY I NJ URY(Per person) $ A -X--SGHEouwEDAHTGS - BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON-OWNED AUTOS $ )( UMBRELLALMB X OCCUR CU BS9257 12/31/2012 12/31/2013 EACH OCCURRENCE $ 5,000,000 A EXCESS me CLAIMS-MADE AGGREGATE $ S'000'000. DEDUCTIBLE X RETEMION $ 10,00 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N WC-20-20-003SO6-0 05/01/2012 05/01/2013 X WCYuh11Ts OE B OFFICER/ME BER EXCLUDED?EECUTIVE❑ N/A E.L.EACH ACCIDENT (Mandatory In NH) $ 500,00 If yes,describe under E.LDISEASE-EA EMPLOYEE $ 500,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) CERTIRYCOATEF1QL ER ,_,, QANCIE LLB.LION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORRED OR Timoth Mo ua h., . .:. ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD.25:(2009/09) The ACORD name and logo are registered marks of ACORD +r+uAY.N"i �\ 07. omvmorciUe¢ e n ' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVyMENT CONTRACTOR I: before the expiration date. If found return to: Re istration Office of Consumer Affairs and Business Regulation S 1ASb89 Typc 10 Park Plaza-Suite 5170 Y Explratlop. 72013,_ Supplement i;ard Boston,MA 02116 NEWPRO OPERATING - - f sc l 7HOMAS FOXOt� >v r - 26CEDP,RST WOBURN,MA 01801 - -- Undersecretary Not valid without signature k Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cunst uctw n n Supcn or f"y License CS-029090 ks` A. n THOMAS P FakON a, 230 WALNU 'STv� ' , READING 1 A 01 a' n Expiration Commissioner 11l19/2013 The Commonweutth ofMvmachusetts Department of lndustrW Accidents O,Bice;of IMwstfgatwns 600 ff'ashington Street: Boston,BSA 92111 www.nwss gov/dia Workers' Compensation Insurance Affidavit: $udders/Contractorsll lectr c ans/Plnn►bers' I Aunlicant Information Please Print Legibly f, Name(Bvsiaessiorgmimtion&dividual); he-w p( ��e �a� `k+ LLC-. Address: ate C IidC S+ Citylstate/Zip r lobor-r) , mfl OI go!... Phonem 71 ' 933 iUo Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with . 5 C+ 4. ❑ Lam a general contractor and I 6. ❑New construction employees(full and/orpart-time).• have hired the sub-conusctors 2. I,mm a sole proprietor or partner- Listed on the attached sheet t 1. Remodeling. ship and have no employees These sub-cone actors have 8. ❑Demoliticn working for me in any capacity. worlrers'comp:insurance: g. Building addition [No workers'comp.iasmance 5. [] We are a corporation and its 10, ]Blectriical repairs or additions required.} officers have.exercised their 3.[] I am a homeowner doing all work right of exemption per MOL 1 LEI Plymbing repairs or or add%tons myself[No workers'comp. c.'I52,§l(4);;andwehavelio 12,nRoofrepairs insurance required]t employees..[llto workers' 13.0 Other cmnp-k.sur+nce required_], , tAay applicanttlatdiecics boxkl:mostaiso II[oottho seedm below showotg theirwodcus'compevsanon policy info,metion. t Bamoow�ts who aandt this afd"kindiontmg they ne doing all,wotk and th,hbe outside contrscfI;mostsuhmitaecw'aMdnvit indicating such Idoopactone that check:this box must;snaeheden additional shmetsh"owmgtfiename:ofthe submonaacom and their wod='comp polcy infinmatiom I am,au:m ployer Uaat is providing workers'compensation insurance fur my employees. 'Below is the Polley and job site inforindjam histaanceCompanyNam yy�e: l s JOGKtr,� i fe �SUYunGG rn Qnu Poliep#orSetfins..Lic.1t: � ll � �LG Expiration Date: a6 'C�C13J06' DO" i 5 -�Oi3�' 42d C /State/Z )cam ('0 fl (219 7 d ,Job Site Address:�7 � �rnri er' ?P� � _ snag a copy of tw workers"compensation policy declaration:page(showing the policy number and expiration date);-. t FailuretaseeUre cquerage as required under Section 25A ofMGL c 152.can leadto the:imposition of criminal pegalties of a fine up to$1,500,00 and/or one-ycar imprisonment as well as civil:penalties in the form of'a STOP WORK ORDER and a fine of ap to.£250.00. dy gaise violator. Badviedhacoyftmeatpo may betorwarded#o the Office of Jnvest galions of the DIA for insurance coverage verification.. Ido hereby certify under6ae,pains mrdpenalties ofperjury thatthe-.infornn5I provided above a t m e and correct sianamre�i�l ��-- Date' Phone#N GFjjicfat use only. Do not write hr this area,to be completed by city ortown offre at City or Town: Permiducense.d issuing Authority(circle oqe): I..Board of Health 2.Building Department 3.'City/Towa Clerk 4.$lectrical Inspector 5.Plumbinglaspeetor 6.Other w Contact Person: Phone ENERGY STAR in Highlighled Regions M Qualified NEWPRO MANUFACTURING Rc SUPERMAX DOUBLE HUNG O % �� Cellular PVC frame, Double glazed, Low E coating (e=0.027, S2; 0.149, 154) National Fenestration Rating CouncilO g Ar onlafr filled ® DEV-K•27.00044-00001 k' ENERGY PERFORMANCE RATINGS U-Factor(U.SA-P) Solar Heat Gain Coefficient 0,23 0, 27 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air Leakage (U.S./I-P) 0,48 0m 1 Condensation Resistance 46 Mowfifter all Do Ness ntin9e wreann he appdceme NFflC paoedumfordemrminkil whole poduot peAomxnoe.NFRC npnpe am delemllmd tw a mtedsm of enNm=W corldmms and a apeolpc moductda:NW does notnawmnend myymdeat aM does not wamntme whaNdty of my pmmwt rmyspeclRc uee.(brlwR mmulocmnYSldmsmm mramerpnatuuipertormance hdormadm. vnwi.nhnorg