9 WEST TER - BUILDING INSPECTION (3) c -7-7a
i The Commonwealth of Massachusetts
4 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
RevlsedMar2017
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Fomily Dwelling
This Section For Official Use C�
Building P�r�muit'Numb�r: Date Applied: _
B_oildingOfGeW(PddtName) Si ut=
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
9 WEST TERRACE 33 33-0736-0
l.la is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Rl SINGLE FAMILY
Zoning Nstlict Proposed Use Lot Area(sq it) PrmdW(11)
1.5 Building Setbacks(11)
Front Yard Side Yards Rear Yard
Requved Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O fie: Outside— Flood
Zone? Municipal❑ On e disposal system (3Check if
SECTION 2a PROPERTY OWNERSHW
2.1 Owner'of Record:
JEAN-PAUL BANVILLE SALEM,MA 01970
Name(Print) City,State,ZIP
9 WEST TERRACE 978-144-3779
No.and Street — Telephom Email Address
Sggp"3:DESCRIPTION OF PROPOSED WOR10(check all that apply)
New Coastr udion❑ Existing Building 0 Owner-Occupied ei I Repairs(s) 2§ 1 Alteration(s) O I Addition 4
Demolition ❑ Accessory Bldg.O Number of Units_ I Other b Specify: REPLACEMENT
Brief Description of Proposed Woriz: REPLACE 8 WINDOWS-NO STRUCTURAL CHANGE
SBCMON 4:ESTIMATED CONSTRUCTIONCOSTS S
Item Estimated Costs: - r OfflcIa4Uae OW,
and Materials
LB $ 14,870.00 4,,Building Permit Feet$ Indicate how fee is determined.-
2.Electrical $ 13 Standard Ciiy/Town Application Fee
❑Total Neq Costs(Item 6)x multiplier _ x`
3.Plumbing $ 2. Other Fees. $ }
4.Mechanical (HVAC) $ Lis
5.Mechanical (Five
S $ Total All Fees?$ z
6.Total Protect Cost: $ 14,870.00 Check No. Check Amount: Cash Amount:' {
0 Paid in Frill 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125 10-06-14
JAIME MORIN License Number Eqaation Date
Name of CSL Holder U
List CSL Type(see below)
86 GARDINER ST. LYNN,MA 01905
No.and Street Iype Description.
U Unrestricted to35 000 cu.R
LYNN,MA 01905 R Restricted l&2 Fandly Dwelling
City/Town,State,21P M Masonry
RC Roollu Covering
WS window and Sidioa
SF Solid Fuel Burning Appliances
508-351-2200 X 55285 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 12-23-15
RENEWAL BY ANDERSEN HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
104 OTIS ST
NORTH Shed
MA 01532 508-351-2200 X 55285 Email address
City/Town,State,ZIP Tel one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G3,.a 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 permiL _
Signed Affidavit Attached? Yes..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE CONFIRM WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject paopmrty,hereby authorize JAIME MORIN
to act on my behalf;in ail matters relative to work authorized by this building permit application
Print Owner's Name(Electronic SWatm) Date
SECTION'7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name low, hereby attest under the pains and penalties of perjury that an of the information
contained in this application' true and accurate to the best of my knowledge and understanding.'
12-19-13
Print Owner's or A Agent's Naok(Electronic Sigoatme) Date
NOTES:
1. An Owner Wobtains a building permit to do hWher own work,or an owned who hams an unregistered contractor
(not registifed in the Home Improvement Contractor(HIC)Program),will ant 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 mess.eov/ax Information on the Construction Supervisor Liceuse can be found at www.masa.rov/dua
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (including garage,finished basemonUattics,decks or porch)
(cross living area(sq.%) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/parches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for`°Total Project Cost" $14,870.00
DATE istamo,"
'°C� CERTIFICATE OF LIABILITY INSURANCE
30/01/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and conditions of Me policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to it,
certificate holder in lieu of such endomemen a).
PRODUCER 1-622-333-3323 A
mays Coupanie0 E-
PHONE 3323FXX
80 South Sth Street •Y,VL . 612-333- IM Ne: 612-373-7270
Suite 700 DRESS'
NimeapoliO, IIB 55402 INSU AFFORDING COVERAGE Wq4
INSURED INSURERA: OLD REPUBLIC rise CO 24147
Renewal by Andersen Corporation INSURER B: RATIONAL ONION FIRS INS W OF FITTS 19445
INSURER C:
104 Otte $treat -
INSURER 0:
Rorthborough, NA 02532 MUM E: .
WSDREp F
COVERAGES CERTIFICATE NUMBER: 36122490 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE PONY R UI INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N MAY
BE ISSUE NO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE AND
O 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.
INSRI TYPEWINSUIUNCE E POUCYEFF POLICY EW
one POl1CYNUNSER LYRE
A DENERALLUIBLLM OMY 300361 10/02/1 10/01/14 MH OCCURRENCE S1,000,000
COMMERCIAL GENERAL UABIUrY Mfg E500,000
CLAIMS-MINE 111 OCCUR MED EW ow 610,000
PERSONAL A AOV INJURY s 1,000,000
GENERAL AGGREGATE s 4,000,000
GENT AGGK"n UMn APPLIES PER: PRODUCTS-COMProPgGG s4,000,000
E POLICY PR0. LOC 4
A AUrONOBILE LMBILIIY 111711 300026
IU/0111 I 1 MINED SIN LE UMn
E IEeeWuntl 5,000,000
ANYAUTO BOpLLY OLIURY(Pm a
I%rrDOSYINED $C 0DULED
BODLLY RUURY(Preoi0en0 i
E HRE'DA1/TOS N
AUTO$ED PROPERTYDANAGE
3
B E UMBM"I'IAB E OCCUR 20562235
EXCESSLw 20/01/1 1o/o1/u EAaloccuRnwcE 4 u,000,000
CWMS#IADE AGGREfiA,R
DED E RETE $25.000 s 2s.000,000
A AWIIOI.NFSL ELWIUIY YIN WC 300359 00 10/01/1 10/01/24 X VA:STATLL OTµ 6
ANY PR W RIETORNARTNEP/OtECME
OFFICEpA1EMaEp EXCLUDED? B� NTA E.L.EACH ACCIOEM i 1,000,000
ryFnaetorym N 4 21000,000
pyyaae eml0e under E.L.DISEASE EA EL• MP
OESLIRIPTION OF11 OPEMTgNS OMw E.L DISEASE-POUCYMIT 41.000.000
DESCRIPTION W OPERATIONS I LOCAMM I WWLES Ofta AMD 101,A4dAienel lbine4u EdNduM,Mmen FWq N mpu0e4) _
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
To Nhm It Rey rp THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
For Insurance Puurpoosesses only ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZEDRWREEEMATIYE
V
®1888.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
jbargreve
36222490
MassachuseMs Department of Public Safety ,e�
'Board of Budding Regulations and Stan#ards� ;
Cgnstruchon SuPen isor
License CS-090125
dl
JAIM L MORN;
86 G,MDNFR Si
LYNN MA-01905 ' IMF
i
"11' Expiration
; :Commissioner. 10/06/2014 !
I
SCA 1 Ci 20M-05111
dlte�panlmxaanuievl/�o�P/�(aeaar�u
frtce of Consumer Affairs&Business Reguladon
... OME IMPROVEMENT CONTRACTOR
Registration! 1I-, 0j
Expiration 12f23/2015 Type:
. RENEWAL BY ANDERSON� Supplement f;
CORPORATION
�1 r
JAIME MORIN 'tz
104 OTIS STREET '...,
NORTHBOROUGH, MA 01532 —
Underse—._
CITY OF Ss',I.ENI, MASSACHUSEM
SULONG DEPAIMENT
120 W.UMNGTON STREET,r FLOOR
TEL(978)745-9595
FAX.(978)740-9846
ICI�ERI.L'Y DRISCOLL
MAYOR THOMM Sr.PmRRE
DIRECTOR OF W;KX PROPERLYIV LDING COMDQSSMER
Construction Debris Disposal Affidavit
(required fix all demolition and renovation work)
In W40MMO with the sixth edition of the State Building Code,780 CMR section 111.5
Debris,and the provisions of MGL c 40,S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as deed by MGL c
111.S 150A.
The debris will be transported by:
RENEWAL BY ANDERSEN
(aux of hauler)
The debris will be disposed of in :
RENEWAL BY ANDERSEN
(name of facility)
104 OTIS ST NORTHBORO,MA 01532
(addms of facility)
si oPpenaitapplieant
12-19-13
date
dicbrimfl:dc
;linen.a MA Home Improvement Contractor
�,N en. License#170810(Expires 12/23/2013)
IdelS
wrsoow aeerseearRenewal by Andersen Corporation Federal Tax ID#41-1918413
104 Otis St. Northborough,MA 01532
(508)351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Bu er(s Name Date:
JEAN-PAUL BANVILLE - OCTOBER 25 2013
Buyer(s)Street Address,City,State and Zip Code
9 WEST TER. SALEM MA 01970
Email Address Home Tele hone Number WoritCell-fielerahone Number
aba5546(ftomcast.net s7s-7aa-377s1 508-523-5725
Buyers)hereby jointly and severally agrees to purchase the goods 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 sheets)(collectively,this
"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Total Job Amount $ 11,240.00 Amount Financed $ 10,000.00 Est. Start Date Method of Payment
Deposit Received(33%)$ 1,240.00 v; Check/Cash
- 8-11 weeks
Balance Start of Job(330k)$ 0.00 Front Deposit(50%)$ 5,000.00 -
Balance an Substantial Substantial Est. Install Time El Credit Card
Completion of Job(33%)$ 0.00 Completion (50%)$ 5,000.00 1-2 days 0 credit is selected,please
see Credit Card Pa meat Form.
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,antl 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(s)and Contractor. Buyers)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,
an the date first written above and 2)was orally Informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE
ANY BLANK SPACES.
Renewal by Anderson Corporation ' Buyer(s) Buyer(s)
By: / VLdGi ,, r8,,. v Signature of Project Manager Signature -Signature
MITCHELL TORO JEAN-PAUL BANVILLE
Printed Name of Project Manager Printed Name Printed 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 NOTCIE OF CANCELLATION,FORMS FOR AN EXPLANATION OF THIS RIGHT..-
_T______
NOTICE OF CAN 1 - NOTICE OF CANCELUITtON
Date of T ortion 10/23/13 . You may eancel this I Date of Transaction W/25/13 - . You may cancel this
transaction,without any penalty or obligation,within three 1 transaction,without any penalty or obligation,within three
business days from the above dam If yen cannot,any property -business days from the above date.If you cancel,any property
traded to,any payments made by you under the Camrar:of Sale, traded in,any psymenb made by you under the Contract of Sale,
and any negotiable internment executed by you wall be returned and any negotiable instrument executed by you will be returned
(within 10 days following receipt by the Contractor("Seger") of within 10 days following receipt by the Contractor("Seller") of
your conceDation notice,and any security interest arising out of your canmBation notice,and any security interest arising not of
Ithe transaction wall be canceled. If you cancel,you must make the transaction will be canceled. If you cancel,you must makr
javailable m the Seller at your residence,in substantially as good I available to the Seller at your residence,in substantially as good
condition as when received,any goods delivered to you under I condition as when received,any goods delivered to you under this
this Contract or Sale; or you may,if you wish,comply with the I Contract or Sale or you may,if you wish,comply with the
instructions of the Seller regarding the return shipment of the I instructioat of the Seger regarding the return shipment of the
goods at the Seller's expense and risk. If you do make the goods I goods at the Seller's expense and risk. If you do make the goods
available to the Seger and the Seller does not pack them up I available to the Seger and the Seger does not pick them up within
within 20 days of the date of your Notice of Cancellation,you I 20 days of the date of your Notice of Cancellation,yen may tend.
easy retain or dispose of the goods without any further or dispose of the goods without any further obligation. If you.fail
obligation. If yeah fail to make the goods available to the Seller I to make the goods avagable to the Seller,or if you agree to return
or if you agree to return the goods to the Seger and fail to do so, 1 the goods to the,Seger,and full to do so,than you remade gable for
then you remain liable for perfarmaae of all obligations under 1 performance of all obligations under the Contract To cancel this
the Couuact. To rettel this transaction,mail or deliver a signed 1 tramaction,mail or deliver a signed and dated copy of this
and dated copy of this cancellation amice or any other written I cancellation notice or any other written notice,or send a telegram
notice,or send a telegram to Contactor, Renewal by Andereen, I m Contractor- Renewal by Andersee,IN Otis St.Northborough,
104 Otis St. Northborough,MA 01532,BY NOT IFTER THAN I MA 01532, BY NOT LATER THAN MIDNIGHT
OF 10/28/13 .(Date) I HEREBY CANCEL THIS TRANSACTION, I OF 10/28/13 .(Date) I HEREBY CANCEL THIS TRANSACTION.
_ I ?
Buyef¢bbnelure Pat Near pate I BuyehslpneW,a - Pa.1 Naas One
_ I
4�,,el ,ew'ah Renewal by Andersen Corporation MA Home Improvement Contractor
wA. ndersen. 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2013)
!mxxow aeaucrraxr �n na.ti,,..,,a.,.a;.,w (508)351-2200 Fax:(508)-986-7072 - Federal ID#41-1918413
Window Specification Sheet
Burye s)Name Date of Agreement
JEAN-PAUL BANVILLE QCtOber 25,2013
The buyer(s)listed above herebyjoindy 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 the Specification Sheet is pan.
WINDOW DETAILS
Style Full/ Appmx. Exterior Manor Hardware Hardware We,E4/ G411e Grille Glass
Ream k Style Detail Insert U.I. Lines Db Sills Color Color Color S le Screens Smarmun Grilles Sash 1/3 Sash 2 Um Options
Bed 1 2 DB:SqUang Equal I Insert 1 85 No Sloped WH WH Stone grandeur FTS Smarts., None ----- ----- --_- No
Bed 2 DB:S uare Equal Insert 85 No Sloped WH WH Stone Land FTS smartsur None ----- ----- ----- No
Bath 1 1 DB:S uare Equal Insert 85 No Sloped WH WH Stone Standarc FTS SmartS.r Nona ----- ----- ----- No
Office 2 DB:Square Equal Insert 85 No Slo ed WH WH Stone 3tandarc FTS 3mar[Sur None ----- ----- ----- No
Landing 1 DB:S uare Equal Insert 85 No Sloped WH WH Stone 3tandarc FTS gmenser None ----- ----- ----- Tem er
0
0
D
0
0
0
0
0
0
Total 8 BAY&BOW DETAILS *See Ba /Bow Measure Sheet
Style Detail/ Approx. Approz. Number Elena Interior End Center LowE/ Roof/ Hardware
Room Count Style Flankere U.I. Casings An re Liles Color Color Grilles sashes sashes Screens Smartsun Sotfll Color
0 0
0 0
SPEC W.TY WINDOW DETAIIA
Full/ I Uo E/ ADDMONALWORR DETAII.NOTES
Appro.. Exterior Interior
Room Count style Insert U.I. S carts to Grilles Gnli. a Color Cobr Caswmer u awes chat with bay/bow xindona under 72lnchrs
0 thK will be 9i ih®nt lass lwe.
0
0
0
ADDMONAL WORK DETAILS
I No Qty of 0 Sills 0 Sill noses to be replaced by Contractor.
2 No Contractor will remove metal(names of windows.
3 No Contnaaor will install new 0 paint-ready or 0 Stain-ready 0 Interior 0 Exterior casings in 0 Pine 0 Maintenana-free material
4 No Contracrr will install new 0 paint-readyor 0 Stain-ready 0 Interior 0 Exteriorstopsin 0 Pine—0 'Maintenance-freematerial
5 No Contractor will wran exterior casings with coil stock of color.
Owner is aware that Contractor does not do any painting/staining or removal/installation of a/em,system,window,treatments/hardware.If is the
responsibility of the homeowner to have the alarm system,window'treatments/ham'ware removed prior to installation. We make no guarantee as to
S whether alarms,window treatments,hardware will fit after replacement. Customer is also aware in some cases there will be glass loss. If there Is,the
amount will be dependent on the type of existing windows,type of installation,insert or full frame and window style.We make no guarantee as to the
amount of glass low.Customer is aware and understands any and all unseen rot is not included in this contract.Should any rot be found there will be
an additional charge for time and materials unless so stated in this contract.
7 yes Contractor will Insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris
windows,doors,storm windows and vacuum nightly Included. Upon completion of the job and payment in full,a limited warranty shall be Issued.
8 Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permigs)is not included in the Contract Price and a separate
check is required at the time of sale for this fee. Check#. 3492 $ '82
9 Yes All discounts have been applied to this agreement.
10 zi Yes f) No Owner agrees to be present on the final day of installation for final Inspection and to deliver final payment/finance form(s).
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 parries,and there are no verbal understandings changing or modifying arty of the terms.This Specification Sheet may not be changed or its terms modified or varied
in any way urdeu such changes are in writing and signed by both the Buyers)and Contractor. Evyer(s)hereby acknowledge that Buyers)has read this Specification Sheet.
Renewal by Andersen Corporation - Buyer(s)- Buyer(s)
ay mitchcd'rora V6J
Signature of Project Manager M,-. Signature Y.....' - Signature_.-ua...-t
1 MITCHELL TORO JEAN-PAUL BANVILLE
Print Name of Project Manager Print Name Print Name
•r�.a. esnaecal �. RG11EW lc l by Andersen Corpototio#1' 1� is f 104 Qd4 Strew 61Vadh
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lithe taddt�ma�novpq+lt� v3 � � ita�r�tbr�Ame�snt, �wab,�s�to�t•t S14u1 f, ,tgrdt A�r�t4> t+adA mx iNfpn oteq added +ot A ten w s6tlot.,
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The Commonwealth ofMassaehusetis
Department oflndustrialAecidents
Of•ftce of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information fJ (� Please Print Leetbly
Name (Business/Organization/Individual): I\Cn eyi�1 ,pN 1 j J� �Q�SC✓�
Address:1 o LA \. p*� S Ss- _
City/State/Zip. O tS3>hone#: 5)D
Are you an employer?Check the appropriate box:
, ' Type of project(required):
1„�I I am a employer with 3 J 4• ❑ I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6• New construction'
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. �modellng
ship and have no employees These sub-contractors have g, ❑Demolition
working for mein any capacity, employees and have workers' y Building[No workers' comp.insurance comp.insurance.: g addition
required.] 5. Q We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I.am a homeowner doingall work officers have exercised their g pairs or additions
11. Phlmtiin re
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees, [No workers' 13•❑Other
comp. insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy ihfoimation.
t Homeowners who submit this affidavit indicating ihey are.doing all work and then hue outside contractors must sutimit'a new affidavit indicating such.
=Contractors that cheek this box must attached an additional sheet showing the name of the mb•wntrectors and state whether or not those entities have
employees. If the sub-contractors have employees,they.must provide their workers'comp;policy number.
I am an employer that is providing workers'compensation insurance for my employees. Bdtiu; s the pollcy'ond job site
information. (�
Insurance Company Name:—LkK l�
Policy#or Self-ins.Lic.#: MW C, 30�3S c Q 6 Expiration Date:
Job Site Address,. Ue, e City/State/Zip: Sc. S di 1 019
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do her y c rtl under the pabis and penaties of perjury that the information p'rovlded above is true and correct.
Si ature. Date: ► —[ r(
Phone
[1- Board only. Do not write in this area,to be completed by city or town official
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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 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
❑ 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 questions regarding this application please call me at: 508-351-2200 X 55285
Regards,
Kelley Donahue
Permit Coordinator
104 Otis Street
Northborough,MA,01532
Phone(508)351-2200 X 55285
Fax (774)-987-3013
Website:www.renewalbvandersenxom