67 WHARF ST - BUILDING INSPECTION (2) Cs. The Commonwealth of Massachusetts
" Board of Building Regulations and Standards FOR
a Massachusetts State'Building Code,780 C 7i'edition N1USE. ITY
MR
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January.
One-or Two-Family Zing 1, 2008
i This Section For O ci 'Use
Building Permit Number-
Signature: A '
t� /
fill
Building CommissinnQ/Inspector dings ate
SECTION 1:SITE TION .
I,I Pro erty Ad ress: 1.2 Assess
ors Map &Parcel Numbers
to LJ�i.r� St . 3�1 3L(- .0tiO%2 5(.:�
1.1 a Is this as accepted street?yes_ no_ Map Number Parcel Number.
1.3 toning Information- \\ 1.4 Property Dimensions:
Zoning District Proposed Use, Lot Area(sq ft) - Frgritage(fl)
I.S.Building Setbacks (ft).
Front Yard Side Yards - Rear Yard -
Required Provided Required Provided Required Provided
1,6 Water.Supply: (M.G.L a 40,§54) 1.7 Flood Zone Information:. . 1.8 Sewage Disposal-System:. .._
Zone: Outside Flood Zone?-.
Public❑- Private❑ — Municipal❑ On site disposal system ❑
Cheek ifycs❑
SECTION 2:.PROPERTY OVJN RSRIP'
Owner'ofdecord 1
Name(Print) - Andrus for Service:
Signature Telephone. .. - -
SECTION 3;DESCRIP'i"ION OF PROPOSED WORK=`{check all that app)y)'
Iseu'CcasCtrct oa ❑ &- sti::g B'u RIL3g.❑ O::itEr'::ccupled ❑ : :°epairs(sl':o ^.l:e t en(s) Addiuot .�
Demolition ❑ Accessnr• Bldo.❑ 1Jumberofllnits Other �Specilp:_. �.' ��4P11—w±
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item. Estimated Costs: Official Use Only .
(Labor and Materials)
1.Building $ 1. Building Permit Fee:S Indicate flow fee is determined:
2.Electrical $ ❑Standard City(I'own Application Fee
QTotal Project.Case (Item 6)xmultiplier X .
3:Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Suppression S Total All Fees:$
Check No: Check Amount: - Cash Amount
6,Total Project Cost: $,3c ��.cJA ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5_ CONSTRUCON"SERCES
5.1 Licensed Construction Supervisor(CSL) €
License Number Expiration Date. .
Name of CSL-Ho]dernn •.
�/`k 0-4 .JO.tY 111i19. UsttSL Type(seebelow)
Addrei 7.:� • e;a::a.v:x:�, . ". `Des"....6on _
.. U Unrestricted TD 35 ouu Cu.Ft
Signature . . .. R Restricted 1&2ra ) DWellin . -
�Ol�-�(�-(�C(�ja ]Y Masonry Only
Telephone. RC - Residential Roofing Covcrin
WS' Residential Wmdow and Sidin
. SF Residmtial Solid Fuel eunnng Api>lianm Installation
D- "Residential Demolition-
5,2 Registered�o a improveme t Contractor(MC) 1�c o Ol
(-I1CCompanyNameor1�] Regi nt,N - Registration Number
o s 5T . AA 032 �y
�Addtnsws
Expiration Date .
"- Tdephonc -.
SECTION 6:WORKERS, COMPENSk-LION INSURANCE A:MXVIT(M.G.L.c.is!-§ 25C(6))
Workers Co MP affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the bmlding permit -
Signed Affidavit Attached? Yes ........... No..........❑
SECTION 7a::O ER�O'R�TION To$E•CpMPZ
QVI,N1R'fiAG1 (�7jTL:CONT ACTCRAPPLIESFORBUII3jTN P8St11SiT-
CA ✓\, cow as Owner of the subject property hereby
authorize ()D y\y r-\ e n r\V S n 7 to act on beh
my alt;in all matters
relative to work authorized by this building permit application. -
St ature of Owner - "- - DateM.
-
.
l: (��G ✓3 IJCYI nc Jl t) at f2�beC nr fti thcrtrzcd Agent 4�errbv declare
that the statemepts and information on the f�rcgong application aretue and ecc'nta'te to the best a y l4Sowledge and
behalf
.Print Nam
Signatury er or ghTorized Agent Date _
(Signed under the 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(111C)Program),will not liave access to the arbitration
program"m guaranty fund under M G I c. 142A.Other important information on the MC Program and
Construction Supervisor Licensing(CST.) can be found in 780`CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq.Ft). (including garage,finished basement/attics, decks or porch)
Gross living area(Sq.Ft) Habitable room count
Number of fireplaces Number ofbedrooms
Number ofbathrooms Number ofhalflbaths
Type of heating system Number of decks/porches '
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project CosP' mj i q t7 .o c�
08/04/2007 22:01 5782785010 JOHN BEAVER PAGE 07/07
104 Otis St.,Northb...ng ,MA 01532 j&L WTNDOWS,INC,D/B/A MA Home Improvement Contractor
919.0900•Fax:(774)9W--:101,9 Renewal License#14980I (Expires f/24/2012)
. ° byAndersen. Federal Tax ID#83-0404201
.es,» sill......I mA,m...,re...,,
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Burefill Nea i Oak of moment
a �� ahcc�v !0
B ,eei Addma,Ciry,Slats and VE Cedn
�� .
E7.1a11 Address Home Tele hone NumMr W i tele he Number w
17 - 956.33(q'a
Buycr(s)hereby jointly and severally agrcea to purchase the products and/or services of I&L Windows,Inc.d/b/a Renewal by Andersen
("Contnaetarr0,in accordance with the terms and conditions described an the front and the reverse of this agreement and on the attached
specification shcet(s) (collectively,this"Agreement").BuyeT(s)hereby agrcu to sign a.completion certificate after Contractor has completed
all work under this Agreement, q
Totol Job Amount:..37/0 Eaimotcd Starting D : Method of Payment: Check OCash OFinonced
Deposit Received(33%l:/Zoo �-&l s
Credit Cards are accepted for deposit
Balance at Start oFJob(33%l:�»Ld
Estimated Complation Dale: only-maximum 1/3 of the project cost.
fidonce on Substantial/ � _ Please see Credit Card Payment Form.
Completion of lob(33%): ,�/__ — Cll
By signing this agreement,you acknowledge that the Balance at Stan of Job and the Balance on Substantial Completion
of,Job cannot be made by credit card and most be made by personal check,bank check,or cash.
Buyers) agrees aed understands that this Agreement constitutes the entire understanding between the parties, and that
there are an verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviatioe
from this Agreement will be valid witliont the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby
acknowledges that Rnyer(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.boss and 2)was oraBy Wormed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
,J its L W., a d/b/.1i—til by Andersen Buyers) Buyer(s)
fly:
sir#turr atP u tMnnager Signature Signaturt
ff-
/h. 4abd/2�
Print Name oF'Prnduct Manager Print Namr Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TOMIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT. -
>s- - - - - - - - - - - - - - -yc- - - _ - - _ _,_ _ ;x- - _ - - - - _ ss,
NOTICE OF CANCELLATION YjNOTICE OF CANCELLATION
Dent of Transaction /0-13-// You may cancel Date of Transaction 40 - -/I . Tou may cancel
this transaction,without any penal ey or obligation,within this transaction,without any pencilty or obligation,within .
three business days from the above dale.If you cancel,any three business days from the above dote.Ifyou 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 contract of Sale,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 canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available ra the
Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition
as when received, any goads delivered to you under as when received,any goads delivered M you under this
this Contract or Sale; Orr may, if you wish, comply 1 Contract or Sale;or you may,if you wish,comply with the
with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of
shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make
ff yyoou do make the goods available to the Seller and the l the goads available to the Seller and the Seller does.not
Seller does Trot pick them up within 20 days of the date l pick them up within 20 days of Hie date of your Notice
of your Notice of Cancellation,you may retain or dispose of Cancellation,you may retain or dispose o the goods
of the goods-without a further obE date n.ff you fail to without any further obligation. ff you fail to make the
make the goods available to the Seller,or if yyou agree l goods available to the Seller,or if you agree 10 return the
to return the goods to the Seller and fail to do so,then Dods to the Seller and fail to do so,then you remain liable
you remain liable for performance of all Obligations under fur performance of all obligations under the Contract.
the Contract.To motel this transaction, mail or deliver a I To cancel this transaction, mad or deliver a signed and
siggned and dated copy of this cancellation notice or any dated copy of this cancellation nonce or any ether wnimen
otlrcr written nwtim,or send a Wiegman to Contractor. J notice,or send a dram to Contractor.J&L Windows,
&L Windows,Inc,d/b/o Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Otis Street,
Street, Northborough, MA 0 532, BY NOT LATER THAN Northborough, 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OF D -1 �/ .(Date) 13 •(Date)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION.
Bow%•sis.=w- Prim Ns- D.I. i B.m;.San,.... rim Hem. ea,
RbA Copy- While Buyer Copy-Yellow Buyer Copy,Pink
08/04/2Oe7 22:01 9782785010 JOHN BEAVER PAGE 06/07
1040115 SfMCi,Nwehborough,MA 013,12 )R I.Windows,Inc.d/b/a
Fhonc S08.9190900-I,,.74.987.30I1 Renewal MA IIfC luamx#149WI(CxPLes I J24/12)
F'cdcnl Tax MO 83.0404201
brAndersen.
WINDOW Nfiveq.FNFNT nn AnAa VC,mM�,y
OF GREATS¢MASSACkleseT19 ANn New aalu,vantaie
WINDOW SPECMcATION SfIM
Buyers)Name
Dah:af•Agreement
5 n re
The Bnyer(s)listed above hereby jointly and severally agree to(mrohase the goods sod/or services listed Wow,in accordance wif i the prices and terms
described at the Speeificadori Shed and the front and the rovers of the aeeom sirrip g CUSiY)M WINDOW AND DOOR REMODELING AGREPMENT,
of which this Specification Shcet is apart.
WINDOW DETAILS
1. Contractor will Install a lotal of windows in Owner's home,using the following individual quaint ties:
Double Flung(DR) ❑ Egual sash ❑ Cottage sash (1/3 top,2/3 bottom) ❑ Oriel sash(2/3 fop. 1/3 bottom)
Cnsemenl(C11) ❑ Hinge rig,bf ❑ Hinge left(as viewed from cxtcrior): ❑ Standard handle ❑ Metro handle
Double Casemem(CDW) 10tairdard handle ❑ Melm handle
Casement/Picture/Casement(CPW) ❑ 1!1!1 or ❑ I:Z:L ❑ Standard handle Q Metro handle
2 Life Gliding Window(GW)
Glider/Ficture/Glider(GPW) ❑ 1:1:1 or❑ 1:2:1
Awning Window(AW) Pctlarc Window(FVr)
Bay or Bow Window Palio Doors(scc.se+n'nlrnI Door tipeeificution Sheet)
2. Yes ❑ff1�o Qty of Windows to be Custom Fit Rcplacernent: .�
3. ❑ Yes �;� - Oily of Sills to be replaced by Contractor:
4. ❑ Yet No Qty of Windows to In New Construction Pull frame(includes new interior!¢exterior casings)and aetual�
Exterior cos' s: ❑ Pinc ❑ Maintenance•frce material ❑ Factory applied 908 Fibrex brickmoid
5. Glazing to be: M IfF Lo E-4 rm ❑ Other If other,please specify:
6. Exterior color'to be; tQ y.Whe ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocea Aeav
7. Inferior color to be: rL-F-f/White ❑ Sand ❑ Canvas ❑ Terratone ❑ Fine ❑ Maple ❑ Oak
Note: Int• or color can only be while,wood or same color as exterior. Wood.interiors need to fmishod by Owner.
8. ilardwac. White ❑ Stone ❑ Canvas ❑ Brass ❑ estate Hardware: Style:
9. ❑ Yes Le NO Install i.ifts with Double Hun endows
10. Screens: windows to have: ❑ Hnlf w Frill screens Screens to be: ❑ Fiborglass Aluminum ❑ TruScutc
GIULLE DEFAIIS
11.Windows have grilles: ❑ Ye9 VNo If yes:❑ Uri&Bctwccn Glass mica❑ Ncmmablc Interior Wood mewl❑ Full Divided T ght,m,o
Qty Qtr Qty Qly: QLy! Qty: Qty:
oN oN oN oN Cw/prclra Glass IF:
Naro
Draw grille patterns above 'Use additionalsheet it needed Owner approved find ails):
ADDITIONAL WORK DETAILS
12.❑ Yes o Coilhrnctor winl remove metal frames of windows, Qty of Units:
13.❑ Yes LV No Contractor will install new quint-ready or stain-ready casings.
Inteno using city of openings: F,xlcrior casings qiy of openings: ❑ Fine ❑ Maintenance-free material
14. 3Yes NO Contractor will install new paint-ready orstam-M
or outsidestops city ofopenings:
Interior stops city d openings: Exterior stop ❑ Pine [J Maintenance-frec material
15. Owner is aF , that Contractor clo; not des any puintirVq. Owner mi -Ls
16.❑ Yes No that
Will Wrap exterior casings with k of color,
ote: Wrapping may be required with storm window removal;removal of storfu windows will leave screw holes in easing.
17.Wes ❑ No Contmetor will insulate,caulk and scat windows with 5-point system to prevent water and air infiltration.
]8.Fee
❑❑No Clean up all job related debris including old window,will bc+'cmuvcd.Vacuum nightly.
I Ii es No A limited warranty shall be issued to Owner upon compaction of the job and payment in full.
20. Yes ❑ No EWWille Permit—Contractor will secure any and.all necessary permits. The fee for the permit(s)is net
(included in the Contract Price and a separate check is mquhed nt the time of sale for this fee.
Z1.Q Ycs ❑No All discoums e be lied l01}'is aeement rice./ n
22. Additional job details: _�ems' /� t�>-' (
23. Yv ❑ No I,wrer agrees lobe present on the final day of installation for final inspection and to deliver final payment.
7✓o fi:ml paymrerrtshnl/be demanded ntifi/the contract is completed tc the mbsfachon d'a/1 panics.
It is agreed rind understood by and between the parties that fits SpCCifiCafian Shell,along with the CUSTOM WINDOW AND DOOR REMODELING
AGREEMENT,constitutes the..tire understanding between the parties,and there are no verbal understandings charging or moddying any of the
terns. This Specification Sheet may not be changed or its terms modified or varied in any way unless such clsarkgu are in writing and Ag led by both
the Bvyu(s)and eter. Royals)hereby aclmewlcdgc that BuMis)bus read this Specldcadon sbeet.
Renew A r of Gfeater MA and NH Buyer ) Buyers)
S act Manager gigeurture . Signature
Print Name of Product Manager Pm Name Print Name
Rem - . 1
byterseno
V 1IADOW IWRLACRb1.EXt an Au4toenCo0watiy
CONDOMINIUM PERMISSION FORM FOR BUILDING PERMIT
67 Wharf Street Salem. MA 01970
We, Rockett Management, being the duly authorized
representatives of Pickering Wharf Condominiums,
have reviewed the specifications for improvements to
i67 Wharf Street Salem, MA 01970.
owned by Carl Bettancourt.
The Condo Association or Management Company agrees that the above owners have
permission to seek permits and to carry out the proposed work.
i
rlrrml�1l�Sor �y� l� �O,�g`11
Signature o ndo Assddation Representattvd and 1iC Date
� Prat Name
(In lieu of this form, a letter stating the same purpose as above, on the Condominium
Management Company stationary may be substituted.)
Cl 0026 13Ca3SUI dH Wd00 =01 TTOZ 90 100
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA,02111
UIV . www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Q I Please Print Legibly
Name(Business/Organization/[ndividual): TE t� tia l 7 ( h,)d S n
Address: I6 7 i s p r(fe I
City/State/Zip: Vg rlk b 6 ra 1 AA . Fi 302 Phone #: ,U6'a(F\J '//(-119 0 0
Are you an employer? Check the appropriate box: Type of project(required):
1.�?JI am a employer with 9 0 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 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] i employees. [No workers' 13.❑ Other
comp. insurance required.]
*My applicant that checks box#1 most also fill out the section below showing their workers'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.
lContracmrs that check this box most attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am anemployer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: J /'/C/J eme- 14SU 1,G A C(Z_- n
Policy#or Self-ins. Lic.#: Expiration Date:_��a_
Job Site Address: (e) r, City/State/Zip: �,IAA kp\_¢ l�l
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 hereby c rt' under th pain and penalties o Vary that the information provided above is true and correct.
Signature: Date: Z l
Phone#: o
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#:
A CERTIFICATE OF LIABILITY INSURANCE DATE o%O�Dii�
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).
CONTACT
PRODUCER NAME:
J.P.McKeone Insurance Agency Inc - PHONE FAX
JP McKeone Insurance Agency, Inc. N . (734)662-6100 (AID,No:
P.O.Box 333 ADDRESS:
Ann Arbor, MI 481060333 INSURER(S,'_AFFORDING COVERAGE NAIC#
INSURER A_ Nautilus 19682
INSURED J&L Windows,Inc. Renewal by Andersen INSURERS: Hartford 37478
104 Otis St' INSURER C:
Northborough,MA 01532
NSURER D
' INSURER E:
INSURER 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.
IN SR ADDL SUBR POLICY EFF POLICY EXP LIMBS
TYPE OF INSURANCE POLICY NUMBER MMIDDIYI' .1IM YYY I
A GENERAL UABILITY NC958461 10/01/2011 10/01/2012 EACH OCCURRENCE $ - 1,000,000
D
COMMERCIAL GENERAL LIABILITY DAMAGET RENTS 100,000
PREMISES E occuoence $
CLAIMS-MADE V OCCUR MEO EXP(Any one person $ 5,000
PERSONAL 6 ADV INJURY $ 1,000,000
I GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
JECT
POLICY PRO- LOD $
AUTOMOBILE LIABILITY 35 MCCXD6390 10/01/2011 10/01/2012 ,'COMBINED SINGLE LIMIT 1,000,000
Ea accident
ANY AUTO - BODILY INJURY(per Person) $
ALL OWNED SCHEDUIFD BODILY INJURY(Peramident) $
AUTOS AUTOS
PROPERTY DAMAGE $
HIRED AUTOS AUTOS
Per accident
$
1UMBRELLA LAB OCCURS EACH OCCURRENCE $
EXCESS LAB CLAIMS_-_MADE AGGREGATE $
-07D7 RETENTION$ $
A WORKERS COMPENSATION 35WECPP1444 G2/1712011 02/17/20121 we srATu- OTH- -
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETORIPARTNERIEXECUIIVE E.L.EACH ACCIDENT $ 500,000
OFIRCERIMEMBER EXCLUDED? NIA - SOO,DOO
(Mandatory In NH) E.L.oISEASE-EA EMPLOYEE $
If yyes,describe under ! 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $
B PEOOH555000507 09/27/2011 09/27/2012
I _
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required)
CERTIFICATE HOLDER CANCELLATION
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
®1988-2010 ACORD CORPORATION. All rights reserved
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
>lassachusettn - Department of Public late[\
Boaird of Buililin- Re_ulatiuns and Standar's
Construction Supervisor License
License: CS 95707
BRIAN DENNISON _
86 CREST CIRCLE
WORCESTER, MA 01603
Expiration: 9WO12
('o luui"i...wr Tr-: 2622
&......co;,waa Uc a�✓lZa4Jarlume�d .
�\ Office of Consumer Affairs&Business Regulation
J HOME IMPROVEMENT CONTRACTOR
Registratior2 601
.ExpiAIN-
7ltCard
RENEWAL BY,r�--
. BRIAN DENNISL�[4 ;'� 3
77
104 OTIS STREET' i/
NORTHBOROUGHO'1Ta32 — Undersecretary .t
Do Pat remove A fmai code InspeciarL save label forftue reference.
co
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v teas�.aoa
Ir
Renewal
b Andersen.
. YAR➢WY Ei^pLgCEMENT vujvd®viCa�uF.W
AND-N-102
'.Ii9!C' LSsk.'C%•'P' WoodNinyl Campcsite
_— __ -- Dual - Argon Low-E4.
Product Typs: Casement
ENERGY PERFORMANCE RATINGS
U Factor Salar Heat Gain Coef inert
0 . 29 1 : 6.5 0 . 28
Metric/5
ADDITIONAL PERFORMANCE RATINGS
Vlslble Transmittance
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WINDOW REPLACEMENT =nAndrzse1'CbmPgn9
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 assail 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
Paz(508)919-0903
Website:an wxanewalbvandesenxom -