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441 LAFAYETTE ST - BUILDING INSPECTION .�c sa The Commonwealth of Massachusetts ' Board of Building Regulations and Standards FOR Massachusetts State Building Code,780 CMR, 7i' edition MI NICIP ITY Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Se . n For Official e Only �� . Bui]dngPermitNumber. Date plied: JI Signature: Building Commissioner/ ectorofBut Date SECTI N :SITE INFORMATION 1.1 Property Address: 1.2 Assessors Ma &Parcel Numbers, i4 ' yLl l LEat.f 1-- ST P 1.1 a is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: '. Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) I.S.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? Check if Municipal❑ On site disposal system ❑ - SECTION 2: PROPERTY OWNERSHIP' 2.1Owner'of Recorrd- C1 jU Z-&Aae- tnf2! ✓\ 4 "11 CGCG IA t,V�' J\ S �PYz M, omo Name(Print) Address for Service: �29 126 Signature Telephone - SECTION 3-DESCRIPTION OF PROPOSED WORW(check all that apply) :l _ _ . .. BWg,❑ r •'O^ upiad ❑ °epa^ Exlsf:gdn , . . :ddi6o [3 Dcnx;lilion ❑ Accessnr, Bld?.❑ NumberofUnits Other4P�-Spculp: .12t -- Brief Dcsaiption of Proposed Worlc'-: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 5,73 G.. 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire Suppression) $ Total All Fees:$ «� Check No. Check Amount: Cash Amount: 6,Total Project Cost: $ 5 $� ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) )o I S S-a 3191 -r D, License Number Expiration Date. Name of CSL-Hold II 11 List CSL Type(see below) P". .DescriptionU Unrestricted a to 35,000 Cu.FLSie . . R Restricted l&2 Famil Dwellinnly �? - [C1-Ogel 1vf Masonry RC Residential Roofing Covering Telephone. WS Residential Window and Siding " SF Residential Solid Fuel Burning Appliance Installation - D Residential Demolition - 5.2 Registered Home Improvement Contractor(HIC) I b v) lee ntt✓a ' W LC-S vt RegistrationNumber - HIC Company Name or IC Re i [rant N e low `� _ Expiration Date � ( a . Signature Telephone _ - SECTION 6:WORKERS' COTYIPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152_ g 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 ..........G No...........❑ SECTION 7a;.OWPNEk AIJMORiZATION TO BE'COMFI=ETED R KN:. . - OWNER'SAGENT OR CONTRAT CTOR APPLIES FOItBUILD�VG P�IRl\3iT I, SU za vt rl e, Co✓e e n as Owner of the subject property hereby authorize I-')fti -\'Sn nc !mss�-c to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date , SEC''iTON 7b:..PWNERt:OR AUTIiORIZED A E11� DFCI SRATCOl?T:. l ndr cl ^a# rnrfcDilxoitzed A"ernttterChvttecl1re..>' :. ...: that the statemen s and utfornt tion ori Lte Lr eein_apphcadoti'are true atsd ncurafe,to the b�isl of mg knoll l'tdge and .beliapr\�\ Print Name (y d Agent I.2d It d Signature of Owner or Authorized Agent Dale (Signed under the pains and penalties of perjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and I IO.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 of bedrooms Number of bathrooms Number ofhalffhaths 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" S,, �3 41_c,6 DEBRIS FOS This form is to be submittei with?u;Idin permit appIicaiions wfieaevor these is debris to be disposed o£ ProgettyAddiess:y�� ( �•��� ce �1- . Ia accordance with the grovisioas of NiGL c,?Q,§54,:a condi8na of the Buile�in,Peaait Number is that the debar nsolt n;from this work shah be disposed of is a properly ficctsed • solsd oast✓disposal facidiy as deiiued by?��iCrL c. I l l§15D_A. . • {.�• This debris adD be aisposbd of is . � �- ti� i M.L�rr�d� 10'1 (dais S?. l�F4Uiu, YL1 dc512 (Location of Facility) Sipatme of P 4Pplicant laleo11 Date 104 Otis St.,Northborough,MA 01532 J&L WINDOWS,INC.,D/B/A MA Home Improvement Contractor (508)919-0900'Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012) byAndersen. Federal Tax ID#83-0404201 N' CPO 0 ¢`(5 areae. ee.uaraEN, .4 (2 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT , Buyerls)Name Dale of Agreement Bu,,erl,l street Address,City,snte,and Zlp Code 4'41 Luh E T fie- .( C>1 2-2p Entail Address Home Telephone Numter Work Telephone Number Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen (`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) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Method of Pymnt:O Cash ❑Check ❑Mastercard ❑VISA Total Job Amount':j.�!? Estimakd Starting Dak: (9 Discover ❑Financed,App#: )y��, Deposit Received(33%): -I 4f{s c'r l2o Name on Credit Card:Su Z c( 4 . tJVe I=��-4-D Balance at Start of Job X33%�:� Estimated Completion Date: Credit Card#: Balance on Substantial /O q Completion of Job 33%: /-f (�" CC Exp.Date: CC Security Code: AIM By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer Initials of Job cannot be made by credit cud and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(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 Ca eellation,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. J&LWmdm /b/a Renewal by Andersen But s 1 Buyers) By: Signature of rodu anager Signa a Signature Print Name of Product 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 THIS RIGHT. qa _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .}c_ _ _ _ _ — — — _ _ _ _ _ _ _� NOTICE OF CANCELLATION K NOTICE OF CANCELLAfl N Date of Transaction IC--/-) /O . You may cancel Date of Transaction — —/C. You may cancel this transaction,without any penal tyy or obligation,within this transaction,without any penal tyy or obligation,within three business days from the abovedate.If you cancel,any three business days from the abovedale.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 nesotable instrument executed Contract of Sole,and any nesotable 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, I by the Contractor ("Seller'l of your concellaton 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 to the Seller at your residence,in substantially as good condition I Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this Contract or Sale; or u may, if you wish, comply Contractor Sale;or you may,if you wish,compl;r with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make the goods available to the Seller and the the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the dant pick them uP within 20 days of the date of your Na ice of your Notice of Cancellation,you may retain or dispose of Cancellation,you maa,yvt retain or dispose of the goods of the goods without arty further obl' otion.If you fail to without any further obligation. IF you fail to make the make the goods available to the Serer, or if u a roe goods available to the Seller,or if you agree to return the ro return the goods ro the Seller and fail ro do so, then goods ro the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under for performance of all obligations under the Contract. the Contract.To cancel this transaction, mail w deliver a i To cancel this transaction, mail or deliver a signed and - =tied and dated copy of this cancellation notice or any dated copy of this cancellation notice or any other written other written notice,a send a telegram to Contractor.J notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Ohs Street, Street, Northbou h, MAO 532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATERTHAN MIDNIGHT MIDNIGHT OF 2 -(Date) OF Z —/rteDale) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyers signature Date I Buyer's signature Duro RbA Copy- White Buyer Copy Yellow Buyer Copy-Pink 104 Otis Stmct,Northborough,MA 01532 f&L Windows,Inc.d/b/a Renewal MA MC License#149601(expires 1/24/12) Phone 508.919.0900•Fax]]4.98].3013 Federal Tax ID# 83-0404201 wAndersen. WINDOW REP"CEMENT mM enmCwo ' or GaaAma MAsSAIXnaEfra ANO NEW HMIPSEOtE WINDOW SPECIFICATION SHELT Buyer(s)Name Date of Agreement / wee It,_ /Z_ The Buyers)listed above herebyjointly 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 part. WBVDOW DEfAIIS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) ❑ 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 F7 Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Acture/Casement(CFW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GFW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Z Picture Window(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. 9 es ❑ No Qty of Windows to be Custom Fit Replacement: _ 3. ❑ Yes FZI.No Qty of Sills to be replaced by Contractor: 4. ❑ Yes Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Fine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: EHPLow-E®SmartSunT (Tax CteditZkole) ❑ Other If other,please specify: G. Exterior color to be: ❑ White ❑ Sand ❑ Canvas [zylef�'atone ❑ Cocoa Bean 7. Interior color to be: ❑ White ❑ Sand ❑ Canvas [/].�enatone ❑ Fine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: ❑ White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style: 1,4- 9. ,¢9. ❑ Yes [3-Nslnstall Lifts with Double Hung Windows 10. Screens: windows to have: ❑ Half or ❑ Fun screens Screens to be: ❑ Fiberglass ❑ Aluminum ❑ TruScene CdMIX DETAILS 11.Windows have grilles: ❑ Yes o If yes:❑ Grille Between Glass(GSG)❑ Removable Interior Wood wnw0❑ Full Divided Light WU Qty Qtr Qty: Qtr Qtr 2 Qty: Qty- J'EI'F on ox ox ox cwm;mJ cueel caw ore Draw grille patterns above 'Use additional sheet if needed Owner approval ADDITIONAL WORK DETAILS 12.❑ Yeso Contractor will remove metal frames of windows. Qty of Units: 13.[_1 Yes o Contractor will install new paint-ready or stain-ready casings. Inteririorcasing qty of openings: Exterior casings qty of openings: El Pine ElMaintenance-freematerial 14.❑ Yes Ivo Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior s penin E] Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any pain' er Initials 16.El Yes o Contractor will Wrap exterior casings wit cod stock of color. Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17. ems El No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. fi 18. res'] No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19. es ❑ No Building Fermft­Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the ContrM Price and a separate checks required at the time of sale for this feeceffN,� 20. Additionaljob details: S'tc° tnr r, C ,A 1x qty= Gam- � Ja 3� J UP� iQ taS (ti + S rte--`/ C' 21. s ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final paymentshall to demanded until the contract is completed to the satisfaction ofall 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 am,no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms-OdTAA or varied in Way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buy has seed this S on Shit. Renewal en of Greater MA and NH Buye (s) Buyer(s) By: ✓/ S a of Product Manager tore /' signature F,t-al/"Yee1J Print Name of Product Manager Print Name Print Name Renewal RENEWAL BY ANDERSEN _ MAHICLocnw#14960 RE (expires l/24/12 Andersen. - OF GREATER MA$$AGHD$ETT$AND NEW HAMPSHIRE Federal Tax ID# 83-040420 wiaaow REPLACEMENT 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Buyer(s)Name - Date of Agreement The Buyer(s)listed above hereby jointly and severally agree to purchase the goads and/or services listed below,at 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 part. PATIO DOOR DETAILS 1. Install total of: Permashield Gliding Patio Door(s) ❑ 5'10'x 6'8" ❑ Other(not available in 8068) Op.panel is❑ left ❑ right(as viewed from exterior) Interior and Exterior Color to be: ❑ White ❑ Canvas ❑ Sandstone ❑ Terratone (Color sere inside and out on PS) Hardware* Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Others-Specify ❑ Yes ❑ No Gliding Patio Door to have sidelight? Size: ❑ Yes ❑ 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: OF.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 ban sidelight? Sire: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (M Divided Light) 3. Install total of: Prenchwood Glidinz Patio Doors) ❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood: ❑ Ere E-1oak ❑ Maple Interim Finish: ❑ Frefimshed White(Available only with white exterior) ❑ Unfinished Taint/stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 4. Install total of: _ t Prenchwood Hinged Patio Door(s) ❑ 6'0"x 6'8" ❑ Other: ❑ Yes ❑ No Active/Passive Panel?: ❑ Left ❑ Right(viewed from ext.which is active) OR ❑ Yes ❑ No Active/Stationary Panel?: ❑ Left ❑ Right Door Swinac J.Imswing ❑ Outswing Exterior Calor: ❑ to IJ Canvas ElSandtone E6-jerratone Interior Wood ❑ Oak ❑ Mapl ' Interior Finish: ❑ Prefinished White Unfinished(Paint/stain done by custom ) Hardware, Metro: ❑ WhitexSWne B tBrass ❑ Satin Nickel `NOTE: Canvas hinted screen frame N/A—must choose white or stone if exterior is auras' Yes M-No Hinged Patio door to have sidelight? Size: ❑ No Grilles? If yes: GBG�INTW ❑ FDL (Full Divided Light) STORM DOOR DETAILS 5. Install total of: Storm Door(s) G. ❑ Full View❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Sandtone ❑ Bronze ❑ Forest Green 8. Size t0 : ❑ 32" ❑ 34"(White only) ❑ 36" ❑ Custom(10 week lead time) Size: 9. Hardware to be: ❑ Bright Brass ❑ Nickel 10. Additional job details: I1. p ru ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction ofall 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 of 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 And sen of Greater MA and NH Buyer(s)/ �Buyer(s) By: / � S' ofProduct Manager S' Signature Print Name of Product Manager Print Name - Print Name Mie ComattonweaLh of Magsarhusettg Department trfIndustrial Arcidents Offue ofFnvesfigattons 600 Washington 37eef Boston,MA 02111 mvw.rnass.gov/di¢ Workers' CDmpests€ti€ra Insurance Affidavit Hrrel�ers/Ccrogtra etQrs/�iectraci�sl�A�aabers )PUCant Info,=a!tion Please PAntLezflyky MV pusinessrorga�—Ondndividuan: j efn Po G.I fJy Ha'I t71Err�n idress: l0,� :ty/3fE-Wap: Nor bo r°, AA 0,.K-M— Phone#: Cy' b�J /C11F' 0Z0() e TDD est er@ploYe? Check the appropruate bor. Type of project{req red): I am a employer with D 4. 0 I am a general contractar and I b. ❑New construction employees (fhlf and/or part-time). have hired me sob-contractors I am a sole proprietor or pad=- listed on the attached sheet t I'• modeIing ship and have no employees These sub-contrattvrs have R. �]Demolition work ng forum m any capacity. workers' comp. 'nom ince. q ilhinc addifian [No workers' comp.insurance 5. Q We are a corporation and its 10.0 Electrical repass or additions required] of tars have esen:ised$BIL I am a homeowner doing all work light of exemption per MOL 11.�Plumbing repairs or additions myself. [No workers' comp. c. 152, gl(4),and we have ran I2.0 Roof repairs iam=ance required_]T employees.[No workers' 13.0 Other comp;iu=anne required.] y appH=ot that checlm box ml most also fill oW&e sectimbclow showing fheirw 1=e 0000P=ratioc Polity iaiv� �meownen who sn6miL this afadavit indicating they am doing all wod:�d 5smhhe outside cow most submit anew affidavit iodieating such. atacfon that chink this be,must attached an addrti®al sheet shewmg the name of The M6_,,O Lt,,avd their wor1MS'comp.policy hfiOnslioa rat an employer that insrrance j or my eneplvyam Bdoty.is the policy and job.site hracativn. n/� /� tr=ance Company Nerve: �' 1,l(' 11 o £ lf'ICafrdne't; - licy#or Self-ms.Lic.n J� IRl cct�� r{ t Erp ralionDa�: / f i Site Address: 4 y I C a rti - City/StaWZ4,:S , IMA 0�9 $a:.li a copy of the workers' eoespernsataon policy declasatiDn page(showing the policy ntnnber sad.ezgiratioa date). ihrre to recuse coverage as requaod under Section 25A of MGL c. 152 can lead to the imposition of crhnival penalties of a ie up.ui 51,500.00 and/or one-year imprisonment, as well as civil penellies in the frena of a STOP WORK ORDER ead-a fine Iup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vesdgations of the DIA for insurance coverage verificati= do hereby c render the pairs¢rod pennities.oj�pn jwy Hurt the information provided above is true and correct =tare: �( Date' o� I L() '�a C)•07aial use orgy. Do not write in this area, to be completed by city or town officiaC City or Town: PermitUcense# FssuEng Antbority(circle one): L Board of Health 2.Building Department 3.City/Towa Cleric 4.Electrical Inspector 5.Plumbing Inspector fi.Other Contact Person: Phone# l 4CORDn CERTIFICATE OF LIABILITY INSURANCE DATE TMMIOD/Y1'YYI 02/10/2010 DUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 333 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Ann Arbor, MI 46106-0333 INSURERS AFFORDING COVERAGE NAIC# 'flet Renewal by Andersen INSURER k' Hartford Insurance Com an J and L WlndowS, Inc. INSURER e: Nautilus 104 Of15 St INSURER C: Northborough,MA. 01532 INSURER D: I INSURER E 'VERAGES HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ,NY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR TAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF.SUCH 'OUCIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I AGO L POLICY EFFECTIVE PDLICY EXPIRATIDN 17rENE�R�AL POLICY NUMBER 0 LIMITS GENERALNC955461 10/01/2010 10/01/2011 EACHOCCDRRENCE E 1 0000DO COMLIABILITY - AMAGt R PREMISES aovvrence b 100,000 ' OCCUR MED EXP(Arty..,.,) s 5,OODIPERSONAL&AOV INJURY E 1 000 DD0 GENERALAGGflEGATE b 2 000 OOO GEN'LAGLIES PER: PRODUCTS-COMPIOP AGO E 20000000 POLLOC AUTOMOBILELIAHIL 35MCCXD8390 10/01/2010 10/01/2011 COMBINED SINGLEUMB ANY AUTO IEeesiaenq E 1.,000,000 X! ALL OWNED AUTOS BODILY INJURY E - SCHEDULED AUTOS (Per Person) HIRED AUTOS BODILY INJURY. b NON-OWNED AUTOS IPera¢IdenQ I , PROPERTY DAMAGE E (Peramid.ntI GARAGE.UABILRY _ AUTO ONLY-EA ACCIDENT E ANY AUTO , ' OTHER THAN EA ACC E AUTO ONLY: AGS S EXCESSNMBREL-A LIABILITY EACH OCCURRENCE E j OCCUR F] CLAIMS MADE AGGREGATE S E DEDUCTIBLE s i RETENTION b E WORKERS COMPENSATION AND - 35 WECPP 1444 02/17/2010 02/17/2011 WC STATLL DTH- ' EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER ECUTIVE EL EACH ACCIDENT E 500 000 OFFICER/MEMOER EXCLUDED? EL DISEASE-EA EMPLOYEE b 500,000 Il PECIAL PROVISIONS E.L DISEASE-POLICY UNIT E 50000 SPECIAL PROVISIONS below OTHER FSCRIPTION OF OPERATIONS(LOCATIONS!VE ICLEB I IXCWSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES ME CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE.CERTRUATE HOLUM NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO DBUGATION DR UASILRTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR i REPRESENTATIVES. AI(TFIORTLED REPRESENTATIVE CORD 25 (2001/06) ®ACORD CORPORATION 1BBB )j += Massachusetts- Department of Public Safetc Board of Building Re,-mlations and Standards ' Construction Supervisor License License: CS 101952 Rest rictetl to: 00 DAVID BANCROFT 5 JOHNSTON AVENUE WHITINSVILLE, MA 01588 Expiration: N192012 ('nnnn issim¢T Tet`: 901952 �i ✓lee-foomnnomwea/.�li of•✓!A'.amar/wdeClb ,' Office of Consumer Affairs&Business Regulation - j OME IMPROVEMENT CONTRACTOR Registmtlon.'�`4 geo i Explmf11 112 —� � Sar�Crnent Card - RENEWAL BY A.�P�7[1__ DAVE SANCROF�' 104 OT15 STREEt� NORTHBOROUGH,Pv1'A` I'd-2 Undersecretary - f 1 -. . • off • e • �r gm1� .'' A"^�Tr'Y�'"�'FIr'2i'�'�.�J r'.T3v4f��a]L�•JCC+N��IGS�Y ^'�t����im-£�.'P''���y"A 4°?� s--' g,'i- " a. x �—� -��1^`4-•�N-n� ?v � X' n •. •1 ice - Y i �� i" � `"�- ��, - � 1 1 n .• u � i 1.�n_NNW= i 1 —=•2 .r OEM .r• „ n+ , I� n.4�,�-' is ¢ � " - fi �' +1 �` - "2< u A�^�,s� ate. '-�R`'b�� `�1 '�3��Y"�,-TY, �`����-is�j�� �.F � >� c, �• S �' � �•> §T' -� ���u`�1� '..`."val`'- `a4 u� lrtS4�' �✓. a > „3 "-�� 'izi �. r S."a�s.�. ,. r �!'.Ia''->':S(,-nom.-�.•' +Y�FY- 1 YAC r , !. - .. IWO -Law 6' wNh J. a� J � ^�„, ENERGY PERFORMANCE.R&TINGS (1-FactorNS.�• ''• . lmf K6atGahiCcie nt '0 - ,36.2' 30 0.0 - ADDITIONAL PFFFQRM ANCE.RATFNGS.' '•. _ �m�aimmawaacmuu���mac,mm,pp�ni�Rrx�pmwamn�rae�n,uwwxnor- .: Pmduct pedcpimlce.WHV IIWItl UMRdmd is s flail M of mUmm nW mama ads .. _ ' apoc�cpm�ctela.�arcurtAf�Ym�ueloro0grprcaue[pulmmma3dmoctlpa . Deign Pressure.(PSF) . . , -HOES(BF�}' ,. . z . . �. - • Mem oruaetlrA4.EC.r�.61EGC.NrInmRWwiem.m,wU6NtWmuretkNlk.Ron FhoYmn `5 n i � l Renewal byAnderser � WINDOW RE?LACEMENE =fcx,d�se�Campat3F VILIG l It May Concern, . Dosed is a permit application package for a project we have been tracted to do in your town. Thank you In advance far receiving this kage by mail. As we work in every town in the state, It greatly helps us in process. have also enclosed a self addressed and postage paidenvelope and jld request that when the permit application Inas been processed, that you old email it back to ccs. :lased far you review in this package is- 7 Permit Appllcatlon ❑ Home improvement Contractor License ❑ constructlon Supervisor Ucense Proo€ of Frnsurande ❑ Proof of Energy Efficiency €,ating ❑ Signed Contract fronn customer ❑ Permit Fee (if accepted at time of applying) you have any question regarding this application please call Me at (E€b8) .g-E�g92. est €tiegards, .Eley/ Donahue irmit Coordinator 104 Otis Stout 1 Nortbbo gh,MA,01532 Phone(509)919 b9DD Fax(508)919-0903 Website:ivww.re¢ewalbrmderseacom