100 WHARF ST UNIT C - BUILDING INSPECTION — The Commonwealth of Massachusetts NS ECTICQ�,QIp�SERVICES
1` Board of Building Regulations and Standards
Massachusetts State Building Code,790 CMR SALEM
101 t herd*m�381 jr: 2 2
(� Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
l
This Section Far Official Use Only
Building Pirruit Number. Applied:
1 t I Bonding Of end(Print Name) — sipstore Date
V I _ SECTION 1:SITE INFORMATION
l1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
100 Wharf St. Unit C Salem, MA 01970 34 34-0408-805
1.1a lsthis en accepted strew yes no Map Number Peocel Number
13 Zoning Information, 1.4 Property Dimensions:
CONDO
r1.6ing District Proposed Use Lot Area(sq ft) Frontage(R)
Buikting Setbacks(fl)
FrontYard Side Yards RearYard
Required Provided RequiredProvided Required Provided
SoppI:(M.G.L a 40,_J54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private O Zone: _ Oalside Flood Zone? Municipal 13 On site disposal system O
Check if esO
SECTION 2: PROPERTY OWNERM&
2.1 Ownert of Record:
John Woods Salem, MA 01970
Name(Print) City.State,ZIP
100 Wharf St. Unit C 857-991-0963 badaka67@hotmail.com
No.and Street Telephone Ransil Address
;SECPION 3:DESCRIPTION OF PROPOSED WORKS(ckechall that apply) ,
New Construction 13 Existing Building Vf Clw=-Occupied 2f I Repairs(s) If I Alteration(s) O 1 Addition O
Demolition 13 Accessory Bldg.0 Number of Units_ I Other af Speeify:Replacement
Brief DescripbonofProposed Wont': replacing one window- no structural changes
SECTION 4:ESTIMATED CONSTRUCTION COSTS. ,
Estimated Costs: -
Item and Materials OglcialUse Only,.
I.Building $ 12,618 1;, Building Permit Fedi$ Indicate low fee is determined:
2.Electrical $ 13 Standard City/Town Appliiation Fee -
O Total Project Cose(lien 6)x multiplier x
3.Plumbing $ 2- OtheiFees: S
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ 12,618 Check No. Check Amount Cub Amount:
a Paid in Full ❑Outstanding Balance Due:
I�AII�� r >v SraSa= lb rl8
- SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125 10-6-16
Jamie Moirn Liceme Number Expiration Dau
Name of CSL Holdai U
List CSL Type(see below)
86 Gardiner St
No.and Sheet ...Iype.. _ Dowipnon
Lynn, MA 01905 U Unrestricted R
to 35 000 eu
R Restricted 182 Family Dwelling
Cityfrown,State,23P M Masomy
RC Roofing Covering
WS window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 1 I 1 Insulation
Telephone Busail address. D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 12-23-15
Renewal by Andersen HIC Registration Number Expiration Date
HIC Company Name or MC Registrant Name
30 Forbes Rd
No.and
MA 01532 508-351-2214 Emai]address
City/Town. ZIP Tel one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GJI e.152.4 25C(6)) a
Workers Compenselion Insurance affidavit must be completed and submitted with this application. Failme to provide
this affidavit will result in the denial of the Issuance of the building peumit
Signed Affidavit Attached? Yes..........9 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COtts PLEM to WHEN '
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby auttorire Jamie Morin
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dau
SECTION 7b:OWNEW OR AUTHOR®AGENT DECLARATION
By entering my name below,j*"attest under the pains and penalties of perjury that all of the information
contained in this appli77"d
. accurate to the best of my knowledge and understanding.
1[. Lo -rJ�
Print Owner's Ors Name(Mechanic Signature) Dau
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(IAC)Program),will M have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Otter important information on the WC Program can be found at
www.mess.&v/oca Information on the Construction Supervisor License can be found at www.mmLg vo /dos
2. When substantial work is planned,provide the fi fun nation below:
Total floor area(sq.8.) (including garage,finished basementlattics,decks or parch)
Gross living area(sq.R) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Gpm
3. "Total Project Square Footage"maybe substituted for`°rota]Project Cost"
CITY OF SALEM, IMASSACHUSETTS
BLTLDLVGDEPARTAGNN T
120 W.WWOTON STREET,P FLOOR.
I'gL(978)745-9595
FAX(978)740-9846
samse.RLEY DRLSCOLL
MAYOR THOMU ST•PIERRE
DIRECTOR OP PLVX PROPERTY/9t:1IatNG CONMaSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance 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 ftum
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by:
Renewal by Andersen
(same ofltanlar)
The debris will be disposed of in :
Renewal by Andersen
(name of facility)
30 Forbes Rd, Northborough, MA 01532
(addrtae of facility)
mgnapua o it applicant
1(-611'
data
dabrinlydae
• Renewal ns Home improvement Contractor
bYAndersen. Renewal b Andersen Corporation License Federal
Tax I fires 1-191 01 3
Y � Fede21 Tax ID#41-1918413
30 Forbes Rd. Northborough,MA 01532
(508)351.2200 Fax(508)-986.7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date:
JOHN (JACK) WOODS - SEPTEMBER 26, 2015
jB er(s)Street Address City State Zip Code
100 WARP ST UNIT C SALEM MA 1 01970
!Email Address Home Telephone Number Work/Cell Tele hone Number
BADAKA67GHoTMA1L.COM 857-991-0963 978-532.8300
lBuyer(s)hereby joinfly and severally agrees to purchase the goods and/or services of Renewml by Andersen Corporation("Contractor"),in accordance with
the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"Agreement").
Buyers)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Est.Start Date Method of Payment
Total Job Amount S 12,618 m Fl,uroee S 0
Deposit Received(33%)$ 4,206.00 rapt.;i a s'gm9 S 0.00 ✓ Check/Cash
1244 Ireeks
Balance Start of Job(33%)S 4,206.00 Cheri g
Balance on Substantial Est,Install Time - Credit Card
Completion of Job(33%)S 4,206.00 comFwaa S 0.00
1.2 days ursedeeod bsdmcted,ploaso
No nnu samaelnelNeo weer In ere damned sac Credit Card Payment form
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 tams of this Agreement. No alteration to or deviation from this Agreement will be valid without Na signed,written consent
of both Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyerts)1)has mad this Agreement,undemtands the terms of this Agreement,and has
received a completed,signed and dated copy of this Agmemant,Including the two attached Notices of Cancellation,on 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 Andaman Corporation Buyers) Buyer(s)
BY IL �). (I/"'�,,
Signature of Corrsullanl __- --'----SignatureSignature— —J!
x WILL SALEM JOHN (JACK)WOODS
Pn cd Name ofWeans Pniniod Name Printed Nemo
YOU.WE BUYER(S),WY CANCEL THIS TRANSACTION AT ARYTIYE PRIOR M MOMiMT OF WE INTRO BUSINESS DAY AFTER THE DATE OF MIS TRANSACTION.
WE WE ATTACHED NOTICE OF CANCELLATION Mines FOR AN EXPIANARON OF Mrs RIGIM
NOTICEOFCANCEIJ.ATIONI NOTIMOTCAtIcI TION I
Dmeor Tramaedoe 926/15 y'oumaylaead Wt. I Mte.f Tramaldw MIGM. yo..'cas<I laid
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.trove a.w V nae aero.ar P•^P•r•Y��m,.ey wrmewa mase ey yon Imo.. I sea..eve.N ye.eare4 aT'PrePlnY.odea e,my paymmu made ey yen seder
vee see,oridd 104a,%e say Oeg r—o4aa.wmemaem,ea ly yeuwm ee I tee rnedvnof 10da neaey ageda ,' — aecn,ea ey yea wid e!
rnor.ld.ao id and following q Imo l by riga Cng our a("Sent")of yom I chanted wiWin IO days fa0owivg IBee:pl ey,he Cenlmnw(^Seder")of yao,
eaeeDadon Wolin,me any aeledry inters.,adding vo,of,he wmacdo.wid ee I raa!<Oadoa mda,arta any ulmi,y ie,e.es,art.tng m,of We,anraNw wIL b
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Sort" n,di,,sale;or iddprnlr ya dol goods.1
do, rele'm.wldoe+or me I g ;aceeelel,a,saes.ynl.may,vya the Soom.1 th.M r'..,m andrisk
slLer gegoratag W goodo.dliPme'. dSe nem m use sdder•s eape 1 P"ri tat. I Sell..do slim do.'.wn ahipmao th.Se gelds a,o, eeOer'a —1 Pidnd r64.
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gd,hiv 20 day.of,t!dateof yowNeta of CIT,ronllee,yae maya,dnmN.peaeI of use odaysor Wlaneyryam Nounof CIf fool ty.omayramieor al.p M.
of riga glad.wrleou,.ey dated eel g.n®. N ye.6rl u mate the goad.ay.aaele to due geld.o rmem.ny ranee.C.dS en. H yoe.vo to--k-d Edd good.o,diend<
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wlaAes RA.rinmeoda.kM,%O1eelegammcenl<aewn Ileeewvi by Aade.aeq l oraod. VA.No mda,er. 0353legama cmunnan 11e.ewvl ey Andl..eq
TD imbec Rd. Nmleeoreugb,OfA 01532. I SIO folbea Rd.NarWeo,ough,MA OISR.
IIDAEBV GN6I TIOErMNSACTIO\. I I HisREBy CANCr1Tms YaANSACITON.
I
I
Dw<++sry.e.e Pna w<! Doo ora
I
Renewal Renewal by Andersen Carporadon MA Hame improvement Contractor
byN Ider$en. = 30 Forbes rd Narthborough,MA 01532 License#170810 (Expires 12/23/2015)
wmaew RtriwetsERr ...m,.L..,.c........ (508)351-2200 Fax:(508)-980-7072 Federal ID#41-1918413
Window Specification Sheet
Bu vet's)Name Date of Agreement
JOHN (JACK) WOODS SAT, SEP 26, 2015
"fhc hover{s)listed alxm:herehv joindv and unvanlly agn:c to purch:Lse the goods and/or vetvip:s listed 1.4ow,it.acconlaure with the prices and Ierals desrril,ed
nn die SIX.T.ificatinu Sheet and die rant and the reverse of 11w ac'mipanying CUSTOM WINDLAV AND DOOR RENIODEI.ING'AGREENIENT of which
the.Specification Silver is pan.
WINDOW&DOOR DETAILS
AG0. qW. ,ipiv EaterimAntmw color Hadware Wrdvore Lo,wEJ I (Lib GNb Gnes
Room R watt M= LLL Wallow/Door Slyle Dealt Cox xa Fat-Mt color We Sownts 5nertvn GNIm a®Iii/! Sazh2 Lina clatters
Dlnin 100 30 60 90 DBs roil Nual meet sloped sill Ext.Wrap PN ark Bron Standard FTS exetser N. No No
Divi 101 :ill 60 g0 DB sli rail egual Insert silo sill ExL PN Dark Bron Stallard FTS evviSerNaw No No
Uve, 102 311 60 90 138 so rail equal resort sloped sill Ext.Wrap lel Bran Standard FTS manse, Hone No No
Living 103 30 60 90 Da star rail eglud insert sloped sill Ext Wrap W WPN ark BM Standard FTS elarKate Nora No No
Ban 1 200 30 60 90 G W insert talo Ext Wrap wpN k Bran Standard FTS Naa No No
Bed 1 201 30 GO g0 GW Insert fall, Ext.Wrap WWPN Bron Standard FTS mars. Nene No No
OF. 202 31 00 90 1 GW insert fall, Ext Wrap PN ark Bronzistarded FTS H. No No
Total 7 BAY BOW&BUILD OUT DETAILS
Syla Detail/ w AgMoa. Numbs, Frame willow Erol Cmta L El Roof/ Hardwaro
Room Count
Style Rankers lin (:av' a M Litm fte- r Evvmt Color Grins smh. aasnaa Bacons Sman. Sola, Cab
SPECIALTY WINDOW DETAILS
Full Ap,... Loa/ spoculiy RAY/BOW ADDITIONAL WORK NOTES
Roan Cmii Ste Imnt U.I. S&exrsve Glia. Grillo S EWlnt Color 1w ry ,hw..fit,luvin,...,in,k.n.,u.trr 71 h.hr.
Ilvn;..ill I—vtnili:rni AWe h,.c
ADDITIONAL WORK DETAILS,
I No Contractor will wrap exterior casings with coil stock mlor of
Owner's award Mat Contractardoes not do any painting/staining d reml,varlmstallandr,of alarm system or window,oeatments/hardware.It is the responsibility o/
Me homeowner to have the a/emi system and wkdow aearm Mlhardware removed pdm to imWiadon. Mmake mo guarantee as to whether alarms or window
treetmenD/hamfware will#t alter replacement C atomer m atm aware in snore vases Mere will W glass lass. It there is,the amount writ be dependent on Me type
-•r, of existing windows.type of Installation and window slNe.Wa make no guarantee as to Me amount of glass loss.Customer is aware and understands any and all
unseen rot Is not included in this contract.Should any ort be found Mere will be an additional charge for time and materials unless so stated in this contract
3 Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltra0an.Removal and disposal of all lob related debris.
windows,doors,atone windows and vacuum nightly included. Upon completion of the job and payment in lull,a limited warranty shall be issued.
I Yes Building Permit–Contractor will secure any and all necessary permits. The fee for the pear il(s)is included in the total contract prim.
yes All discounts have been applied to this agreement.
f r \:s .• :No Owner agrees to be present W the final day of installation fa final inspection and to deliver final payment/finance form(s).
h ie aV•rcluml uuM:nlndfig and Mraren the Palle,dal lLi.,SPsili,.nual Shir,:
uuk:aunding h:n.am the Innicr,sad dorm am nr�.arleJ um1,e,awlinyn dcmh ng or nualiyinq:n:p or'hee:rm..Thi.Sluvilia:nion 5!u•m coup tan In:dumRxl ar iU u-nn.nuullf A or.:.rird n
•mlh"u i du lyr. m:in..rilirg.:nA.g and fin•1.4d, :q q ( n Ir.:e H r et(.r)hnM>! rkluud,d.,,d I H l i.)IN..-.11111011 Sh"I.
Renewal by Avdeeeen Corporetionn ! 14 n:d j Hop r,)
Signature of Consultant Signature Signature
WILL SALEM JOHN (JACK) WOODS
Print Name of Consultant Print Name Print Name
PICKERING WHARF CONOOMCN IM ALSSOCAJTION
57 WHARF STREET SUITE 2E
SALEM;MA 01970
(978)740-6890
Ottaber 6,2075
John (lack]Weals
1000 Wharf Street:
Salem, MA01970
Re_ Pici e6ng Wharf Condominfum Association for Permission to Replace Windows
At.100c Wharf Street,Salem,MAOILWM
TO Whom It May t orcein;
we.Pi&ering Wharf Cordombdum Assodaifon.have renewed the speciRDMUDnt for new
windows and doors to 1000 Wharf Street,Salem,MAA The P`idrer9atg Whad Condoemiinium Association
agrees that the above owners have permission to seek permits and to carry out U*Rropased:worit.
oatlined in attached window.and door speaHeatbris sheet. The work will becompleted by licensed
and Insured,Renewal By.Anderson;30 Forbes Road, NorthboroL0% FAA 01532_
T. IAii;ha¢ ietk�Trustee
Pickering Wharf Condominium
ASMOCiation
patE: /'
Renewal by Andersen Corporation
Renewal
30 8'ofIMN Road•NC1ftI1b roagll. M234ae LIDaLL5 01532 MA I{oa(a t1minuar
byN Iden, en. Phone SOR)351-2'7`815. 173.x SC\F�73G-7072 +lll�a« ae 17'.V101212 .101ce
WIND= Y.[PlA[rMRNT ,n Ra3n.nG�laM
!'mlemt3'sx 119tt dl.L91tL113
CONMACR AMSNDFLIRNf
'nds MWIlLIMILILl ("Antondnctlt") is to LFI.LAMOM WINDOW,4\1v voLix kYamCJIYtuNc;AC.u.r.mr-mC 1«:1*r+3 neetrl )iv acid
bclnree,n'Jteri Wa3 tn•Atl&-Irsejt CarlsoroLluat altd J062t%WNAs ebuters')- CCML11z`IIC10I'and JkLyer(s)hereby Awe to ttnte,Ld and Inexiify 11te
&; IUentertl:Is ind calal Lx10w. OLFler I,hall rusleielllr,111v IrldicaIFA 1 e1au+,!1.11 111e LOVILS.IAd 6^c AX1La1tsof Ilse A,:4ILVI%2I11 lvlIF M-2Ir1aLa in full
faive:aid erRTI, 'I•hk AftleAdn+rLd is snb]OCL to the 401110 And Couldifions of the 'Igto Milawing nddill a u,Alterations,or clef`l inn e
Lo lbe prodwis and services l3LI%Vr(3)Ot dMA My being nude.
Change screens on two double hung windows from fall screen to half screen
No price change
AS u m5alt of these Changes:Ille fallawing lerms al Ilse.,x•mealclet am, also changllxy, W Llxre is no cbsn;µ, an.ilmn will be left blank or
tiLaxlked.:13",N/A*:liulkal..ln„Ilial nach.u%k4e'snAlcv.
NEW Tolcd job Mooned S 12,(51800 Paymcat Method:
Ncw DelmdI RZ ixtd:$4,20133.00 Ch&k
New V3aIz,lce At Slsna of jab:$a Z+'stit.tt0 Climk)Credit Card
Mew CuUuam Check.cfedit Card
SaLMuiaial CvnL*.1km afJab:$4.,206.03
It is ttgrerd and tandusood by and between the MAN Pant this Amndment and late odglnal AV=mwI camd o the onelre undo lsrtding ho-
twsen thrptutles,and there ale tso vestal wldsstsAdings ebattgitlg or rloodLt}Ltg alpr cd Itle teems of"Amendme L etrye2'G)haMW at?Jmow1-
edBra/hat 1hUc *has seed this Amendment and has raxivod a osmpleW,sovd,and dakd oupy of this Aawndment on tthhce date wrtpat below.
Rcrtmal by Andum Corpaaaliwt &gra'fr)
E-.Signed, LCIf2If2G1501:03PMCST
5lg9talu,I>:of t«n'atlx:t Atunit;:µr John Woods t.�aee
badalwo70 hatma ilcorn
1D:7 D.U.2 1.4,193
Witl9aldn - A . 2 10/21/21715
1'02Ll.Ksnte&Fyraiucl ALalager SLpInture Dale
zhe C�onreronwmuh refAMWh
Dt ant of 1Jtdtts&W Accidents
Ope 00MV049411ions
_ 690 Washington Street
Asaon,MA 02111
www:nrast;.g"1d1a
Workers' Compensation Insurance Affidavit:BuUdera/ContractordElectriclana/?lumbers
A ulicant-information pleaes Print F.etnbtr
Name(Busine--dOrganize ionrindividual): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
City/State/7ip: NORTHBORCLMA.01532 Phone W. 508-351-2200
Are man an employer?Check the approprtate box: Type of pmjed(aeequir�:
1.i 1 ren a enployer with 30 4. Q 1 am a gonecal`couttector and 1 6. New e ctism
employees(full and/or part-time).' have hired the,sub-contractors
2.❑ I am a sole proprietor or partner- l4bed on the attached shftt.t 7. . panodeBng
ship and have no employees These sub-contractors have 8. 0 Demelidon
working for mein any capacity. workers'comp:insurance. 9. Building al litiGn
(Pio workers'comp.insurance 5. ❑ We are a corporation and its
rte,) offims have axwcised dteir 10.0 elect ical repairs or additions-
3.❑ 1 am a homeowner doing all work right of exemption per MOL l l.[]Plumbing repairs or additions
myself.]No wvrkem'comp. a 152,$1(4),and we have no 12.E Roofrepairs
insurance required.]t employees.[No workers'
comp.assurance required.] 13.[]Ckhe_i
appliceat Ides moats box g I must deo fill am the semiae beto4 showing dM*wmkms'aatpean�oa 1 �Y fitorm�o
t Iiatreowsms who submit ddb afadevit indicating ate;:'are doing as work antd tum bhe outsW amuusers am submit a nm aa5&vA,W1ks*such, .
rd:mtemrms duo mise.*this box must sttetteu m iMtiosel sheet slcwingthe risme attbe aubw:oeeeaoom and Ntte.wort ms'Woo policy b0imstiam
J am ma sorMyar ikm k pnovldhg workers'eompenradon hmrwxefor mgr&Vfuyees. Below 1r the potley mrd job&lore
informa"
Insurance Company Name; OLD REPUBLIC INS. CO.
Policy N or Self4ns.Lic.#: MWC 3QWTQQ:_:_- __ t xpiration Dam 10-01-16 _
100 Wharf St. Unit C Salem, MA 01970
Job Site Address:--- City/Statts'Zip:_,
Attach a copy of the warkera'dwmpsas stion policy declaration page(showing the pofiq number card expiration daft).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of.Austral petwh[es of a
fine up to$1,-500.00 atxUor owns-year imprisonment,as well as.hail penalties in the form of a STOP WORK ORDER and a floe
of up to 5250.00 a day against the violator. Be advised that a copy of this statemera may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby n r the Ins andpa hies ojpedav draw the bljorsaWks prosWed above is nue and
Sign
phone: 50 -351-2200
Offla a!ase only. Do not write In this ries to be caupleted by ct(r:or town QBWk
City or Town: Permlidjecuse#
Issuing Authority(circle one):
1.Board of HaMb 2.Building Department 3.City/Town Clerk 4.Electrical lusisector S Plumbing hasinctor
6.Other
Contact Person: Phone 0:
ANDECOR-01 YADAVYO
A� CERTIFICATE OF LIABILITY INSURANCE
1011f2015
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),AUTHORDMD
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy les)must be endorsed. IfSUBROGAT10N M 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
certtfirate holder In lieu of such en s).
PRODUCER CONTACT Wllile CerUBCat-Center
WUIIS of Minnesota Inc. E Mqj 8 845-7978 im
ato 26 Century BWd :CertlR IIbO.cem Ne° 888 487-2378
P.O.Boa 905191
Nashville,TN 97290-6191
WRIURERM)AFFORDINGOOVERAGE NAIC0
MMRERA:Old Republic Insurance Company 24147
INSURED
LxsuraXN a:
Renal by Andersen LLC INSURER c:
30 Forbes Road INSURER D;
Northborough,MA 01692 INeURm 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 SUBUECTTOALLTHETERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS1`1 JURAL BUSH —115LUTUV
LTR TYPE OF INSURANCE PgJCYNUMBER UNITS
A X CDMMritCVlL oe LIABILITY EACH OCCURRENCE s 1,00%
CLAIMS-WADE OCCUR MWZY 906440 10/01/2016 10I01I2016 PREMISES ararmggp Es 609,
MED EXP ale pavan) 10,0
PERSONALSADVSUURY 1,000
GEWL AGGREGATE LIMIT APPLIES PER: GFRERN.AG GREGATE POLICY O JENCT F-1LAC PRODUCTS-CONPIOPAGG 4,000
OTHER 3
AUTOMOBILE LIABILITYOManSIRG a 6,000.00
A X ANY AUTO MWTB 306438 10II01=16 10101=16 BODILY INJURY(Perpevan) S
AUOOTBYHFD BOOS LED BODILY INJURY(Pw eoNDeN) $
HIRED AUTOS AAUTTOSOVMFD � y
i
UMBRETJA LUS OCCUR
51CM OCCURRENCE i
EXCESS UAB CLAIMS#ADE AGGREGATE $
DEO I I RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYFRC LIABILITY YIN X BTATU(E R
A ANYPOFFICEOPRIETRIPARTBER TNERRiE'WIC �N� N/A MWC30549700 10101=15 10101=6 EL EACH ACCIDENT i 1,000
Offim luyln NN) E.L.DISEASE-EA EMPLOYEE $ 1
Hyyl�d.wW Nemr
OESCRRRION OF OPERATIONS below _ ELDIBEASE-POLICYLIMR i 1,000,
I
DEBCRIPOONOFWERAnONSILGCATIONSIVERW Ce(ACORU1m,AaWanalRW Sebes,N%MAYWeUadWNmen"welswR„YeAJ
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCW BED POLICIES BE CANCELLED ED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR
®REPRESENTATIVE
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Evidence of Insurance / '✓
®1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Sapenisor
License:C84000125
86 GA"D=SW i
j LYW KA 01986 -
92� ti�s Expiration
Conrnissioner 10100/2016
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WoodNflyl Composite IF
"�OCs�:x^33 Dual Argon Low E4 SmartSun 'I
Double Hung
100-00473518-010
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)/I-P Solar Heat Gain Coefficient
0 . 29 0 . 19
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0 . 42
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. ENERGY PERFORMANCE RATINGS
U-Factor - Solar Heed Gels CodRelerd
0.29 .11-65 0.21
snP ddrJ6 -
AOOITION&PERFORMANCE RATINGS
Vlslhle.TtansmKI:n -
= 0.49
9mMerd R."
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