4 CAULDRON CT - BUILDING INSPECTION (4) Tr6- ` y - 10gS 5(0 q?
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011 _
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
- .. This Section F.or Official Use:Only.
Building Permit Number: "' Date Applie
r_
Buddmg0fficial(PrintName) Signature
SECTION'1: SITE INFORMATION i K
.- 1.4
. roperty Address: �V�'T 1.2 Assessors Map &Parcel Numbers -
- 1.1a Is this an.accepted sti?:etv'yes 3)E' ' ,no P..ap Number Parcel Nwnber
1.3 Zoning?nfw:r,ation: 1. P, •narty Dimensions:
Earn 'I1 off? ae.r.
Zoning District Propose se J Lot Area(sq ft) Frontage(ft) - -
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required erovided
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 yes❑ Municipal❑ On site disposal system IJ
-
SECTION 2:;PROPERTY OWNERSHIP'
,J Jwnerr Record:
-,d rr)a r skin 91A D19-1b
Name(Print) ki City,State,ZIP
No—n-S'roet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repaus(A I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ' j r)hD '
bin aI h _
SECTION 4:ESTIMATED CONSTRUCTl6N'COSTS
x
Item Estimated Costs, x OffiGalUse Only
Labor and Materials _
1.Building $ 2 5,00 1 Bmldmg Permit Fee:$ Indicate how fee is determined:.
❑Standards CityfPown:Application Fee
2.Electrical $ O TotatProject Cost-'(Item 6)x multiplier x
3.Plumbing $ 2. 'Other Fees: $
4.Mechanical (HVAC) $ -List:
5.Mechanical (Fire $
Suppression) Total All fees.$
Check No. f Check Amount: Cash Amount:
6.Total Project Cost: $ gar,qrJ z)O ❑Paid in Full O Outstanding Balance Due.
Ivy l C- T b co N 7-R-(�aTO-g, r1 M K I L G:10 (p 11'1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -
rr— bago�o 6 11-Iq-15
�� y-nk j�� License Number Expiration Date
Name of CSL Holder
List CSL T see below
t�r4-G Type( )
No.andj�S�"treet�L � T Description
yin[71I!t� r yj)QPjj) U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 FamilyDwelling
CiI flown,State,ZIP M Masonry
RC Roofing Covering .
WS Window and Siding -
SF Solid Fuel Burning Appliances
����� ' �)Zk7 —b�42J-I'7ei.�C�fD, C Insulation - -
Tele hone Email address D Demolition _
5.2 Registered Home Improvement Cnntractor(HIC) _ -
/ _ _L`L65 4*q .--- ram
HIC Registration Number Expiration Date -
MC m Comp aeor, C.Registrant me
^^
I.andStreet mail ad ss
0e)-6ofnr �YIA b1�3O1 �$IG33 ylvo -
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) _
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7ao OWNER'AUTHORIZATION TO BE COMPLETED WHEN--
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit apprcation.
Frmi vwner's Name(E echbruc Signature) Date
SECTION 7b:'OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
' Print Owner's or Authorized Agent's Name(Electronic Signature) - - DAte
.r... . - _ . ... ::; NOTES:i.-
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) 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 Open
3. "Total Project Square Footage"may be substituted for"Total Project Cosy'
MA Reg#146589 from eur Nome to Yours...
CT Reg#0605216 &1 Contract#
WMANG
RI Reg#26463 energy Saving Homelmptawments Federal ID#20-2625129
Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com 65964
THIS CONTRACT MADE THE day of -J t d 7 20 ri between /
)L r it tt L '� 7 Ll -'
(Home Owners) Home" Phone)
) (Bus/Cell Phone)
(Address) '
(City) (State) (zip)
)`t
the"Owner"and NEWPRO Operating, LLC, "NEWPRO". (E-Mail) for proprietary use only
NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install the
following described work at the premises located at:
❑ The job address is a condominium.
(Job Address)
TOTAL# r NEWPRO _ / JJL/x�/��_ WINDOW OPTIONS ,.: AM fir,. sbA A .9, x'tM�� , ;'
WINDOWS SERIES# `��� �/C,F Grids: YES NO CONTOUR LJSDL EURO LJ DIAMOND
Window Color CITY Window Color CITY OBS/TMP: (Location) [_]TOP []BOTTOM
Int: Id -( / I, f Int: Screens:(Exterior color Full Screen Standard) [—]HALF []FULL
i I(.�. Ext: Vent Latches: ❑YES ❑NO
Capping Color. J DOORS` MODEL CITY Please Initial:
PVC V Smooth LJ NoMar LJ No Capping LJ Sliding Glass Door:y,7 I
MODELNAME M,OI�DEL#- ;. _ CITY;. Color In: Out: Customer understands that NEWPRO®
Double Hung V/ 'Active: Left Center Right does not do any
y painting or staining.
2 Lite Slider _757 HDWR: SN Be WH i BGE (ie:when removing or replacing interior
3 Lite Slider (1/4,u2,v4) 753 Entry Door S le u.-„ -.'. 1 stops or trim). NEWPRO®is not respon-
3 Lite Slider (1/3,113,113) 756 Color In: Out:' sible for conditions or circumstances be-
Casement(Hinged Right) 851 Fiberglass ' Steel yond its control including condensation result-
Casement(Hinged Left) - 852 .� HDWR: SN Be AGB AB ORB ing from or due to pre-existing conditions.
Twin Casement 853 — SideliteS a a, .•. ,h Style (circle one):
Stationary Casement 856 — color 1. Out: / CASH
Triple Casement (114,1/2,1/4) 859 'Storm Door Style�:•'�" :+. Balance paid to installer at completion
Triple Casement (1/3,1/3,v3) 860 Color '
Picture Window 751 HDWR: SN , 'BB AGB AB FINANCE
Sash Only 752 Left Hinge Right Hinge / Bank completion form signed at installation
Hopper 491 Entry Door Style�.;`:,•,•
Awning 351 '" Color In: Out:/ :TOTALS'
Garden Window 798 Fiberglass /Steel[
Bay Window(Roof/Sofkt) — HDWR: SN BBB- AGB AB 05B PRICE
Bow Window(Roof/Soffit) Other Door,. . . ze'-' DEPOSIT•
y
Other _ Color In: our „WISH
Other Z`"'"""`
HDWR: l "ORDER,
DESCRIBE WORK&PROMOTIONS APPLIED: :.{�.� I/ '�1--J'� /� f! ' ,Tf')L ',TOTALS
C
f( T n; y) r yDUEAT� ��`f�
�. ,Yl'-tr"/
t ! r ti fJ E1�'i 3 J7 C " `3' P"7i 7/ s�7i, 5 FT 77 t.'rs� t
j
Est. Start Date:11L`'6 ii%&st. Comp. Date: l " Y /ter- _.�f Customer understands this is an"estimated
Owner has read and agrees to the terms and conditions on the front and the reverse of this Agreement. Owner
specifically agrees to the(1)Total Cash Price; (2)work being performed; and (3)work not being performed. Owner
understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been
orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the
date of this transaction and Owner was provided with two(2) copies of a cancellation form explaining this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
(Rhode Island Sales Only): Notice to buyer: (1) Do not sign this Agreement if any of the spaces intended for the
agreed terms to the extent of then available information are left blank. (2)You are entitled to a copy of this
Agreement at the time you sign it. (3)You may at anytime payoff the full;unpaid balance due under this Agreement,
and in so doing you may be entitled to receive a partial rebate of the finance and insurance charges. (4)The seller
has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased
under this Agreement. (5)You may cancel this Agreement if it has not been at the main office or branch office of
the seller in the Agreement by registered or certified mail, which shall be posted not later than midnight of the third
calendar day after the day on which the buyer signs the Agreement, excluding Sunday and any holiday`ri which - 1-
regular mail deliveries are not made. See the accompanying notice of cancellation form for an explanation of
buyer's rights.
(Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing
Board consumer education materials. f j E((OO/wner's initials)
By: '911 �j>�K 4 .a`-C��r.�� EIN# Signed: (/ ...�• CGo t, '�--r- UI 14( ''f' , .
Product Specialist(Printed Name) ) Owner
/
By: .Y+. '/•%-��f ����'�/�/7 Signed:
NEWPRO Operating,LLC(Signature) Owner
WHITE: Branch Copy YELLOW: Customers Copy PINK: File Copy GOLD: Finance Copy
US-15
R1012
ADDITIONAL TERMS AND CONDITIONS t
- r
Warranties: •An) product warranties are provided by the manufacturers of the products that Owner is purchasing. NEWPRO is also
Providing Owner with a labor warranty, which covers NEWPRO's labor. Owner understands that Owner should read all the written
warranties for complete details of warranty coverage and that warranties are available for complete review before signing this Agreement.
Late Cancellation: Owner understands that Owner has three (3) business days to cancel this Agreement. Owner understands that if
Owner wants to cancel this Agreement after those three (3) days, NEWPRO does not have to allow that. Owner understands that if
NEWPRO does let Owner cancel, however, that Owner will have to pay to NEWPRO a late cancellation fee equal to 33.3% of the
purchase price in order to cover NEWPRO's labor, administrative,and material costs, so long as that is legally allowed.
Delay/Unknown Conditions/Damages: Owner understands that if NEWPRO determines within thirty(30)days of the date of this
Agreement that it cannot perform the work according to NEWPRO's professional standards,NEWPRO can cancel this Agreement,notify
Owner of cancellation, and promptly return Owner's money.Owner understands that issues that may cause NEWPRO to cancel this
Agreement include incorrect pricing or unknown pre-existing conditions to the property. Owner understands that NEWPRO is not
responsible for structural or other defects in the property,and that NEWPRO's products do not cure these problems.Owner understands
that the work could be delayed by events that NEWPRO does not control. Owner understands that NEWPRO is not responsible for(a)
damages due to causes beyond NEWPRO's control,(b)damages arising from a delay in NEWPRO performing wider this Agreement,or
(c)unintentional damage to Owner's personal property,it being understood that it is Owner's responsibility to remove/secure his personal
property prior to commencement of work.
When Money Is Due: Owner agrees that when the work is"substantially complete", Owner will pay the balance due on this Agreement.
Owner understands that "substantially complete" means the work has been materially finished, functional as intended, and a final
inspection,permit, or occupancy certificate, if required,has been obtained. Owner agrees that once Owner has paid the purchase price,if
Owner believes any of the work performed by NFNVPRO is defective or incomplete, NEWPRO will inspect the work and perform any
service Owner is entitled to under this Agreement and/or any warranty. Owner agrees that if Owner does not pay any of the money when
it is due,Owner can be charged a late fee of'1.5%on the amount owed for each month the money is not paid. Owner agrees that if Owner
defaults on any promises under this Agreement,and NEWPRO hires an attorney to enforce this Agreement,Owner will pay NEWPRO its
reasonable legal fees and related costs or expenses,as long as it is legal for Owner to do that.
Other Understandings: Owner agrees that Owner will assert a dispute, claim,or controversy (hereafter referred to as a "Claim")
arising under or relating to this Agreement only on behalf of Owner's own self and that Owner will not assert a Claim on behalf
of,or as a member of,a class or group in either an arbitration proceeding,a private attorney general action or in any other forum
or action. If a court determines that this specific paragraph is not fully enforceable, the court's determination shall be subject to appeal.
This paragraph does not apply to any lawsuit or athuunistrative proceeding filed against NEWPRO by a state or federal government
agency even when such agency is seeking relief on behalf of a class of buyers. Owner agrees and understand that if Owner finances the
work, Owner's separately provided financing docwnents will include the number of monthly payments and the amount of each payment,
including any finance charge. Owner promises that he will provide NENVPRO with access to the work area, including access to electrical
outlets. Owner understands that this Agreement and any attachments make tip the entire understanding between the parties. Owner agrees
that any change to this Agreement must be in writing and signed by both parties.
(Massachusetts Sales Only): All contractors and subcontractors must be registered by the administrator of the Board of Building
Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of
Consumer Affairs and Business Regulation,Ten Park Plaza, Suite 5170,Boston, Massachusetts 02116 Telephone: (617)973-8700.
It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent.NEWPRO
shall advise Owner of any necessary-permits.The Owners who secure their own construction-related permits or deal with unregistered
Contractors will be excluded from the guaranty fund provisions of MGLC, 142A.
Any deposit required under this Agreement to be paid in advance of the commencement ofwork shall not exceed the greater of one-third of
the total contract price or the actual cost of any materials or equipment of a special order or custom-made nature,which must be ordered in
advance of the commencement of work,in order to assure that the project will proceed on schedule.No final payment shall be demanded
until the contract is completed to the satisfaction of the parties.
(Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE.During the term of this Agreement,NEWPRO shall
maintain public liability and property damage insurance covering the work of not less than$500,000 combined single limit,bodily iniury
and property damage and workers' compensation insurance as required under chapter 29 of title 28. NEWPRO and/or subcontractors or
material persons may file a lien in accordance with Rhode Island Mechanics Lien Act,chapter 28 of title 34.
(Maine Sales Only): Consumers are strongly advised to visit the Attorney General's publicly accessible website
(www.maine.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their hones.
The Attorney General can be contacted by telephone at 207-626-8800.
Any alteration or deviation from the above contractual specifications that results in a revision of the contract price will be executed only
upon the parties entering into a written change order.
In addition to any additional warranties agreed to by the parties, NEWPRO warrants that the work will be free from faulty materials,
constructed according to the standards of the building code applicable for this location, constructed in a skillfid manner, and fit for
habitation or appropriate use.The warranty rights and set forth in the Maine Uniform Commercial Code apply to this Agreement.
If a dispute arises concerning the provisions of this contract or the performance by the parties that may not be resolved through a small
claims action, then the parties agree to settle this dispute by jointly paying for one of the following: ❑ Binding arbitration as regulated by
the Maine Uniform Arbitration.Act, with the parties agreeing to accept as final the arbitrator's decision; ❑Nonbinding arbitration, with
the parties free to not accept the arbitrator's decision and to seek satisfaction through other means, including a lawsuit; or Oxxi Mediation,
with the patties agreeing to enter into good faith negotiations through a neutral mediator in order to attempt to resolve their differences.
(Connecticut Sales Only): THIS INSTRUMENT IS BASED UPON A HOME SOLICITATION SALE, WHICH SALE 1S SUBJECT
TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT. THIS INSTRUMENT IS NOT NEGOTIABLE.
The owner(s) of NEWPRO is or has been a shareholder, member, partner, or owner of the following corporations, limited liability
companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous
five years:NONE
,- 5/2/2014 11:16 AM FROM: Fax Mackintice Ins A9cy Inc TO: 17819320860 PAGE: 002 OF 002
1
Accill CERTIFICATEQF Ij4 DATE(MMMDIWYY)
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[he certificate holtler 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 endorsements .
PRODUCER NCONTACT AME: Melissa Pflug
Mackintire Insurance Agency Inc PHONE .me(508)366-6161 ac No: L50el366-5202
11 West Main Street li IS. @m ckintire.com
i
—INSURE S AFFORDING COVERAGE NAIC a
Westborough MA 01581-1931 INSURERA:Libert Mutual/Peerless 4198 _
INSURED INSURERBAcadia Insurance Co.
Nal Operating LLC INSURERC.
26 Cedar St. INSURER D:
IN IRE:
Woburn MA 01901
INSURERf'
COVERAGES CERTIFICATE NUMBER:13 - 14 Master REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
M UUL
LTR TYPE OF INSURANCE POLICY NUMBER M I I MI POLICY IYEXP -LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oNu:uODence $ 100,000
A CLAIMSMADE ®OCCUR Zap 8589577 2/31/2013 2/31/2014 MED EXP Lary oneperson) 5,00
PERSONAL 6 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY PRO- LOC $
POMOBILE LIABILITY M LIMIT
Ee accident 1,000,000
AMY AUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED 8584174 2/31/2013 2/31/2014
AUTOS AUTOS BODILY INJURY(Par saident) $
HIRED AUTOS X NON-OVNJEO PROPERTY DAMAGE
AUTOS Perecddent $
Uninsured motorist 91split limit $ 250.0001
X UMBRELLA LU1a X OCCUR EACH OCCURRENCE $ 5,000,000
A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000
DED I X I RETENTION S 10,000 O 8SS2578 2/31/2013 2/31/2014
B WORKERS COMPENSATION MSTATU- I OTH-
AND EMPLOYERS LIABILITY TORY LIMITS
ANY PROPRIECR/PARTNERENECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ E.L.EACH ACCIDENT $ 500 D00
N/A _
(Mescal in NH) -20-20-003506-01 /1/2014 /1/2015 EL.DISEASE-EA EMPLOYE $ 500 000
1(yyaa s,describe under -
DESCRIPTb, OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACO RD 101,Additlenal Remarks Schedule,it more space la re4ui red)
CERTIFICATE HOLDER CANCELLATION -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TO Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENpTVE
T Moynagh/MARIAN
ACORD 25(2010/05) ®1988.2010 ACORD CORPORATION. All rights reserved.
INS025(201005).01 The ACORD name and logo are registered marks of ACORD
. y ,
` The Commonwealth ofMassaehusetts
Department oflndustrial Accidents
tce o nvestigations
600 Washington Street
Boston,MA 02111
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organimtior✓Individuai): ��pr, -fir � � .]—t rk: LL L
Address: ar,
City/State/Zip: JnE�uro i M q c)l aor Phone #: 22L 923 :k-`{unn
Are you an employer?Check the appropriate box: Type of project(required):
LEJ I am a employer with SO 4. ❑ I am a general contractor and 1 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 y K 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
required.] officers have exercised their 10.❑Electrical repairs or additions
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.]t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant drat checks box#1 must 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 must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I mu art eutp[oyer that is providing workers'cornpensatioi insurance for try employees. Below is the policy and job site
information.
Insurance Company Name: l)ac A��
Policy#or Self-ins. Lic.#: (;,JC - 1 -�� - Qp3 �E - a Expiration Date:_�j (y
Job Site Address: 0L City/State/Zip:�,4ern M79 Q Jq-7o
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 certify under thepains and penalties of eijury that the information provided above is true and correct
Signature: Date: (v g
Phone
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 -
y
I
a
q ���e�nA/ulPn/nen�(�r/n.��rLnr�u�c(h
ffice of Consumer Affairs&Business Regulation License or registration valid for individul use Only
ME IMPROVEMENT CONTRACTOR before the expiration date.-If found return to:
Registration: .146589 Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170
Type:
ssr'`
R Expiration:-5/5/2015 Supplement C1ard
NEWPRO OPERATING-- U-C. Boston,MA 02116
THOMAS FOXON
26 CEDAR MA 01801 � �Jk�1a' '.� T/r'✓ ..
Undersecretary
MA
WOBURN, Not valid without sq; tore
i
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'isor _ -
Lcense: CS-029090
THOMASPFOXON -
230 WALNUT ST, � +
READING MA Oglh .�
a:,anon
commissioner 11/19/2015 -
/ /
,.•moo
® =quallfled In all zones
NEWPRO MANUFACTURING
A07NFRc SERIES G NEWPRO 2000130001
4000 DOUBLE HUNG
1i Cellular PVC frame,Triple glazed,
Natlonal Fenesh9w Low E coating (e=0.027, S2&5),
Rating 0oundl
s Argon/air filled
DEV-K-27.00 G34-00001
s
ENERGY PERFORMANCE RATINGS
U-Factor(U.SJI-P) Solar Heat Gain Coefficient
0.21 0.24
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Air Leakage (U.S./I-P)
0.40 0. 1
Condensation Resistance
67
ManuFaclumretlpNatnthet Ihne npin"conlamin appllnple NFRCppcedurtsfortleterminlnpwhole
protluct pertormenpe.NFRC mdnps are determined forenxed eM of emlmmnemel contlltlone and a
epecine product Sao NFRC don nM nam Any yyopdductvgdoes not wanant theeuftebllltyolaiy
product ror any speclnc uaa CNrsuN man ldeoWrerBINBRturt for other pmducl perlormerica Itdormallon,
wµfsy, orp