11 CHURCH ST - BUILDING INSPECTION 103 The Commonwealth of Massachusetts EC �g��l�E
Board of Building Regulations and Standards ISVEE 108i bF
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair,Renovate Or Demolis�llrnp��WO
One-or Two-Family Dwelling
::'Ibis Section For Official
Building Perm t Number:
Building Official(Print
Name)t, € eta
aa4 aM1.RH. a'TM' ieh:+ rci.
� En SECT[ON9:SITE
INFORMATI ON'7a
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
11 CHURCH ST UNIT 103 35 35-0207-803
1.1a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
CONDO
Zoning District Proposed Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requle Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if yes13 Municipal D On site.disposal system ❑
SECTION 2 =PROPERTY OWNERMW..
2.1 Owner'of Record:
MARIE HEINZ SALEM, MA 01970
Name(Print) City,State,ZIP
11 CHURCH ST UNIT 103 978-744-4896
No.and Street _ Telephone Email Address
,SE("`l:ION 3:DESGRUTION OrPROFOSED WORK':(check- I that apply)
New Construction❑ Existing Building l4 Owner-Occupied 19 Repairs(s) 6 1 Alteration(s) ❑ 1 Addition ❑
Demolition D Accessory Bldg.D Number of Units I Other. b Specify:REPLACEMENT
Brief Description of Proposed Wore: REPLACE 5 WINDOWS- NO STRUCTURAL CHANGE
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials F< =UfRciai Use Os1y s
1.Building $ 6,926.00 1 Building Permit Fee $ :V.T Indicate how fee is ddammW.7
2.Electrical $ ❑Standard CtiyPI owii AppficaYio a Fee t : . r ax
D Total Project x mulupltea "s R
3.Plumbing $ 2 10
4.Mechanical (HVAC) $ Lisk
5.Mechanical (Fire
Suppression) $ Total`All Fees.$ ' >•
6,926.00 Check No. Check A6mr . Cash Amount:
6. Total Project Cost $ ❑Paid in Full ❑Out�anding Balance Due. '
SECTION S-1i CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL)
90125 10-06-14
JAIME MORIN License Number Expiration Date
Name of CSL Holder - U
86 GARDI NER ST List CSL Type(see below)
No.and Sued .,IYpe-' , sue, ,:_,Desaiptmn
LYNN , MA 01905 U Unrestricted uildin s up to35 000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 1 Insulation'
Telephone Email address D Demolition -
5.2 Registered Rome Improvement Contractor(HIC) 170810 12-23-15
RENEWAL BYANDERSEN HIC Re 'strationNumber
HIC Company Name or HTC Registrant Name Expiration Date
30 FORBES ROAD
No.and Street Email address
NORTHBORO,MA 01532 508-351-2214
City/Town,State,ZLP 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..........M No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMFLETED WHEN `r
-'"`OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII:DING PERMIT .It 1
I,as Owner of the subject property,Hereby authorize JAIME MORIN
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
"`' 'SECTION 7bi OWNER'OR AUTHORIZED AGENT DECLARATION;: r,
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 i
° a.
z L,A •'ir W ,�tici+'''sFyo: ,`u.'F'
v �-c:. ., 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 can be found at
www.masst. v/oca Information on the Construction Supervisor License can be found at www.m4&., og v/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (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 of half/balhs
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"
CITY OF S.UENI, 11lAssAcHmTTS
& ummG DEP.kitntENT
120 W.%smoTON STREEff,Va ftoOR
TEL(978)745-9S9S
PAX(978)740.9846
KIMBERLEY ORWOLL
MAYOR Tttomu ST.Pmm
DmEcroR op PUBLIC PROPERTY/lIU MG cONMOSSMER
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 from
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
(name of hauler)
Ito debris will be disposed of in
RENEWAL BY ANDERSEN
(name of facility)
30 FORBES ROAD NORTHBORONA 01532
(address of facility)
signature of pemdt applicant
08/28/14
date
dr6risalydac
i
--- --_ --- - -- - -- _-- - --- -----
Renewal MA Home Improvement Contractor
Inv
vAndersen Renewal b Andersen Corporation License Federal(6 Aires 1?-1918 1 3
Y rP Federal Tax ID#41-1 91 841 3
104 Otis St. Northborouah.MA 01532.
Iw aaaw I. "r (5081 351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer( Name Date:
MARIE A HEINZ - JUNE 2, 2014
�Bu ors Street Address Ci State Zip Cade
1 I CHURCH ST UNIT 103 SALEM MA 01970
Email Address' Home Telephone Number Work/Cell Telephone Number
G MHEINZCHOTMAILCOM 1 978-744-4896
Buyer(s)hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("Contractor"),in accordance with
the terms and 'conditions described on the front and the reverse of this agreement and on the attached specification 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 $ 6,926.00 amount Roommi
1411 Check/Cash
Deposit Received(33%)$ 2,308.67
10-12 weeks p
Balance Stan of Job(33%)$ 2,308.67 ospos0 at signing 0 Cneck# 318
I Est.Install Time
Balance on Substantial At substantial '4. Credit Card'
ompletion of Jab(33%)$ 2,308.67 completion$ 0.00
itl 1-2 days If credit selected,please
see Creditdit Cam Payment form
Buyer(s)agrees'antl 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 Ouyer(s)end Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has
received a completed,signed antl dated copy of this Agreement including the two attached Notices of Cancellation,on the date first written above and 2)was
orally informed of Buyer's fight to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renew it by Andersen Corporation `ter r Buyer(s)
By ,,q Pe6er /U &/a1111
Signature of Project Manager Signature Signature
PETER H RYAN MARIE A HEINZ
j Printed Name of Project Manager Pdnted Name _ Printed Name
I
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.
11 SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT,
NOTICE OF CNNCEMATION I NOTICE OF CANCELLATION
I
Date of Transaction 612/14 . You mayeancelthis Data a Tramaction 6/2/14 . You may canedth:s
Itransaen",grid you.,any penalty of obligation,within three bos:uesa days from the I transaction,without any penalty or obligation,writ., Wee business days from the
above dam.IF yop�,cancel,any pmpeay traded in,any payments,made by you under I above date.If you came],any property traded in,any payments made by you under
the Contract of Site,and any negotiable instrument executed by yen will be Ithe Cavtr ct of gale,ord ory vegotiahle imavment mecuted by you wm be
returned within 10 days following receipt by the Contractor("Seger") of your I returned wlWn tU days,fbgowin,receipt by tha Cre tractor("Sager") of your
�cavU.'an.noae$and any security interest arising out of the tran tion sac will be ancellation mfice,and any security far.—.Militia,out of the transaction will be
celeci. If ya cc=ca,you nmat make ara:IaMe to the SeHer mt ur msidencq be connected. If you cancel,you tarot mate available to the Seger at your residence,in
subsmutlagy as good coudidon as when received,any goads delivered to you trader 1 substantially as Fund condition as when received,any goods delivered to you under
this,Contract of Sile; oryau may,U you wish,complyw:th the instrvetious of the 1 We Contract or Sale; or you may if you wish,comply w:dt the:vatructioas of the
auger regarding the return shipment of the goods at the Seller's separate and risk. Seller regarding the return shipment of the goods at the Sale:s espouse and rich.
If you d6 make the goods available to the Seger and the Seller does not pick them up If you do make the grade available to the Starr and the Sallee does not Pick them rip
w:tb:n 2'0 days of the data of your Notice of Cancellation,you may retafa or dispose within 20 days a the time of your Notice a Cancellation,you may retain or dispose
�of the goads wiitiout any further abggedan. If you fail to cumin dte,nods available of the goods without uny farther obligation. If you fail to make the goads available
ItotheS¢Iley or iF you agree an return the goods to the Seger,sad fail an do so,than to the Seller,or if you agree to return the goods mthe Seger and Fail to do so,earn
you remain gable for performance of all obligations order the Co..... To cancel I you remain Hold.for perfic—tee of all obligations order the Co..,.To cancel
this ransacton,—U or delivers signed and dated copy of We cancellation notice I this nansacdon,mail or deliver a signed and dated copy of Ws cancellation notice
r any otherwritten notice,or send a telegram to Contractor: Renewal by Andememl oranyother ttennotice,orsendmtaegramwCwtracton Renewaby Andersen,
104 Otis SI, NaAhbomugh,MA 01532,BY NOT LATER TITAN MIDNIGHT OF I 104 Otis St.Nurthboreugh,MA 01532,BY NOT LATER TITAN MIDNIGHT OF
6/5/14 t.(D..) I HERESY CANCEL THIS TRANSACTION. 6/5/14 .(Date) IFIEREHY CANCEL TFIa TRANSACTION.
q _
agora spas re Pivx name o"re i eowra sbamure cam Hans wn
1 i,f
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— -----.
NRenewal4 � Renewal by Andersen Corporation MA Home Improvement contractor
ndersen� 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2015)
w...ow eaeuernaa "„Amx,.,.r.,,, (508)351-2200 Fax:(508)-988-7072 Federal lD#41-1918413
Window Specification Sheet
Bu er s N e ! Date-of cement
I
MARIE A HEINZ MON, JUN 2, 2014
I
The buyers)listed above herebyjaindy and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms
described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING
AGREEMENT,of which the Specification Sheet is part.
WINDOW DETAILS
Approx. Eterion terim Color Hardware Him. LowE4/ Grile Go I. Glass
Room N U.I. �i Window/Door St le Detail Casings Extmint Color she screens sci n ce 1 s-1t/3 Sesh2 LIiS 0 Ions
Family 2 72 DB sq rail equal insert flat sill Ext.MF 908 wHi White Standard FFG 3consin 3/2
Living 1 90 08 sq rail equal insert flat sill Ext.MF 908 wHiwH White Standard FFG 3reardthir a/2
Bed 1 2 90 DB sq rail equal insert Bat sill Ext.MF 908 WWWH White Standard FFG social 3/2
S
i
I
I
I
Total 5 J BAY&BOW DETAILS *See Ba B.Measure Sheet
Style Detail/ Approx. 'Approx. Number Frame Wndaw End Center LowE/ Root/ Hardware
Room Count 'Style Plackets U.I. Cazin s An le Utes IMerlor rheu tCo,Or Galles sashes sashes Screens Smemem Soffit Color
FFG seems.I I White
`Q
SPECIALTY WINDOW DETAILS
hi
Full/ Approx. Lowe/ SpimalN RAY/BOW ADDITIONAL WORK NOTES
-
Room Cennt le Insert U.I. Sorenson Grilles Grilles le ExUlnt Color Customer u aware dim with ba/bow windo.s under 72 inches
there will be nemifierat Ocia I.—
ADDITIONAL WORK DETAILS;
J i
l )
I No -Contractor;will wrap exterior casings with coil stock color of
Owner isaware ar that Contractor does not do ty painting/staining or removal/installation of alamr system or window treatments/hardware.It is the
respon at lit"of the homeowner to have the alarm system and window treatments/hardware removed prior to installation. We make no guarantee as to
2 whether alarms or window treatments/hardwas will fit after replacement. Customer is also aware in some cases there will be glass loss. If there is,the
amount will be dependent on the type of existing windows,type of installation and window style.We make no guarantee as to the amount of glass loss.
Costome'r is aware and understands any and all unseen rot is not included in this contract.Should any rot be found there will be an additional charge for
Urns 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 infiltration.Removal and disposal of all job related debris,
wintlows,floors,storm windows and vacuum nightly included. Upon completion of the lob and payment in full,a limited warranty shall be issued.
4 Yes Bbiding Permit--Contractor will secure any and all necessary permits. The fee for the permits)is not included in the Contract Price and a separate
check is required at the time of sale for this fee. Check# $
5 yes All discounts have been applied to this agreement.
6 J. Yes -Emir. No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance forri
JI
It is agreed and indention d by and between the parties that his Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the
entire i nder t. ing beaver.the panics,and there arc no verbal undersmvdings changing Or modifying any of the terms. This Specification Sheet may not be changed or its terms
modified or va' of in anyway unless such changes are in writing and signed by both the Rayons)and Contiose oc Buyers)hereby acknowledge that Buyers)has read this Specification
Sheet. I ///���
Renw ealby Asderre jra Cor/potio R n uyc/1s� Buyer(s)
a, (�" 'Vrllr
Si9 naturisrof Project Manager Signature Signature
PETER H'RYAN MARIE A HEINZ
Pr Namelof Project Manager Print Name Print Name
39i
I
y
The Essex Condominium
Telephone: 978-532-4800 1 Fax:978-532-6023
c/o Crouminshield Management Corp.
18 Crouminshield Street
Peabody,MA o196o
Mrs. Marie A. Heinz
Unit 103, The Essex Condominium
11 Church St.
Salem,MA 01970
Dear Mrs. Heinz,
The Essex Trustees have reviewed your request to replace the windows of your unit. The Trustees
have given their consent for you to proceed with your project,but with the following
qualifications:
The Trustees are not in a position to assess the engineering details of your request nor can they be
assured that the final product will be in accord with the plans.Thus you the Owner retain the
responsibility for ensuring that the finished work does not"affect the appearance or structure of
the Condominium, or the integrity of its systems",that"all materials used and Work performed
shall comply with all OSHA, other federal,state,county, and municipal laws, rules, ordinances, _
codes and regulations," and that the work is carried out by the contractor in the manner specified
by the Essex Condo Documents* (vis a vis hours, removal of refuse, noise, etc.).
Regarding replacement windows and doors,please be aware that:
Windows must be of a quality equal or greater to the original windows;
Installation shall be done by a reputable contractor with a good work record and
references;
The appearance from the outside must be identical to that of the original windows,
specifically as to color(white),number and spacing of mullions(grids), and location
of mullions/grids on the outside the outer pane(not between the panes);
Screens must cover only the bottom half of the windows to match those throughout the
rest of the building;
Flashing must be to Massachusetts code standards.
Please contact the Management Company if you have additional questions.
Good luck with your project.
Signed: ALI 4 ---- as managing agent Date: July 9,2014
for the 14sex Trustees
*Exhibit C of the Certificate as to the Rules and Regulations, Book 23224,Pg. 241, South Essex
Registry of Deeds and Sections 5.2 and 5.15 of the Declaration of Trust,Book 101169,Pg. 84.
Both are available in the black bound copies of the Essex Condo Documents available from the
front office.
The Commonwealth of Massachusetts
DeparhnentdflndnstrinlAccutents ,
Office of Investigations
600 Washington Street
Boslon;'MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f} /� \, Please Print Legibly
Name (Business/Organuation/Individual): .I�C�!()ew c,_1 `per (), die l SCi�
Address: 3D C-oe-6-s
City/State/Zip: A 0 Q LS3>hone
Are you an employer?Check the appropriate box-
Type'or project(required):
1„l,J 1 am 9 employer with 7 J 4.•� I am ageneral contractor and I ,�.,p' u.,' i
employees(full and/or part=time).* have hired the sub-contractors 6. O New constiuohon
2.❑ I am a sole proprietor or pir mer- listed on the attached sheet. 7. Ji 1(imodeling „
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance.: 9. Building addition
required.) 5. We are a corporation and its ]0.❑Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised then ❑ g paw or additions
1]. ` Plumbin re
myself [No workers'comp. " right of exemption per MGL 12. Roof
insurance required.]1 c:152, §t(4);and we have nopairs
employees,[No workers' 13:0.Other
comp.imsurance reWed.]
'any appliFant that ctiecks box ql must also fill out the sect on below sic ng thea workers compen9alfo 1 policy`info°imzt o
t Homeowners who sutitnit this' n.
a5ldavn�indiomting they are doing all work and then litre outside contta'etors d4f subillitta'newiffl" l mdreatidg such.
tConoucton that check this box must atteehed so ndditioual sheer showhig'the mne ofdhe sub-contractors and state whether or our those entities have
employees. 1f the subcontmotors have employees,they must provide.their-,workers'comp„policynumhr
lam an employer that Is providing workers'compensation insurance'for My employees. Below is thepglicy and fbb site
information
R n
Insurance Company Name. ou
Policy#or Self ins.Lie:#: e1 ^D b-- Expiration Date:
JobSite'Address t1 C U/ �� J� C4/State/Zip: QIq 0
Attach a copy of the workers'compensation policy declaration page(showing the p lley cumber and eipiration date).
Failure to secure coverage as required under Section 25A of MGL"c. ]52"can lead to the miposition of"riminal penalties of a
fine up to$1,560.00 and/or one-yea-r imprisonment,as well as civil penalties in the lb,6 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 Terbyrti 'under thepains andperurldes ofperjwry`that the noformation provided`above ir'true and correct'
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#:
AiI CERTIFICATE OF LIABILITY INSURANCE Den(M"DfrYVY)
` 10/01/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pOlicy(ies)must be endorsed. U 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 endorsemeM(S).
PRODUCER 1-612-333-3323 C ACT
Rays Companies INUME,
PHONE . 612-333-3323
80 South $to Street EJI/NL xR: 612-3T3-T2T0
Suite 700 ADDRESS:
Hiweapolie, M 55402 INSURFAB AFFDRDIHG COVERAGE NAICB
INSURERA: OLD REPUBLIC INS CO 24147
INSURED Renewal By Andersen Corporation INSURERS:NATIONAL UNION FIRE INS CO OF PITTS 19445
INSURER C
204 Otis Street
N8URER D
NOrthborough, HA 01532 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 36122490 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.
INER I TYPE OF INSURANCE D S POUCYEFF POUCYE%P
LT POLICY NUMBER LUO LIMITS
A GENERALIMBILITY MNZY 300361 10/02/1 10/02/24 EACH OCCURRENCE E 1.000,000
% COMMERCIAL GENERAL LIABILITY 500,000
PREMISES Eeac .. 7
CLAIMS-MADE PilOCCUR MED UP(An me Penn S 10,000
PERSONALSA)VIWURY N 11000,000
GENEMLAGGREGATE S 4.000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO 1 4,000,000
11
POLICY PECTR0. LOC S
A AUTOMOBILE LIABILITY MATS 300026 1 1 0 COMBINED ED
SINGLE LIMIT 5,000,000
% ANY AUTO BODILY IWURY IPorpenm) $
ALL OWNED SCHEDULED
AUTOS - AUTOS BODILY IWURY(Pm mdwnl) S
% MIRED AUTOS % MED
AUTOS PROPERTY DAMAGE
Par S
S
B E EXCESS e E OCCUR 20562235
10/01/1 10/O1/14 EACH OCCURRENCE S 25,000,000
EXCESS LIAB CLAIMSa.1ADE
AGGREGATE S 35,000,000
DEC, I E I RETENTIONS 25.000
A SCOMPENSATION
ANDEMPLOYERS'WASIUTY S
YIN NEC 300359 00 10/01/1 30/01/19 E WC STATLL OTH
ANY PROPRIETORNARTNERIEXECUTNE
OFFe:EWN1E.NH)
FNN/A EL EACH ACCIDENT S1,0001000
OfteddoWS'Ndjryln NH) E.L.DISEASE-EAEMPLOYE S 1,000,000
Byes,tleevON OF O
DESCRIPTION OF.OPERATIONS below E.L DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AN ACORD 101,AAAImal Remade BCMeule,N mere&,we N rpWna)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
To Nhom It Hay Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
For Insurance Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORRED REPRESENTATIVE
V
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
lhargro,re
36122490
r
Massachy,ketts Department of Public Safety
lard of Building Regulations and Stand
ards4
Construction SUpFrvlsor
License: CS+090125
JAIME L MORIN= s
86RARDINERSI ug
LYNN MA 0190sf
1&16w:. " Expiration "j
,L`Commissioner 10/06/2014
SCA 1 0 20M-05/11
. d��a' r�alr�gec�llaoo��rr�
dice of Consumer Affairs&Bssiness Regulation
-. OME IMPROVEMENT CONTRA CTOR
Wegistration io810-
Expiration ,1,?.%23f2015' Type.
tl
RENEWAL BY ANDERSON'CORPURATION Supplement r:
JAIME MORIN -
1. 104 OTIS STREET
o NORTHBOROUGH,MA 01s32 --�_
. Undersecretary
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To whom it may concern:
Enclosed is a permit application package for a project we have been contracted to do in your
town. Thank you in advance for receiving this package by mail. As we work in every town in
the state, it greatly helps us in our process.
We have also enclosed a self addressed and postage paid envelope and would request that
when the permit application has been processed, that you would mail it back to us.
Enclosed for you review in this package is:
o Permit Application
o Home Improvement Contractor License
o Construction Supervisor License
o Proof of Insurance
o Proof of Energy Efficiency Rating
o Signed Contract from Customer
o Permit Fee (if accepted at time of applying)
If you have any questions regarding this application please call me at: 508-351-2200 X55285
Regards
Kelley Donahue
Permit Coordinator
30 Forbes Road
Northborough,MA,01532
Phone(508)351-2214
Fax(651)-3514807
Website:www.reoewalbyandersenxom
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