0 CLARK AVE - BUILDING INSPECTION (3) Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): NEWPRO
Address: 26 CEDAR STREET
City/State/Zip: WOBURN,MA 01801 Phone #: 781-932-8300 Ext.251
Are you an employer? Check the appropriate box: Type of project(required):
1.X I am a employer with 50+ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. T ?. X Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9
[No workers' comp. insurance 5. ❑ We are a corporation and its ❑ Building addition
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work fight 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.] + employees. [No workers' 13.❑ Other
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most 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 am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information.
Insurance Company Name: ARBELLA PROTECTION INSURANCE
Policy#or Self-ins. Lic. #- 90967005 Expiration Date: 05/01/2008 n
Job Site Address: 0(�>geL ��� City/State/Zip: �� LE71-/, AY Q197-D
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.
Ido hereby certify and the pains and penalties o y that the information provided above is true and correct.
Signature e.0%01-
4 4z FOR NEWPRO Date: //
Phone#: 781-953-8146
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 . Building De artmen 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
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PUBLIC PROPERTY
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MA Reg. #146589 FIT
� ® 5228CT Reg. #0605216RI Reg. #25463 HOE Federal ID #20-2625129
Corporate Headquarters:2666 Cedar St.,P.O.Box 2696 Wobum,MA 01888 (781)9334100 1-800.342.2211
THIS CON T MADE TH . . . . . . . day of. . ..
. . . . . 200 . between . . . . . . . . . .
} ) (Hers) Home Phone) ( one_Bus. ell
/ � J ome ) (Ivir./Mrs.) .
(Address) (State) (Zip Code)
the "Owner' and NEWPRO Operating, LLC, "NEWPRO".
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
(Job address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(E-Mail Address) .
TOTAL NEWPROAdditional S le Ot TOTAL CASH
Windows Purchased Work y PRICE
Window Color S eci Sliding Glass Door DEPOSIT
Capping Color S eci ON Steel Security Door WITH ORDER �/?Z
Double Hun
Picture Window Obscure Glass P BO BALANCE
StationaryCasement Screens HALF` ULL DUE AT
Casement - Model# INSTALLATIONu
2 Lite / 3 Lite Slider NEWPRO' does not do any painting or u
Ba / Bow Frame staining. CASH
Garden Window NEWPRO' is not responsible for conditions Balance Paid to
or circumstances beyond its control including Installer at Installation
Awning condensation resulting from or due to pre-
Other ex conditions. Morm
NCE Bank Completion
GRIDS Colonial Diamond Signed at Installation
DESCRIBE WORK, QNr10 I S ?AA- Ad eflfL S' /rU e.�
•� :n.;c cue,err b;scuK v:� . `?�i �ba cM�- st.,i �
All steel sedurity doors will have a 3/4"aluminum threshold installed over existing threshold. Customer Initials
Est. Start Date: .07 Est. Comp. Date: c Z.
It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement, as the Owner's Agent. 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.
Alt Home Improvement Contractors and Subcontractors shall be registered by the Director and any inquiries about a Contractor or Subcontractor
_relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301,
Boston, MA 02108, (617)727-8598.
If the Owner is obtaining financing by way of a Retail Installment Sales Agreement, such Agreement shall include a time schedule of payments to be
made under said contract and the amount of each payment stated in dollars, including all finance charges. The Retail Installment Sales Agreement
shall be incorporated herein by reference. It the Owner is obtaining a revolving credit line to pay, in whole or in part, for the contract amount herein,
the terms of the revolving line of credit including interest rate and payment terms, shall be clearly set out on the credit application. The portion of the
credit application referencing a time schedute of payment,to be made under this contract, and the amount of each payment stated in dollars, including
all finance charges, shall be incorporated herein by reference.
NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of$100,000-$300,000.
If the Owner refuses to permit NEWPRO to proceed with the work herein;or in the event of any breach of the Owner of this agreement,for any reason
whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid, as fixed,
liquidated and ascertained damages, and not as a penalty,without further proof of loss or damage.
NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners
to enter into this agreement.
This contract represents that entire agreement between the Owner and NEWPRO and Cannot be changed except by a writing signed by both the Owner
and NEWPRO.
You are entitled to a copy of the Contract at the time you sign. Keep it to protect your legal rights. We, the aforesaid
owners, certify that immediately after the signing of the aforesaid agreement, a copy was furnished to us.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,
which may be his main office, or branch thereof, provided you notify seller in writing at his main office or branch by
ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the
signing of this agreement. (Saturday is a legal business day).
See the attached notice of cancellation form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
The 0-2wn s seen "sample" warranties that will be provided by NEWPRO upon installation.
Sample warranties provided to Owner.
IN/ �IJESS WHER OF kfle�a11'es have hereunto signed their names this--�__,�RT� day of� _200V� ,
✓" ��' /' "�EIN# Signed � x �-'�
Marketing1thRepr entative Print N e Ownef
Accepted• PRO re 'ri�y C
By Signed
Marketing Rep sentative Signature Owner
WOBURN BRANCH OFFICE SHREWSBURY BRANCH OFFICE WARWICK BRANCH OFFICE
26 Cedar Street 151-153 Memorial Drive BusinessFark 45 Gilbane Street
Woburn,MA 01801 Suite B-C Warv&K RI 02866
TEL 781-932.8300/EXT:330 Shrewsbury MA 01545 TEL 401-732.2407
800-242-9974(FROM NE) TEL 508-842-6876 800.356.3312(FROM NE)
FAX:781-933-0717 BM456-0555(FROM NE) FAX:401-732.1371
FAX:508.842-9248
WHITE: Branch Copy YELLOW: Customers Copy PINK: File Copy GOLD: Finance Copy
US-15 100/PKG. 11/05
ACORD„ CERTIFICATE OF LIABILITY INSURANCE cSR JB
NEWPR-1 05/01/07
-', ps00ucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Amazican First Ins Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
122 Quincy Shore Drive
North Quincy NA 02171 NAICk
Phone: 617-770-9000 INSURERS AFFORDING COVERAGE
INSURED INSURED Arbella Protection Ins. CO
INSURER B:
NoWpYO Operating LLC WBURER C.
PO OX 2696 INSURER O:
Woburn NA 01801 INSURER E'
COVERAGES
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 OESCMDEO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
A LIMITS
LTH NSR TYPE OFINSURANDE POLICY NUMBER DATE MIODIY DATE MWDONY
EACH OCCURRENCE $1,000,000
GENERAL LIABILITY
A X COMMERCIAL GENERA-UARUTY 850000010649 01/01/07 01/01/08 PREMISESEacccurencBl $50,000
CLAIMSMPDE $❑OCCUR MED EXP(MY one pereon) $5,000
PERSONAL 6 ADV INJURY $1,000,000
GENERAL AGOR50ATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY Pffoi LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
p MY AUTO 81037400001 12/31/06 12/31/07 (Ea acaaenl)
ALL OWNED AUTOS DOUILYINJURY $
(Per pBl6B11)
X SCHEDULED AUTOS .
X HIRED AUTOS BODILY INJURY $
(Pet eccitlenp
X NON-OWNED AUTOS
PROPERTY DAMAGE $
(PBr.tXId..B
AUTO ONLY-EAACCIDFNT $
GARAGELNIBILITY
ANY AUTO OTHER THAN EAACC S
AUTO ONLY: AGO $
EXCE561UMBPELLA LIABILITY EACH OCCURRENCE $5,000,000
A X OCCUR CLAIMS MADE 4600010709 01/01/07 01/01/08 AGGREGATE $5,000,000
$ i
$
DeoucneLE
RETENTION $ _ �T
WORKERS COMPENSATION AND X TORY LIMITS ER 1
A EMPLOYERS LIABILITY 90967005 05/01/07 05/01/08 E.L EACH ACCIDENT $500,000 t
MMPIOEO/MEMBEREX UREOTECUTV E.L.DISEASE-EA EMPLOYE $500,000
Ry tluctlDe antler E.L.DISEASE-POLICY LIMIT $500,000 '
SPECIA.PROVLSIONS UeIpw
UOTHER
RIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
OPERATIONS OF INSURED
CERTIFICATE HOLDER CANCELLATION
SPECIME SHOULD ANY OF THE'ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRP
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYSWRITTI
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHB
SPECIMEN IMPOS/ 0IOATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REP ESENT IVES.
AUTH SIZE EPRESE A E
Ja$R
on,
O ACORD CORPORATION I
ACORO 25(2001/08)
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BOARD OF BUILDING REGULATIONS
1 f' License: CONSTRUCTION SUPERVISOR
i
11
- k s i aryl Number: CS 029090
Birthdate: 11/19/1953
Expires: 11/19/2007 Tr.no: 9879.0
ncr.m9l4.JPG Restricted: 00
THOMAS P FOXON- -
230 WALNUT ST
READING, MA 01867 Commissioner
Board
y� � iio�runzar'uvicea�l� o�✓�^'aaac+�Caaelta
\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:" 146589
Expiration: 5/5/2009
Type: Supplement Card
NEWPRO OPERATING,LLC.
THOMAS FOXON'
26 CEDAR ST. . .
WOBURN, MA 01801 Administrator
SAMPLE COPY
®,Q1041d �n ell toms.
GEVCO PRODUCTS, INC.
04NMCM Newpro/Oenall 2000 Picture Window
Vnyl frame, Triple glazed,
Nedmesre maylm Low j coating (a-0.034, 62& 5),
Re6gcmwl Kr,rpton/Argonlair filled
E94•DEVOI"O'
ENERGY PERFORMANCE RATINGS
LI-Factor(U.S.A-P) Solar Heat Gain Coefficient
0, 17 0.29
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Air Leakage (U.S.A-P)
0.42 0. 1
Condensation Resistance
74
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sn NRC r*gs am dbfar&fixed set oferwimwwdal�ndl6 e
specificpNducCg uftmanufeCWnrslmbnforOMUpOdoctpr eO
www.nfrc.org
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PUBLIC PROPERTY
DEPARTMENT
KI\RIF U-FY DRISCOLL
MAYOR 120 WASHINGTON 5TREEr•SAL.FM.XASSACHLSI-1-M 01970
TF1s 978-73S-9S95*FAX 97&730-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: f-1AeCl flC- PS,jzE/VN
Address:
Telephone: 7 k — Z — 8a
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
)eE PC,O E 9 Wl"DOLAJS / nf---U
EX l STJNCa OPEM A16S
Mail Permit to: 42KB G :� iL
r ,
What is the current use of the Building?
Material of Building? if dwelling, how many units?
Will the Building Conform to Law? Asbestos?//
Architect's Name /I�L lit�Pi , Td f OXO/V
Address and Phone o7Lg S 7—
Mechanic's
Mechanic's Name 1XJO6 de-Al O J 90
Address and Phone
Construction Supervisors License# 01;?91090 HIC Registration# 9
Estimated Cost of Project$ /A 401 Permit Fee Calculation
Permit Fee$ t Q3 Estimated Cost X$7/$1000 Residential
�i7
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit
tto build to the above statedspecifications. Signed under penalty of perjury X
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