185 FEDERAL ST - BUILDING INSPECTION (2) 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 For Official Use Only
Building Permit ber: D e Ap 'ed:
f _
Budding Official_(Print Nam Si Date
SECTION 1: SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map& Parcel Numbers
I .ro l Ste_ 2 r pta-(—
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 oning Informatio 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHH't '
2.!/,�pwn r'of R cord:
tC,Lo. lJ�,� ��n s Sd, SU`> �tA . dLt�n Dl 99—c7
Name(Print) City,State,ZIP
yg-9 °I4F- 7- NS- �ICa �
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other -Er-Sp—ccify: e
Brief Description of Proposed Work: c c,)l✓� o=�r
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ Ct w 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
S ssion) Total All Fees: $
Check No. Check Atitoimf Cash Amount:
6. Total Project Cost: $ S� qS od O Paid in Full 0 Outstanding Balance Due:
SECTION 5:,CONSTRUCTION SERVICES`
5.1 Construction Supervisor License(CSL) Lp S.a i"- _a
`.10 C_.D License Number Expiration Date
Name of CSL Holder _ 1
1I.� G ��� I71 1� List CSL Type(see below) V
No.and Street
V Type "Description
pn l' I U Unrestricted(Buildings u to 35,000 cu.ft.
1\�• U'r'1'12�t)�`d. a��{od R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M MasonryA
RC Roofing Covering
WS Window and Siding `
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5yh�2 Registered Home AA
Contractor(HIC) ,�j g[J j:1
NY tJer 1 �4-✓t CA2Y`Si'vt HIC Registration Number Expiration Date
�HI�CtCom„paPy,�ZHIC Registrant Name
Ny 'and Sqq e-t,II Email address
Jv 0./"I'I.-l�JON, lAAa D IS hb4-p 51—�cu
City/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'7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING,PERMIT
I,as Owner of the subject property,hereby authorize Sh C e 0 h 1K e ti
to act on my behalf,in all matters relative to work authorized by th�s building permit application.
Print Owner's Name(Electronic 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 rized Agent's Name(Electronic Signature) Date
- - 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 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 Cost" j f �( S.Cv
CITY OF Sad .&M. INIASSACHUSETTS
BL'u.DWG DEPART1MNT
120 W ASHINGTON STREET,3'a FLooR
\ Tom.. (978) 745-9595
PAX(978) 740-9M
KJMBERIEY DRISCOLL
MAYOR THomAs ST.PtEm
DIRECTOR OF PuBuc PROPERTY/Buu-DING CO3-M SSIONER
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 11 L5
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:
(nakne of hauler)
The debris will be disposed Iof in
itn n
(name offacility)
10y
(address of facility)
si a it applicant
plicant
b b-� I
da e
dcbrie fldw
1 s
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ .Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage O Other Work
as described below does not.involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 185 Federal Street
Name of Record Owner: Richard Williams Jr-
Description of Work Proposed:
Replace three (3) winclows at the rear of the house. No work will be visible from the street.
Replace fi-ont storm door as shown in specifications dated 8112113. Non-applicability dace to the work being
outside of the Ifistorical Commission 's jurisdiction.
Dated: August 15, 2013 SALEM HISTORICAL COMMISSION
By.
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
08/23/2013 14:53 9787418509 THE UPS STORE PAGE 02/02
Renewal
bAndersen,
WINDOW REPLACEMENT anAndemfCompny
rep-1+CD )MINI UM JEAE&MjssjoN fpamO U! DlNC QERMh
285 Feder"S* MA 02.470
11 Ri.eka{&W i,4i4- ,+a,ye Lf-w.aa ageaL u wi i
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01976
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage O Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 135 Federal Street
Name of Record Owner: RichardWilliams .Ir.
Description of Work Proposed:
Replace three (3) windows at the rear of the house. No work will be visible from the street.
Replace front storm door as shown in specifications dated 8112113. Non-applicability due to the work being
outside of the Historical Coinniission 's jurisdiction.
Dated: August 15, 2013 SALEM HISTORICAL COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be-completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
Renewal MA]ionic Improvement Contractor
A,., .� 'J License#170810(Expires 12/23/2013) ��
byA Idersen' Renewal by Andersen Corporation Federal Tax ID#4 1-19184 1 3
WINDOW REPLACEMENT ...Mde—Comreny
104 Otis St,Nonhborough,MA 01532 ..
(508)351-2200•Fax:(651)351-4810
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyers)Name Dare of Agreement
�; cvE )i+NcS v� -act -/�
Buyerlsl sIRtreeett Address,City.sees,and Zip/Code (\ _
E4Aail Address Home Tole hone Number work Telephone Number
Buyer(s) hereby jointly and severally agrees to purchase the products 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').Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
Estimated Sinning Date: Method of Payment:
Total Job Amount Amount
FinancedOCheck ❑Cash
Deposit Received(33%(: y ( l5 �� OViissa/MC LIDiscover
/
Balance at Start of lob(33%1: U
Estimated Compl If cinanaed OAMEX
etion Date: If credit cord is selected,please
Balance an Substantial gyp" y—� see Credit Card Payment Form.
Completion of Job(33%): A _
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties, Rod 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. Buyer(s) 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 Cancellation,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 BIANK SPACES.
Renewal by Andersen Corporation Buyer(s) Brayer(s)
Bl� --
Signature of Product Manager *natum Signature
Print Name of Produci 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.
- - -.-_ - - - - - - - - - - - - - - - - - X- - - - - - - - - - - - - - - - -
�
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Date of Transaction ir- -P 3 You may cancel Date of Transaction -i You may cancel
this transaclion,without any penalty or obligation,within this transaction,without any no o Elation,
r oblition,within
three business days(romthe above date Ifyou cancel,any t three business days from the above if you cancel,any
nts property traded in,any payme made by you under the property traded in,any payments made by you under the
Contract of Sale,and any negotiable instrument executed Contract of Sale,and any ne�ofiable instrumend 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, l by the Contractor ("Selki of your cancellation 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 t 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 Contract or Sale;or you may,if your wish,comply with the
with the inshvctitc, 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 date pick them up within 20 days of the date of your Notice
of your Notice of Cancellation,you may retain or dispose of Cancellahon,you maayy retain or dispose of the goods
of the goods without any further obligation.t you fail to without any further obligation. t you fail to make the
make the ggcods available to the Seller, or if yyoe agree goods available to the Seller,or if you agree to return the
to return the goods to the Seller and fail to do so, then 000ds to the Seller and fail to do so,then you remain liable
you remain liable for performance of all obligations under Tor performance of all obligations under the Contract.
the Contract. To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and
sigBrad and dated copy of this cancellation notice or any dated copy of this cancellation notice or any other written
other written notice, or send a telegram to Contractor. notice,or send a telegram to Contractor.
Renewal by Andersen Corporation, 104 Otis Renewal by Andersen Corporation, 104 Otis Street,
Street, Northborouph MA 01532, BY NOT LATER THAN Northboro h MA 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OF !to :��'3 .(Date) -Y3 .(Date)
I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL THIS TRANSACTION.
Bvye:r Bignmure Print Nome Dine Buyei a BignaWro Print Nome Dote
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink CJBLLP2009.RBAF6ANNn
l p
Renewal enewal by Andersen COCporati`S MA Home Improvement Contractor
Andersen. - 104 Otis St.,Norlhborough,MA 01532 License#170810(Expires 12/23/2013)
(508)351-2200•Fax:(508)986-7072 Federal Tax ID#4 1-19184 1 3
WINDOW REPLACEMENT an A, ,eCompany
WINDOW SPECIFICATION SHEET
Buyer(s)Name Date ofAgreement
�f
The Buyer(s)listed above hereby jointly 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.
WINDOW DETAIL
1. Contractor will Install a total of windows in Owner's home,using the following individual quantities:
Oriel sash(2/3 to 1/3 bottom) Harrill aNlercsoomer is of
Double Hung(DB)_Equal sash_Cottage sash(1/3 top,2/3 bottom)_ P f Go.toss)
Square Check Rail VC.rve Check Reif
Casement(CS)_Hinge right_Hinge left(as viewed from exterior)
Double Casement(CD)
2 Lite Gliding Window(GW)
Casement/Picture/Casement(CI)_1:1:1 or_1:2:1
Glider/Picture/Glider(GFW)_1:1:1 or_1:2:1
Ficture Window Bay or Bow
Awning Window _#Lifts Soffit/Roof Shingle/Copper
Specialty Window Patio Doors(see srpurre door sttt sneer Seat to be Primed/Oak/Pine
❑�
Q y of windows
to be Custom Fit Replacement:
3.�Qly of Windows to be Custom Fit FtiB forme(INCLUDES NEW INTERIOR&EXTERIOR CASINGS)
Exterior,caassings:_Pine_Maintenance-free material_ ractory applied 909 Fibre.brickmold
4.Glazing to be:_� nr Low/-E4m SmartsunT- _Tempered —other If other,please specify.
5.Exterior color to be:V White_Sand_Canvas_Terratone_Cocoa Bean—Dark Bronze_Forest Green_Black—Red Rock
G.Interior color to :_JVV�ite_Canvas Par._Maple_Oak_Same as Exterior Note:Wood interiors need to finished by Owner.
7.Hardware: Whim Stone_Canvas_Estate Hardware: Style:
8. Install Lifts with Double Tlung Wind ws
9. Screens:windows to have_Half or u11 screens Screens to be: Fiberglass_Aluminum_TruScene
GRILLE DETAIL
10. Windows have grilles:_Grille Between Glass(GBG)_Removable Interior Wood(INTW) Full Divided Light(FDL)
Owner approved(initials) Draw grille patterns below 'Use additional sheer if needed
Y: Qty Qty: Qty: Qty: Qty- Qty:
F-1
ADDITIONAL WORK DETAILS
11. AJCJ Qty of_Sills_Sill noses to be replaced by Contractor
12.�y///���osss��� Contractor will will remove metal frames of windows.
13. Contractor will install new_paint-ready or_stain-ready_Interior_Exterior casings in_Pine_Maintenance-free material
14. PO Contractor will install new_paint-ready or_stain-ready_Interior_Exterior stops in_Fine_Maintenance-free material
15.(WIV )Intls-Owner is aware,contractor does not do any painting or removal/installation of alarm system/hardware. It is the
responsibility of the homeowner to have the alarm system/hardware removed prior to installation.
16._W _Contractor will wrap exterior casings with coil stock of color.
Note:Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17.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,
windows,storm windows and vacuum nightly included. Upon completion of thejob and payment in full,a limited warranty shall be issued. Customer is
Aware in some cases there will be glass loss If there i glass loss,the amount will be dependent on the type of existing window,type of installation,insert or
full frame and the window style. We make no guarantee as to the amount of glass losa Customer is also aware and understands that any and all unseen not is
nN. 'laded in this contract.Should any ort he found there will be an additional charge for time and materials unless so stated in this contract.
18.;Yes Q No Building Permit--Contmetor will secure any and all necessary permits.The fee for the permits)is not
included in the Conlmel Rice and a separate check is required at the time of sale for this fce. Ck
19. 1'es No AB discounts have been applied to this agreement price.
20.Additional job details:
21. Yes❑No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s).
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 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.
;Rene�walf rs/en.Cyrpo anon euyer(s) Buyer(s)
; /S're of Product Manager Signature Signature
Print Name of Pr duct Manager Print Name Print Name
RenewalA MA Home Improvement Contractor
{„'fit^/� ��� License#1708 10(Expires 12/23/2013)
JN dersen• I Renewal by Andersen Corporation Federal Tax ID#4 1-19 184 13
WINDOW REPLACEMENT mMdmenCumpvry
104 Otis St.,Northborough,MA 01532
(508)351-2200•1ax:(651)351-4810
SPECIFICATION SHEET
Buyer(s)Name Date of Agreement
w L lf1 s The Buyer(s)Buyer(s)listed above hereby jointly 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.
PATIO DOOR DETAILS
1. Install total of: Permashield Gliding Patio Dcor(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 same inside and out on PS)
Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Other—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 08" ❑ Other: Op.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 have sidelight? Size:
❑ Yes ❑ No Grilles? Ifyes: GBG ❑ INTW ❑ FDL (ALIT Divided Light)
3. Install total of: Prenchwood Gliding Patio Door(s)
❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior)
Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone
Interior Wood: ❑ Pine ❑ Oak ❑ Maple
Interior Finish ❑ Prefinished White(Available only with white exterior) ❑ Unfinished(Paint/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 (Fall Divided Light)
4. Install total of: Frenchwood Hinged Patio Door(s)
❑ 610"x 6'8" ❑ Other:
❑ Yes ❑ No Active/Passive Parnell: ❑ Left ❑ Right(viewed from ext.which is active)
OR
❑ Yes ❑ No Active/Stationary Pane17: ❑ Left ❑ Right
Door Swing: ❑ Inswing ❑ Outswing
Exterior Color. ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone
Interior Wood: ❑ Pine ❑ Oak ❑ Maple
Interior Finish: ❑ Prefinished White ❑ Unfinished(Paint/stain done by customer)
Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel
'NOTE: Canvas hinged screen frame N/A—must choose white or stone if exterior is canvas'
❑ Yes ❑ No Hinged Patio door to have sidelight? Size:
❑ Yes ❑ No Grilles? If yes: GBG ❑ INT W ❑ FDL (Full Divided Light)
STORM DOOR DETAILS
5. lnst total of: I Storm Doors)
6. Flail View View
7. Color to be: 'te ❑ Canvas ❑ Sandtone [Q B ❑ Forest Green
8. Size to be: ❑ 32" ❑ 34"(White only,❑ 36" Custom(10 week lead time) Size:
9. Hardware to be: ❑ Bright Brass ickel
10. Additional job details:.
IL R rYE] No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shall he demanded until the contract is completed to the satisfaction ofall parties.
If is agreed and understood by and between the parries 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 be changed or its terms modified or varied in any way uniess 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 b rdersea orporation Buyer(s) Buyer(s)
Signature of Product agar agnature Signature
�f�
Print Name of Product Manager Print Name Print Name
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1.0 I sm a empheyer wig: 3 O 4. 0 1 am a genera{coo Or and I �e of Project(requirep,
�ployees(full and/or part-time).* have hued the 6. Q New canshv
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listed on the attached sheet, 7.
ship and have no earployees These sub-comtracmrs have
waui®g formeinanycapacity, employeesandhavewo*=-
iNo warioms'comp.insurance comp.hmumuce t 9. 0 Buitdiog addition
3.Q I�red.] was 5 0 We are a corporation and its 10.Q gl����or���
doing all work officers ben asercised am
myself (No wo&s•gyp, right of axon Per MGL ]l.Q Pbwbiog reMb or additions
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Insttrmm c mpmy Name:M� P b�� G Zn C 6
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Job Sitedddaesa,
Attach a copy of the workers'eompttraatlom
polky 5A of oL PW(ahaa the etpimtlon date).
I?atlure ro secure talky nnneber and lion
CO`"�8e.s required tinder me,,, s w ll as c. 152 a m had to the,uWdthm off Po akW ofa
fine up m$I,500.00 audlar one-year unprisanroent as well as cif Pier in the norm of a STOP WORK ORDER and a fine
Of up to WO-00 a day against the violator. Be advised that a oopy oftbis sttmemmut be f OlSee of
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CERTIFICATE OF LDEILITY INSURANCE ":a5/"'�"'.
THE CERTIFICATE IS NBBJED AS A MATTER OF WOREEATNM ONLY AND CONFERS NO RIGHTS UPON TIW 7E NOLD6L 71W
BELOW. THIS CERTFN:A INSURANCE DOES:CERTIFICATE DOES NOT AFRRKATIVELY OR NOWT Y AMID, EXTEND OR ALTER THE COVERAGE AFFORDEO By THE p0�!
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER. E A CONTRACT BEIIAHQ00 THE Idi11U(G ti AUTIIpITaR
JAWORTANP KBOB eGHWkw hoMw It M" NSURED,tlIa PoBeypu)mus4 bo aWerBod. NSUBROGJ4TIDN BL WAIVED
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ln001/C 1-612-333-9929
EcyE 0oapcalea JOmeale E'styzov pz gip Johesep
PHONE .
612-33l-333!
BO south Btb BtresC ,612-373-7270
Bodo 700
EisseepoliB, IMF 55402
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10F OtiB Street
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COVERAGES CEkftFY_ CERTIFICATE NUSI®ER 29229436 REVIgpN NUMBER;
II
tMCATED. NNOTWRHSTANDING ANY REQUIREMENT,TERM OR T THE POUCIES OFBELOW HAVE BEEN ISSUED TOTHE METFIEpoucy PERIODTE MAY BE MSUED OR MAY PERTAIN. THE INSURANCE AE O pm�BV YTNE POLq OR R ��PECT TO WHICH THISS AND CONDRIONS OF SUCH POLICIES.LIMITS SHONry!MAY HAVE BEEN REDUCED BYPAID CWN6 H IS SUBJECT TO ALL THE TERMS,
' IBW 59028 10 Ol 10/01 13 tarts
COMMERCIAL GENERAL LIABILITY 1�H . 00;p00
mm"oDE OOCCUR P 1�1nmt • 500,000
1EDE1P om men 110.000 _
. PER80NALAADVINAmy 0 2,000,000
GENLAGGNEGATEUMITAPPIEBPEt GENEIALAGGREGA7E 14,000,900
= POLICY m LOC I -COMPAOPAGG B 3.000,000
I^ AYFOESpEEUABNrlY lot= 21700 10 O1 I 10 01 1
Z ANYAUTO ( MFNNEu0r
6 83,000,000
ALLOmE91AUTOG BOOLYNANty(pw 1) B
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EIIRb IMB q��pE OCmiNME/CE $25.000,000
D A 25,NOB,000
= 23.000 B
A Aw Bi0t9 UAI=PROPRIETORNMMERIDIECLInVE r/N ERC 127940 00 10/01/1 30/01/13 E WCETA OWN.
0OFi10EMB/ElE MADEm O MIA
y�By�ae,ma.~, .F ESL EACHACCIDENT Bi,000,000
0E3'a1WDONaP OPERAT10NAbekw i ,000.000
E�DBEABE.PouCv t 1,000.000
DEBOVAnION-0-FORLoreTnNa YEattHS VMeFn 01.
Evidence of Insurance.
CERTIFICATE HOLDER CANCELLATION
Evidence of IDRurcace SHOULD LATME ABOVE DEtCNW0 POLICIES BE CANCELLED S&ME
THE EXGATE THEREOF. NOTICE VML BE DELIYBBEO R
ACCORD THE POLICY pROV610NS.
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ce of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
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RENEWAL BY ANDERSON CORPORATION I
JOSEPH REZZA s
104 OTIS STREET
NORTHBOROUGH,MA 01532 UnderserretarY {
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Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor
License: CS-065272 '
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JOSEPH P REZW
168 KELLEY BLYD
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921- Expiration
Commissioner 04125f2014
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WINDOW REPLACE►IINT enMdet,mCmmybry
WoodMrryl CDmposlte IF
Dual Argon Low E4 Mattson
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momi 100-00473518-010
ENERGY PERFORMANCE RATINGS
U-Factor(U.Syl-P Solar Host Gain Coefficient
00129 0 . 19'
ADDITIONAL PERFORMANCE RATINGS i
Visible Transmittaqce Qm42
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Product Type: Awning
ENERGY PERFORMANCE RATINGS
U-Factor Solar Heat Gain Coefficient
0. 29 1 . 65 0 . 28
U.SJI-P Metie/SI
ADDITIONAL PERFORMANCE RATINGS
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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
104 Otis Shia
NmdbmwgA,MA,01532
Phme(508)351-2200
Fax(651)-3514807
website: