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1A FLETCHER WAY - BUILDING INSPECTION (2) t a. ,s � ► The Commonwealth of Massachusetts Department of Public Safety ,�'�„I \lasachusa•Its dale Building Code 1%SUC\IR)Seventh Edittain of City aV Salem Buildin Permit Application for an Buildin other than a I. or 2-Family Dowtilinjil (rhis Section For Official Use Only) Budding Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION 11slease indicate Block 0 and Lot s for locations for which a street address is not available) I iQ r tom. WA h4A d/9 7 y No. and Street Cit.v /Town Zip Cade.' Name ut Budding(it applicable) SECTION 2:PROPOSED WORK If New Construchun check here❑or check all that apply in the two rows below Existing Building Repair Cl Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) ChangeofUw D Change of Occupancy ❑ Other ❑ Specify: �— Lai vd)ND -r / FIDt>2 Are building plans and/ur curistructiun documents being supplied as part of this permit application? Yes No D / Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0- Brief Description of Proposed Work: t'Lt®-z-4-t-t= t�i r/V In-,, t7 TMJ s - e0-Zd5- r P.s rc m 7 ..lz SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) D Existing Use Group(s): Proposed Use Group(s): Y Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area (.sq. ft.)and Total Height(ft.) SECTION St USE GROUP(Check as applicable) -2r O A-2nc❑ A-3 A ❑ -5O B:A: AssemblyA-1 D A Business ❑ E: Educational ❑ F: Facto F-I D F2❑ f H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 D 1-2 D 1-3❑ 1.4❑ M: Mercantile❑ R: Residential. R-10 R-2❑ R-3❑ R-4❑ e 5: Store S-1 ❑ S-2 D U: utility❑ Special Use❑and pleas,io describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ Ilea IIIA ❑ 11180 IV ❑ VA D vea SECTION 7: SITE INFORMATION(refer to 760 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: I'ubha•❑ C hack if oulaidr Fhxal Luna•❑ Indicate municipal D A trench will not be Licenseal Disptt+.d Site O required❑or trench ur.pctidv: I'nvate❑ or indentifv Zone: ur un,rte,e.tem D permit is enchiseal ❑ _ Railroad right-of-way: Hazards to Air.Navigation: \L\ 1 h•4•rp t •om❑..,i,•,t Itr,ir,a Pr.•....; \ol \)•)•hcdda•O I.SIruc4oc within airport apprnach,tree' I.their rruata cumpletao rd.' a l•un.ant I, Iknl.l vndord D 1 v❑ nr No,Cl 1'rs❑ \, D SEC`rION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY I .Inim d ( . da•. _ Lw rl pa•ul Condruclion: Occupant Lead per l It,, Ihv� ihabuddutt;.,utLun.ntSl•nnAlcrpa.Icm': �pa•a'i,ilShpulanons: o k1/koc6aa, SECTION9: PROPERTY OWNER AUTHORIZATIO7permatapplicamn ,Propvrty Owner 5'~• z cc wd�1 I Li r=i tHiae- lam "/ •9Z- 71�Name(Print) .No. and Street l d�•/ ruwnipnrr(-ontaet Information: Title TelephoneNo. (busmrns) Trlephonr No. (cell)Ifapplicable, the pntperly owner hrretwauthorizes .Name Strarl Address Cily/Town toact on the tro +erty owner's behalf, mall matters relative to workauthunzed by this buildi SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 21 (it buildinst is lags than 3$,t1UU cu.it.of vnckwsd s ace anWor not under Comtructiun Control then check here(3andAup SmItun IU.1) 10.1 Re istefir Professional Rea onsible for Construction Control / Name(Registrant) Telephone Nu. e-mad address Registration Number S- A CVAI iti sn�� GX 1i1✓d R-i<L!!- AM o a f= `/-12 fZ— Street Address City/Town ` State Zip Discipline Expiration Date 10.2 General Contractor L.i Xl" o Company Name: Hli6 N ✓9d.9-e., f,7v4tzy c -f a 3 Name of Person Responsible for Construction License No. and Type if Ayplicable c-! �i9 c c s �t_ �e x B cs�_o ce zy d ��9 d z,J 3S Street Address City/Town State Zip Tele one No.(business) Telephone No. cell e-mail address SECTION 11:w V (M.G.L.c. IS2 2506)) A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a si ned Affidavit submitted with this application? Yes O No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=f 7 Yf 9 >d 1. Building f '{ If S,e Building Permit Fee.Total Construction Cost x_(Insert here 2. Electrical is appropriate municipal factor)=f J. Plumbing f 4. Mechanical (HVAC) f Note:Minimum fee=f on tactmur Ipality) 5. Mechanical (Other) f Enclose check payable to (�l�J\\LS 6. Total Cost f (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below. I hereby altet under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the bet tit my knowlecigeand understanding,. IV-YX, /1e r� /7ma�d sQo L e 780 -93?. S,Vv, 7 Please print and sign name ritle rclephone No. Date/ _t _F Ati @a PL - e dl .D 71 �Irca•1 .Wdru" C•rt1'i Tuw'n 4t.1 Ltp Municipal Inspector to fill out this section upon application approval: a r Date $ CITY OF SALEM QA%-)1;, PUBLIC PROPRERTY DEPARTMENT -,I11it;R(I[1''JRISC111.1- 14.\n,n 12C WASHIN610N S*ri<EL.T• Ssua4,Msyndanscl is01970 Tta:978-745-9595 is P:\x:978J4v 9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers mliwnt Information Please Print Leeiblv 411ne(0urilwss/Organizatirn>/Individual): /N / N 0 prY J tf .f ef-r 29 Address: tr,4 CC2 oi, J i�zC" `+ pk City/Stater%ip: in/0 49✓c2y7 C� Phone0: Are you an employer?Check the appropriate bo "Type of project(required): 4. I am a.general contractor and 1 1.❑ I um a employer with G. ❑ N construction employees(full and/or putt-time).' have hired the sub-contractors 7. emodeling 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition 'No workers'cum insurance 5. ❑ We are a corporation and its l p• 10.❑ Electrical repairs or additions required.] oftieers have exercised their 3.❑ I am it homeowner doing all work g exemption right of per MGL 1 I.[] Plumbing repairs or additions Pon P' myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] -Any:q,plicatn thin chucks box ill musl:dso till 0,11 Ili secjioa w.ow,showing their workers'cumpenwtion policy intinn,atium ?Homeowners;who submit this affidavit indicating they are doing all work and then him outside contractors must aubmit a new al lidavil indiuling such. �C,mtractun that check this box must altxhdd,n additional sheet showing the name of the subcontractors and their workers'comp.fndicy information. l❑nr an employer that is providing workers'c•oatpensatiun insurance fur my employees. Below is the policy and job site infuralation. Insurance Company Vmne: �/.•oJ�s✓e.¢_lAU1-te.a rI_,__... _ iYSa.--_��_- I'olicv 8 or Self-ins. Lic.0: 6 e 6 �/ __....__.... .. __....___ Expiration Date: Job Site Address: 14 254 �e_ City slate/zip: 7�1L9�/12 �l.B J' Attach it copy of the workers'compensation policy declaration page(showing;the policy ntunber and expiration date). Failure to secure coverage as required under Section 25A ul-}IGL c. 152 can lead to the Imposition of criminal penalties of a tint up In S1,500.00 andlor one-year imprisonment, as Weil its civil penalties in the form of a STOP WORK ORDER and a fine of lip to S250.00 a day against the violator. Be advtscd that a copy of this statement may be forwarded to the 011ice of Invrstigalions ol'thu DIA for insurance coverage verification. z da hereby certify under the pains and penalties ofperjuty that the iufornnution provided above is true and correct. Sil�:lautr e: -_l�� sr — Datc• '7' Imo[ '� t� _— Ofjic-ial ruse only. Do not write in this ureu, to be completed by city or town official. City or Town: . .. Purmit/License ill— ___ _ ............... ..__.. . _ . Issuing Aulhurity (circle onc): 1. Board of llealth 2. Building Department 3. Cityfl owv Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Oliver— Contact Person: Phone Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the.perfornwnce of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s) namc(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confuniation or insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pernidlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicants proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I'lio Off ice of Investigations Would like to drank you in advance for your cooperation and should you have;try questions, please do not hesitate to give us a'call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised 5-26-05 www.mass.gov/tire CITY OF SALEM r ., PUBLIC PROPRERTY _ DEPARTMENT •,I -.�, n CC %,; ONSI UT • S.\i r\t, \I.\;;.\, :r. :1I , :I't '_ I71: 'O8-?4i')iUJ 1'.\x: 978J4 "9,141, Construction Debris Disposal Affidavit (Mluired lirr all demolition and renovation wurk) In accordance with the sixth edition of the Statc Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit It _ is issued with the condition that the debris resulting from this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: (name of hauler) fhe debris will be disposed of in (name of facility) (address of facility) signature of permit applicant ► "I — ieD date --- DWn ATE IMMIDDTY 1 ) 'ar4c�d/R CERTIFICATE OF LIABILITY INSURANCE PID 2 03/31/10 PRODUCERTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Senn Dunn - GSO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3625 N. Elm St. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P 0 Box 9375 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Greensboro NC 27429-0375 Phone: 336-272-7161 Fax:336-346-1397 INSURERS AFFORDING COVERAGE NAIL INSURED INSURER A p .icm 1vurance CA 36064 INSURER B'. Window World of Boston, LLC 1INSURER 118 Shaver Street INSURERD: North Wilkesboro NC 28659 INSURER E: COVERAGES THE POLICIES CC INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED WWED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWIH TMDING MY REQUIREMENT,TERM OR CONDITION OF MY 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 CONDITION OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSRE TYPE OF INSURANCE POLICY NUMBER DATE(MM/ODIYYYY) DATE(MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A x COMMERCIAL GENERAL LIABILITY OZR7902S27 04/01/10 04/01/11 PREMISES EeEo"Twence S 300000 CLAIMS MADE }1 OCCUR MED EXP(Any we person) $ 5000 PERSONAL B ADV INJURY $ 1000000 GENERAL AGGREGATE s 2000000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2000000 POLICY JJECCT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ee accdent) S MY ALTO ALL OWNED AUTOS BODILY INJURY $ Per Dersm) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per eccidenl) NOKOWNEO AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY ALTO OTHER THAN EA ACC S AUTO ONLY'. AGG S EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A }[ OCCUR ❑CLAIMSMADE OER7902527 0410lYlO 04/01/11 AGGREGATE $ 1000000 S DEDUCTIBLE $ RETENTION 5 S WORKERS COMPENSAnON TORV LIMITS ER AND EMPLOYERS'LIABILRY Y I N MY PROPRIETOR/PARTNERIEXECUTNE E L.EACH ACCIDENT S FF,IICC tR/MEnMBER EXCLLCED'1 ❑ EL DISEAGE-FP.EMPLDYEE $ (MauryIfyes descnne under EL DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS.below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONB Certificate holder is additional insured Policy is primary and non-contributory CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL GIDEAVOR TO MAL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Cummings Properties, LLC REPRESETATTVES. Attn: Robert Yacobian AUTHOran:D RESENTATNE 200 West Cummings Park oburn HA 01801-6396 ACORD 25(20(19/01) Q1988-2009AeORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registretlon: 168025 Type: LLC Expiration: 4/12/2012 TO 295878 WINDOW WORLD OF BOSTON, LLC. HOWARD INGLE 118 SHAVER ST N. WILKESBORO, NC 2B659 - Update Address and return cord.Mark reason for change. Addross Renewal -- Employment Lost Card oascA, ,314 Massachusetts- Department of Public Safety Board of Building Regulations and Standards :Construction Supervisor License License: CS 103478 ReStncted to 00 4 HUGH MAC'DONALD 4 FALES PLACE FOXBO13 GH MA 02035 . V - �-y Expiration: 2/15/2013 (inm�isei««oe/ Trp: 103478 The Commonwealth of Massachusetts 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 Le ibl Name (Business/Organization/Individual): Z�,t IIV 0671a 1 ✓r/��� G' S" Address: /S xg Ukg M r City/State/Zip: Phone #:7,9( Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. �1 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide thew workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: //9' JYGC �A3t/ri L'7�/ Policy#or Self-ins. Lic.#: dr55( 4j9C- '6 36 7 5 Expiration Date: Job Site Address: S /r cs'4/ f' �� � City/State/Zip: Zw-e�- 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer der the /and allies ofperjury that the information provided above is true and correct Si¢na �' C`✓�� Date: Phone#: -7 41 3- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1. Other Contact Person: Phone#: 04/12/2010 13:24 15097529303 UNIVERSAL INS AGENCY PAGE 01i DATE IML/OVIYYYY) AC Q. CERTIFICATE OF LIABILITY INSURANCE 4/12/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Universal Ills.Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 374 Belmont Street HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Route 9 Worcester, MA 01604 _ INSURERS AFFORDING COVERAGE NAIC.M INSURED Magic Droam HomadmprovtlmantB,-Inca. INSURER A: E TINEL INSURANCE CO_L�. 2 403 34 Crabtta Lana INSURER B: H TFORD CASUALTY INS CO 29424 Leominster,MA 01453 INSURER CI INSURER D: INSURER E: COVERAGE THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THW POLICY PERIOD INDICATED,NOTWITHSTANDING ANY RBOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'Pit OF 10"RANCE POLICYRUMBER uC EFFEC POLICY EXPIRATION Lwmc A GENERALUAILTTY OBSBMFO3134 aM2WI`10 '02/02111',_,' EACHOC uRRENCB S I,OQO`000 COMMERCIAL GENERAL UASILITY RE I6.IEa occvencq S 11,000,000 CLAIMS MADE 2cCCUR MED BJtPV.ny Pam.person) _ S 1Q QO P R6pNALd ADVINJURY S t.�()(),000 GENERALAGGREGATE S _2-02-000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG a.oQD QQQ _�POLICYJ"X P O LOC AUTOMOALI LIABILITY ANY AUTO fpsM�ft�)INGL9 LIMIT 9 ALL OWNED AUTOS BODILY INJURY S 6CHEDlILED AUTOS (Px pen.onl . HIRED AUTOS BaDILV INA S NON-04NEO AUTOS (Pu SCEMeM) ' — PROPERTY DAMAGE S (PE!RONeA11fJ DARAGH UAIILNY AUTO ONLY-EA ACCIOSNT S ANY AUTO BA ACC $OTHER THAN - AUTO ONLY: A00 S EXCH39AIMIRELLA LUBRITY EACH OCCURRENCE S JOCCUR CLAIMG MADE AOOREGATE S _ 9 i DEDUCTIBLE 9 RETENTION S S B WORKERS CaMPENSATIONAND 08 WEC LE3025 OW21/10 03/21111 _ ony"MS ° - EMPL OYRB'LaAHIL RV NPROPRIETDRPAATE sr"VE NO EG:,LL.DACHACCIDNEE �51 OFFICER04EMBER ICLUDEDI E9YQOQQ Ie 0.vw PRN d b L, 0 QQ OTHER DBBDWPTION OP OPERATKINSf LOCATfON31 VEHICLES!EItCW9pN3 ADDEb DY QIDORERMENT ISPEdgL PROVISIONS ' CERTIFICATE HOLDER CANCELLATION SHOULD AHY OF THE ABOVE MOOROSO PGLRNEB IS CANCELLED BEFORE THE E+EATION WINDOW WORLD OF BOSTON DATE THEREOF,THE ISSUING INSURER MLL ENDEAVOR TO MAIL_20 CAY9 NRITT6N 24 CUMMIN©S.PAORK STE 158 NOTICE TB THE OERTIPR:ATE HOLDER NAMED TO THE LEFT,BUTFAILYRE To DD so SHALL WOBURN; MA 01801-2122 REPOSE NO O OATION OR LIAHI V KIND UPON THE INSURER, ITS AS OR RcrANSUNTA 00. AVTNORQ®RE NTATIve Or FAX: 898-722AQ52 ACORD 25(2001/06) GACORD CORPORATION 198B JUL-19-2010 MON 10: H PM P. 001 Window World of Boston MA HIC Registration 2a Cummings Perk,Suite 154 Number: (781)Woo 9 MA 01801 feral U ( .932-4805•Fax: s1cn cc:nn 28 Federal 665 -. Www.windOwwOddOfbOston.cOm 2]4481665 "Simply the Best for Less"' Customer: pcko_ '-•'lo/%4Na✓ t /I"eres. V Sty.1/anoY Phonelh) 6Y7- Z96-Z*y Install Address' / A fLercAl WAY a S"'K . MO 0197e Phone(w) 781'B8Y-P 9'7(-J BIII Address E-mail WINDOW WORLD GLASS OPTIONS 10W Seri a CHI Mach i18o 13 Stimulus Energy Package' eZ 7 _ 2000 Sens DH MeeMWek 5180 Includes Solar one ErC Package I 4000Sedes DHAlI.Weld ZLC° — G Sdan o Glass $45 Argon Gas $16 80005erias OH All-Weld 5235_ _Triple Glazed TG2^"'(Argon Flllad) $155 _R Lite Slider $aPy Tole Glared TK2*'(Krypton Filled) $196 2 Life Suer 5wing&Clean $339_ ('Sties 4000&6000 Only-Oualdlea for Federal Tax Cradio --,„3Uta Slider Iva.w.om nparsnle suoi P'$e++as 6000 Ouao Feomal lax Credltl —3 Life Slider Wn v.p a Clean um.Irmo, I ia.w _1SS95 WINDOW OPTIONS IS 1J2 Screens _Picture lFeed Lite $329 11_Foam Inwladon on Jambs and Head A.unb $2A5_ I b Double Strength Glass $15 N 0 _C..—r, $235 _Double Locks(&28-) $5 2 Lite Casement $tl6o —Full Screens $22•' — _a Lite Casement ulaw+ry ua,+a,wl s655 Colonial Grids(Contourad/FIM) S38 Bugmgnt H.,Pc, $200 —Prairie Grids $44� Diamond Grids S69 —Say Wll grid_ Simulated Divided Lite $182 _gpw window s2s75 Tempwod C Sash(BSO)(TSO) $65� _Carden Window $1575— — CHI Glass(BSO)05O) $35 Soeoielty Window $ _Onel style(40/60 or 60/40) $ad— _Beige $35 _Foam Enhanced Drama l5enas 6000 Only)$25 _Wood Gmin Irnmior(Sens 4"1 0000an1y)sags_ PRE 1978 BUILT HOMES(Federal Lead Conte inment Lam) (Login Oak/Dark cold Cherry/What Fox Wood) With Custom Premium Exterior Trim $5Q- -Brown Eadril(S.H.6000 Ol ,gas_ _Without Custom Premium Exterior Trim$70_ MY HOME WAS BUILT IN THE YEAR Initial Window Color Wklk / w^� MISCELLANEOUS mama Ouralaa Custom Exterior VIII/Wrep WOOd Out DOORS O Tg#urcd$60 19 Smooth G.8 $75 $ 4 7S _Vinyl Rolling Patio Door Eft. leagal Facing Color _Vinyl Rolling Pal Door M. S995 _Custom exterlOr'nim/Wrap Metal Out ❑Temred S75 ❑Smooth G-8$90 $ _Ynyl Foiling Patio Door Ind, 51035 Fading Color Includes Exteelor Ymyi Trim _Special Custom Exterior Ttlm/Wrap $� Facing Color Mdll to Form Muhl Unit $30 Specialty Door Install Exterior Stops $45 _Install In error Casing $46 _Gtlde Paolo raceoor $100 Fr pat Window —Solanolw GWss for Padp Door 5125 —�'—Insulate Weight Boxes $20 —Solac,one Mile Gass for Pais Door` $1611 Repelr Sill Or Jamb $50 f`Oualil nor Fedow lax Credit) Reml Wood Mull $00 s _Remove Storm Window $15 Remove Bay/Bow $250'�� $ _Roof for Bey/Bow $500 storm Door 5 Ino.1l Sent Board for Bay/Bow Silo Remove and Install A/C $50 Door Color / WINDOW WORLD CARES Inasde pwalde _SL Juries Children's Research HPaPlpl $ DISCLAIMER:The information herein related to the Federal Stimulus Package i5 for informational purposes ONLY.This information is not intended to be legal or tax advice.You should contact your accountant Or Other tax professional for advice related to st to tax benefits Of purchasing energy efficient windows. NO EXiBA WORK IF NOT IN WRITINGI Customer agrees to the terrrls Of payment Be follows; Extra L.abw&Materials $ y7YS.Do Green Environmental Disposal Fee $ $175,00 Total Amount $ 119z 0,00 Cusom Older D¢posit 50% $ Z lJ46'Ck;r_ Balance Paid to Installl upon Completion $ Amount Financed $ - Wndow Woddol 2pmn dmelpates sommg Tls wonton '6o P Ana bell substantral completed fin 2.days.5ecully dilrcst its No My d0p0E1!Yabull0d Ip advance(II NP SlL'n al and wont S ee 3 1/3W piths totalContract once or III&Actual teat of any moving or eGYIpri 01 a - EpgCel order or cllsam made rental,Glitch mug be ordered In a0afts of me Man Of rile wINk W m&u(!that the project Will mal on schedule.No Ing payment shau be demanded until be mplract a wdrondlyd to the sadslacun on ad oartlm