14 FORRESTER ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revlsed Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Ttvo-Family Dwelling
This Section For Official Use
Building Permit Number: Dde App.
Building Official(Print Name) sl8tature ate
SECTION 1:SITE INFO ION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
14 FO1 TER ST UNIT 2 35 35-0442-802
1.1a is tbis an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
CONDO
Zoning Distict Proposed Use Lot Area(sq n) Frontage($)
1.5 Building Setbacks(8)
Front Yard Side Yards Rear Yard
RequireA 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:
Public 0 Private O Zone: _ Outside Flood Zone?
Check if esCl Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSEW
2.1 Owner'of Record:
MARC BERUBE&KEN KAYSER SALEM,MA 01970
Name(Print) City,State,ZIP
14 FORRESTER ST 978-594-5594
No.and Street Telephone Email Address
SEQ ON 3:DESCRIPTION OF PROPOSED WORK'(chaek all that apply)
New Construction❑ Existing Building N I Owner-Occupied 10 I Repairs(s) t1 I Alteration(s) O Addition O
Demolition 0 Accessory Bldg.13 1 Numb of Units I Other b Specify: REPLACEMENT
Brief Description of Proposed Workr:
REPLACE I WINDOW-NO STRUCTURAL CHANGE
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only .:
l and Materials
1.Building $ 1664,00 1,:Building Permit Fee:$ htdicate how fee is determined'
2.Electrical $ 13 Standard Cily/Ttiwn Application Fee
3.Plumbing $ ❑Total Project Costs(Item 6)x multiplier x
2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
g •on) Total All Foes:$
1664.00 Check No. Check Amount: Cash Amount:
6.Total Project Coat: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125 10-06/14
JAIMEMORIN License Nunber Expiration Daft
Name of CSL Holder
List CSL Type(see below) U
86 GARDINER ST LYNN MA 01905
No.and Stect Iype Descailo°°
U Unrestricted(Buildim up to 35,000 eu,ft.
LYNN MA 01905 R Restricted 1&2 Family Dwelling
CityRbwn,Steft.ZIP M Masomy
RC Rooflu Con-ring
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2200 X 55285 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
170810 12-23-15
RENEWAL BY ANDERSEN HIC Registration
HIC Company Name or HIC Registrant Name gestranon Number Expiration Date
104 OTIS ST
No.and Steel Email address
NORTHBORO,MA 01532 508-351-2200 X 55285
City/Town,S ZIP Tel one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ALGJ,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 permik
Signed Affidavit Attached? Yes..........19 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNHT
Las 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 Signatim) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name elow,I by attest under the pains and penalties of perjury that all of the information
contained in this application is a and accurate to the bent of my knowledge and understanding.
/-a- /
Print Owner's .A Agent's Nam(Electronic Signature) Daft
NOTES:
1. An 0,*nerwKo obtains a building permit to do hislher own work,or an owner who hues an urnegistered contractor
(not&pgWcrcd in the Home Improvement Contractor(HIC)Program),will nor have access to the mbibatian
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mag-ry/oca htformation on the Construction Supervisor License can be found at www mess.go is
2. When substantial work is planed,provide the information below:
Total floor area(sq.fL) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.f L) Habitable room count
Number of fireplaces_ Number of bedrooms
Number of bathrooms Number of hanaths
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" $ 1664.00
e Crry of S.yt, MAssAcxus=
BUMDING DEPART1dt11U
120 W.WMGTON SYREEr,r PLOM
TEL MM 74S-9595
FAX(978)74"846
KIMBERLEY DRISCOLL
MAYOR TF OUM ST.PMUR
DiltECrolL Cw PL;Kx Pitopa[Y/ouni r.CONMUSSMM
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)
The debris will be disposed of in s
RENEWAL BY ANDERSEN
(name of facility)
104 OTIS ST ST NORTHBORO,MA 01532
(address of facility)
si of t applicant
01-08-2014
date
Iabria f.aoc
Renewal MA Home Improvement Contractor
by
Andersen. License#170810(Expires 12/23/2013)
Renewal by Andersen Corporation Federal Tax ID#41-1918413
WINDOW REPLACEMENT mMderrmCampmy J
' 104 Otis St.,Nomhborough,MA 01532 ,
(508)351-2200•Fax:(508)986-7072
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Beyerlsl Name Date of A regiment
e
Bayerhl Street Addinn,City,Slle,and Zip Coda
Ndail Addrev Home Tele hone Number Work Telephone Number
9�a��-may
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 Staling Data: Method of Payment:
LBaI.nceatStadofJob(33%):
b Amount: gtnounf Financed /�QTL OCheck OCash
ved(33%):� _ "� Qvisa/MC ODiscover
Job(33%): 0 OFinlnced AMEX,
Estimated Completion Date: If credit card is selected,please
obstantic see Credit Card Payment Form.
Job(33%): !S� ,
Boyer(s)agrees and understands that this Agreement constitutes the entire Emderetauding 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 Buyer(s) and Contractor.Beyer(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 fast
written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES. ,
Renewal 9Corpora Buyer(s) Buyer(s)
Signature of Produc anger Signature Signature
/�/) NII I jQh/2i2- pJERyg(--� K41sez
nt Name of Product 4anager Print Name P' t' t 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.
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Date.of Transaction //'-/ You may cancel Dale of Twnwction 122-- - . You may Cancel
this transaction,without any pena or obligation,within this transaction,without any pens yy or obligation,within
three business days from the above If you cancel,any I three business days from the above date.if you camel,any
property traded in,any payments made by you under the property traded in,any payments made by you under the
Contract of Sale,and any tegohable instrument executed.. Contract of Sale,and any negotiable instrument 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, I by the Contractor ("Seller") 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.R you cancel,you must make available to the
Seller at your residents,in substantially as good condition 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; ormay, if you wish, comply Contract or Sale;or you may,if you wish,comply with the
with the instructions of ,Cu Seller regarding the return instructions of the Seller regarduna 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 ro the Seller and the the goods available ro 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 Cancellation,you may retain or dispose of the gtwds
of the goods wiNwur any furrier obligation.If you fail to without a rtFer obligation. R you fail to make the
make e�ood s available to the Seller, or if out ogres goods trvai to the Seller,or if you agree to return the
to return the goods to the Seller and fail to do so,then I goods lathe Seller and fail to do so,than you remain liable
rm ble
you remain liable for performance of all obligations under tor :=rI once, of all obligations under the Contract.
the Contract.To cancel this transaction, ma'iI or deliver a I To Cancel this transaction, mail or deliver a signed and
signed 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,
Sheet, Northborough, MA 01532, BY NOT LATER THAN North MA01532,BYNOTLATERMM A&IDNIGHT
MIDNIGHT OF I/--/ f-/ .(Date) _ OF _3.(Date)
1 HEREBY CANCEL THIS TRANSACTION. n.. >•_ I HEREBY CANCEL THIS TRANSACTION.
I
Buy.il5ipnatu,e Print Name D.M - I B,".sianmun Print Name D.I.
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink 0BUnD09.nA-Ph.MANH
Renewal
Renewal by Andersen Corporation'� MA Home Improvement contractor
�7yAf� ��� 1040tis St.,Norlhborougb,MA01532 License#170810(Expires 12/23/2013)
"" '••dersen• (508)351-2200•Fax:(508)9867072 Federal Tax ID#41-1918413
WlhDGW REPLACEMENT anAMuq,Comgny
WINDOW SPECIFICATION SHEET
Buyers)Name Date of Agreement
Th 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 parr.
WINDOW DETAILS
1. Contractor will Install a total of windows in Owners home,using the following individual quantities:
Double Hung(DB)_Equal sash_Cottage sash(t/3 top,2/3 bohom)_Oricl sash(2/3 top.1/3 bottom)_Flat sill a ease cmy moo
Square Check Rail_Curve Check Rail
Casement(CS) Hinge right_Hinge left(as viewed from exterior)
Double Casement(CD)
2 Lite Gliding Window(G W)
Casement/Picture/Casement(CD_1:1:1 or_1:2:1
Glider/Picture/Glider(GPW)_1:1:1 or_1:2:1
Picture Window Bay or Bow
Awning Window _#Liles Soffit/Roof Shingle/Copper
Specialty Window Patio Doors tsa sepoim aws sr»t mall Seat to be Primed/Oak/Pine
2. Qty of Windows to be Custom Fit Replacement
3. Qty of Windows to be ustorn flit Pull frame(INCLUDES NEW INTERIOR&EXTERIOR CASINGS)
Exterior casings: e Maintenance-free material_Factory applied 908 Fibrex brickmold
4.Glazing to be:_HP low-E4°' J?S'naexaniso . Tomm _Other Bother,please specify
:
5.Exterior color to be;_White_Sand_Canvas 1/Terratone_Cocoa _Dark Bronx_Forest Green_Black_Red Rock
6.Interior color to be:_Whit _Canvas_Pine_Maple_Oak_ ame as Exterior Note:Wood interiors need to finished by Owner.
7.Hardware:_White lone_Canvas_Estate Hardware: Style:
8.-Aj�?--Install Lifts with Double Hung Wm cos
9. Screens:windows to have:_Half or uB screens Screens to be:�.idzrglass_Aluminum_TruScene
QUIL E DETAILS
10. IUQ.Windows have grilles:_Grille Between Glass(GBG)_Remceable Interior Wood(INIW)_Full Divided Light UDL)
( rnA a Owner approved(initials) Draw gNle patterns below "Use additional sheet if needed
Qty QtY Qty QtY Qty: Qty Qty:
L[aDLD
_E]DO
IF7_
ADDITIONAL WORK DETAILS
11. Qty of_Sills_Sill owes to be replaced by Contractor
12. 1V(0 Contractor will remove metal frames of windows.
13. I'Ll"O Contractor will install new_paint-ready or_stem-ready Interior Exterior casings in_Pine_Maintenance-free material
14. UY Contractor will install new_paint-ready or_stain-ready—Interior—Exterior stops in—Pine—Maintenance-free material
15.( Mn�1 Intls-Owner is aware,contractor does not do any painting or removaVinstallation of alarm system/hardware. It is the
responsibility of the homeowner to.have the alarm-system/hardware removed prior to installation.
16. Nei Contractor will wrap exterior casings with cod stack 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,storrn 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 them will be glass lass If there is glass toss,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 loss Customer is also aware and understands that any and all unseen rot is
tin ded in this contract.Should any rot be found there will be an additional charge for time and materials mess ro stated in this contract
18.z es .No Buildinv Permit-Contractor will secure any and ail necessary permits.The fee for the permit(s)i n
included in the Contract Price and a separate check is required at the time of sale for this fee Ck# $�
19. Yes 0 No All 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 forri
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.Buyers)hereby acknowledge that Buyer(s)has read this Specification Sheet.
Renewal sen Co tion Buyer(s) Buyer(s)
V/
Signature of duct Manager Signature Signature
Yz�i�/� �/�'lA1'� c� �C � ✓i a ti se�2.
Print Name of Product Manager Print Name Ischia Name
12/10/13 09:20 FAX 617 923 5643 Medlcare Preferred OPs U001
Renewa . 0byAndersensIr
WI?ADOW REPLACEMENT anAnder.,=Company
DO 1 IUM Pg:PMISSION FORM FOR JUII.-DING PInRMLE
2.4 ForreO&r Sfre +*;Z S0144w, MA 0l'?70
We., 14 Farr•tsfer Sheet��Aswc�.af�be,.�g fi"•e-nCr.�1y o.�,sfi�.ovined reprasews•,
N&N£revi,ewe&fHe,SMZ,¢i.catiowy fm- iA-Ifrove Yfrr
14 For"4e-r Sf►uk#Z Sate A—, MA OI 70
Owva4 by Mary ser•'wba. -
7t,&Co,.ge 6jssori.afi.ow_or Manage^ wf-Cawtpav•y Per-wK Waw
fo wk,perm4Yarnd,fmu+rry prcp04& work,
S g of Co do Re�„rsehtuAivto•vl rule vale,
Fkl6f-Nr
(Iw Li.a w of fItiLY fof-rw, w Lefter sfuti.wg fl^�saws Pu-rl'+ a:�above 0'1 'Cawalo�x+.Kutivw - .
N1awa.ge.swewtCo•rwPa,n.y y w�a+,f 6ew+•bsf�Fwteol�)
9
104 Ong Streer
Northboroogh,MA,01532 _
Phone(508)351-2200
Fax(508)98&7072
Websire:anew ren;nmIhvandersen.cor
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affndavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
Name (Business/Organization/Individual): �ei e w c,` \per `—t A�U`
Address:� o.LA
City/State/Zip: Q M>hone#:_
Are you an employer?Check the appropriate box:
1 io'l am a employer with 3 t) 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6• ❑New constriction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. L2-115�mndeling
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 10.0 Electrical repairs or additions
3.❑ I atn a homeowner doing all work officers have exercised their I I-❑Plumbing repairs or additions
myself. No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees, [No workers' 13.[D Other
.. comp.insurance required.]
*Any applicant that checks box Nl 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 hive outside contractors must submit a new affidavit indicating such,
tContractors that check this box most 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 then workers'comp;policy number.
I am an emploper that Is providing workers'compensation Insurance for my employees. Below is the policy aid1'ob she
information.
Insurance Company Name: QU L" lCl n In S l n
Policy#or Self-ins.Lic. (#: M 3 )6 3 S 1 . Q 6 Expiration Date:
Job Site Address: ' �_ rOf fr.J r 2— �2 City/State/Zip:136L 1P v. lvk� ni
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.
7 do hereby rt un er the pains and penalties ofperjuiy that the information provided above is true and correct.
Sit'nature• Date• �— �'(
Phone#:
[Fo
only. Do not write in this area,to be completed by city or town of kiaL
n: Permit/License#
hority(circle one):Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
CERTIFICATE OF LIABILITY INSURANCE D10/01//n/2013Y)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THI8
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: H the certificate holder Is an ADDITIONAL INSURED,the pollcy(Wes)must be endorsed. H 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
ceANkate holder In Ilea of such endorsement s). .
PRODUCER 1-612.333-3323 CONT
Bays Compaulea PHONE FAx
. 613-333-33]3 Ay:612-373-7270
90 South Bth street ESS
Suite 700
NSlmeapolis, He 55602 InUeEaflo AFFORDING COVERAGE NNCe
IN6URED INSURER A: OLD REPUBLIC MS CO 26167
ReneFml By Anderson Corporation IN6UXFR a: RATIONAL OBIOB PIRG ZBB CO OF PITTB 19665
INSURERC:
106 Otte Street
INSURER O:
Morthberouah, MA 01532 INSURER E, .
MSURER 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 DESCRIBE[)HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IMaR TYPE OF INSURANCE POUCYEFF JPRM�.=--=—Tg�.41.0.000.00
PoLN:Y NUMBER �(re
A GENERAL LNBARY NNZY 300361 10/01/1 OCCURRENCE S 1,see,000
i COMMERCUM GENERAL 11ABItfrY 1 500,000 ILES Duane m S
CIAINS MADE i OCCUR XP M ma ere S 10,000.'SAOV INJURY S 1.000.000
AL AGGREGATE S 11010,D00GENT AGGREGATE UMR APPLESPER IICTS.COMPIOPAGO 361000,00i P011G1• PR0. LOCfA AUToucome LIABLLJTY SIwTB 30002 11 1INEOSIN MITae 5,000,000
ANYAIlIO INJURY(PorwRenl SAU.OWNED SCHEDULEDAUTOS AUTOS RUIIRY(Pweo-JEBM) SHIREOAUTOS i AUTOMNED RTY DAMAGE
s
s
B i UMBRELLIILMB [9 OCCUR 2OS62235
E%CES9 tMB 30/01/1 30/01/16 EACH OCCURRENCE f 35,000,000
CWMS�E
AGGREGATE 3 15,000,000
OED i InBrENTICN$25.000 f
A WORK C011"S Ulm MC 300359 00 YIC STATLL OTR
AND EYPLOYERs'LIAa1LMY YIN 10/O1/1 10/01/14 i
ANYPROPRIETOARARTNER,FXECUfNE S 1,0001000
OFMEWSu9ER EXCLUDED? a NIA EL EACH AOCIOEM
ptelMle .w NH) E.L.DISEASE.EA EMPI S 1,000,Goo
ayynn dewisle der
OESCIRIPTION OF OPERATIONS below E.L.DSEASE-POLICY UMn 11,1,000,000
DESCMPTN)N OF OPERAnOMaILOCATroNSIYEIOCLES(Aeech ACOR)101,Add'WerWaeeartesw W,ffN egmAMp d)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TO whom It Nay Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
For insurance Purposee Only ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
V
4D1SSO.2010 ACORO CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
iharsrow
36222490
Massachusetts Depar'tthent'of Public$ifet:y
ir `'Board of Building Regulations and Stan{,Lacds"-
Construction Supenisor
License CS-090125 ')
JAIME L MORIN, U
86 GARDINFR ST
LYPAH MA 01905=';
Expiration
�t Commissioner 10f06120.74
SCA 1 f< 20M-05/11
ftice of Consumer Affain&Business Regulation
OMEIMPROVEMENT CONTRA CTOR
Registration 17081t)'
Expiration �1y23/ZO15 Type'
RENEWALBYANDE Supplements
RSONCORPORATION
JAIME MORIN
104 OTIS STREET I ..
NORTHBOROUGH, MA 01532 --
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WINDOW REPLACEMENT an Andersen Company
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:
❑ Permit Application
❑ Home Improvement Contractor License
❑ Construction Supervisor License
❑ Proof of Insurance
❑ Proof of Energy Efficiency Rating
❑ Signed Contract from Customer
❑ Permit Fee (if Accepted at time of applying)
If you have any questions regarding this application please call me at: 508-351-2200 X 55285
Regards,
Kelley Donahue
Permit Coordinator
104 Otis Street
Northborough,MA,01532
Phone(508)351-2200 X 55285
Fax (774)-987-3013
Website:www.renewalbyandersen.com