Loading...
28 CALABRESE STREET - BUILDING JACKET � 8 Ca 1�6�eS , Y§ ° CITY OF SALEM, MASSACHUSETTS t g;! BUILDING DEPARTMENT ;�. 120 WASHINGTON STREET,30.0 FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER May 7, 2010 Denise LeBlanc ReMax Realtors R.E. 28 Calabrese Street Dear Ms. LeBlanc, The lot at 28 Calabrese Street and 25 Francis Road are both undersized by current zoning regulations. The regulations require 15,000 square feet and 100 feet of Frontage. Due to the fact the two lots are undersized and held in the same ownership, the lots have merged to become one lot. Therefore 25 Francis Road is not a buildable lot. Sincerely, cM�-Q Thomas StTierre Building commissioner/Zoning Officer CITY OF SALEM, MASSACHUSETTS `! BUILDING DEPARTMENT R 120 WASHINGTON STREET,3m FLOOR ro TEL. (978) 745-9595 FAx(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER May 7, 2010 Denise LeBlanc ReMax Realtors R.E. 28 Calabrese Street Dear Ms. LeBlanc, The lot at 28 Calabrese Street and 25 Francis Road are both undersized by current zoning regulations. The regulations require 15,000 square feet and 100 feet of Frontage. Due to the fact the two lots are undersized and held in the same ownership, the lots have merged to become one lot. Therefore 25 Francis Road is not a buildable lot. Sincerely, Thomas St. ierre Building commissioner/Zoning Officer 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; u a; __ . .. Building Pentit Number.. Date A li Building Official(Pant Nona) _€. has a x SECTION 1:SrM INFORMATION.1 . Ll Propel Address: 12 Ass rs Map&Parcel Numbers cl 28 CALABRESE STREET 25 25-0367-0 ~ x ? 1.1 a Is this an accepted street?yeses no Map Number Parcel Number J l 1.3 Zoning Information: 1.9`PropertyDimensions: R1 SINGLE FAMILY rn .Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) _C 1.5 Building Setbacks(ft) _ rn 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: Public❑ Private❑ Zone: _ Outside Flood Zone?'Check if esO Municipal E3 On site disposal system O `-SECTION 2::PROPERTYOWNERSHIPI.. , 2.1 Ownert of Record: CHRIS SCHOEN SALAM MA 01970 Name(Print) City,State,ZIP LL 28 CALABRESE STREET 978-594-5036 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK,(checkall that apply) 4, 4:, New Construction O Existing Building M Owner-Occupied b Repairs(s) 6 1 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg.O Number of Units_ Other M Specify: REPLACEMENT Brief Desch' lion of ProposedWor)O: REPLACE 6 WINDOWS- NO STRUCTURAL SECTION 4:19T11MATED CONSTRTTCTION{OSTS ` �_ Item Estimated Costs: , (Labor and Materials) `, ;_ Official Use Only 1.Building $ 8,315.00 1 Building Permit Fee S 4 " ; Indicate how fee is determined 2.Electrical $ D Skandaiid Ciiytowni Appficerion Fee m ❑Total Protect Costs(I(em 6)x iiiulhplier 3.Plumbing $ 2 Odier Fees ,$ 4.Mechanical (HVAC) $ LiaL 5.Mechanical (Fire Suppression) $ Total All pees.$ ` Cash Amour: 6,Total Project Cost: $ 8,315.00 Check No. Check-Amount:❑Paid in Full ❑Outstanding Balaztce Due. SECTIONS: CONSTRUCTION SERVICES: r ._ -3 Iv ° 5.1 Construction Supervisor License(CSL) 90125 10-06-16 JAIME MORIN License Number Expiration Date Name of CSL Holder List CSL Type(see below) 86 GARDINER ST No.and Street .IYPe,_; s'Description ,w LYNN, MA 01905 U Unrestricted uildin s u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M - Masonry RC Roof Coverin WS Window and Siding SF Solid Fuel Burning Appliances 508-351-2214 I Insulation -Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170810 12-23-15 RENEWAL BYANDERSEN HIC Registration Number Expiration Date. HIC Company Name or HIC Registrant Name - 30 FORBES ROAD No.and Street Email address NORTHBORO,MA 01532 508-351-2214 City/Town,State ZIP Tel hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:G 152.1 25C(6)) , ' Workers Compensation Insurance affidavit must be completed and submitted with this application.. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. _ Signed Affidavit Attached? 'Yes..........M No SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN'7 g " OWNER'S AGENT OR CONTRACTOR'APPLIES.FOR RUILDING PERMIT '`5 =fi. I,as Owner of the subject property,hereby authorize JAIMEMORIN to act on my behalf;in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) - Date SECTION 7b� WNFW ORAUTHORIZED AGENT DECLARATION By entering my name belo ,I hereby heat under the pains and penalties of perjury that all of the information contained in this applica' n is true d accurate to the best of my knowledge and understanding. Print Owner's or Autho ' is Name(Electronic Signature) Date 1. An Owner ins a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(IIIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.e.;142A.Other important information on the HIC Program can be found at www.mms.gov/aca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planted,provide the information below: Total floor area(sq.fL) (including garage,finished basementlattics,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. "rotal Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts ' Board of Building Regulations and Standards FOR Massachusetts State Building Code,7.80 CMR T°edition TNNICIPALITY USE. Building Permit Application To Construct,Repair,Renovate Or Demolish a REvfsedJanuary. . One-or Two-Fami7yDwCjirng 1, 2008 This Section For O cial Use y' tN:uilding Permitumber �e E+pp ' r Commissr er/Inspecto uMmgs ate SECTION 1: OP24ATION 1.1 Propgt�y AQdress: .2 Assessors Map&Parcel Numbers 3 lac\o� brc�c 5�. . aS, ?,c ' 036 -� 1.1 a Is this an accepted street?yes_, no Map Number Panel Number. 1.3 oningInformation: 1.4 Property Dimensions: 1i 6i'\e P6-,, tA Zoning District Proposed Use. Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks (ft). Front Yard SideYainds Rear Ward- 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:. -- - Public❑' Private Zane _ Outside Flood Zone?.. Municipal❑ On site disposal system ❑ Check ifyes[7 SECTION 2: PROPERTY 01�'I�TERHHIPr 7. wnert of ee__pp11r--d: nn,7 _ a r A. 1=6,e.Y� 4 a C6 6AQ t ,e St— Name(Print) Address for Service: q +8- .SAY - S63 G Signature - Telephone SECTION 3-.D'ESCRIPTION OF PROPOSED W6R1e"(cheek all that apply)' . Nea'CoasCtrac C Ex s irgBuild:ng.❑ Owher occupied ❑ .P epai s(s]''.0 ';:he rticn(s) ^' Addi iur C Demolition ❑ Accessnry Blt.' ❑ Number orl knits_ Other tpc ify:_._. :_6 V. Zu C!hra_� Brief Description of Proposed "Work'': Re jok efc L l p r SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1.Building $ 319dj) ,0 a 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount 6.Total Project Cost: $.31 Q�l� 0 Paid in Full 13 Outstanding Balance Due: _,___ SECTION 5: CONS, C. DIV'SEl SCES 5.1 LicensedC�tonstruction Supervisor(CSL) L?s-'�b he 111L License Number Expiration Date. Namc o CSL-Hold . �(a t..e J� .L�_'` W wr"/ \'e fie` List'CSL Type(smbelow) Addr - pt(oo�3 T9P.D.. ._.�.Gon ' U Umesu-ieted(up to 35,000 Cu.Ft Signature / - - .: R Restricted 1&2 Family Dwelling- . _SDg �TL ( o Cyr �. M M� Telephone. RC - Residential Roofing Coverin - - - - WS' Residential Wmdow and Sidin SF - Residential Solid Fuel Surning Appliance Installation . . . . D .Residential Demolition 5-�Registered$ome i rov meat Contractor(EUC) H7C Company ME or R C Regirant N Registration Number Addm IyoJ'�F 'Ci(c-6gq'D Expiration Date Signature. Telephone SECTION 6:WORKERS, COMPENSATION INSURANCE AAMkVIT(M,G.L,c 152.g 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 budding permit - Signed Affidavit Attached?' Yes .......... No...........❑ " SECTION 7ac.OR- E EAWLTT OVZ-AkTION TO RE•Cl3MPT ETE3�;W N'. . OM NER'�uAGENT OR"CON'�:4C.l'ORAPPLSESFORBIIII3i3N l n I l i I\�f`t S e V a A as Owner of the subject property hereby . authorize (�t�tz to h t Sd✓t to act on my behalf in all matters relative to work authorized by this building permit application . Signature of Owner . - Date S C O1a 7b:J'RNER'-OR WUMA.I } n C'Q Wt ✓1 sl i:sc7 rf ai C1uroeC nr A4tfiotncd Agent tiecebv deCla;e Mat the =tatenrents and information on the f remetn" application aretrue and accurate, to'tfie best of my k io-w]edee and behalf. �it.� .1Je i►it t.ki-il _ . Signature of Owner or Authorized Agent Date (SigDed underthe pains and penalties of "u - 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(MC)Program),will not liave access to the arbitration program or guaranty fund under M.G.L.c. 142A-Other importantinfornnation on the MC Program and Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations I O.R6 and I10_R5,respectively. 2. When substantial work is planned,provide the information below. Total floors area(Sq.Ft). (including garage,finished basement/attics, decks or posh) Gross living area(Sq.Ft) Habitable room count Number of fireplaces Number ofbedroom& Number ofbathrootns Numbei ofhalf/baths Type of heating system Number of decks/porches ' Type of cooling system Enclosed Open -- .-_.._.- — — - - -- - 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" 3, lOd '0� Aug 22 11 08:36a David Sullivan 19784105478 p.5 I hi Utls Sr.,Y:m bburuugh.T'I.A N.532 ,J&L 1bbNm nms.l[M%,D/131.% MA Home Improvement Contractor I,iOfl)919-09(70 (771;987-3013 Renewal License�140(;01 (Expires I/'Ld/201 Z) Andersen. Federal'1'ax lD#83-0404' I .11,.er.ot, . , _.. m.., g/,* 9 CUSTONkf WINDOW AND DOOR REMODELING AGREEMENT 6y'e,h'Nome Cale o!Asraemem cl lvl SGi 4 el✓ Fla I a-O Byer;Sl:exr Add-,Ciry,Sure,and ZIp Code aE> C%�I-VgAeSue a/9 7� Heoil Add,.n Hcme Tele sore N.,mber W«k Lbpione Number Ila)cr(sl hereby jointly and severally agrees to purchase the products and/or services of 1&L Windows,Inc.d!b%a Renewal by Andersen ("Contractor') in accordance with the terms until conditions described on the front find Ittc reverse of this agreement :red ou the attw.hed specification shce(s) (collectively,this`LAgraemev t').Buyer(s)hereby agrees to sign a conplelion certificate alter Contractor has completed all work under this Agreement. r� 3 / Eslimm starlin Method of Payment: OCheck OCredit Card Cash Total Job Amount:. /__ _ jd� _g Da ❑Finonced Deposit Received(33%):/3 3ala,ce at 5tartol Job(33%):/300_. E,Intted ompicfion Cate: If payment is by Credit Card, please fill out O �(,v�( , the Credit Card Receipt of Deposit Form Balance on&lastonty' 3 R6 t Complelion oF1ob(33e I _ {/_ _ --__ ...-_....._....-..-._._. By si,,in;.this agec.....nt,ynv aeknuxcledyr That t he eu Start of,job and ihv Balan,o av tiubaanrial Comph:riun of Job aun'A be made I" r rdk card aed ntmt be re,d,by prlsonN duck,hmnk,heel:,or rah. Buyer(s) agrees and understands that this Agreement coustitutes the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of Loth Buyer(s) and Contractor. Buyer(&) 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 BLANK SP CES. J&L Windows,Ire.d/b R e vat dersen uYen(.) Btuyer(s) By: Sinnature of Pror sett\'a 1 r Siynatu rn Signal urn Print Nam'of Prcdncl\4anagrr Print Nan" Prnt.\-a'uv YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTERTHE DATE OF THIS TRANSACTION.SEETHE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. x_ _ _ _ _ _ _ _ _ _ _ _ _ _ _�. _ _ _ _ _ _ __ _ _._ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ NOTICE OF CANCELLATION NOTICE CANCELLATION N Date of Transaction . You may cancel 1 Date of Transaction ) / . You may cancel this transaction,without any penshy or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.Ifyou mncel,any 1 three business days from the above ate.R you cancel,any property traded in,any payments made by you urxler ilia property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed 1 Contract of Sale,and any ne�ofiuble instrument executed by you will be resumed within 10 days following receipt I by you will be returned within 10 days following receipt by the Contrition ("Seller") of your cancellation notice, by the Conlrtxtor ("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.If you cancel,you must make available to the Seller at your residence,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 Comraet or Sole; or you may, if you wish, comply 1 Contract or Sale;or you may,if you wish,comply with the with the instructions 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 yyou do make the goods available to the Seller and the the gtlods available to the Seller and the Seller does not 5elIce does not pick them up within 20 days of the date 1 pick them ufr within 20 days of the date of your Notice OF your Notice of Cancellation,you may retain or dispose of Cancellaion,you may retain or dispose of the goods of the goods without any further obligation.If you fall to without any further oblgation. If you foil to make the make the goods available to the Seller, or if you a@ree goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail ro do i Gu then ! ?Gods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under 1 fw performance of all obligations under the Contract. the Contract.To cancel this transaction, mail or deliver a I To caned this transaction, mad or deliver a signed and signe an d d dated copy of this cancellation nonce or any doted copy of this cancellation notice or any other written other written notice, or send a telegram to Contractor. J notice,or send a telegram to Contractor:J&I.Nfmdows, &L windows,Inc.d/b/o Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Otis Street, Street, Notthborough, MA 01532, BY NOT LATER THAN North o u MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF .(Date) Of_. (Date) I HEREBY CANCEL THIS TRANSACTION. t I HER BY NCEL THIS TRANSACTION. Buye:',Slgnomra Vrim None Dma ft Y,o'a51gnolwe Print Name Dole Rb,A Copy- Whits Royer Copy-Yel Ww Inver Couv- Fink Aug 221108:36a David Sullivan 19784105478 p.4 )2 L Waldews,Inc.a/b/a 104 ous Sheet,Ncrlhbomegiu Atk 01532 _ M9HICl.iccaxc 1491ol lespirts 1"24:121 Phone 503.919.000C•Fsx 774.MT.3013 Renewal , Federal Tax ID453-040420T byAndersen. W IMeOW PEYLICCMENT an MdeoenCgiapoT' OF GRGTEY MASSAC'FnlSrl'IS A.+m New RA tFs1�. WINDOW SPECIPICATLON SLEET fluver(s)Name - L Date of Agreement C.S/lZl Fla/ '['lie Buyers)listed above herebypit ly and severally agree to purchase the goods mid/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the from and ale reverse of rite acnompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specrfication Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following hndMdual quantities: Double Hung(D0) ❑ Equal sash ❑ College sash 0/3 top,2/3 bottom) ❑Oriel sash(2/3 top.1/3 berom) r Cascmcnt(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ A Ic / Casement/Picture i Casement(CPW) ❑ 1:1:1 or Standard handle Metro handle 2 Ill.Gliding Window(GW') G .-20"- Glider/Picture/Glider(GFW) ❑ 1:1:1 o>r Awning Window(AW) Picture,Wbndosv,(PW) Bav or Bow Window Patio Doors(see separate Door Specification Sheet) _. ❑ Yes-K No Qty of Windows to be Custom Fit Replacement. 3. ❑ YeaA No Qty of Sills to tie replaced by Contractor: �-- 4._2 Yes ❑ No Qty of Windows to ba New Construction Full frame(includes new interior&exterior casings)and actual—C-4 Exterior c }ngs: ❑ Pinz -Maintenance-free material ❑ Factory applied 308 Fibres brickmold 5. Glazing io be:4n H E-4 rM ❑ Other If other,please specify: G. Exterior color to be: While ❑ Sand ❑ Canvas ❑ n Teatone ❑ n Cocoa Bea 7. Interior color[o White ❑ sand ❑Canvas ElTerratone ❑ Pine ❑ Maple ❑ Oak Note: h tenor color can only be while,wood or same color as exterior, Wood interiors need 10 finished by Owner- S. Hardwar White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ Yc. No install Lifts with Double IL,8 Windows 10. 5o'cens: windows to have: ❑ Half Full screens Screens to kx�Fberglass .] Aluminum ❑ TraSce e, GRILLE DETAB.S 11.Windows have grilles: ❑ Yes No If yes:❑ Grille Between Glass case)❑ Removable Interior Wood urmv)❑Full DividtL�fight 1Fola Qty: Qty: QIY Qty': Qty: Qty: Qty: I ps oN oN oN cv�vmre cses, c Draw gnlle patters above 'Use additional sheet if needed Owner approved(initials): ADDMONAL WORK DETAILS 12.❑ Yes No Contractor will remove metal frames of windows. Qty,of Units: 13.❑ Yes Ip No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of opalungs: Exterior casings city of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Y'tivc Contractor will install new pawn-ready or stain-ready inside or o hide stops qty of openings: Inferior steps qty of openings: y pari0r stp* ❑ (Sae ❑ Maintettar'.ce-Line material 15. Owner u aware that Contractor does not do any painting O er Initials 1 G.❑ Ye �g No Contractor will wrap exterior casings with alum s xk of .color. ANote: Wrapping may be required with storm window removal;removal of loran windows will leave screw holes in casing. Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. Yes ❑No Clean up all jab related debris including old windows will be removed.Vacuum nightly. �.� Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 2aV Yes ❑ No Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contras Price and a separate check is required at the time of sale for this fee. Al Yes ❑No Ali discounts have been applied to r'••am-cementyrice. 9e? dditio:ml ob details ('BN Y4U fMu X ye . / L� a; rw N / IV C G / JR 60 �o ev T Cs. !.c>ryyll h/,( O k— G •f��2¢. /l..V d T� O/✓i 77,PA Lcad S "'Zk7 Yes [] No Owner agroes to be present on the final day of installation for final inspection and to deliver fiscal paytnenl. No final payment shall�k,dermaaded until the contract is completed fo the sanslWction ofa l parries. It is agreed and underotex d by and between the parties that this Specification Shea,along with the CUSTOM WINDOW AND DOOR REMODELING AGREE;Signat=o stitutes the understanding between the parties,and there arc no verbal understandings clumging or modifying any of the terms. ication eat not be of its terms modified or varied in any way unless such changes are in writing and signed by both the Buyonte B )h knowledge that Buyer(s)has read this Specification Sheet. Ree o Gre s Buyer(s) By: Product. ager S(grlature Stgnauire .�,2✓u0/' Print Name of Product Manager Print Name - Print Name Renewal by ere3 -: WINDOW REPLACMENT an An&rsenC6mpany 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 question regarding this application please call me at (508) 9 S9-g992. Best Regards, Kelley Donahue Permit Coordinator 104 Otis Street _ 1 Northborough,MA,01532 Phone(508)919-0900 Fax(508)919-0903 Website: wwwxenewalbvandersen.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UIV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name(Business/Organization/Individual): TE n e,1 G IR Address: f 6 tl 7 i S W re e Iy \ City/State/Zip: !V a r lh k 6 r6 A A dd,9 2 Phone#: t�J O EI/`'c 9 Q 6 Are youan employer?Check the appropriate box: Type of project(required): y 1. &1 am a employer with `9 0 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 7 Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. [J Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LD Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box tiI most 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 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: �J rr zq"lC/J eo/)� Lu relI1 L(-- Policy#or Self-ins. Li`c.. #: JS l(/ ( /�Y Expiration Date: -Z 0 �— Job Site Address: D eCi',, U)V,e S, City/State/Zip: S4 L AA AA-r,. 1,9?b 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 c rtify under th pain and penalties a rjury that the information provided above is true and correct. Si nature: J Date: z d t Phone#: tAi)� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYVV 02/09/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE.DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate h6fder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER _ CONTNAMEACT Joseph McKeone P ONE FAX a . , 734-662-8100 ac Na: JP McKeone Insurance Agency, Inc. E-MAIL ADDRESS: P.O. Box 333 INSURERS)AFFORDING COVERAGE NAIC# Ann Arbor, MI 48106-0333 INSURER A: Hartford Insurance company INSURED J&L Windows, Inc. Renewal by Andersen INSURER B: Nautilus 104 Otis St. INSURER C: Northborough, MA 01532 INsuREN o: INSUPEfl E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AD L SUBR POLICY EFF POLICY EX P LIMBS LTR TYPE OF INSURANCE POLICY NUMBER MMInD/YYYY MMIDDIVYYY B GENERAL OABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO HEWED COMMERCIAL GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 PREMISES Eff p $ 100000 CI-AIMS-MADE ©AIMS-MADE OCCUR MED EXP(An one person) $ 5,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000.000 POLICY PRO LOG $ AUTOMOBILE Etlf 1 000000A COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDAUTOSULED BODILY INJURY IPereccldenp $ X AUTOS NON_O" PROPEPTY DAMAGE $ HIRED AUTOS AUTOS Peraccitlent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RETENTION $ AND EMPLOYERS'LIABILITY 35 WECPP1444 02/17/2011 02/17/2012 WC STATU- OTH- A AND EMPLOYEfls'LIABILITY AN OFFICERNEMBER EXCLUDED?Y PROPRIETOWPARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ SOO OOO (Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $ 50O 0O0 II yes,describe under DESCRIPTION OF OPERATIONS below IE.L.DISEASE-POLICY LIMIT $ SOO OOO DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD I01,Additional Remarks Schedule,If more a pace is required) CERTIFICATE HOLDER CANCELLATION INSURED COPY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD F �lassnchusetts- Department of Public S❑fcn 1 Bo:udiof Buildin' Rc L•ulatiuns and Smnd:trtls Construction Supervisor License License: CS 95707 BRIAN DENNISON' �',,_` 86 CREST CIRCLE WORCESTER, MA 01603 II•" Expiration: 9/8/2012 (-inumisiunar Tr4: 2622 L/Oe4�D[!�✓die a�✓vLadd¢r/usde�fd ,:a g_ Office of Consumer Affairs&Business Regulation HOME IMPROVENT CONTRACTOR Registration`3r51 601 .Expilfl (;f${ 12 l SUP � t Card RENEWAL BY,` BRIAN DENNISK�yf��- - -� 104 OTIS STREET,,", --, NORTHBOROUGH, 01532 Undersecretary '. ' Do not remove until final code inspection. Save label forfuture reference. • m Canada . . • � law Ra/-sow - ' O' mermRbrana C) m 4 O N E a aEi E.U. . � �B88lez-Ta37 . Nenei9ycGnBm' Renewal byAndersen. W1NaYW REPLACEMENT mA.dva.,Q,.pm WotANr 02 nyl Composite ' :-----=--•--------• Dual Argon Low-E4. Product Type: Casement ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0 . 29 1 . 65 0 , 28 U.Sh-P Metdc/s ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0848 ' MamaaCurer>OPupP am[av�e reMav¢nm(n�.m WWlbaEle NFnC Pm¢amUmr tle2mlWnp WMle PmtluQ . ¢. NFfiC raMgv aR Oetr RJIIeE IGralbntl ve[@enAmnmenbl mnoltlwf�Qm<��P�abc. ' Cmnuc ma¢PQ'a lam+WMre�omernOm.uapenomn�Nmmmnm af>nY Pm t ' MwYNrt.nry Andersen Co Ora on: A Caseme n oW - c r s P s conmrmmtw a PwnA . Standard Rating NAv arAAMM1NDNAiL5AmlasLAE 5 DP psf DP35 - �� $ERl Tw PmaaQnmm. 4 i seen ae.ra ,o< , mnuomneraai . ^' aNmmb . �mmeamrm ma n� L`.E$C 14 min.mwmuwd 10"0513972-001 ' Meg mm'vb MEL..C£-C.l1EC.C..Ur hPaOratlan R9��¢�WOMA HemnmN CODtImtlm�Prvgrzm. I