1 GARDNER ST - BUILDING INSPECTION (2) �j � !'hc Cbmmumvcolth ul Massachuseus
� �� Ouard ul BuilJing Rrgulrtiuns anJ S�anJards ���TY
, �n OF tiALFM
� � � ' Masmchusrns Sta�e BuiWing Gxle, 780 CMR, 7 rJition
� � Rr�•irrJJuim�iry
�� ' 13uilding Prrtnit Applicatiun To Cunswct, Rapair, Renovat r Drmulish a /. :o�6Y
Onr-ar T�vu-Fumilv Dwrlling
This Sectio or ORcial U nl
BuilJing Prrtnit Number: te p ied:
Sigw�ure: /� "� ��//���U
NuilJin�{Cwnmiaioner/lmpec ufBuildin�a f��e�
SECTION 1: E INFORMATION
I 1 Propert�Addrea: 1.2 Aaaason Map d� Parcel Numben
r ��:rd�nel� S� � 3� o�1Ca
I.la Is Ihis an acce ted s�reel?yes no Map Number Po'cel Num6er
I.l,/Z�o�n7lo�loformatlo�no: I.J Property Dlmeaslons:
�'S J �`e.�\�til��..,�
Zuning Disuic� PropoxJ Use Ld Area(sq Il) Rontoge(fl)
I.3 Bu11dInQ Setbaclu�R)
Fionl Vord SiJe Yarda Rear Yard
Requircd Provided Requi�ed Provided Requi,cd Provided
�.6 Water Supplr:(M.G.L c.a0,§54) 1.7 Flood Zooe tnfornutlon: 1.8 SewaQe DVposd System:
Public� Priva�e O Zune: _ Ouuide Flood Zane7 Municipal� On eite dispenal syslem O
Check if te0
SECTION2: PROPERTYOWNERSHIP�
2.1 Owner�of Rceord:
VY1A1��[ �,)r� 7-c.1 ' 1 Co����.nrr S�. ��Y,Lt-. �/blcn n14�t3
Nume IPrinl) Address fw Service:
� �t�A-�ys-�sa�a
Siynatu�e Tdephoro
SECTION 3: DESCRIPT(ON OR PROPOSED WORK�(c6ecic aU th�t spply)
New Conetraction O Exieting Building O Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition O '
Demolition O Accessory Bldg. O Numberof Unib_ Other � Speciry: 'e- 0. �' I
Brief Descriptioa of Proposed Work': l
io — � r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Uae Only
Labor and Materials
1. �uilding 5 . . � I. Duilding Permi�Fee:S Indicate how fae ia Jntertnined:
�. Elnctrical S ❑Standard Citylfown Application Fee
O Total Projal Cosl�(Item 6)a mulliplier x
3. Plumbing 5 2. O�her Fea: S
a. Mechanical �HVAC) E List
S. Mechuiical (Firc S
Su resaion Tu�al All Fees:S
Chrck No. Chrck Amoun�: CZth Amount:
6. Total Project Co�t: 5 �� ��G,d� O Paid in Full ❑Outsmnding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) f CSI �a 3 —ICJ-1 a
License Number I:.rpiraiion Date
Name o1'(-'SJ--I luldet A e List CSL Type tree below)
LA n.Si�1,n rnJt ����Wl v�v� e. V"vF f lhscri ion
ress C.>(S 3� U Unrestricted u to 13.1100 Cu.Ft.
_ R Restricted 132 Famil IT Alin
Signature M M Only
�03 — q)G'b�9 p7 RC Residential Routine C'overin
1'clephone WS Rnidential Window and Siding
SF Residential Solid Fuel RumJna A liance Installation
D Residential Demolition
S.j ReglateredHo�Impfove est(rt Coatructor(HIC) j4g6o (
t(�g�p�,�« a-1•n elf f SU07 Regisuation Number
lit IC Cumpany Name or F IC Re utram N• e �A j j`3 a
a-
�,� AS2ti 0, cn 1 - 56R-Cil Expiration Date
TSECTION
re Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 25C(6))
rs Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
idavit will result in the denial of the Issuance of the building permit.
Affidavit Attached? Yes ......... No...........O
7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
R'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
9e l as Owner of the subject property hereby
ze Gut .1 e erne r t t to act on my behalf,in all matters
relative to work authorized by this building permit application.
Sianature of Owner Date
SECTION 71b: OnQWNEW OR AUTHORIZED AGENT DECLARATION
1 , A N ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my wledge and
beham4
t
�nnli•1an l l (t V
\ � (�AA Cn .d11
. rgoature of Owner or Authorized Agent Date
Si under the aina andpenalties 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(HIC)Program). will MW have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, respectively.
3 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (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
). "Total Project Square Footage"maybe substituted lor"Total Project Cost"
t
r
DEBT FOS
This form is to be submitted with i uu6in perli it appIicaiions whenever the.a is debris to be
disposed of
Property 1ddmss: a r A—Ag-r ST .
In accordant:with the provisions of MGL.o.40,.§54„a condition of tis Buil —Pe mit
Number is that the debris re.-ulti=ii om this From shall be disposed of is a properly lic=ed
solid was a disposal facr0iiy as d-n"ned by MGL c. Il l § 150-A.
. ` This debris vain be aisposed of ia: I .
(Location 011,amlity)
Sieaatza:of P”!spplicant
Date
OCT-18-2010 11 :05 PM P.01
J&1.WTNT)OWS,Ivo.,n/B/A MA Home Improvement Contractor
[l)4 Otis St,North6omugh.MA 01532 I taense#149601 (Expires 1/24/201'2)
15(1B1!J I FI-0900•Fax:(774)987-10 J3 Renewal Federal Tax IV#89-0404201
byAnderserl
wixeow et,utewen �,n„aeer•.,,.•r
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Dare of Agrwm<�t
2 N �—
BoyeP,d 51reet Addmss,City.Stara,and Zip Code
1973
CMai AdA.=-, Home iea _Numbn work reiephee=Number
Baycr(s) h.rely jointly and severally agrecs to purcluum the products and/or services of j&I Windows,Inc.d/h/d Renewal by Andersen
(`Como 1 lar),in ascot dance with the terms and conditions described on the front and the reverse of this trgretmcnt and on the.attached
spcuiftcrl lion aheot(s) (eoilectively,this"Agreement").Ruyer(s)here Fry tkKrees to s;4m a cosnpJchun certificate after Contractor has a inpleied
all work ander this Agreement.
Method of Pymnt❑Cash heck O Mastercard ']VISA
} 7 Enimaled Starring D9kC Q Discover J Financed,App
#:
lob Amount.../.�p -��- Wl r N:
Deposit Received(33%(:Q y Q.-. ---6 Name on Credit Card'.
Balcnce at Start of Job(33%)DIY 7 C).- Estimated.Co^m #:plei;on Date: Credit Card#
Balance on Su6stantial --,..,.' -Cy WY
Completion of Job(33%('v?y$j ..- - r, CC Exp. Pate: CC Security Cade:
n- I B)nilialing her. oo odmowlcdkerhat the Belotcrar Start offoli rhe Balance car Substantial Complction
Bayer midi----rTM of job rannot tar.meth Iry credit card and must bc 11,1,11.6v pis o1:.l check bank check,or cash.
Buyer(%) agrees and understands that this Agreement constimres the entire understanding between the parties,and that
there am an verbal mderstandi ogs 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. Bayer(s) hereby
acknowledges that Buyer(s) 1)has read this Agreement, aaderstands the terms of this Agreement, and has received a
completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancenation,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 SPACES.
J A LN'indo c.d/b/a Rewe cal by Awde,%ee Bayer(a) Buyer(s)
Ir SI nev.urr of Pn //,t:blanagcr Signature �signawle.
?Init-H• �i /�J /17A,elG F W&WLaZ
Print Nanic of ProdMt tknage.r Print Nam, print Nano
YOU, THE RITYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACI4ED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIB RIGHT.
NOTICE OF CANCELLATION k NOTICE OF CANCELLATIOFI
Date of Transaction You may conal Dara of Transaction You may cancel
this transaction,without any perish or obligation,within this transaction,without any penal!or abligaton,within
three business days from the above lore.if you cancel,any three business days from the above date•t yea cancel,any
property traded in,any payments made by you under the I properly traded In,any payments made by you under the
Contract of Sale,and any bleinstrument executed Contract of Sale,and anyn le instrument executed
by you will be returned with n10 days following receipt by you will be returned with n 10 days following receipt
by the Conowtbr ("Seller") of your cancellation name, i by the Contractor (`Seller") of your cencallation 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 rhe be canceled.if you cancel,you must make available to the
Seller of your residence'
In substantially as good condbtorh Seller at your restdenee,in substantially as good condition
as when received, arty this
goods delivered to you under as when received,any goads delivered b you under�fFha
this Contract or Sale; or �u may, if you wish, comply Cantnact or Sale;or you may,if wish,<omph' m
with the instrudions of the Seller regarding the return instructions of the Seller regarding the retum sh of
shipment of the gods at the Seder's.expense and risk. the goods of the Seller s expense and risk.N do make
IF you do cicalae the goods available rite Seller and the rho goads avalleble b she Seder and the Seller does net
Seller does not Ella ahem up within 20 days tit the date pkk them up whim 20 days of the date c err Notice
of your Notice of Cancellation,you may retain or dispose d Cancedo int,you renin or dispose t f the deeds
of the gwwds without an Further obil�altpn. t you fail to without any further obigatwn. t you Fall ro make the
make the goods dyed le ro the Se1Ter, or if you ogles goods available to the Seller,or if you agree ro return the
ro return the ggoads ro the Sellar and fail ro th se, then deeds ro the Seller and fail ro de so,then you remain liable
you remain liwlsle far performance of ail obligtlnons under fu performance of all obligations under the Contract.
the Contract. To cancel this transaction, mail or deliver a I To cancel this transaction, mal or deliver a signed and
signed and dated copy of this cancellation notice car any dated copy of this cancellation notice or any otter written
other written notice,or send a telegram ro Confracror: J notice,er send a tole ro eam.aeror:J 8 L wndawc,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/a Renew* by Andersen, 104 01is Street,
Street, Nerihberough, MA 01532, BY NOT LATER THAN Northborough,MA 01531 BY NOT LATERT AN MIDNIONT
ABDNIGHT OF -a(Daft) ._.. •(rots)
I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION.
I
Bayer"Signature Data Buyarh skinaru a Dole
KbA Copy- White Buyer Copy-Yellow 9uyer Copy-Fink
OCT-18-2010 11 :06 PM P- 02
J d L WindOWs,tall.d/b/e MA HIC License#149601(expires 1/24/12)
1040111$trod,NOrthboruagh,M 01532 �Ml Renewal
Federal Tax 1134 85-0404201
M,eae 508.91 nAa00•Fax 7-74.987.3013014 '
►YAndersen.
mmmgsm—
WINDOW 119a4AernaNr ,,.nMeneaCmmwm
Or GaG's'IB t,[" SrM AND NEW HAMPSHIRE
WINDOW SPECRTCATION SHEEP
Date of Agreement
Buyer(s)Names
h the prods Bad terms
The Ruyerls)listed alsnve hereby Jointly and sevcmlly ggrc0 in purchase he aced p and/or
r services Listed
AND DOOR accordance AG EMFNT,
described cn the$peci6ralinn Shc6 anA the front and the tcvexse of the accOm an C
of which this 4,ec ii,dron Sheet is a part.
WBVDOW DE AIU
1. Contractor will Instill a total of=wnnMws in Owner's home,using the following Individual quantities;
__Double Hung(DB) [3 Equal sash ❑ Cottage Sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1 bottom)
Casement(CW) [2 Hinge rlgh Hinge len(as viewed firm exterior): [J Standard handle I— Metro handle
Double Casement(COW) Standard handle ❑ Motto handle
Casement/Picture/Casement(CFW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 lite Gliding Window(GW)
Glider/Picture/Glider(GFW) ❑ I:1:1 or ❑ 1:2:1
Awning Window(AW)
Picture Window(FN7
Bay or Bow Window
�Patio Rio's(ice separate Door Specification Shect)
Z Ud"rr C-] No Qty Of Windows to he Custom Fit Replacement;
3, [t�'ffu LJ No 4t'of Sills to be replaced by Contractor:,s.
4, ❑ Yes E] No Qly of Windows to be New Construction pull Ikame(includes new anterior&exterior casings)
Exterior cash Fine ❑ Mointcnance-free material ❑ Factory applied 908 Fibrex brickmOld
5. GLAIIS to lx:: u'Law- �SmanSun- (Ter nintfI 7/gible) E] Other If other,please speOIM
6. llsterior calor to bC � Ite ❑ Sand ❑ Canvas [)Terratone ❑ Cocoa Bean
7. Interior color to be: Cqllylute ❑ Sand [] Canvas ❑ Terratone ❑ Fine ❑ Maple ❑ Oak
Note: lntcr :olo um only be while,wood or same color as exterior. Wood interiors need to finished by Owner.
A. Hardware' InWhite ❑ Stone ❑ Canvas ❑ Bra+s ❑ Estate Hardware: Style:
9. ❑ Yes ❑ NO Install LINs with Double Hung Wi ws
10. Screens; wtudows to have: ❑ Half or 1 screens Screens to be: ,glass ❑ Aluminum ❑ Tru Scenc
GRILU Dlil'AJIS
11.Wirulcm have grilles: ❑ Yes ❑ No If yes: Gnlle Between Glass(one)❑ Removable Interior Wood aNIW❑ Full Divided Light u'Oq
Qh': QIY: say: Qty: Qty: Qty' Qty'
orb lin DN oM cw ICNn Olax cRNmG
Draw grille pauenw above "Use additional sheet if needed Owner approved(initials):C, 1
ADDMONAL WORK DEPAAS
12.❑ Yes nN crntractor will remove metal frames of windows. Qty of Units:
❑ Yes o Contractor will install new paint-ready or stain-reedy casings.
[n .s'ior ca' ggty Of olsenitrgs: Extzrtor casings qty Ofopcnings: ❑ Fine ❑ Maintemm a-free material
l4.(� o CAnlractor will insist]new paint-ready or stain-ready inside or outside stops qty of openings: _
Interior stops qty Of openiggs: Exterior stops qty of openings: m ❑ Fin Maintenance
materiel
15. Owner is awl that Contractor does not do any painting LA F --J Owner Initial$
1G.❑ Yes Eq'No Contractor will wrap exterior casings with aluminum coli stock of color.
,Note: Wrnppirtg may tr required with storm window removal;removal of storm windows will leave.screw holes in casing.
17.r[,�r"Yes NO Ccmtraclor will Insulate,caulk and seal windows with 8-point system to prevent water and air infiltration.
- 18. r� r No A limited warranty shall he issued to Owner upon wmplction of the job and payment in full.
I,). Yea ❑ No aigkp Hr Pundit—Contractor Will secure any and all necessary permits. The fee for the permit(s)IS not
included in the Contract F,ice and a separate check is required at the time of sale fee this fee.
20. eklAitinnal,J�b detalLa:
21. ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
NL, payrnant shell to demandckl unfi!the 00Htrae1is completed ro the seUslach'on O all parYIes.
It is agreed and understood by and between the patties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING
AGREEMF.N'I',consNmtes the entire understanding between the parties,and there are no verbal understandings,changing m =aitying any,of the
teerv. This S,,eification Sleet rna,not be changed or ala terms modified or varied in any way unless such chargee us,in writing and signed by both
the Buyer($)and COntmotor. Buyer(s)hereby acknowledge that Buyers)has read this SpeoiBeation Sheet.
ltenaD dersen o rate old NH (s)
Buyer(s)
lure oP uc ar (
Signature IF &VW=
�N MARK F WEN24L-
Print Name Print Name
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Coinpeansatian Insurance Affidavit: Builders/Contra<ct€rrs/Electricias/Plumbers
.kpt:licant Ialarmstion I Please Print Lezibiy
Name (Business/6rganizationfindividuaD: j)a en 21J G
Address: ^j o-Y �2 S Ll4-Yec L
City/State/Zip: A/ -k-k bo r'o , Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.TrI am a employer with 00 4. 0 I am a general contractor and I 6. []New construction
P
mployees(full and/or part-time).- have hired the sub-conhactors
2.❑ Ism a sole proprietor or partner- listed on the attached sheet : 7' odelhng
ship and have no employees These sub-contractors have B. Demolition
working forme in any capacity. workers' comp.inen*anae. 9. Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 9. Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, gl(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' 13.❑Other
comp.insurance required.]
`Any applicant that checks box#1 most also fill out the section below showing thea worker'compensation policy infn®atiom
t Bomeowum who submit this affidavit indicating they ate doing ali work and thea hue outside Gmumomrs most submit a new affidavit indicating such.
=Cootractns that check this box nmst anaehed an additional shed showing the name of the sub-contractors and thea worker'comp.policy bribrmatina
I arts an employer that is providing workers'con-tpensadon insurance for my employees. Below.is the policy and job site
information. �^nn
Insurance Company Name: I l//C K2a"1 Zn Cre r-a n C Z
Policy#or Self-ins,Lic.1h EzpirationDate:
Job Site Address: ' rn tic- Atn e.r ST - City/State/Zip: 0194
Attach a copy of the workers' compensation policy declaration page(shoe ng the policy number and expiration date).
Failure to secure cover ge 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 undjer the pains and penaMcs,ofperjury that the information provided above is true and correct
Signature: r( � l Date: 1 1 IIU I t d
Phone# Z �
G.If�icial use only. Do not write in this area, to be completed by city or town officiaC
City or Tovim: Permit/License#
Issuing Authority(circle one):
L.Board of Health 2.Building Department 3. Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMMONYYY)
02/10/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 333 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC#
INSURED Renewal by Andersen INSURER A: Hartford Insurance Company
J and L Windows, Inc. INSURER B: Nautilus
104 Otis St - INSURER C:
Northborough, MA, 01532INSURER D: -
NBURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADVL POLICY EFFECTIVE POLICY EXPIRATION
LTR POLICY NUMBER --)Nn LIMITS
B GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 EACH OCCURRENCE $ 1,000,000
DA AGE O RE
COMMERCIALGENERALLIABILITY PREMISES Eaaccurence $ 1DD DDD
CLAIMS MADE EJ OCCUR MED EXP(Any one person) E 5,000
I PERSONAL d ADV INJURY $ 1 DDO DOD
GENERAL AGGREGATE $ 2.000.000
GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 20000000
JECT
POLICY PRO- LOC
A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT $ 1,QDQ,DDD
ANYAUTO - (Ea accitlanp
x' ALL OWNED AUTOS BODILY INJURY
i SCHEDULED AUTOS (Per Parson) $
—I
HIRED AUTOS BODILY INJURY.
NON-OWNED AUTOS (Peramid.nt) E
i
PROPERTY DAMAGE $
(Per madent)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO - - OTHER THAN EA ACC $
AUTO ONLY: AGG a
EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
E
DEDUCTIBLE
a
RETENTIDN a $
A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/2011 We STALIM OER
EMPLOYERS'LIABILITY E.L EACH ACCIDENT E SQQ QQQ
ANY PROPMETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
EL DISEASE-EA EMPLOYEE $ 500,000
iSPEt yesCIAL 1"Aa antler
L PROVISIONS below E.L.DISEASE-POLICY LIMIT E SDD DDD
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE.CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATNE
elo
ACORD 25(2001/08) @ ACORD CORPORATION 1988
!F
-• Massachusetts - Department of Public Safet}
Board of Building Regulations and Standards
--� Construction Supervisor License -
License: CS 101952
Restricted to: 00
DAVID BANCROFT
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01588
Expiration: 3/192012
e
t'ummivxinncr
Tr--: 101952
v .Mna-c/wAelYd .
✓ f6an� of
&Business Reoula6on
Office of consumer nsum
er Affairse
' OME IMPROVEMENT CONTRACTOR
gz JL4
" Re istratio q,9 01
9 nom_ 6
Expire.!-9-Q12
12
esent Gard
DAVE BANCRO
104 OTIS STRE
NORTHBOROUGH,•F�1Y�Z01:532 Undersecretary -
y
a
Fri
• . . .• • ' . . ,: 4 • Ns�a4=e�.a - ... .•Woor�nyl,CcryceslL•
j Dual Pane �r23n' CowE
G�semen[ . . RESQI
M=Mlmz{ p�'.Ctic�r� 4Al INGS. .
C�-Factor (t�•?3n`P So tar Hms'G=in CosFfic=_nt
Gm-U = '
DD[ IONA!
.. Ylsible'Tnris�itt'snc . '.• ,: : ; , .
hiintr�Mlnef:tlpWeV=drzl Rim Marpi xnlZrIL IS eppllocbl?11�C,7f�°dV[-s,Ie4 OahrunhC.eheN '
i to =P61HOM and L
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WINDOWbAn
REPLACEMENT COM arrp
o Whom It May Concern, _
°nclosed is a permit application package for a project we have been '
:ontracted to do in your town. Thank you in advance for receiving this
zackage by mail. As we work in every town in the state, it greatly hells us in
sur process.
We have also enclosed a self addressed and postage paid envelope and
would request that when the hermit application has been processed, that YOU
€irould mall it bade to cis.
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)
.919-0992.
Best Regards,
Kelley Donahue
Permit Coordinator
104 ods Street 1
Northborough,MA,01532
Fbone(508)919-0900
Fax(508)919-0903 -
Website:1vww.reneweIbyandersen.com