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3 GOOD HOPE LANE - BPA B-12-927 The Commonwealth of Massachusetts " Board of Building Regulations and Standards FOR Massachusetts State-Building Code,7.80 CMR, 7 h.edition MUNICIPALITY ' USE. Building Permit Application To Construct,Repair,Renovate Or:Demolish a' Revised January. - One=or Pwo-Family Dwelling 1, 2008 Tms-Section For Official Use only . n�\ BmldingPermitNumber Date Applied 11\` Si�rature: -6116o% Z— BuildingComrrsiss' edInspectorofBuildings Date SECTION 1:SITE INFORMATION Ey A`ddress 1.2 Assessors Map&Parcel Numbers as accepted street?yes_ no MapNumbcR Parccl 3Jumbrr. Informstiori: LA Property Dimensionsict Proposed Use: Lot Area(sq 8) Frontage(f) - 1.5.Building Setbacks (ft). Front Yard Side Yn{-ds - Rear"Yard - Required. Provided Rcquimd Provided Required Provided L6 Water Supply: (NLG.L c.40, §54) 1.7 Flood Zone information:_". 1.8 Sewage Disposal"Systems Public❑' " Private Zone _ - Outside Flood Zone? - Check if yes[] Muaicipal❑ On site disposal system .❑ SECTION 2;—PROPERTY 6 WNERSH' 2_I Owners of Recor +1_ t� Name(Print— ) Address for Service: Cl 31 -&bIa Signature - Telephone - SECTION 3;.DESCRIPTION OF PROPOSED WOR&(check'all that app)y)"'. " _,_'Gan�Cactia^ ❑ 'F"•c Ana ..,ui:.tlin'^. ..:;;ter- ..^n^:^d airs s'.. eraticn(s) C�-'' �,ii�..,. C Demolition ❑ AccessoryBldg: ❑ Numberofl)nits Other �cciry:_. Grief Description of Proposed work'': ' ix-� � y d� l 0 6.4 T , SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ .: 1. Building Permit Fee:$ Indicate how fee is determined: v 2.Electrical $. ❑Standard City/Town Application Fee QTotal Project Cose(Item 6)x multiplier .. x. .. 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List S.Mechanical" (Fire $ Su cession) Total All Fees:$ .au 6.Total Project Cost $"1�� (] Check No. Check Amount Cash Amount ❑Paid in Full O Outstanding Balance Due: SECTION 5: CONSTRIIC7 G)A'gRV1110ES 5-1 Licensed Construction Supervisor(CSL) . . '✓ h (� del � tseNnmber .Ezph-anio,Date. /o�m ✓l/1t \ Lim Name of CS1,Holder ( ' C' t` I )i\J'C CS W ei I*C§L Type(see-below) _ Address --d :. . Des pion 'i� O( b d3 •U UmrsGicte (u to 35 0DO Ca Ft) . . - Signature . Y= R. - Restricted I&2 Famil Dwd&n . m Mi Onl Telephone. _ RC - Residential Roofing Coverin - - X S)c�d'S S. Residential Window and Sidin ,. .. SF Residential Solid Fud Bumin A liance installation 1) Residential Demolition 5. Registered'Hom ImProXemeV � Contractor(HIC)'� I �o81ti HICCpmpany Name``or11Hl Re�$$tstragqt s�trilpe Registration.Number OIL:'. i �-F' NO•r`�.I�„be.n+t L'✓lG OIS I Address .. S.)A� - •C I'��O ` Expiation Date .Signature Telephone . . ssa8s' - SECTION 6:WORKERs, CO1v13ENSA.LIONpgs RANCL AFFIDAVIT M.G.L.e:152_•§ 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 f the building permit Signed Af5davitAttached? Yes No _ SECTiPN7ac:O A E-R90 519T{MZ2+TIONT.OBE•CpIv EEfED.,� O'STirthTER'tSAGEPIT7dR;C4NTBACT'OR'APELIII;S:FA3IBIIII.� 'F+F11211�T'- . I, l O!E:e,'A as,Owner of the subject property hereby authori a Or n n n i�e'A to act on my behalf in all matters relative to work authorized by tbis building permit application signature of Owner . .. .. - Dati SECOAT 7b � 3t'4R AId1 H©ItTG33"iF 33 I ARA T(©I>' Vl A t CP �t�u�eC nY fctathrn2zod Agent 4iete?yt1eSIS2C that the=tatenicdLs and infommhon en th•f� enetne spphcatiot arefr e ails accuran, to the best of my.L�o-uledge and behalf. . - l` n .Print Name y Signature of Owner or Authoriz Agent Date - (Signed underthe pains and pmzdties of NOTES: 1. An Dvnrr who obtains a building pmmit to do his/her own work,or an owner who hires'an unregistered contractor (not registered in.the Home Improvement Contractor CHIC)Program), will nor liave access to the.arbitration programor guaranty fund under M-G.L c. 142A_Other importantinformation on the MC Program and Construction Supervisor Licensing(CSL)canbe found in 7S0`C2VR Regulations 110R6 and 11025,respectively. 2. When substantial work is planned,provide the information below. Total floors area(Sq.Ft). (including garage,finished basement/atties, decks orporch) Gross Hving'area(Sq.Ft.) Habitable room.count Number of fireplaces Number ofbedrowns Number ofbathmoms Number ofhalf/baths Type of heating system Number of decki/porches Type of cooling system Fmclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" L-) ?CI.Ob -- _- DEBRIS FOB ; This farm is to d-bris to be disposed of PropertyAddressi • (^n�-n�, ��e V>1 J2.. �, - In accorda=viithfizzpm,i D=ofMGL_cAD,§54„a ccndi ion ofthe B+i1 gPe it Number is that t-26tis resulting iioni this taor]:shall bC disposed of in a properly fio sed solid'Rasts disposal Lxgit,as d.-5n-d by 1 CrL c. III 3150-k This d bri. vw.4 be disposed of is (Location of Facility) 5imatat=Of�Pmnv APplicaut Date Renewal - -� MA Home improvement Contractor ♦♦� -- ^License#170810(Expires 12/23/2013) byAndersen. Federal Tax ID#41-1918413 WINDOW REPLACEMENT ,n A„uutu,Compny' Renewal by Andersen Corporation 104 Otis St,Northborough,MA 01532 (508)919-0900•Fax:(774)987-3013 ' CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Bayed.)Nome Dote of Agreement e v 6-1 - h - Boyer(.i Street A ss,Ciy,5 te,and Zip code C'3 u-o - TO t 7 0 E Mail Address Home Telehone Number Work Teephone Numbn 9-F- 317 - 1b-2/ 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 sheets) (collectively,this"Agreement').Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. ` Total Job Amount:�f/ ?SD Estimated Smrnng Date: Method of Payment: OCheck OCosh }I&nonced Deposit Received(33%): W--P If s Balance at Start oFlob(33%(: Credit Cards are accepted for deposit Estimated Completion Date: only- maximum 1/3 of the project cost. Balance on Substantial Completion of Job(337.): Please see Credit Card Payment Form. By signing this agreement,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes 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 both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date frost 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� � &-r,by�Andersen Corporation Buyers)) Buyer(s) ,/e,, Buyers) By: �t x�,,. 6 F �L C- �.9-rZc.cO �C,4 Signature of Product Manager Signature Signature gofaf-,d Rpnlps+ /2Ql�rencln©IJiC.y Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. g�— — — — — — — — — — — — — — — _ _ — — — — — — — — — — — — _ . _ _ _ — _ _ _ — _ _ — — — _ —� NOTICE OF CANCELLATION K NOTICE OF CANCELLATION Date of Transaction c/- /6 - / '�? You may cancel Date of Transaction . You may cancel this transaction,without any penalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,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 negotiable 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, by the Contractor ("Seller'l 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 Contract or Sale; or you may, if you wish, comply 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 you do make the goods mailable to the Seller and the' the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date pick them up within 20 days of the date of your Notice of your Notice of Cancellation;you may retain or dispose of Cancellation,you maayy retoin or dispose of the goods of the goods without Ian further obliggation.If you fail to without any further obligation. If you fail to make the make the goods mailable to the Sellep or if you agree goods mailable ro the Seller,or if you agree ro return the to return the goods ro the Seller and (ail ro do so, then Dods ro the Seller and fail ro do so,then you to liable - you remain liable for performance of all obligations under for performance of all obligations under the Contract. the Contract.To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice, or send a telegram to Contractor. notice,or send a telegram to Contractor. Renewal by Andersen Corporation, 104 Otis Renewal by Andersen Corporation; 104 Otis Street, Street, Northboroug , OI532, BY NOT LATER THAN Northborough,MA01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF d. (Date) OF .(Date) I HEREBY CANCEL THIS TRANSACTION. - I HEREBY CANCEL THIS TRANSACTION. Buyer's stg..Wrt prim Ncme D.I. Buyer'r signoture Print Nam. Dote RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink CV102009 RBArhWNs t Renewal . h .,ewal by Andersen Corporation^ MA Home Improvement Contractor �pinderSen. 104 Otis St.,Northbomugh,MA 01532 License#170810(Expires 12/23/2013) WINDOW REPLACEMENT en Mdnun( want' (508)919-0900•Fax:(774)987-3013 Federal Tax ID#41-1918413 WINDOW SPECIFICATION SHEET Buyer(s)Name Date of Agreement �,Q a is Y_/6 l� The Bityco listed a ve herebyjointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Sp ification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: Double Hung(DB) ❑ Equal sash ❑ Cottage sash(I/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(C W) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW)-❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture./Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(PW) Bay or Bow Window �_Patio Doors(see separate Door Specification Sheet) 2. [gacs ❑ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes No Qty of Sills to be replaced by Contractor: 4. ❑ Yes No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)and actual Exterior,casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrinsbrickmold 5. Glazing to be:tZ HP Low-E-4- ❑ Other If other,please specify: 6. Exterior color to be:0 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean 7. Interior color to be: 0,White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note: Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware:14,White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style: 9. ❑ Yes IR.,No Install Lifts with Double Hung Windows 10. Screens: windows to have: ❑ Half or Full screens Screens to be:J,Fibeiglass ❑ Aluminum ❑ TruScene xal GRILLE DETAILS11.Windows have grilles: ❑ Yes No If yes:❑ Grille Between Glass(GBG)❑ Removable Interior Wood oNrvit❑ Full Divided Light(mu Qty: Qty: Qty Qtr QtY Qty: Qty: F71 on on ory F ew(amw,e coae ePw n,c Draw grille patterns above 'Use additional sheet if needed Owner approved(initials):( ) ADDMONAL WORK DEEAB.S 12.❑ Yes K No Contractor will remove metal frames of windows. Qty of Units: IS.❑ Yes FgLNo Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings ❑ Pine ❑ Maintenance-free material 14.❑ Yes X No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any paintin Initials g. ( 1 Owner Initia 16.❑ Yes$No Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17. Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18.[ Yes ❑No Clean up all job related debris including old windows will be removed.Vacuum nightly. 19,4 Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 20g Yes ❑ No Building Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract Price and a separate check is required at the time of sale for this fee. 912.7 Yes ❑No All discounts have been applied to this agreement price. 22. Additionaljob details: 23,KYes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the se tisfectroa otall parties. 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 ere 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 Buyers)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal bbbyyy,,,Andersen Corpoorgih�on Buyer(s) Buyers) By: y lLy Signature of Product Manager Signature Signature _2alano( P-eILe+tel )"—a4; v_. 4it",kovl'"4 Print Name of Product Manager Prmt Name Print Name RenewalMA Home Improvement Contractor :A^ ��� license#170810(Expires 12/23/2013) Idersen• �� Federal Tax ID#41-1918413 WINDOW REPLACEMENT xn MdegenCgm{ y Renewal by Andersen Corporation 104 Otis St.,Northborough,MA 01532 (508)919-0900•Fax:(774)987-3013 SPECIFICATION SHEEF 3uyer(s)Name Date of Agreement The Buy list above herebyjointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR _ REMODELING AGREEMENT,of which this Specification Sheet is a part. PATIO DOOR DETAILS - - I. Install total of: Permashield Gliding Patio Doors) - Z5110"x 6'8" ❑ Other(not available in 8068) Op.panel isX left ❑ right(as viewed from exterior) Interior and Exterior Color to be:Zg�White ❑ Canvas ❑ Sandstone ❑ Terratone (Color same inside and out on PS) Hardware: Metro:K White ❑ Stone ❑ Bright Brass ❑ Other—Specify ❑ Yes N-No Gliding Patio Door to have sidelight? Size: ❑ Yes �Vo Grilles7 If yes: GBG ❑ INTW ❑ FDL(Pattern is standard as viewed in book for all doors) 2. Install total of: Narrowline Gliding Patio Door(s) ❑ 00"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone (Interior is WOOD and customer must paint or stain) - Hardware: Menlo: ❑ White ❑ Canvas ❑ Stone ❑ Bright Brass ❑ Other—Specify: ` ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 3. Install total of: Frenchwood Gliding Patio Door(s) ❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood ❑ Pine ❑ Oak ❑ Maple Interior Finish, ❑ Prefinished White(Available only with white exterior) ❑ Unfinished(Paint/stain don by custom ) Hardware: Metro: El White El Stone ❑ Bright Brass El SatinNickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilka? If yes: GBG ❑ INTW ❑ FDL (Fall Divided Light) 4. Install total of: Frenchwood Hinged Patio Doors) ❑ 6'0"x 6'S" ❑ Other: ❑ Yes ❑ No Active/Passive Panel?: ❑ Left ❑ Right(viewed from ext.which is active) OR ❑ Yes ❑ No Active/Stationary Pam ❑ Left ❑ Right Door Swim ❑ Inswing ❑ Outswing Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood: ❑ Pine ❑ Oak ❑ Maple Interior Frmh: ❑ Prefinished White ❑ Unfor shed(Paint/stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel *NOTE: Canvas hinged screen frame N/A—must choose white or stone if Exterior is canvas" ❑ Yes ❑ No Hinged Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) STORM DOOR DETAILS 5.' Install total of: Storm Door(s) 6. ❑ Full View❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Sandtone ❑ Bronze ❑ Forest Green 8. Size to be: ❑ 32" ❑ 34"(White only) ❑ 36" ❑ Custom(10 week lead time) Size: 9. Hardware to be: ❑ Bright Brass ❑ Nickel 10. Additional job details: - 11. 9Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction of fiflPaztIcs, 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 loth the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal by Andersen Corporation Buyer(s) n //n Buyer(s) By: JZ ^�—r Signature of Product Manager- Signature Signature (Z� (anc)( P I I pt1�r r i� RQOc L,O ( �!' Print Name of Product Manager Print Name Print Name - 1 newa byAndersenza WINDOW REPLACEMENT an.AndemnCompatty CONDOMINIUM PERMISSION FORM FOR BUILDING PERMIT F 3 Good Hope Lane Salem, MA 01970 We, Crowninshield Mangement, being the duly authorized representatives of Mariner Village Condominiums, have reviewed the specifications for improvements to 3 Good Hope Lane Salem, MA 01970 owned by Gregory Rabinovich. The Condo Association or Management Company agrees that the above owners have permission to seek permits and to Carry out the proposed work. Stgna r o ondn Association Rapres, WIIe and Tltle D to i Print Noma - (In lieu of this form, a letter stating the same purpose as above,on the Condominium Management Company stationary may be substituted.) t , ,I i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wnymmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information \ .. Please Print Lezibly Narne(Business/Orga nization/Individual): �('\P U)a \ 1')i.,l N—t (\Ae S,LC✓\ Address: �0 City/State/Zip: K to r-4 )r o, Phone#: Are you an employer? Check the appropriate box: Type of project(required): I. I am a employer with 3 D 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 T Oemodeting 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' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised then 10.❑Electrical repairs on additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑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#1 must also fill out the section below showing their workers'compensation policy infomation. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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:_ 1V 1� �n 7A S, Cb W . Policy#or Self-ins.Lic.#: l l— , 1�(�� Expiration Date: Job Site Address:-C O n nL I��e City/State/Zip: ��`�� ON _CAq 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 certify nrery.ihepain nd penalties ofperjury that the information provided above is true and correct. Sitmafore: - - Date: 9'19 :7-1�. Phone#- ' .3 5 1 'c9a,)V 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#: CERTIFICATE OF LIABILITY INSURANCE 01 1i212 ' 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 TI4E ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.. . IMPORTANT: If the certificate holder 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 1-612-333-3323 - CONTACT done Hargrove H rove or Katie Psimos NAME: g Hays Companies - PHONE FAX A/C No E : 612-333-3323 INC' NC No:612-373-7270 80 South Sth Street _ E-MAIL - ODRE55: Suite 700 PRODUCER Minneapolis, MN 55402 USTOMES,ID 9 - INSURERSAFFORDINGCOVERAGE NAICN INSURED INSURERA: OLD REPUBLIC INS -00 24147 - Renewal By Andersen Corporation INSURER B: NATIONAL UNION FIRE INS CO OF PITTS 19445 104 Otis Street - - INSURER C: Northborough, NA 01532 INSURER D; INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 25114267 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. INSft - ADDLS BR POLICY Err POLICY EXP - LIMITS LTR TYPE OF INSURANCE IRSUZ Won POLICY NUMBER MMIDDIYYYY MMIDD A GENERAL LIABILITY - MWZY 59313 10/01/1 10/01/12 EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea oseunence $ 500,000 CLAIM.-MADE ril OCCUR MED FXP(Anyone person) $ 10;000 PERSONAL&ADV INJURY. $ 1,000,000 GENERALAGGREGATE $ 4,000,00D GEN'L AGGREGATE LIMITAPPUES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 - X POLICY PRDJEC- LDC $ A AUTOMOBILE LIABILITY MWTB 21377 10/01/1 10/01/12 COMBINED SINGLE LIMIT $ 3,000,000 (Ee accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY Uernrldent) $ SCHEDULEDAUTOS PROPERTY DAMAGE $ - - X HIRED AUTOS (Pa re,cldent) X NON-OWNED AUTOS $ B X, UMBRELLA LIAB X OCCUR, 25030519 10/01/1 10/01/12 EACH OCCURRENCE $ 25,000,000 EXCESS LIAB CLAIMS-MADE - AGGREGATE $ 25,000,000 DEDUCTIBLE - $ X RETENTION $ 25,000 - $ A _ WORKERS COMPENSATION NWC 117140 00 10/01/1 10/01/12 X WC STATU- I OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERT)IECUTIVE YIN EL EACH ACCIDENT $ 1,000,ER 000 OFFICEWMEMBER EXCLUDED? N❑ NIA (Mandatory in Nru E.L DISEASE EA EMPLOYE $ 1,000,000 If yes,deecdbe under DESC RIPTION OF OPERATIONS below' E.L.DISEASE POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS.I VEHICLES (Anach ACORD 101,Aounional Remarks Schedule,if more specs is required)' - Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE .EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN .. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _ Pwwp .. 4'_ R N ,FrreY�.,yy 7. kpsimos - - ©1986-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) _ The ACORD name and logo are registered marks of ACORD - 25114267 - 1 .''-.. 1lassachusctts - Dcp:uYmcnt of Public`:ifcts 7 - -Board of Buildin" Requletions and `standards Construction Supervisor License License: CS 95707: BRIAN DENNISON 86 CREST CIRCLE WORCESTER, MA 01603 -�--�"-� Expiration: 9/8/2012 ('oumii..i„nrr Tr#: 2622 j �y Consumer Affairs o�✓�amac/uxeslte aa-\ Office of Consumer Affairs&B❑sioess Regulation R HOME IMPROVEMENT CONTRACTOR Registration: 0810 Type: Expiration:_ Q013 Corporation i VRWAt BY AI p -v16WR,4TION t BRIAN DENNISO a, 104 OTIS ST. /') g — NORTHBOROUGH, Undersecretary 3 tY i a PRODUCT PERFORMANCE r„ :. Andersen' Nr`"1R' C Certified ioi:al Unix Peri*ormmnce (ron➢naea) RW Mdcmen'Produet! Glass Type U Pa=O SHGC' VP 200 Sen. Clear Dual Pane OA5 050 OM _ - -Gear Dual Pane•.vhh Glles 0,45 0-54 0.56 .'..ntWasM1 Le { 030 032 055 _ Du bl H 9 W,.dow Imo-E ft Gallen 0,30 029 049 HPW RSmartSun 0.30 021 0.49 - ,�' HP Imr{Snna un•x/Galles 0.31 0.19 OA3 � Clear Dual Pane - 0.45 0.61 0.64 ftnnline Clear Dual Panen Gnllu 045 0.54 09 --0 bl N ng Wintlow Ipw{ 030 0� 0.56 Imx-E:dN Gles 0.31 029 0.5D Clear Dual Pane 0.44 OM 0.66 Nanphne. - Llear Dual Pane wl Gnllaa 0.44 O.Si 0.59 '.T Window` lull{ 027 034 0,58 W,,E ft Gnllee O27 030 0.52 ` " Clear Dual Pane 0.45 0.60 OM 0.10.1 Pane.viN Galles 0.45 034 0.56 F Gltl ng Window Ww{ 030 022 0.55 - Wn{,.vNM1 Gies 030 029 049 ]. Imu{smansun 030 021 0.49 : 23m Law{SmanSun with Gnlles 031 0.19 0A3 -- � Clear Dual Pane 0.43 061 O.E5 Clear Dwl Pane erM Galles 0.43 a 0.58 W E 0.48 us 056 -CrW Tp Winddw._ !' Imv-Ew Giles D28 030 0,50 SmanSnn 021 022 Osl - Ww-E Smartun with Gnlle U7 020 045 � ' Cle=_r Dual Pne 0.44 0.61 O.fi4 Clear Dual Pane all Gnllm 0.45 0.53 0.56 Ww{ a19 032 M6 - N rmrine' Ww{wiN Gnnes 0 30 029 - DA9 - n•Gilding PA.Soars Imo{Sun 029 020 0.31 - Ww{Sun wh Gles 0.31 018 U7Y - Wrv{SmadSun 028 021 0.50 Ww-E SmartSun wiN Glen 030 019 0.44 Clear Dual Pane 0.43 0.61 0.64 - ClearDualPanervMGnlles O43 0� M6 - W E 028 032 0.56 :P sA�r1d l E.mM1 Galles 030 O29 049 - � - I d g Paho D.. Ww{Sun Mg 0.19 030 -"_-_; Ww San Gnlla 0.30 0.17 027 '® lw�E Smartsun 027 02 0.50 1 Wnti Smartsun wW Gles O29 0.19 0.4 Clear Dual Pane 043 0.45 0.47 ' - Dear Dual Pane wNN Galles 0,43 039 0.40 -t Wwf 0.32 024 0.41 Hl.geAl ng WmE wM Galles 033 Gm 0.35 a_Raft Doane Sun 0.32 0.15 02 9n lmr{S.w Gies 0.34 013 0,19 W ESmaM1un M2 016 0.37 Imo{Srn.6u.wM Gig p33 0-14 031 r dersen. ! Andersen NFRC Certified Total Unit Performance (continued) -� Andeaself.Pmduct - Glass Type UFactro SHGC VP Andeisen Product Glass Type U Factor' SHGC' VP _ Architectural )" 400 Serest '.( t .1:.., .. HP Ian F4 p27 035 0.60 [�' HP luw-E4 •V032 028 04] !E �^® XP Imv-EO wM Grilles 0.28 0.31 054 He 1mr Ed wrthGrills 025 0.42 - 0.32 HP lax E4 Sun U.2] 021 0.33 f'T i'q® HP Liar Ed Sun 0.32 01] 0.26 ri cl de Top- C Bement W d. HP 1vn Ed Sun with Grills 0.32 0.16 0.23 I®. C sem nt Wi dow ' HP Iva-E4 Sun with Grilles UP 0.19 0.30 0s� �® t. HP Ian E4 Sman5un 0.31 0.18 0.42 t R ,J HP inn{q Spent5un 0.26 023 0.5q -{® 'I HP)arc E4 Sm ll poSun w/Gs 0.31 0-17 0.38 •F±11 n r•,: HP Ivx-E4 Smal5im w/fills -028 021 0.49 .n® OR ` _<{ HP tun-E4 02T D35 0.60 lip HP love-E4 032 028 0.4T -9 HP Inw-E4wM Galles p.28 031 454Do HP tax-E4 mada Goes 0.32 025 0.62 HP Inn{4 Sun Oil' 021 0.33 Q 1® French Case t NP lax-E4 Sun 0.32 O.1T 0.26 circle&0 I W ntl { HP w-E4 Sun with Galles 0.29 0.t9 030 Y' wood, HP Imv-E4 Sun with Galles 0.32 0.16 023 HPlmv-E45maR5un 0.2fi 023 0.50 -:'i® HP Wrc{4 Shm1Sun U." yj HP love-E45mart5un w/Galles 028 0.21 099 G"q ` © HPtux-E45man5unw/Glles 0.31 0.1] 0.38 � HP]ax-E4 028 033 0.58 { HP Low-E4 0.32 028 04] l HP Lew-E4 withGalles 0.29 030 0.52 G] x HPw-E4 with Glles 0.32 025 OA2 ® HP love-E45un 032 O.1T 0.26 1' ® HP lmv-E4Sun 029 020 031 Eq "i® A ing Wind AreM1 Yf d HP love-E45unwM Galles D29 0.18 028 IF1 'A HP 1vn-E45un with Galles 032 DSfi 023 "®® HP Imv-E45man5vn 0.2] D23 0.52 ® HP lax-E45mar15un 0.31 0.18 0.42 °17.i® BitImv-Ed SmartSun w/Grilles 0.31 0.17 0.38 HP Low-Ea SmartSun w/Gales 028 021 0.46 '3�® HP lmv-E4 031 032 0,55 _ HP Ina-E4 U.27 033 0.58 HJj_. i HP low-E4 with Galles 0.28 93D 0.52 1+ HP Iow-E4 with Giles 0.31 029 049 HP lux-E45un HP ImnE45un 0.27 020 D.31 (� C menl/Awn g Flex Dam W dun I HP Imv-E4 Sun who Grilles 0.29 018 028 El 110 PI tore W mdo HP Inx-E4 Sun with Galles 0.31 0.18 028 �1- NPivx{q SmaRSun 0.26 023 0.52 8, 7� HP lux-E4 SmaodSun 0.31 U21 050- rl® HP tow-E45maR5un w/Grilles 0IS 021 046 Oar I 'I.I� �! HP Love{45mart5un w/Grilles 031 0.19 064 'i FAT® HP love-E4 D31 033 0.58 HPIw-E4 0.3D 03T 0.64 `lei 'M 4 wmv-E Galles 0.32 030 0.52 HP I i.`I HPw-E4 with Grills 030 033 O.ST IV G Sun 0.32 00 0.31 �)},�']. HP ims Eil Sun 0.31 022 U.36 mii ON l0 Spec SpNogl Window , ialty YY tlow HP Low-E45un with Giles 0.31 O20 0.32 1� Hp Love-E4So,on Giles 0.33 0.18 0.28 c� How{45ma6 o 0.30 U24 0.58 P-9 PT'.® HP tun-E4 Sman5un 030 023 0.52 ['r '® ! ! HP lan£45mart5un rv/Galls 032 HP lux-Ed Sman5un w/Galles 0.30 022 052 ® '' ® HP love-E4 0.30 02T 045 µ'9 !'r'•� HP lax-E4 0.32 022 0.3] j HP Ww-E4 with Galles 0.33 010 033 - HPtan-E4 with Giles 0.32 023 039 K��g ?4� ryp w_E4Son 033 0.14 Oil - HPImv-E4 Site 031 0.16 025 Ym !°r!El Hmgad herldmg Freuchvr d French Oor HP low-E45onwM Galles 034 0.13 0.18 Gliding Pah D or HP Inw-E4 Sun wM Grilles 0.32 0.14 022 !�'+I� Hit luw-E45mart5un 0.32 0.15 033 HP Len-E45maR5un 0.30 018 0 E`� v'.9® HPw{45mart9un w/Gnlles 0.33 0.14 0.30 - will He Inv-E4 Sman5un vilGnlls 0.31 0.16 035 35 '�� HP wr-E4 033 025 061 - m HP Imr£4 031 024 04l 7R ri® ' HP law-E4 with Galles 0.34 D22 0.36 ..j HP Inn-Ed an Giles 0.32 021 035 MP ® HPw{4 ate 0.33 0.16 023 cE Frentbw d Hr g d :, HP Low Ed Sun 031 0.15 023 T ^i M ranged Oufsn g vL 'Insw ngP t Date, HP lnrrE45un with Galls 0.32 013 019 ;1 French Door HP lan£4 So.with Galles 0.35 0.14 020 HP ImrE4 Smaniun 030 0.16 03] gn F® HP luw-E45man5un 0.32 O.11 0.3T ®'I9 ® HP Low-E45martSun w/Grilles 0.31 014 031 �, �® HP Ime-E45manhn el/Galles 0.34 0.15 0.32 ee Hw/Gso4 0.31 025 041 4 'I® HP Imr-E4 0.33 023 0.38 - coo F•® ? Hpw{4sdth Giles U.33 021 0.34 - HPlaw-E4 w"M Galles 0.32 021 035 9 NP Inn-E45un 0.33 U-14 ml2 HP lmv-E4 Sun 0.31 0.15 D 23 Gu •3 Ftetl Parch Door - French m Bogart "' Sidelight, HP)arc-E4San with Galles 034 0.13 0.19 Outset gPah Me" HP lan-E4 Sun vtith Giles 032 0.13 019 i'la 11P wr-E65mart5un 032 0.15 0.34 - Hp Me 45m,R5un D.30 U-17 037 _.i HP Inv-E45man5un w/Galles 0.31 0.15 033 yiI� HP tun-E4 SmatSu0 w/Galls 033 0.14 0.30 HP tun-E4 0.32 025 HP Inv-E4 0.31 022 0.3 F� 'f® , HP Iav-EO wM Galles 0.33 022 0.37 - HP love-E4 wM Galles 0,32 020 U 33I HP Inx-E4 5un 0.32 0.15 023 - Freachwood HP BNE4 San 032 0.16 021 hE'1 �`I� Flood Tranum _ PatinDoor S defghk ;! Hit W-E4 Sun with Giles 0.32 013 PAS 11 -ir]® F rich Do HP tun-E45un with Giles 0.33 0.14 0.20 HP lax-E4 bute.un 032 0.16 03] HPw-E4 Smzn5ud 031 0.15 033 -'i �'�1® _ - HP lax-E45maR5un yr/Galles 0.32 0.14 0.29 !'{® 1� HP lmr-E45man5un rr/fills 0.32 015 0.33 - p_-, HP1un-E4 035 026 O46 ryp w{q p.30 024 D 40 ® l HPIva-E4rvMGrilla 0.30 021 035 Md "3� HP tun-Ed with Galles 0.36 023 0.38 - HPtax-E4 Sun 0.35 0.15 OP4 Frenchw tl HP lux-E4 Sun 0.30 0.15 0.22 Folding D r - PatioP r Tansom I HP ImnE4 Sun with Gnlla 0.31 0.13 0.20 R E'!® HP Inn-Ed Sun with Galles 0.36 014 0.21 NP law-E4 SmaRSun 1.34 0.37 0.39 HP love-Ed SmmcSun 029 0.16 HP law-E45maR5un rv/Galles 0.36 0.15 0.34 - HPlmv{45manSunw/Giles 0.30 0.1 0032 �"-!�. •J® wn4nu91 nn nvlpa� •For NFHC cerOfied late unitperforsonce on umB wM capillary brealhertu ece for high alfiNtles,please visit andamenwindowa.cpm. •'HighFRC eamance Low-E4'(HP Lmv-E4),'High-Performance•law-E4 SmartSun'`(NP law-Ed SmanSon)and-High-Perfomrance-Low-E4'Sun-(HP Low-E45un)are Andersen lrademals for'Law-Eglass- ' U-Factor defines Me monamof heat loss through lie total unitln BTU/hrsr.k'E the asocial'value,Ne less beat iosllM1mugM1 the entire prptlucC Window values represent nova-tempered glass.Use of temperetl glass can increase U-Farmratings.See mdmr a.wirmwscon fprspecific Performance values.0oorvalus aepresen mbapered glass. ' Solar Heat Gain CoefiClanl(SHGO)degree Me bamboo of,Olar ad!apan admitted through the glass both directly mansmihed and absorbed and subsequently released Inward.Thelawerthe value,the less hea[istransmitted through the product -the M1igherNe value.lmm O 1p 1.the mot daylight the product lets in overrhe product's total matarea.Visible TramsmRtadce 'Vm@lenamermttance(VI)measmee how much light comes Nmugh a product(gloss and frame) is measured Overthe 380 to 760 nanomelerpprlon of the mlat spechum. •NFHC ratings are based on modeling by a third parry agency asvalidatedby an independent indu eeL lab incompliance memoryprogram m antlals orrommencM,this data may changeover time xadmgameforshessperifiedby NFRCfar •This data is ammete as of Deoember2010-Due to ongoing pmtluc[changes,upM[etl test resul6 ornew stry Georg and certification.Ratings may vary depending on use of tempered glass,tli0erent grille options,glass for high SCRindes,am •PassiveSun'glassvalues are available mrine at andemenwindows.con. - 277 ❑- mon.vc.rz. ' i 1 j. I�� ����h. AN U - _ R��eoY ® -o,nrr�°arnar¢r�aaia al Renew t�f 'tea -. t'�EC9¢tY—RWL4L.F3a5F�}�IT�—'v"^ fLVV^N "E cYE6�eE - \No❑d/V�rry Composite IF .' .. PGF`: Dual Argon L❑w-E4 5martsun . .E FroductTYpe:.GBder - . ENERGY PERFDRASANCE RATIN&S ' - U-Faclnr SeVar H�Gain CoefFiclent �®� d Oo1 I .Sh-P Metrict5[ . - - 0Dr7)DKAL'PERFC) MANcG RAT[NCS ` Visible Tfansmitfance t P ' . . Nmmc'msmrsErmnG mmomnmv nmme N�cpm�uraclvrvwmAlYnv✓mv¢pmme nwlMam�Rr_p wnJnev Mert spsNuMmnmmvl mnmtl.p was le Pmwaauc F;:,—na Nri�latln6cartv u¢an[mcnvcveval¢m'aulmvip9:m'vm plmuciwamvPrclfF�+•a. . ft'-Pc vnL`n�fuNnm-nvaMPmv v�irJolmvlinr_� ��.T�.:scl�ma�wm:f�evcpvllgN" ❑ oK RhAG ID ,Window ' - - .Andersen Co t� : Paste . - snurvmu�r srtWne=:coruonnsn¢c 'mlwnnv Standard . NpFsm.wAnMuit�onur-'roLL:. Mao-ns DP psf vetluug,n�ab'mme ' - QNmet¢meam sssT ' _ � maml4 pacrismnme mnmmvrauntlwtl . E gS4�i mammc . jaD-EC51i40&lUI2 . - (,s�waca 4(Fl.�'..�IFLLAt'INl�dvn laNlRIM1¢ICVAM�ktiIINe1C�NmIGtloll F'fNGr+IM1 Kenewal by I ) Andersen WINDOW REPLACEMENT =AndmertCompaay 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(508)774-987-3013 Website: www.reiiewalbvaiideisen.com