3 GRANT RD - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
UPBoard of BuildingRe;ulations and Standards EIFFORMassachusetts State Building Code, 790 CMR, Vh edition Building Permit Application To Construct,Repair, Renovate Or Demolish aOne-or Two-Family Dwelling
This Section For Official Use Only: ,
Building Permit Number: I Date Applied: 11, 1 D
Signatlre:
Buildin ommusioner/InspcctorofBuildings Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� C ro-n k `2L
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fi) Frontage(fi) -
1.5 Building Setback (ft)
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: I I.S Sewage Disposal System:
Zone: Outside Flood Zone?�
Public❑' Private❑ — Chenlc it yes❑ Municipal M On site disposal system ❑
SEECTION2. PROPERTYOWItERSF1IP? . .
Owner'.of Reco o:. . /+ n
r:rA t'. e d_f�ui?.t • 60 � l[ d L �J
n lUrcnn, �C \r nn E�QLG� \9�0
Name(Print) .� Address for Service
S\G
Signat re - Telephone -
SECTION 3--DESCRIPTION OF PROPOSED WORK�`:(check all that apply)'
ldev; onsti ct v ❑ I E IS utr6Eui^^ w .tp:"d ^
DemriliIion ❑ Accessory Bld_o. ❑ Number of f Inits
Brief llcscE tit) of Prop�o1sed VJorlr': \ 1:ri _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 15 3 C) O J 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑.Total Project Cost? (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4-Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Supnressicn) Total All Fees: S
y, Check No. Check Amount: Cash Amount:
5,Total Project Cost: I $ �, 3 /v Uv 0 Paid in Full 13 Outstanding Balance Due
SECTION 5: CONSTRUCTI:ON'SERVFCES
5.1 Licensed Construction Supervisor(CSL) W �
Licen;eNumber Expiration Date
Name of CSL-Holder List CSL Type(see below) 1�
a 21� r\- r/)n Aoc LJ�1,�-t �VO-0\ T e Desm tion
Adams ;`'. _
U Unrestricted(d to 35,000 Cu.Ft)
R Restricted 1&2 Famil Dwelling
Si ature�j - M Maso Only
- RC Resid-4-1 oonn Coverin -
Telephone. WS Residential Window and Sidi n
SF Residential Solid Fuel Bumin Appliance Installation -
D Residential Demolition
5. egistered Ho a a ImprSS.ve ent Contractor(HIC) \ q bU
�1CCompanyNameorHl Re-isirant -
0�1 RegistrationNumber
fr��ljfr�� o,rt�x�t-T h\��7e, �IS3�
1 ) o C A/t/lp, L —clI (,`�9� �Expiraion Date
Siot ture Telephone .,
SECTION 6:WORKERS' CONirENSA-11ON INSURANCE AFFIDAVIT M.G.L.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 permit
Signed Affidavit Attached? Yes —....... No...........❑
SECTION 7x;:OWAER,47JTI€£ZY4TIOi3 TO)?E Cp11DT ETEEtVrMN'. '
OWNTER'S:4GENT.OI:C ONTIL4CTOR APPLIES FOREL7LilI1\TG$N RIv�IT
I, (. ✓�)� o—e DC)e,I as Owner of the subject property hereby
authorize_ n i 1i a_ ex V\ o.rJ Q� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signa ure ofowner Date
(� \ (�SE, CTTON7b:..O�tNEF.' OR 4UII'ORiZESl 4 EN$.Ib£ 4R4IJdN
l �J.��'� 'I�CAy�'C� ,L'?S�'4" ��:7kry ror:Att1lnnzed Aunt h rehv.d cl9te'_ :. ..
diet tt e statcmer s and information on fire f=:egoine'application are true'azid accurate, to'the Lest of ui;.l at It lge and
,e i t Ok.A O-f L)
.'mint • . :
Signet of Owner or uthonze I Age - . � Date
(Si�nedunderthepain;an pen2lties - eriu -
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(notregistered in the Home Improvement Contractor(HIC)Program),will not liave access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important.information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780'CMR Regulations 110.R6 and 11D.R5,respectively.
2. When substantial work is planned,provide the information below: =
Total floors area(Sq.Ft.). (including garage,finished basement/attics, dells or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number ofbathrootrs Number ofhalffbaths
Type of heating system Number of decks/porches '
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cesf' /j, 3 W ,p J
DEBRIS FORM
This form is to be submitted viE building pmmait applications 197hMever there is d bris to be
-- disgosmd of.
till nn t1 -
Property Address: '� l� Asll�• � ��'ey -E V� b��� ,
1n a=ordaac.cdth the provisions of 2l4GL c.4O, §54,:a condition of the B si.Idin,P=ait
Number is that the debris rcmidng from this vrork shall be disposed of in a properly licensed
solid'vmas -disposal facility as dcfmd by 3jiGL c. 111§ 15DA.
This d bris vdll be disposed of in:
S3,D .
(Location of Facdiiy)
Simathm of Permit 4pplcant
Date
r .
109 Olt"Sr_Vorthhornuglt.A1,1 pl 532 )
€zI.N% n/u/.% ➢1A Home Inrprovemcnt Contractor
:907i; )I!)-C90r)•I-hs: 77d !)8i;t01a Renewal Lica F,, #1i9601 (Expires 081- h/L4/'L012)
Federal 1'nx fU#83-0404201
byAndersen.
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Dine pI r nI
10,
Bya,l/sl//N�orr,e d/
It clf
,.yer�l Address,Cill, e,an Zlp/Code 1
EJeml Address Hom,lone Hone rrombe, wo.k ielepho�e NtmSe,
Ciuyz,(s) hereby jointly and severally agrees to purchase the producls and/or Services of j &L Windows,lac Cl Renewal by Andersen
('-Contractor''),in acenrdance with the terms and conditions described on the front and the reverse of this agreement and on the attachad
slxcification shaet(s) (eollectivcly,this•'Agroemenm)-Buyers) hereby ayrces to sign a completion certificate after Contractor has completed
all work under this Agreement.
? d Method of Pymnt 7 Cash Check 7 Mosre¢ard U VISA
Tolo1 Job Amounl:�S 37� Estimoled Starling Dore: J Vef J Flnonced,App#'.
Deposit Received(33%) �_rl--/,-_- Nears on 'edit Cord:
Balance at Snarl of Job(33,i):�(i3• Eoimolad Com lotion Bar. Credit Card
Balance on Substantial 5=f r3 tl P �•` Z" C4 A'
Completion of Job 133`el' CC Esp.Dole: CC Sece- de:
'� Rs-inlrialir,�(herc.you xrknrn,4cdgr rJwuhr Mdaom at Snvi of,)ob and doe Bnianrc on Snlpyantial Cnmplrtinn
Buyer Initial of lob cannot 4>c made b)credit crud and mini be made by pefYanal rl:eck.bank chock,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 devlation
£ram this Agreement swill be valid without the signed, written consent of both Buyer(s) and Contractor Buyer(s) hereby
acknowledges that Buyers) 1) Ira 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
tvritten 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.
I&L Windows,tar.d/b/a Reu...al by Aodemea - Boyer(s) Buyer(s)
By, tii na[� f due\[onager v tiignn re wr Signamrr
B '
Print Name of prodacl Xtanager print Name Yrint Name
YOU, THE BUYER(S), htAY 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 EYPLANATION OF THIS RIGHT. _ _ _ _ _ _ _x
NOTICE OF C CELLAHON NOTI F A CELLATION
Dote of Transaction t" 6 I . You may cancel Date of Transaction ,9LPL—.. You may cancel
this transaction,with a perwl}dy or obligation,within this transaction,wiNtou an penalty or obligation,within -
threebusinessdaysfrain the above dale.If you cancel,any three business days from the above date.If you cancel,any
property horded in,any payments dada 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 negtniable 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") of your cancellation notice,
and any security interest arising out of the transaction will r 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 Sake;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 of the Seller's expense and risk.If you do make
If you do make the goods available 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 dote l pkk 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 goods
of the goods without any further obligation. If You fail to without any further obligation. If you fail to make the
make the goods available rg the Seller, or if :ou agree goods available to the Seller,or if you agree to return the
to return the colds to the Seller and fail to do so, then gods to the Seller and fail to do so,then you remain 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 To cancel this transaction, mail or deliver a signed and
signed and dated copy of this cancellation notice or any l dated copy of this cancellation notice or any other written
oil, riHen netiee, ar send a telegram io Contractor: J notice,or send a telo' roan to Contractor. J &L Windows,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis r Inc. d/b/a Renewal byy Andersen, 104 Otis streets,
Street, Norfhborou 01532, BY NOT LATER THAN Norihbo ug MA 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT OP o I® '(Date) IOHER Y� N EL THIS TRANSACTION.
I HEREBY LANCE THI TRANSACTION.
Buyer's signaNre
Dfltt Bayer's Signature sole
RNA Copy- White Buyer Cory-yellow Buyer Copy• Pink
1It L Windows,Inc d/b/a MA I IIL I.iccnec# 149G01 (txplI s l/Z4/IP)
109 OIt,stn'at,l`Vr:I,LW:VPgh.\M1e\ 01=1'1 Renewal Federal f2X fi# w?-04012o1
.•a Phone 5ab 1 v-0900•Yax P'/4-9*7,3013
byAndersen,
WINDOW REPLACEMENT "" n�.run Grtapn,
Or GarnlEa AtassacBUSEM.wn Mw F i`aa"smn
WINDOW SPECIFICATION SHEET
Bnyer(s)Name Date of Ag ettne
1'hc yzrU)listed shrove hcrcby lou y and severally agree to pu:dnsa 1h�4ouds and/or services listed belt
,gj d N t p and tenu..
described on the 5pecificatiou Sheet and the front and the reverse of the;wrump:mpinR CI'STOM WINDOW AND DOOR RFMODEI,ING MAEEMENF.
of which thi;Specification Sheet is a part.
WINDOW DETAILS
I. Connvcicr will Install a total of IJ windows in owned.,horn.using the tonowing individual gµar icst
Doublc Hang(Dlf) [ rqual sash ❑ Cottage sash(1/3 lop,2/:3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom)
-✓ _Casement(CW) ❑ Hinge fight ❑ [Urge left(as viewed front mcrior): ❑ Standard handle ❑ Metro handlr
Double Casement(CDW) ❑ Standard handle ❑ Mcim handle
Casement/Picture/Casement(CPW)'❑ i;l:I or F1 1.2.1 ❑ Standard handle ❑ Mdre,handle
Z Lite Gliding Window(GW)
1' Glider/Retire/Glider(GFW) ❑ 1:1:1 or ❑ 172:1
✓' Asming Window(AW)
picture Window(FW)
r Bay orBow Window
Patio Doors(see separate Door Specification Sheet) ��
2. fg Yes El No Qty of Windows to be Custom Fit Replacement
3. D Yes 4 No Qn of Sills to he replaced by Contractor:
q. ❑ yes E&No Qty of Windows to be New COnstniction Full f mine(includes new interior&exterior casings)
Exterior cr�asinssis'. ❑ IYnc ❑ Maintenance-free me lcrid ❑ Faclory applied 90S Fibrcx brickmold
5. Glazing to Ix:0 fit'Low-ER AnarlSunrM (yg-v Cro&fFJ,lble) ❑ Other lfolher,plcasr speedy ---
6. Fsletior color to la: gN White ❑ Saud ❑ Canvas ❑ Terialonc ❑ t xea tics"
7. Interior Color lobe: W White ❑ Sand ❑ Canvas ❑ Tcttslone ❑ line ❑ Alapte ❑ Oak
Nate: Interior color can Only be white,wood Or some color as tatelior. wood interiors need to finished by Owner.
S. Hardwdre: X White ❑ Stone ❑ Canvas ❑ Brass ❑ Ltatc Hnrdware: Style'.
9. A Yes ❑ No histall Lifts with Double Hung Windows
10. Screens� windows to have: ❑ Half of KFul)screens Screens to b : �Flberglass Aluminum El'(ruScene `—
GRILLE DETAILS
11.Windows have grilles: ❑ YesK No If yes:❑ Grille Be twcell Glass n;n•a❑ Rcmova ble interior Wood umvn❑ Full Dividcd Light(1111.)
QIy1 Qty. Qty: Lill: Qty. Qty: QIy:
1
1-L
eN nH nn ON cW:vluo,e G11ab cRM crcRN
praw grille patterns above "Use additinnxl sheG il'needed Owner approved Gnilals):! l
ADDITIONAL WORK DETAILS ti
I Z.❑ Yzs O Coctor will remove metal frames of windows. Qly Of Units'.
I3,❑ 1'es NO Cottt ntraraetor will Install new paint-rcadv or stain-ready casings.
Interior casing qN of opeufugs: Exterior casings qly of openings: ❑ Fine ❑ Maimenance-free material
14.❑ Ycs krNo Contractor will install new paint-ready Or Hain-ready inside or outside stops qty Of openings:
Interior stops city of Openings: Exterior stougt pen' qs: ❑ pint ❑ Maintenance=free material
15, Owner is aware that Contractor does not do any painting.;Owner Initials
16.❑ Ycs [-No Contractor wtil wrap exterior casings with aluinm n coil stock of color.
Note: Wrapping may be required with Storm window rciroval',removal of storm windows will leave screw holes"I cssi"S
17. Yes ❑ No Contractor will insulate,caulk and seal windows with I-point system to prevent water and air infiltration.
18 yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19 Yes ❑ No Buil it—Contra for will secure:env and all neccasay permits. 'line fee for the prnnh(s)1s not
Included in tho Contract ice an a sc rat c reek a requrn)al the timr L1E,fie foj jl)is f Al ! /S�•
70 AAditional jab deceits: �e cki P.F,/" tme f - y /c / S
Z I. Z Yes ❑ NO Owner agrees lobe present on the f inal•9a)•of installxlirnn for final inspection and to dclivcr final payment.
Nn IirlAllre}veers!shallix demanded utt///the c intrxct it comp&relf torh'-1finsfhe!ion olel/facets.
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR RPMODELING
ACRREMENT,constitutes the entire understanding between the parties,and there are no,verbal understandings ehangui or modifying any of the
terms. This Specification Sheet may not be changed or its temss modified or varied in any way mile"such changes are in writing and vgned by both
the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet.y�*ttew � n of Greater MA and NH 13uyu(o) Bf/
y a b17a1(/ � �2 l/KnsAYtWA1/=
Signs o odnet Manager Signature Signature
A0 (JUG J Z C�ol'AP FIvP/1n�—
Print Name of Product Manager Print Name Print Name
I
Rene
byAndersen® In
WINDOW REPLACEMENT mAndetsenCompany
PROPERTY OWNER MUST COMPLETE & SIGN THIS SECTION IF USING A BUILDER
as Owner of the subject property hereby authorize
Rene ] Andersen (d.b.a. -J & L Windows) to act on my behalf, in all matters relative to
work authorized by this building permit application for:
—7C
Address of fob
1�71 L v vJPo � .2D 10
�Ho owner Signature Da
OWNER OR BUILDER As AGENT OF OWNER MUST COMPLETE Ez SIGN THIS SECTION
as Owner /(Authorized Agent
m hereby declare that
the statements and information on the foregoing application or:
Address of Job
Signed under the pains and penalties of perjury.
Print Name
�,
—�Sigrlature of Owner/(A entj Da
104 Otis Street
Northborough,MA 0153A
Phone: (508)919.0900
Fax: (508)919-0903
w .renewalbyandersenxom
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U1V I www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
NaMC (Business/6rganizadon/Individual): Renpoa' �V An��erSen
Address: /0g/ /i 5 3+ree.1—
City/State/Zip: /Vof-"A bo 1"o Q1j,3_:7_ Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
L aI am a employer with 00 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 �• modeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp.insurance. q, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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 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.
tContrnctors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below.is the polity and job site
information.
Insurance Company Name: � l t/leo n /n ✓r n C
Policy#or Self-ins.Lic.#: 19J jj) Expiration Date:_=/
Job Site Address: 3 G rcnA V,. City/State/Zip: \2utn t (Oi
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 ce u er the pains and penalties,ofperjury that the information provided above is true and correct
o mature �O Date
Phone#: 0 �U
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#:
fF
u, Nlassachusetts- Department of Public Safm-
Board of Building Regulations and Standar(Ix
Construction Supervisor License
License: CS 101952
Restricted to: 00
DAVID BANCROFT
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01588
Expiration: 3/19/2012
('onnnissiwrer Trp: 101252
j
. ✓� IOd/]YIILO'ttAl�ed/.�L 6� EClQC�
office of Consumer Affairs&Business Regulation b
OME IMPROVEMENT CONTRACTOR - f
Registratio ,U,9 n 601 E
ExPir ,is 12.
o ,1c---, ferx'tent Card
RENEWAL BY DI---- 1>�
°t --�
DAVE BANCROF-cTi g ��Q
104 OTIS STRE
NORTHBOROUGH,N139g2 Undersecretary
F
DATE(MMA)DnyM
ACO . CERTIFICATE OF LIABILITY INSURANCE 02110010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
NG
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Joseph McKeone HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
JP McKeone Insurance Agency, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333 NAIc a
Ann Arbor,MI 48106-0333 INSURERS AFFORDING COVERAGE
INSURED Renewal by Andersen INSURER A. He ord Insurance an --
INSURERS: Nautilus
J and L Windows,Inc. INSURER C:
104 Otis St _
Northborough,MA 01532 INSURER D:
INSURER Et
I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.MAY
BE I S ISSUED
O
ANY REQUIREMENT, TERM E 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. EFFECTIVE POLICY EXPIRATION LIMITS
wSR D'L POLICY NUMBER EACH OCC URRENCE S 1 DOD ODD
B I GENERALUABLTY NC958461 10/01/2009 10/01/2010 PREMISE EaPanaara S 1000DO
COMMERCIALGENERALLIABILITY NEDW(AnyP Pa ,,) S _. 5,00D
CLAMS MADE ❑OCCUR PERSONAL S ADVINJURY S 1 ODO ODO
GENERAL AGGREGATE S Z DOO oDO
. .PRODUCTS-COMPA]P AGO S 20000000- . ..
GENL AGGPC,3ATE ULM APPLIES PER:
I wPR
0/02009 10/0 /2010 Dn SINGLE I S 1,000,000LOG
A UOMOBILELIABIim 35MCCXD6390 1 (Ea=kkUl !)
--
ANYAUTD
BODILY INJURY $
X ALL I OWNED AUTOS (Par penes)SCHEDULED AUTOS SONLY INJURY S HIRED AUTOS (Per�m)
NON.OWNEDAUTOS pROPERN DAMAGE S
Ipur A6Dantl ---
AUTO ONLY-EA ACCIDENT S
GARADELIASIUTY OTHER THAN EAACC S
RANY AUTOAUTO ONLY: AGO S
EACH OCCURRENCE IS
EXCESSNMBRE I e UABILrrY AGGREGATE S
OCCUR CLAIMS MADE $ - -
S
DEDUCTIBLE S
RETENTION $' WC STATU- OTM-
A wORKERscOMpEHEATIDNaro 35 WECPP 1444 02117/2010 02H7/2011 EL EACH ACCIDENT _ s 500,099
EMPLOYERS UAB'UrY E.L.DISEASE.EA EMPLOYEE $ 500000
AAFFICER,AIP?J,EMPARTNEEEDi ECUTNE SOO ODO
E.L.DISEASE POLICY LIMB S
It yet aesnita enaar
SPECIAL PROVISIONS WIPx
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CANCELLATION
CERTIFICATE HOLDER SMODU)ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATON
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO:MAIL 10 DAYS WRITTEN
INSURED COPY NOTICE TD THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SNAIL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORCBD REPRESENTATIVE
9)AACCvOR'D`—CGORRPORATION 1968
ACORD 25(2001/DS)
i
i
Renewal Q>t>> bYAndersen �`
WINDOW P.EPLACEMEMT =And.mC=,my -
h3brelFe a trafron WoDWInyl CDmposlte IF
Rarmgcm T& Dual Argon Low E
I Double Hung
IDD-DD4145eS-007 "
ENERGY?ERFCRf&LkNCE RATINGS.
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Renewer IIIII
byAndersen.
WINDOW REPLACEMENT anAnderse-nCorn any
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)
919-0992.
Best Regards,
Kelley Donahue
Permit Coordinator
104 Otis Street i
Northborough,MA,01532
Phone(508)919-0900
Fax(508)919-0903
Website: www.renewalbvandersensorn