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2 GREEN ST - BUILDING INSPECTION 5: 1v- ao The Commonwealth of Massachusetts (� OF Board of Building Regulations and Standards CITY SALEM Massachusetts State Building Code, 780 CMR dMar Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a YYY One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pied Building Official(Print Name) 49ignature SECTION 1:SITE INFORMATION Z t 1.1 Property Address: Z)O/ 1.2 Assessors Map&Parcel Numbers `Z �rtcn Si 6 --33 - 6S3d - Pa/ l.l a Is this an accepted street?'yew no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(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: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' - 2.1 Owner of Record: �Ilt CV ;� rnA Olq'70 Na (Print) ttyC� State,ZIP `7' 6rccn S+- §sq - 81�l No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)- I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': I-Stoll 1 wf',Abo 1n-fD F3X.�S1'1r1G �OcJI_ A1F�c — p I ] SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1. Building $ ) LIDO OO 1. Building Permit Fee.$ ?� Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ; 13 Total Project Cost (Item 6)x multiplier x 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: $ , �LIOp.pp 13 Paid in Full - 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) }}-- D-)90 9 0 11- 19, 13 T)1?JMii C t O YDr1 License Number Expiration Date Name of CSL Holder List CSL Type(see below)_ U lz No.and Street ( T - Description I � U Unrestricted(Buildings up to 35,000 cu.ft.) W D b J(n. 1"Y'I p O l t5 01 Restricted 1&2 Family Dwellin City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Ig1 -933- 4D,-1faxon@r-edress C� -� I Insulation Telephone Email ad D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Co any Name or HIC Regis t Name —�?(b Cc,Iar S+. j,L]�b>>�v -r r, 71pxey)P No.and Street Email address WDbot,r) h01B I2I E d i -7£1 V) 6o City/Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Aletop to act on my behalf,in all matters relative to work authorize6 by this building perm t application. E1 le c r a -6-,3 Print Owner's N e(Electronic Signature) Date ro SECTION 7b:OWNER'OR AUTHORIZED AGENT:DECLARATION, By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. i> Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.niass.gov/oca Information on the Construction Supervisor License can be found at www.mass.uov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,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. "Total Project Square Footage"may be substituted for"Total Project Cost" I From Our Home to Yours... JOB#: LEAD PAINT STATUS ' Yr Built lszo LSWP: C/ ONE MUST Windows;,Siding and More page__�Lof( EXEMPT: BE SELECTS CUSTOMER ELLEN CYR E-MAIL DATE 1-14-13 978-534-58181 ^ HOME PHONE ADDRESS GREEN ST WORWCELL PHONE CITY,STATE,ZIP SALEN MASS BEST DAY TO INSTALL:(M2 T W TH CF (circle one) PRODUCT SPECIALIST JAMES KASSIOTIS ESTIMATED START DATE 02-14-13 TOTAL#OF #OF BOW/BAY/ GRID COLOR WINDOWS GARDEN #OF DOORS (Inside/Outside) CAP COLOR 1 Bay Bow Storm SDL MFG NAPCO / Norandex / Garoen oshof� Steel WHITE Contour other�_, Roof or Soft Patio Prairie 11 (circle one) Diamond PVC / Smooth Locks&Keepers(circle one): White Almond Bronze Brass (circle one) (cim/e one) Handles 8 Night Latches(circle all that apply): WF� Almond Bronze No Bottom Handles Night Latches(Nighttatches are Nora standard feature) Inside Color(circle one) hite _Natural Oak London Walnut Colonial Cherry Muskoka Oak Barrister Oak Outside Color(circle one): hit, Univ.Brown Wicker Forest Green Wedge Blue Sandstone Burgandy Bronze Custom OPENING SIZE STOPS NO. STYLE W x H U.I. LOCATION GRID SCR IN OUT VCONV ADDITIONS OPENING CUT 1 2755 33X40 70 LIV H >�/'L x��� 3�I x 2 x x 3 x Axu � 4 LL ' 1 C x x� 5 / x X VU IN d� tZ4..s L c' tIr . !et l7 /; x x x x x x I x x x x x x x x x x x x x Measuremam71f Ida IA tials Date Crew Size Needed Time Frame to complete job Capping Type Special Installation Instructions: Revised 12110 MA Reg#146589 rmm Our Norretoawn,CT,Reg#0605216 SL_ '�J Contract# RI Reg#26463 Energy Saving Home improvements Federal ID#20-2625129 Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 IF)781-933-9626,www.newpro.com 66 377 THIS CONTRACT MADE THE �`l day of / 20 /3 between (Home Owners) (Home Phone) (Bus/Cell Phone) of 4- J LJl4Grr, 104 o) �4V-70 (Address) (City) (State) (Zip) the"Owner"and NEWPRO Operating, LLC, "NEWPRO". (E-Mail) for proprietary use only NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install the - following described work at the premises located at: ❑ The job address is a condominium. (Job Address) - TOTAL#�,-..`- ,4, NEWPRO _ WINDOW OPTIO r. ,. WINDOWS':,.,.,`. SEk1E5# oJ'a Grids: YES NO UCONTOUR LJSDL EURO DIAMOND Window Color QTY Window Color QTY OBS I TMP: (Location) []TOP ❑BOTTOM Int: LJ Int: Screens: (Exterior color Full Screen Standard) ®.HALF ❑n]''FULL Ex )­1 © Ext: EZ Vent Latches: ❑YES [yNO Capping Color: DOORS T. . ea k . 'xYMODEL•QTY Please Initial. PVC LJ Smooth NoMar No Capping LJ Sliding Glass Door a'•:jr­,I I E MODEL NAME tvio$42W- x .:+.MODELIII ",QTY::; Color In: Out: Customer understands that NEWPROS ` Double Hung 3 755 1. Active: Left Center Right does not do any y painting or staining. 2 Lite Slider 757 '" HOWR: S Be )WH 13GE lie:when removing or replacing interior 3 Lite Slider (114,v2.114) 753 ' Erdryi Door Sty e.=a- stops or trim). NEWPRO®is not respon- 3 Lite Slider (113,1/3,113) 756 Color In: O t: sible for conditions or circumstances be- Casement(Hinged Right) 851 Fiberglass Steel yond its control including condensation result- Casement(Hinged Left) _852 HDWR: SN BB A B AB ORB ing from or due to pre-existing conditions. Twin Casement 853 SideliteS le ,1, - (circle one): Stationary Casement - 856 Color In: out: CASH Triple Casement (114,112,114) 859 4 S torm- DOOf Style,; Balance paid to installer at completion Triple Casement Lri 113,v3) 860• olor n Picture Window =751 DWR: SN BB XGB AB FINANCE Sash Only 752 Left Hinge Right ge Bank completio nad at installation Hopper 491 Entry Door Style _;._, �... Awning 351 Colon In: out: ',,T07AL Garden Window 798 Fiberglass Steel F CASH.,x.. Bay Window(Roof/Soffit) HDWR: SN Be AGB AB ORB Bow Window(Roof isoffi0 Other Dooro-xirt?� , I DEPOSIT, Other Color In: Out: A,s ( �+ ) Other WITH HDWR: ;ORDER DESCRIBE WORK&PROMOTIONS APPLIED: 1Iry / GJ/L l r DUE AT Ul.r Est. Start Date: d`)t-1 Est. Comp. Date: -) 'r t—1 Customer understands this is an"estimated date' Owner has read and agrees to the terms and conditions on the front and the reverse of this Agreement. Owner ' specifically agrees to the(1)Total Cash Price; (2)work being performed; and (3)work not being performed.`Owner understands that this Agreement and any attachments contain all of the promises made by NEWPRO. Owner has been orally advised of his right to cancel this transaction at any time prior to midnight of the third business day after the date of this transaction and Owner was provided with two(2)copies of a cancellation form explaining this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only): Notice to buyer: (1) Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank. (2)You are entitled to a copy of this Agreement at the time you sign it. (3)You may at any time pay off the full unpaid balance due under this Agreement, and in so doing you may be entitled to receive,a partial rebate of the finance and insurance charges. (4)The seller has no right to unlawfully enter your pret'hises or commit any breach of the peace to repossess goods purchased under this Agreement. (5)You may cancel this Agreement if it has not been at the main office or branch office of the seller in the Agreement by registered or certified mail,which shall be pasted not later than midnight of the third calendar day after the day on which the buyer signs the Agreement, excluding Sunday and any holiday on which regular mail deliveries are not made. See the accompanying notice of cancellation form for an explanation of buyer's rights. (Rhode Island Sales Only): Owner acknowledges receipt of required Contractor's Registration and Licensing Board consumer education ❑mmmaterials. Owner's initials By: �� EIN# Signed: Product Spediaist(Printed Name) Owner BY r Signed: NEWPRO Operating,LLC(Signature) Owner �. WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy 1 US-15 R1012 1 ADDITIONAL TERMS AND CONDITIONS c C C Warranties: Axly product warranties are provided by the manufacturers of the products that Owner is purchasing. NEWPRO is also providing Owner with a labor warranty, which covers NEWPRO's labor. Owner understands that Owner should read all the written warranties for complete details of warranty coverage and that warranties are available for complete review before signing this Agreement. Late Cancellation: Owner understands that Owner has three (3) business days to cancel this Agreement. Owner understands that if Owner wants to cancel this Agreement after those three (3) days, NEWPRO does not have to allow that. Owner understands that if NEWPRO does let Owner cancel, however, that Owner will have to pay to NEWPRO a late cancellation fee equal to 33.3% of the purchase price in order to cover NEWPRO's labor,administrative,and material costs, so long as that is legally allowed. - Delay/Unknown Conditions/Damages: Owner understands that if NEWPRO determines within thirty(30)days of the date of this Agreement that it cannot perform the work according to NEWPRO's professional standards,NEWPRO can cancel this Agreement,notify Owner of cancellation,and promptly return Owner's money.Owner understands that issues that may cause NEWPRO to cancel this Agreement include incorrect pricing or unknown pre-existing conditions to the property. Owner understands that NEWPRO is not responsible for structural or other defects in the property,and that NEWPRO's products do not cure these problems. Owner understands that the work could be delayed by events that NEWPRO does not control.Owner understands that NEWPRO is not responsible for(a) damages due to causes beyond NEWPRO's control, (b)damages arising from a delay in NEWPRO performing under this Agreement,or (c)unintentional damage to Owner's personal property,it being understood that it is Owner's responsibility to remove/secure his personal property prior to commencement of work. When Money Is Due: Owner agrees that when the work is"substantially complete", Owner will pay the balance due on this Agreement. Owner understands that "substantially complete" means the work has been materially finished, fimetional as intended, and a final. inspection,permit, or occupancy certificate, if required, has been obtained. Owner agrees that once Owner has paid the purchase price, if Owner believes any of the work performed by NEWPRO is defective or incomplete, NEWPRO will inspect the work and perform any service Owner is entitled to under this Agreement and/or any warranty. Owner agrees that if Owner does not pay any of the money when it is due, Owner can be charged a late fee of 1.5%on the amount owed for each month the money is not paid_Owner agrees that if Owner defaults on any promises under this Agreement,and NEWPRO hires an attorney to enforce this Agreement,Owner will pay NEWPRO its reasonable legal fees and related costs or expenses,as long as it is legal for Owner to do that. Other Understandings: Owner agrees that Owner will assert a dispute,claim,or controversy(hereafter referred to as a "Claim") arising under or relating to this Agreement only on behalf of Owner's own self and that Owner will not assert a Claim on behalf of,or as a member of,a class or group in either an arbitration proceeding,a private attorney general action or in any other forum or action. If a court determines that this specific paragraph is not fully enforceable, the court's determination shall be subject to appeal. This paragraph does not apply to any lawsuit or administrative proceeding filed against NEWPRO by a state or federal government agency even when such agency is seeking relief on behalf of a class of buyers. Owner agrees and understand that if Owner finances the work, Owner's separately provided financing documents will include the number of monthly payments and the amount of each payment, including any finance charge. Owner promises that he will provide NEWPRO with access to the work area, including access to electrical outlets. Owner understands that this Agreement and any attachments make up the entire understanding between the parties. Owner agrees that any change to this Agreement must be in writing and signed by both parties. ('Massachusetts Sales Only): All contractors and subcontractors must be registered by the administrator of the Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation,Ten Park Plaza, Suite 5170,Boston,Massachusetts 02116 Telephone: (617)973-8700. It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent.NEWPRO shall advise Owner of any necessary permits. The Owners who secure their own construction-related permits or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. Any deposit required wider this Agreement to be paid in advance of the commencement of work shall not exceed the greater of one-third of the total contract price or the actual cost of any materials or equipment of a special order or custom-made nature,which must be ordered in advance of the commencement of work,in order to assure that the project will proceed on schedule.No final payment shall be demanded until the contract is completed to the satisfaction of the parties. (Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE.During the term of this Agreement,NEWPRO shall maintain public liability and property damage insurance covering the work of not less than$500,000 combined single limit,bodily injury and property damage and workers' compensation insurance as required under chapter 29 of title 28. NEWPRO and'or subcontractors or material persons may file a lien in accordance with Rhode Island Mechanics Lien Act,chapter 28 of title 34. (Maine Sales Only): Consumers are strongly advised to visit the Attorney General's publicly accessible website (www.maine.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their hones. The Attorney General can be contacted by telephone at 207-626-8800. Any alteration or deviation from the above contractual specifications that results in a revision of the contract price will be executed only upon the parties entering into a written change order. In addition to any additional warranties agreed to by the parties, NEWPRO warrants that the work will be free from faulty materials, constructed according to the standards of the building code applicable for this location, constructed in a skillful manner, and fit for habitation or appropriate use.The warranty rights and set forth in the Maine Uniform Commercial Code apply to this Agreement. If a dispute arises concerning the provisions of this contract or the performance by the parties that may not be resolved through a small claims action, then the parties agree to settle this dispute by jointly paying for one of the following: ❑ Binding arbitration as regulated by the Maine Uniform Arbitration Act, with the parties agreeing to accept as final the arbitrator's decision; ❑ Nonbinding arbitration, with the parties free to no accept the arbitrator's decision and to seek satisfaction through other means, including a lawsuit; or `DI Mediation, with the parties agreeing to enter into good faith negotiations though a neutral mediator in order to attempt to resolve their differences. (Connecticut Sales Only): THIS INSTRUMENT IS BASED UPON A HOME SOLICITATION SALE, WHICH SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT, THIS INSTRUMENT IS NOT NEGOTIABLE. The owner(s) of NEWPRO is or has been a shareholder, member, partner, or owner of the following corporations, limited liability companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous five years:NONE AC01 R4 CERTIFICATE OF LIABILITY INSURANCE DATE,(MWDD/YYYY) 01/03/2013 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: It the certificate holder is an ADDITIONAL INSURED,the policyyes)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 endomement(s). PRODUCER e IhsU anCe Agency,-Inc' S08.366.61MC 508.366.5202 11 West Main Street E- L ac No: Westborough, MA O1S81-1931 "A, Peari n RID : 00013793 INSURERS)AFFORDING COVERAGE INSURED NAICp : Pearless Insurance Co. 24199Newpro Operating LLC B: Acadia Insurance Co.26 Cedar St. :Woburn, MA O1$OS ::: COVERAGES - CERTIFICATE NUMBER: 12-13 Master REVISION NUMBER: THIS' TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGV PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HICH 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. INSP ADOL SUER LTR TYPE OF INSURANCE INSR MD POLICY NUMBER MM/UIYYYV POLC EXP LIMITS LIABILRY CBP 8589S7 12/31/2012 12/31/2013 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DA AGE TO RENTED P EMISES Ea ocourren S 100,OO CLAIMS-MADE �OCCUR MED EXP(Any one person) $ S,OO PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRODUCTS-COMP/OP AGG $ 2,000,000 JECT LOC $ AUTOMOBILE LIABILITY BA SS8417 12/31/2012 12/31/2013 COMBINED SINGLE LIMIT ANY AUTO (Ea accident $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Par person) $ A .X_3GHEBUEEB-AUTOS __ BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Per accident) X NON-OWNEDAU OS - $ X UMBgELLALUIB X OCCUR CU 958257 12/31/2012 12/31/2013 EACH OCCURRENCE $ 5,000,OO A EXCESS LIAS CIAIMS-MADE $ S,OOO,OOO AGGREGATE DEDUCTIBLE X RETENTION It 10,00 Is WORKERS COMPENSATION $ WC-2O-20-003SO6 XCV OEHAND EMPLOYERS'LIABILIT ANY PROPRIETOR/PARTNER/EXECUTWE Y/N OIMITS B OFFICEWMEMBEREXCLUDED' N/A E.L.EACH ACCIDENT $ 500,00 (Mandatory In NM E.L.DISEASE-EA EMPLOYEE $ SDD,OOO If yes,tlescriba antler DESCRI PION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S00,00 r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more apace la required) CERTIFICCAH_HO nE_ L gg.,_ ,_` .._ ._ _, _CANCEL�_TION 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 Titltoth Mo na h ' m INuu-2009 ACORD CORPORATION. All rights reserved. ACORD.25(2009/09) _. - The ACORD name and logo are registered marksof.ACORD - . . +9—\ ✓�e Vim�vnrmuneal� naaa�udeC7d Of ice of Consumer Affairs d,Business Regulation I License or registration valid for individul use only OME IMPROV=MENT CONTRACTOR i before the expiration date. If found return to: Registrahon,::.zlri6a89 T�� Office of Consumer Affairs and Business Regulation s to Park Plaza-Suite 5170 P Expirafion,- /5r'2D1�3 Supplement are - Boston,MA 02116 NEWPRO OPERWTO'dG r� 7 THOMAS FOXOftA , 1 VJOBURN,MA 01801 - - ' Undersecretary Not valid without signature � I I Massachusetts -Department of Public Safety Board of Building Regulations and Standards i Construction Supemsur License. CS-029090 r'rq i THOMASPF07ZON 230 WALNUTSTIq READING w"�tstts` Expiration Commissioner 11/19/2013 i I I I II j I i Ye CommoRweatth ofMassackweas epartrnent of Induytrid AccidenO Ofrce Pf,Inveskgolons 600 Washington Street: .Boston,AfA Q UI ia -��AgpQlii:antI�otwatton dWorkers Compeusation lnarance Affidavit:Bugeers/ContractoMTledapOPlamlrs PI tLezy� .- 1 �t OJera ; •, - Name(susiaesr✓QrBanimton�[udividual); � �2c��c� ��__�j Y Address: ati Cre d a r S-r I, ci /state , ab - . ty /Zip ( I J<rl �mfl OI 8.0 l Pfione#: F l ' 4100 j 1 Are J� TamaemployerpeCheck the O appropriate bus by❑Newpe of oco Project(required): + 4. ❑ I:am a general contractor and I nstroction employees(fall andlor part-time).* have hoed the sub-contractors 2.El I;am a sole propmetor or PM - listed on the attached sheet 1 7• f Remodeling slrip and have no employees. These sub-contractors have ElDemolition working for me is an c workers'comp;insurance.. 9. _❑Building addition y ity. [No workers'comp.insurance 5. (] We are a corpoxation and its 10 ❑Electrical repairs or additions - required.} officers have exercised then 11. Plumbing repairs or additions 3,❑ I am a homeowner doing all-work right of-exemption par MGL Q _ myself[Noworkers' comp. c.,152,,§I(4)i and we have no 12i❑Roofrepahs r -insurance required.) emplo.,I ,[1Qo;wnrkers' u -- -13'EOther comp.instuance required kAnY npplicdat.tbachwka box9l muatolso fill out the semen below 6diviog thew wotk'ud'mmp.Mstion policy mfmmatiom 't Homoowixawhb=bmitlidsnfndavit:mdiosting Weyuredoingallwork sad lien hveuWside covtzscmis must submdMis affidavit iodimdog such tCmaacrosihat Thal:ttiis.box mcg-fthed en additional sheetsbOwingltie osme of the mb -"memos and ftirwodmrs'oomp.Potic9'iurormahow jam an.employer fiat is providing worlrers'compensation insurance for my employees. Below is the policy and job site information. I Insuance Company No= Y�G1GkInT,'c-e T-r)s-kjra r)Ce, Con-t©anu Pblicy,#or Self-ins. -,;k o 003506- Expxafin oDate: 5 a 013 Job Site Address:.—, � +'Gc UY11f" A City/Stmcaip SaJem m{j- 0)970 Atlenh s copy of the workers,compensation Polley declaration Mae(showing the policy number and expiration date); Failmeto sectae coverage as required under•Section 25A©fMGL c.-152.can lead toxhe imposition of criminal penalties of a fine up to s1,500,00anWor one year imprisonment,as well ascivfl penalties iu the form'of a STOP WORK O1tDElt and a fine Investxgato they.a fonts viol mer. Beaevised tacopyofthisstatementmayate£oxwardedmfieL7fiaeof pp yagamak aticn. .. I do Beret,certify ti/nder fh' 'rcc-midpeudYies ofpesjury tbaribefnformadm provided above is true and correct- Si�ature` /�+��2d^✓Lr0 (! Lt? Date, a/,</�`S Phone#' 7if1 -5 Z 83 K_ZS/ -. OffieTal uss only. Do not write in this area,to be coi�leted by city or town offrdal City or Toren:_ _ .. Perm"cense.k Tasuing Authority(circle one): 1.Board ofHeakh 2.BuildiggDDep§rtment 3.GityPl'own Clerk 4.Electrical Inspector 5 Numbinglnspector 6 Other Contact Person::._ Phoae#: •�mrW1aY0 HP{1VIp}Vi,4�pf�y' I ENERGY STAR' n in Highlighted Regions ® - Qualified In all zones I NEWPRO MANUFACTURING �R� SERIES G HUN 2000 DOUBLE HUNG CellularlPVC frame,Triple glazed, National Feneeiradpn Low E coating(e-0.027,S2&5), Ralmg Oaandim Kryptonlair filled ® DEV-K-27-00030.00001 ENERGY PERFORMANCE RATINGS U-factor(U.S.A-P) Solar Heat Gain Coeffident 0. 17 0,24 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air Leakage (U.S./I-P) 0,40 0.1 Condensation Resistance 70 Nlemhoturer MI W Wee that them Nthpe tontmm fo applkobk NFl10 pixedume mt tlehrminlno xlime pmdudpertammm,NFRCtatlirye medeteanNml aNmdeetatemlrenmmdetoandmmeentla epeamapmduetelHe.NFRCdeee not memmendegmmnoedsete ddoaeeetNwrtmmeautleWa!/ofmry pmdud far ear eoedM W.Gwen man mermae mt other pm0ud pedmrnam pdorme0m. �I