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71 LEACH ST - BUILDING INSPECTION The Commonwealth of Massachusetts =' Board of Building Regulations and Standards FOR Massachusetts State'Building Code,7.80 CMR, 7 h.edition ' MUNICIPALITY, s USE, Building Permit Application To Construct,Repair,Renovate Or Demolish a' Revised January. One-or Two-Family Dwelling 1, 2008 Tbis-Sectim For Official*Use Only, . . uildingPermitNumb a pplied: ignature: Building Comm' ro Spector Bu- - Date ON 1:9fTE INFORMATION 1,I Property Address: 1.2 sensors Map &Parcel Numbers 1 Le/A c .�T - 1. 3 �3 O533 '903 1.1 a Is this an accepted street?yes_ no Map Number ' Parcel Number. 13 toningInformatioC�a 1.4 Property Dimensions: a Zoning District Proposed Use. Lot Area(sq 8) Frontage.(f) - I.S.Building Setbacks (ft). Front Yard Side Yards Rear Yard > Required . Provided .Required Provided Required Provided - 1.6 Water Supply:(ivLG.L c.40,§54) 1.7'Flood Zone Information:. . 1.8 Sewage Disposal.System :-.- -. Public❑' Private El Zone Outside Flood Zone?•: — Municipal❑ On site disposal system .❑ Check ifyes0 SECTION 2i TROPERTY OWNERSHIP' �Qiw� ner//'��ofRecor : /� jr 1 C`rt'.� �[ll,h2e✓ 4 SkA/1✓I U/I � !1.t3/1h<l1 �� L2tA(�, ST y_3 . A,M. pL a 0�I Name(Print) _ Address for Service: - RY 3 � Signature - 'telephone - SECTION 3-DESCkl]'TION OF PROPOSED WORI&(cheek all that apply) hea'Coas4oction❑ 'Exis ing B iild'ui�. Ocher-Occupied Fepairs(s)`' "hu�tion(s) Addition C Dernolition ❑ •A ccessor,Bldg. O Number orUnits Other. Cpeci Brief Description of Proposed Work'-: wn, s", ' SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I.Building $ c 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑.Total Project.Cose(Item 6)xmultiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical,CHVAC) $ List 5.Mechanical (Fire $ Su pression Total All Fees: $ Check No- Check Amount: Cash Amount-. 6..Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: < SECTION 5: CONS, _C. RgN'SF_m"S 6 5.1 Licensed Construction Supervisor(CSL) . _,l_�!� ✓1 1 /P h n 1 L�.✓1 Licarse Number .Expiration Date. Name of CSL-Holder l .. S 1e ���(' } List•CSL Type(smbelow) Address _ fi.:? °`.< �" 'a�=*i•, `Des cij tioa . _ U Unrestricted(` •to 35,OD0 Cu.FL) Signature _ - R Restricted 1&2 E!i--Lly Dwelling - -Masonry Onl - .. Telephone. '�ii-- i RC Residential Roofing Covenn - .� WS' Residential Wmdow and Siding. - IResidential Solid Fuel Burning A P liance Installation Residential Demolition 2 Registere H me 1m ov6t ent Contractor OMC)' - - �Jq] 1C CH .p -e or IC R g'stra- yN In RegistrationNumbcr - Address . .' .. .. 1� a 3-t 3 Expiration Date . ..- Signature.' Telephone ' SECTION 6:WORKERS' COMt ENSAI110X INSURANCE AFFMAVIT(M.G.L.c.15i_§ 35C(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 th riding permit _ Signed Affidavit Attached? ' 'Yes : ....... No.. ........[] SECTION 7a::0Yt1hIFAZW JTHGRi TION TO BE-COI;W yE D,S tN O R'S AGENT fl1}C0AXAC` IETOR APPLS�RQ BUII.'ii ll�Ti<P73R11�T I. s `t S V r ODOkm, I as Owner of the subject property hereby authorize t n to act on my behalf in all matters relative to work authorized by this building permit application . Signature of Owner .. - Date - .. }` [�Y K!a a�P 1 1'✓4 \6 t : . .'n3 OnbernrftiifhMizsd Agent 'erefiydeclfte ` hal the sttemts a aen acid in e'rmation bn tM fptcgotn� pplicatitit 'arc rate aisd accurait;to fire hell of nij k io vledge and . behalf. . PrinrNamo Signature of Owner or Authorized Agent - Date _ ' (Signed underthe pains and enalfies ofp- 'u - -- - NO'IBM: 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 liave access to the arbitration program or guaranty fund under hL i.L.c..142A-Other important.infomiation on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and I ID.R5,respectively. 2. When substantial work is planned,provide the information below. Total floors area(Sq.Ft). (including garage, finished basementlattics, decks orpomh) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number ofhalflbaths Type of heating system Number of decks/porches ' Type of cooling system Enclosed Open 3. "Total Project.Square Footage" maybe substituted for"Total Project Cost" DEBRIS FOB This fore is to be submitted with b' riding pmmit applications whenever ih= is d big to be disposed of. Properly Address: ` e6A VIA In Accordant.v�fh fhc pro-,,mD s of MCiL c.40,§54,..a edition of the Bvildin,Pcmiit N=bcr is that the debris resoltn;from this work shall be disposed of in a properly Hosed solid waste�P' osal famliiy as&imid by lfCrL c. III §150_A, This d bris vvM be disposed of . (Location of Famlity) L. 5i—plature of Permit Applicant • IO�Ci —I' � 1 • Date Renewal I - MA Home Improvement Contractor l/t.,1.,E,Itr YY� 'e .� ,✓ License#170810(Expires 12/23/2013) byA dersen, KI -Federal Tax ID#4 1-1 91 841 3 WtaUaW REPLACEMENT za Md—Company Renewal by Andersen Corporation 104 Otis St.,Northborough,MA 01532 (508)351-2200•Fax:(651)351-4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s�NP Date of Agreement Q 3 - Buyer(e)Street Address,CI ,State,and Zip ode Eldat Address Home Tele hone Number Work Telephone Number Q-4:3-g n-d:433 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 sheet(s) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. 2 Xry Estimated Starting tie: Method of Payment: Total Job Amount: 7 (J Amount Financed / �j i J��S Check OCosh Deposit Received(33%): 0 6'F S139 Y. JV 10-b W uvi /MC ❑Discover Balance at Stan of Job(33%): , 6 E 0 7nced GAME% Estimated Completion Date: If credit card is selected,please Bolonce on Substantial / 4 3 50 _a ©' see Credit Card Payment Form. Completion of Job(33%): O ..J 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 Contraction 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 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. - --� Renewal by Ande e C eporation �: But r(s) Ruyer(s) By: Signa r \or Fir du t Manager Signature Signature ..Jt/ 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,a_ _ _ _ _ _ _ _ _ _ _gc _ _ _ _ _ .gam_ _ _ _ _ _ _ NOTICE OF CANCELLATION TICE Of CILLATION Date of Transaction /O—a —/2— . You may cancel Date of Transaction O- - +— , You may cancel this transaction,without any penshy or obligation,within this transaction,without any penal y or obligation,within three business days from the above date.Ryou cancel,any throe 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 rhecgotiable instrumem executed Contract of Sale,and any nenotiable 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, i by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under as when received,any goods delivered to you under this this 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 rt'Qum shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.R 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 date pick them up within 20 days of the date of r Notice of your Notice of Cancellation,you may retain or dispose of Cancellation,you may retain or dispose of the goods of the gy0000dds without any further obligation.If you fail to without any further a Illation. IF you fail to make the make the goods available to the Seller, or if you aggree goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so, then goods 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 I To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any 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, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF /O- /0 -1 L.(Date) OF /n -(o —/ Z—.(Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. I Buyer'r Signmure Print Name Dine Buyer',Signature Pr in,Nome Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink crI3u 20p9.RBA.P6,MANH Renewal .. J mewal by Andersen Corporath .MA Home Improvement Contractor {„' J 104 Otis St.,Northborough,MA 01532 V License#170810(Expires 12/23/2013) byAndersen. 508)351-2200•Fax:(651)351-4810 Federal Tax ID#41-1 9184 1 3 WINDOW REPLACEMENT a�AMaun Company WINDOW SPECIFICATION SHEET Buycr(s) am Date of Agreement Q Q — The uyrio)listed above hCmbyjcI!ntIy.iJsCymIty 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. /� WINDOW DEEMS 1. Contractor will Install a total of windows in Owns home,using the following individual quantifies: Double Hung ME)_Equal sash_Cottage sash(1/3 top,2/3 bottom)_Oriel sash(2/3 top.1/3 bottom)Flat sill awercsoi ciaai loss) Casement(CS)_Hinge right_Hinge left(as viewed from exterior) Double Casement ICD) 2 Lite Gliding Window(GW) Casement/Picture/Casement(CID 1:1:1 or_1:2:1 Glider/Picture/Glider(GFW)_1:1:1 or_1:2:1 Picture Window Bay or Bow Awning Window _#Lights Soffit/Roof Shingle/Copper Specialty Window Part.Doors(see&,ram deor c a vL-o Seat to be Primed/Oak/Pine 1:1 F-1 El FE11 2. Qly of Windows to be Custom Fit Replacement: 3.L Qty of Windows to be Custom Fit Full frame(INCLUDES NEW INTERIOR&EXTERIOR CASINGS) Exteri�o sings: Pine Maintenance-free material_Factory applied 908 Fibres brickmold 4.Glazing to Ire: ✓lip W -E-4 TM _Tempered _Other If other,please specify: 5.Exterior color to be: ✓ hite_Sand_Canvas_Terratone_Cocoa Bean_Dark Bronze_Forest Green Black 6.Interior color to ✓White Sand_Canvas_Pine_Maple_Oak_Same as Exterior Note:Wood interiors need to finished by Owner. 7.Hardware:_White—Stone_Canvas—Estate Hardware: Style: S. — Install Lifts with Double Hung Wi9d6ws 9. Screens:windows to have:_Half ar_ II screens Screens to lac Fiberglass_Aluminum Tm$cene GRILLE DETAILS to. Windows have grilles: Grille Between Glass(GBG)_Removable Interior Wood(INI'W)_Fall Divided Light(FDQ ( )Owner approved(initials) Draw gNle patterns below 'Use additional sheet if needed Qty: Qty: Qty: Qty: Qty: Qty: Qb' iq V54f ADDITIONAL WORK DEEMS 11. �� Qty of_Sills Sill noses to be replaced by Contractor 12. Contractor will remove metal frames of windows. 13. Contractor will install new_paint-ready or_stein-reedy_Interior_Exterior casings in—Pine_Maintenance-free material 14. ems J'tor Will install new_paint-ready or_stein-ready_Interior_Exterior stops in_Pine_Maintenance-free material 15.` ntls Owner is aware that Contractor does not do any painting. 16. Contractor will wrap exterior casings with coil stock of color. q� Note:Wrappigq maybe required with storm window removal;removal of storm windows will leave screw holes in casing. 17. C Contractor will insulate,caulk and seal windows with 3-Point system W prevent water and air infiltration. Removal and disposal of all job related debris,windows,storm windows and vacuum nighty included. Upon completion of thejob and payment in full,a limited warranty shall be issued. I8. Y No Building Permit—Contractor will secure any and all necessary permits.The fee for the permil(s)is not included in the Contract Price and a separate check is required at the time of sale for this fee. Ck# $ 19. Yes❑No All discounts ben lied to this agreement price. / t 20.Additione job details: ` C S 21 aYes❑No Owner agrees to be present on the final day of installation for final inspection and to deliver Final payment/finance forests). 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 modifie 6k varied in any way unless such changes are in Writing and signed by both the Buyers)and Contractor.Buyer(sl hereby acknowledge that Buyer.)'has d_�is Specification Sheet. Renewal b Ande s o oration Buye s) Buyer(s) l By: Sig t re of P d I Manager gn me Signature cl Print Name of Produ tanager Print Name Print Name RenewalMA Home Improvement Contractor License#170810(Expires 12/23/2013) byAndersen.� � Renewal by Andersen Corporation Federal Tax ID#4 1-19184 1 3 WINDOW REPLACEMENT104 Otis St.,Northboroagh,MA 01532 (508)351-2200•Fax:(651)351-4810 Provis Specification Sheet Buyers a Date of Agreement �. 2✓j— M /O - 3—l 7� The Buyer(s)listed above hereby joi y 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. Entry Door Details 1. Install a total of entry door(s). 2. Location of door Fre ✓ + 3. Door Type: Legacy Steel: _Smooth Woodgrain Heritage Fiberglass: _Oak _Hemlock Signet Fiberglass: _Cherry _Mahogany _Oak _Fir 4. Door Style# �'{G d 5. _Yes VINO Door to have Sidlite: Style# Sidlite Qty. Size G. _Yes �L No Door to have Transom:Style# 7. Door Size: 32"x 80"_36"x 80"VDouble 32"x 80"_ Double 3G"x 80"_Other 8. Interior color to be: 1�� 9. Exterior color to be: WWII 10._/Yes _7No Glass to have Caming: Canting Finish:_Brass_Patina _Zinc 11. ✓Yes _No Glass to ave Grills: Grill Color: WA�'4_ G a6 - 12. Hardware Series: Schlage�Vintage Schlage Classic 13.Hardware Style: Exterior: V Addison —Camelot —Plymouth Other Interior: _Georgia _Accent _Flair Other 14.HarAware Finish: _Bright Brass _Satin Nickel _Antique Brass _Aged Bronze 15.Threshold Finish: ✓Silver _Brass _Bronze _Wheelchair Accessible Silver only 16.Handle Location (Viewed from inside):_Left lAight Double Door:_Left Active _Right Active Storm Door 17._Yes —No Install a total of Storm Door(s) 18.Storm Door Style#: S 9 _7 19.Storm Door Color: 20.Storm Door Hardware#:_ %err0. D/�/L a-qY 21.Additional job details: 22. Yes ❑ 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 unid the contract is completed to the satisfaction ofall 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 are no verbal understandings changing cr 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 Buyer(s)and`Conractor�qu erelry aclatowledge that Buyer(s)has reed this ,lluyer(,) ficati eel. Renewal by ns n orporation Bu / Buyer(s) By: Signs of uc gerSignature 46111 / Signature h /�Ai e �P/k A�a yrl dYl G� Print Name of Product Manager Print Name Print Name Renewai .�..�.._, . byMdersen WINDOW RE LAGEMENT an Andersen Company 2NDOMIN1UM ,PERMISSION MRM .EQR f5UlLi lNrd P'EXZ1� 72 t^eac. ,Sf- Un4* 3 Sakz4w, MA 01970 lee, Leas k-Sf . brie n a. Self• wt-a age4od covkz�� Have, rvk�f k4l �z,vv�y for .vv�-o v�-vvc s�f& 71 Le tok,, Sf Uw+,f 3 S(ate*w, MA 02970 Uw k.e4 by Pe4y.r Ra.yw-.o* & S O'r>a•yu Asr +� d,- Maage. ev► - ��,M, ,�,y agve f !'#h.e� aktoy /t, p rW445 i,aw iv- v Wt,$o, aLft& f&- carry &&tl-f kt, r0r&P0V d- H aMVt -Apt+a P.W a.A4-rU(.& DcL{p. Pri4-f N 74 U,w of fks f arvv -, a✓ Leffw pfi4 9 f s pvwpolz, any u4;�ovv, o dovwi vt.i,t,uM Ma Au ge ",*V co•w� s y mayb s-AV� Ywe of sae Depmbtstirt.of£ridrrazrral�4rcidttsta' Office of&viw ip oria 600 WashbVton Si?' Boatvx, MA 02111 >smmrmassgov/dia . . Workers Compensation Insurance Affidavit Bmldare/ContracinrwElectridansTiumbpers A� Iicrnt Zafermasion (� 1 (� -Please Print S eo±k.fv Name tS'e nAeken Address: 1 b 4 D-r s S-c Cfly/Staffi/Zig: i�L .r � o �iV �I S 3 Ph ne# .SOS - S 1- 22 C1U Are you ap employer? Chwk fie oppcopriale'bem Type of projent(regotmp: 1.�dtI am a emplvpe with�� 4. I am a gm mal coubwbx®d I 6, ❑New c6amxnction employees(fall andtorPmf-thw),e havo lmrd the sob-oomractus 7 2, I am a soL pmpdeaa orpmfoec- Ifs on the ixftnhm sheet = La 73 abip and have no employees esd sob eca et�s ve S. ❑ Wm";Mg for me m any wacify wuda=' camp'msmance q, O Bmldmg Addrtron . [No vvCd=c' comp memance S. We axe a ooxpoxatixn and its 10.[]MOcidnal nPaim or additions of5D=bane en=iscd iboff . 3,[] I am a bcaneowxns Being all wodc rj&of=esuptiom per MC$ 11.E Phrmbiag xelraus oa additions myabd No wod=T,-comp• c, .52, ¢1(4}, and we Lgve rco 11[3 Rmf xepaixs insurance;xvgmied_7 t .. _ � insurance i quire4l 13.E Omer Nvh=nt&me mi�b=s1maa:t.o fin Cutmo►mue=b& dowiDs amirw l—'wq ®ram t l9ommazea who R4=k tic affidavit i-eA s dm e doiap a➢reotaod fi=hire aomde nova aobmdt anwe af5davk iadca�g coca tf..aamm=6W oheot tic b.�aneohd=adds "Mmd dim to e aftbegdcmdacten ma theirwCamm'comp.tedO9h I am an mrplgyc firm¢•pry idmg worbr-r'ebmpenFM&on m m a=for my empley= Below is tiro policy mrd job� •ryen„n.ce�ampeay Name_ . y� [�/� K e.Q J�� s a policy*or self ins,I ic. #.) 3 l U J C , 1 �C1 -� $pkzfim Dace: 1 © — A - l 3 Job SatzAdilrem: LP!lC �- tSfY Jls'piv\ Ill(a ()1Cl AtfaA a copy of to workrm' eompmsation policy d IRMfinr gage(Showing the Palwy nuaLbw and eq*dion&14, Faihaz'm immm co*n.ge as Ted n�Sacrum 25A ofMM c. 152 can teed to me imposition of�isel Penalties of a fine-up to 51,500.00 and/or ono-yem recta ae VVnll as civilPmelfies in the fnon of a STOP WORK ORDER and a fine of eP to 5250.00 a day against the vroletox. Be advised fiat a copy of this sbt=cxd maybe fmwmded to 1bc Office of jrwws gdtions of thcDlA for insmanoc wvaage v=fficd® n - I do hereby. y pC1�ofPQjmy firm fire oefnrmetian provided above is rrae mrd wig .. - Dale: .���— I� • ' D[�xeial race osefy Do notWrifr in fi&mieq to be eompletAd by City or mmn•of acid . CUT ur Tovats: Ilerm H Acense 0 larmbug Andbmity{rtede.oae): mqmdDr IBoard of HtR tL z B>ndmg Dqw maw a. aty?xown clerk 4,Me,d ai bmrpecfnr S Phrm58ng cCba>Drr re eaa _ Phone CERTIF D;zX/ ICATE OF LIABILITY INSURANCE G9/a5/a0121a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THII CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIMEI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOR90 REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject h the terra and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the carts icate holder In lieu of such andorsems s. PRODUCER -1-612-333-3323 CONTACT Jonelle Hargrove or Eric Johnson Nays Companies PHONE: . 612-333-3323 FNe; 612-373-7270 a 80 South ath Street IAII Suite 700 PRODUCER Minneapolis, Ng 55402 NS S AFFORDING COVERAGE NAN:a INSURED Reneral By Andersen Corporation INSURER A: OLD REPUBLIC INS CO 24147 INSURERS: NATIONAL UNION FIRE INS CO OP FISTS 19445 104 Otis Street ' INBURERe: Northborough, Kh 01532 - INSURERD: INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 29229436 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. W p TYPE OF INSURANCE OLZU POLICY NUMBER PoNCYEFF PoLICYOO' Loam A OENERAL UABRJrY MRZY 59828 30/01/1 10/01/13 EACH OCCURRENCE E 11000,000 E COMMERCIAL GENERAL LIABILITY DAMAGE O PREMS a oxvl S 500,000 CLAMIS4ADE a OCCUR MED EXP Ww are pare,, $ 20,000 PERSONAL a ADV INJURY S 1,000,000 GENERAL AGGREGATE S 4,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 E POUCV PRO- LOC JECT $ A IAUTOMOBILE UABUITY MNTB 22700 10 O1 1 10 O1 13 COMBINED SINGLE UMIT S 3,000,000 E ANY AUTO Meooddwd) ALL OWNED AUTOS BODILY INJURY('w pe ) S SCHEDULED AUTOS ' BODILYINJURY(Per ecdde"d) $ E HIREDAUTOS PROPEL DAMAGE S E NON*WNEDAUTOS S i B A "OREL"UUB E OCCUR 1327335S 10/02/1 10/Ol/13 EACH OCCURRENCE S 25,000,000 EXCESS I" CLAIMSMADE AGGREGATE' S a5,000,000 DEDUCTIBLE s HRETENnoN 25,000 a A ANWORKERSN ��Y YIN NWC 127946 00 20/02/1 10/OS/13 Y WC SIR— ANY O7N- i PROPRIETOR/PARTNERADECUT1VE EL EACH ACCIDENT 11000,000 OFFICERAAEMBER EXCLUDED? � N/A S (WAaslerY In NX) E.L.DISEASE-EA OF O EMPLO S 1,000,000 s�a dercrAe DEBCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OFW'nONS/LOCATIONS/VENICLES p1eAe0 ACORD 101,AddWoW Romano,Schedule,Nmore qww le rputred) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRID REPRESENTATIVE cries —.--- _--- Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen i.sor License: CS- M707 BRIAN D DENNISON 7 LAMBS POND 6IRC ' Chariton MA O15i17 Expiration I Commissioner 09/08/2014 i o1e �ione�na>eurealC/s .�.aoeuc/umelta �\ Office of Consumer Affairs&Bulsiness Regulation 1 TWAI HOMEIMPROVEMENT CONTRACTOR Registration s,170810 Type: Expiration 7212k013 Corporation BY AN TION j BRIAN DENNISONr� 104 OTIS ST. 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I + I i r hJY� pry L,- i I r P d t 7 I r {1`✓r r t ' k I 7+i; y b r r r616,� ri �,{i"� I}f M I . . r I' I�I ' I ".f 'L 41fIIr tl" + iL IINI i¢Is1 i�Ill lil V��;ly '1 r y +Nil1 "4 I1� SV}J flk`S i 1. p{ 4� I;1j1 _II at ll¢ fi} +I IMP 4 i i - L`s -�. ,t, l:.I I,I II,,IL,>F,i " I,s.rLkb uIIS.,�1 f 4-��t�`4�a I, •Y rala9l sa,.^Y ¢ Menewal .. AMe 9�[I�B�1Y REPLk4E�ENT snAudsroseC-0m ' ro WhamItMayConcem. Enclosed is a pemrit application package for a project we have been contacted to do m your town. Thank you in advance foz receiving this package bymarl As we work in every town in the state,it greatty helps us . in our process. We have also enclosed a self addressed and postage paid envelope and would request that when the permit applicafion has be=processed, tbgt you would marl it bark t:)-us.. Enclosed for you review in this package is: ❑ Permit Application ❑ Home Improvement Contractor License D Contraction Supervisor License ❑ Proof of Insurance, ❑ Proof of&nagy Efficiency Ratting ❑ Signed Contract from Castomea 'D Permit Fee C¢Accepted at time of applykO If you have any qn=d=regaz'dmg this apph don please call me at; 508-351-2200 X 55285 Kodey Donahue Psi# Cooniiaabr'.. • roao�sties - Nm*bmnngA�MA, DM2 PbmuYsoa73s1,zwo�ss28s , ' - 3t{509)n4-9t7-3o13