116 LEACH ST - BUILDING INSPECTION Y` The Commonwealth of Massachusetts'
F—�uilding
of BuildingRegulations and Standards FOR
Massachusetts State'Building Code,780 CMR, 7'" editionJAIJNIUSE Permit Application-To Construct,Repair,Renovate Or.Demohsh a RevfsedJa»uary. . '
One-or Pwo-Family Dwelling' 1, 2008
This'Seation F . cial'Use Only
Building Permit Number ate A pliecL r'7
Sigztatare:
\ Building Commissioner/Insp ild'm Date -
SEC INFORMATION . .
1.1 Prop rty Ad ress: 1.2 Assessors Map &Parcel Numbers '
33
L I a Is this an accepted street?yes_ no Map Number Parcel Number.
I3 Zonin Information 1.4 Property Dimensions:
Zoning District Proposed Use. Lot Area(sq ft) Fr4atageT)
1.5.Building Setbacks (ft).
Front Yard Side Yards ' - Rear Yard-
Required. Provided -Rcquimd - Provided Acquired - Provided -
L6 Water.Supply: (NLO.L c.41),§54) 1.7'Flood Zone Information:_ 1.8 Sewage Disposal Systems'-- --
Zone: Outside Flood Zone?-'.
Public❑' Private❑ — Municipal❑ On site disposal system .❑
Check if -
SECTION 2.i TROPERTV OV;NEILSH-
2. Owner'of or I I II
i %vieG t , raf n ���o `Q/Af In ST . SQ \e i'tn yltic�
Name(Print) - _ Addicss for Service: -
Signature - Telephdne'
-SECTION 3:D'ESCk12TION OF PROPOSED WORK 2-�chei kill that gpply) .
;;eu''Ccns�u t c ❑ 1 Existing B'ui rlLng. 0wher*=upied °epai s(s; ':ate icu(s) L' idi ice C
Detiolitinn ❑ -Acce'ssnryBldg. ❑ Number of Units Otber Er�Spcdry:_...t` ee `�-
Brief Description of Proposed Work'': AQ I
O TfJG t�ldu i G c. m�
SECTION 4:ESTIMATEI) CONMUCTION COSTS
Item Estimated Costs: Official Use Only
(Lab dr and Materials)
1.Building $ 7 Uu 1. Building Permit Fee:S Indicate bow fee is determined:
2 Electrical $. ❑Standard CityrPown Application Fee
Q Tota1 Prof ect.Cas[� (Item 6)x multiplier .. X ..
3.Plumbing $ 2. Other Fees: $ "
4.Mechanical (AVAC) $ List
5.Mechanical. (Fire $
Su ression) Total All Fees:$
CheckNo. Check Amount Cash Amount
6,Total Proj ect Cost $.'L ❑Paid ut Full ❑ Outstanding Balance Due: ___..
SECTION 5: CONSTRIICQZZ SR>3�CES
5-1 Licensed Construcfiop Supervisor(CSL) .
gS9o:a CI-- 8, is
. - AA I-&-(b �LicenseNumber Expiration Date. -
Name of CSL-H41dq/
.. i^ 'Y Of VIA4 0((76-3 Ust'CSLType(seebelow).
Address T ,&..
U Unrestricted( ' m 35,000 Cn.Ft) '
Signatwe. - .. R Restricted i&2 1-am0 Dwelling '. .
T2
Telephone RC - Resdmtial RoofingCovering
- .x.,S.Sir Dos WS' Rcsideotial Wmdow and 5idin
SF Residtntial So3id Fvel Bumin A kianct Installation -
D .Residential Demolition • '
5_ Register ''H ed p)me im.p�ove ent Con 4 actor
�e✓1pt,Jr� 1tIL✓t�r�rh CHIC)
HIC Cpmpan 'Name or IC is ame Registration.Number -
IQ" to c � �dv0{j dtss�
Aaareaa - _
Expiration Date
Signature, Telephone . - -.
ss as'
SECTION c:WORIMRS' CO1tPENSAYTONINSURANC> AFFTDavlr(M.GL.c�151:§ 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 the building permit
Signed Affidavit Attached? Ycs _...........•C�%. No... ......❑
SECTION 1a::Ol ER';LUMOR;-- TION TO BE Cf�NA T 1 3FiD.? N.. , . .
O�'h'ER'{/S�,AGII?7TfJii:Cf�PNTRAC�'OR dPEI�S:F'0�2BI7II.-D�N�'P+FSRL1�''S3T- -
G as Owner of the subject prapecty hergliy !
. authorize .. . ('21"A A 'Of A 4 1 s 4 n .. - to act on my behalf in all matters
relative to work authorized by this building permit applications
Si atum ofowner . .. - - Date
tiQnbeCnYfc4fhnnzedAgrni+seyflaClSfC'_
tliaf the tatemen6 and nfo mahon err,L�f;:c_euin. application aretrµe a sd ace uait,to tlie�best of nn k do rTedgc and
beb'niL
e\
.Print Name . . ;
- - -t z
:Signature of Owner or Auth gent . _ Date
' (Signed undarthe pains and penalties of - -
NOTES:
1. An Owner who obtains a building-permit to do his/her own work,of an owner who hires an unregistered contractor
(not registered in the Home Improvement Conrad' CHIC)Program),will not liave access to the arbitration
program or guaranty fond under M.G.L c. 142A_Other impottant.information on the HIC Program and
Construction Supervisor Licensing(CSL) can found in 780`CMR Regulations 11 D.ltb and 11D.R5,respectively.
2. When substantial work is planned,provide the information below. t
Total floors area(Sq.Ft_). (including garage,finished basemmt/attirs, decks orporch)
Gross living aura(Sq.Ft) Habitable room count
Number of fireplaces Niimber ofbcdrooms
Number ofbathmatns Number ofhaMaths
Type ofheating system Number of decks/porches
Type of cooling system Enclosed Open
Project Square Footage"may be substituted for"Total Project Cost"
G 'tea e:�wni�.rtsas�-+n vv-..�.�..—Two. +ac".vv'••s �.��. � .®rvne a
DEBT FOB
This fora is to In sabmittd with buildiagp-rmit applications whmevw th e is debris to be
disposed o£
Proparty fsddi-ss: I l (-D L ezt-jn CT .
En ac^.oedancs v�ffi the pro-,no=of MC3L c,40,§54„a condition of th-Bail g Pmnit
N=ab=is that t1-¢-.biis resuldn;tram this wa3 shaII be d'ispos-d of.in a properly Ha=s d
solid c ast disposal fac!ty as d.-5=d by TmaL C. ill § 150_A.
This dpbas wiU be di,posed of is .
: (Looatioa of FamE y)
Sq6t=of Pewit?Ppliomt
' 1?ste
{Renewal t. MA Home Improvement Contractor
J/ll Ide�en. �••�, �tcense#170810(Expires 12/23/2013)
Renewal b Andersen Corporation Federal Tax ID#41-1918413
byAWINDO REPLACEMENT an Mdc w-111 piny ['
104 Otis St.,Northborough,MA 01532
(508)919-0900•Fax:(774)987-3013
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name - Date of Agreement ,
Buyer(s)Skeet Address,City,State,and Zip Code
Y O1g
WA Address Home Telephone Number Work Telephone Number
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. ^ t
Total lob Amount-3 -) Estimated starting Date: Method of Payment: OCheck ❑Cash ❑Financed
Deposit Received(33%):-1-t t 'iR,-l O K7�LS
Balance at Start of Jab(33%l: Credit Cards are accepted for deposit
Estimated Completion Date: only— maximum 1/3 of the project cost.
Balance on Substantial ,fit s,1 t.) ( -a &__ S_ Please see Credit Card Payment Form.
Completion of Jab(33%). 1_1..-�
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 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 Andersen Corporation Buyer(s) Buyer(')
By. ._.j0
tgnature ofro P uct Tanager Signature J Signature
ern �!!4t\s D1,rna= izx�
Print Name of Product Manager Print Name Prim 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.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -�
NOTICE OF CANC LLATION - K NOTICE F CA CELLATION
Date of Transaction You Toy cancel Date of Tromso a You may cancel
this transaction,without a y pen Iy or obligation,within this transaction,without ny p na ty 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'l of your cancellation notice, 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 t as when received,any goods delivered to you under this
this Contract or Sale; or yyoou 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 Sellers expense and risk. I the goods at the Seller's expense and risk.If you do make
If you do make the goods available to the Seller and the t 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 ujp within 20 days of the date of ur 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 ant further obligation. If.you fail ro make the
make the goods available to the Seller, or if you ageee goods avai able to the Se er,or if you agree to return the
to return the goods to the Seller and fail to do so, then oodsto 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
at tied 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, Northboro h, 01532, BY NOT LATER THAN Northbo gh, 01532,BY NOT LATER THAN MIDNIGHT
MIDNIGHT N�1�,(Dale) pF Y (pare)
I HEREBY CANCEL IS TRANSACTION. I HEREBY C THIS TRANSACTION.
Buyer' SBignaturt Print Nome Dore Buyer's glgnmurt Prim Name Daro
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink aauPsaos.raArh.mANH
Renewal
al MA Home Improvement Contractor
Jul.` ,l.V V(A Re. .wal by Andersen Corporation
-:- - License#170810(Expires 12/23/2013)
• 104 Otis St,Northborough,MA 01532
�Af1deACSen. - (508)919-0900•Fax:(774)987-3013 Federal Tax ID#41-1915413
WINDOW REPLACEMENT aw Mdersen(bmpny
WINDOW SPECIFICATION SKEET
euyer(s)Name Date of Agreement
b .a
The Buyer(s)listed above hereby jointly and kJrally 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 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(CW) ❑ Hinge right ❑ Hinge left firs;viewed from exterior): ❑ Standard handle ❑ Metro handle
1 Double Casement(CDW) ❑ Standard handle ❑ Mx1rajillridle -
1 Casement/Picture/Casement(CPW) ❑ 1:1:1 ok&1:2:1 ❑ Standard handle ❑ Metro handle
TT 2lite 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. ❑ Yes l? No Qty of Windows to be Custom Fit Replacement:
S. ❑ Yes'K 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;�Z Factory applied 908 Fibrex brickmold
5. Glazing to be: R HP Low-E-4 TM ❑ Other If other,please specify:
6. Exterior color to be: White ❑.Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be: 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-.X White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style:
9. ❑ Yes X No Install lifts with Double Hung Windows
10. Screens: windows to have: ❑ Half or X Full screens Screens to be� Fiberglass ❑ Aluminum ❑-TruScene
GRILLE DETAILS
11.Windows have grilles: ❑ YesK No If yes:❑ Grille Between Glass(csc) ❑ Removable Interior Wood armor❑ Full Divided Light(ML)
Qty: Qty: QlY - Qty: Qty: Qty: Qty-
F. 1F. ]'F]'F7]'D'[ crme< cow arc
Draw grille patterns above —Use additional sheet if needed Owner approved(initials):( )
ADDITIONAL WORK DETAIS
12.❑ Yes CK No Contractor will remove metal frames of windows. Qty of Units:
13.'A Yes ❑ No Contractor will install new paint-ready or stain-ready casings. p� n
Interior casing qty of openings:_� Exterior casings qty of openings: ❑ Pine IR Maintenance-free material
14,❑ Yes ❑ No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings:
Interior stops qty of openings: Exterior p qty of o nings: ❑ Pine ❑ Maintenance-free material
15. Owner{is7a�ware that Contractor does not do any painting. & Owner Initials
16.❑ Yes yP No Contractor will wrap exterior casings wit alif inum coil stock of color.
Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17.W Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
18.1W Yes ❑No Clean up all job related debris including old windows will be removed.Vacuum nightly.
19. Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
20, Yes ❑ No Buddiu2 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.
21..N Yes ❑No All discounts have been applied to this agreement price.
22. Additional job details: o�,'t' ,�+ �Ps L'�Q_Cs rip .W� oZO�j— a S� USA
QX 51� 1 J dS
23. ❑ 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 until the contract is completed to the satisfaction of all 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 or modifying any of the
terms. This Specification Sheet may not be changed or its terns modified or varied in any way unless such changes are in writing and signed by both
the Buyers)and Cont rsem, Buyer(s)hereby Acknowledge that Buyer(s)has read this Specification Sheet
Benewal by Andersen Co satiet B yet(r Buyer(s)
By
tature of Pro hictnMar swriitut Signature
Trint Name
of Product Manager Print Name Print Name
yWe Commonwealth of Hassachusettr
Deparg-ment of industrial Accidents
office of Investigations :
600 Washington Street
Boston, MA 02111
WWw.mass.govldia
Workers' Compensation Insurance ASdavit: Bmolders/Contractors/ l Pleas pleas;ie PrianPtuntL mbers
A alicant Information
Name(B,siness/organ;zaation/lndividoal):
Address:
City/State/Zig: �c ���� 2 1�2� CIS 3� Phone#: 5 6 3 5 1 - ,2-2C`L
Axe you an employer.? Check the appropriate bar: Type of project(required):
1.[ I am a employer with -3 D 4. ❑ I am a general contmctnr and I 6. ❑New coil h tion
emplo ees art-time
( p 1 full and/or .m have hued the sab-contractnis iemodsling
I am a sole proprietor or partner-
y fisted an the attached sheet I [ ,R
2,❑
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Ruddigg addition
[No workers' comp. iu;uraum 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required] orTicers have exercised their .
right of axe lion er MC'iL 11.❑Plumbing ress pa or additions
3.❑ I am a homeowner doing all wade p
myself [No workers'comp. c. 152, §1(4), and we have no 12,❑Roof repairs
insurance required.] t employees. [No workers' D.❑ Other .
:comp..'nmrance required]
`Any applicant that checks box#1 most also fill out the section below showing their worL..c'c•compeusadon policy info®atioa
t Aomcowum who submit this affidavit indicating they are doing all work and f M hie outsde cMta.WM must submit a new affidavit indicating such
P
tContraemrs that ehmk this box must atlachrli m additional nc='t showrmg the name of the'sohconhaetors and[6rk worke[S'a�p oGoY infinmumoa
I am an.employer that k providing wor(rers'campenSafion insurance far my employees. BeLow is the pobky and job site _
Insurance Company Name:_ lJ
Policy#or Se -its. LiicII. # (( •� , `� E p ation Date: C� 1 - 1 a
Job Site Address: l l o l eG City/Stu
.Attach a copy of the wor3cerg, compensation policy declaration page(showing the policy number and expiration date}.
Failure to secure coverage as required under Section 25A ofMCrL c. 152 can lead tD the imposition of criminal penalties of a
fine-up to 51,500.00 and/or one-year imprisonment;n well es civil penalties in the form of a STOP WORK ORDER and a fine
of up.to 5250.00 a day againstthe violator. Be,advised that a copy of this statement may be forwarded.to the Office of
E=es(ioations of the DIA for msuraii=coverage vardicatioa
n
I do'hereby certify af+�dertlie peen and penattia of perjany tint the informad6n prowded above $r true¢nd carrecC ..
:Simat te:
Phone# ��` S , [ - aa,6J
Okla(acre an1y. Do not writs in this area, to be completed by city or trrwrt offrciaL ,
City or Town: PermivLkmn#
-lagumg Authority(circle.one): -
L Board of Health uiil 2. Bding Department a. City/Town Clerk 4.Electrical hispectar S. Plumbing Inspector
6. Other.
Contact Person: Phone k
a IMMIoonD•1�
. CERTIFICATE OF LIABILITY INSURANCE DATE D1/l1/2D,2
THIS CERTIFICATE IS ISSUED.AS A MATTER OF INFORMATION DULY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND-OR ALTER THE COVERAGE AFFDRDED SY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CDNSTPFUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORVED
REPRESENTATIVE DR PRODUCER AND THE CERTIFICATE HOLDER,.
IMPORTANT: If the cerffficate'holder lR an ADDITIONAL INSURED, the poficy(ies) must be endorsed. If SUBROGATION IS WANED, suhjed to
the terms and conditioms of the policy,certain policies may require an endorsement, A statement on this cariificaie does not confer rights to the
certificate holder to lieu of such endorsement(s).
PRODUCER 1-612-333-3323 NAG J.Pelle Hargrove or T3tie peimoe
Hays Companies PHONE 612-333-3323 fPa.IC,Ne: S2.2-373-7270
E-MAR
BD South Bth Sttreet - AnnRE811
Bait. .7D0 PRDOUCER
Mieneapo LiS, TIN 554D2 _ cU ID
INSURER AFFORDING COVERAGE - NAlc 9-
INSURED INSURER A: OLD 'RSPUHLSC IM CO 24147
Renewal 9y )mdersen Corporation INSURER e: =ZONAL UNSOH FLAB 2NS CO OF FI:=S 19 Lzs
ID4 Otis Street - - INSURER C'
INSURER D:
ND thborocgh, .NA 01532 - -
- INSURER E:
INSURER F
CDVERAGES CERTIFICATE NUMBER: 2SL4267 REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELDW HAVE.BEEN ISSUED TD THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWfTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUE OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EY.CUISIONS AND CONDTIONS'OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
WSR wool sORR POLICY?F POLICY EXP LIMITb
LTR TYPE OF INSURANCE S POLICY NUMBER OIM/DD fMNRDD
A G@bERAL UABD]iY MWEY 55313 LO/Ol/1 10/01/12 EACH OCCURRENCE s 1,ODD,000
nAWING TD SDO,ODD
% GOMMERCVLL GL_IJERAL UA9ILIIY PREMISES anon® b
al-AIMS-MADE O OCLWR MS) TAM one Pa..) b 10,OOD
PERSONAL A ADV INJURY S 1,DD0,D0D
GENERALAGGRLLATE S 4,ODO,ODD
GEM'LAGGREGATEUMR.APPLIES PER - -PRODUCTS-CDMPIDPAGG S 3,ODD,ODD
17 POuC— P_RCw UDC s
A A MoeILE LWaMY MFTB 21377 10/01/1 1D/01/12 GOM8INED SINGLE UMIT b 3,000,000 _
- fEaemdenp
ANY AUTO BOUILY.INJURY fPer pro.) b
ALL OWNED AUTOS - BODILY INJURY(Par S
SCHEDULED A=S PROPERTY DAMAGE S -
HIRSAUTOS - (PereLAdenq
% NON-DWMED AUTOS S
d
8 HZETEL1Ae EXCESS LIAR Gi-,V LMADE - AGGREGAIEOEDUCTIeLE RNmON b 25,DDI, t
p. WORIQZS cOMPENSAT1oN 'RING 11714D 00 10/02/1 I.D/DL/12 % WC STATIC -
ANDEMPI-DYIERC LtABILtTY 1'/N 1,000,'DDD
ANY PRDPR=R/PARTNER/F-CUTIVE FI EACH ACCIDENT 5
OPFICEFUMJABEA IXCWDEI➢7 O MIA EL DISEASE-EA EMPLD b 1,OOD,DDO
(Mandatory In MID
Ryes,RIP70N OFF EL DISEASE-POUCY LIMIT S 1,DD0,ODD
06CRIPTION OF OPERATtON3 ba1gW ' '
D6CRIPnDN OF OPERAPONS/LOCATIDN6/VEHICLES (AYmch ALLRD lel,AdtRno�ml Raman¢Sd+edulS it more gpaa is require[!)
Bv'LA—e of Snessrance.. .
'CERTIFICATE:HOLDER - CANCELLATION -
SHOULD ANY OF THE ABOVE OESCRIBEE)POLICIES-BE.CANC:R I ED BEFORE
Evi_de�e of rnals^=nce - THE ET�IP.fiT10N -DATE THEREOF, NOTICE WILL BE' DE1NERm IN
ACCORDANCE WRA T RE POLICY PROVISIONS
' � AUTHORIZED REPRr3ENCATIVE - .
}
msimos 9IRS -2DQ9 ACDRD CDRPDRATIDN. All rights reserved
?'CORD 2E (ZDDB/¢g) The AGORD-name and-iogD are mgistereci mares of ACORD - -
'5L14267 -
.'-- Massachusetts - Dcparimcnt of Public tiafcn -
ry Boitr(f of Builifin- Rcttulations and Standards
.Construction Supervisor License -
License: CS 95707 -
BRIAN DENNISON
86 CREST CIRCLE -
WORCESTER,MA 01603
i
I
Expiration: 9/812012
('inumi>sim•r Trm: 2622
C lno�nmw�wrP.¢CC�c .
Office of Consumer Affairs&Sdsai�s Regulation
HOME IMPROVEMENT CONTRACTOR
Registration 1.70810
Type:
�
Expiration 1223/2013 Corporation r _
R URWAL BY ANDERSEN CORPORATION
BRIAN DENNISON _ t- j1:•
104 OTIS ST.
NORTHBOROUGH MA O'(532
Undersecretary
i
Do,nd remove mff lid Dude Inspection:sa ve.lahJ im-hu E Riereuce,
ji
.K
_ .S
_ns.l e.¢ ... ..
Renewal
�Ar�d�rsen, f
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To Whom It Mayconoam-:
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 greatty helps us .
in our process.
We have also enclosed a self addressed and postage paid envelope and would request that when the p(-=t
application has been processed, that you would mail it back to as.
Enclosed for you review in this package is:
❑ Permit App;=catiau
❑ Rowe Improvement Contractor License
❑ Constrecidon Supervisor License
❑ Proof of insurance
❑ Proof of E Aergy weneney Rating
Signed Contract from Customer
❑ Permit Fee (if Accepted at time of app)Ymg)
If you ha-ve any questians regarding this application please call me at: 50&-051-2200 X 55285
&egards, .
Kelley Donah:u
Permit Coordinator
. 104.CtisSrnd - -
- Narthbamugi,MA, 01532
Phone(509)351-22DOX 552&5 -
. - Fn(509)774-387-3013
websm: wHRv enewalbvendesen-cam