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PUBLIC PROPERTY
I)EPARTIMN T
h+'L�+�•!se m7��y
1.0 SITE INFORMATION
Prop"Addnaee'
t�1o0eAy kueMd b N Conwv@ft Area YM %✓ tAMeele Olwlot YM
13 OMERsf111P INFORMATION
11 Owier of Land
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Addrew q V i
Teleanaw. , y'.3 ?(U-9
3.000MPLaTM THIs> SECTION FOR WORK IN
uwm.WWN&OWG ONLY
Addloon
End"
Rewwvatkon � Number Of Storlee Renovated
Chang°in Use
New
D�molitlon
ApWoxkna%year of Area per floor E* tp
str conuction or renovation (a8 Renovated
a1 existirq buitdkp
New
add Description of Proposed,Work:
),�/Q�I VT 0 W Y)V OLL6
Mad Permit to:
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CITY OF SM EIN1, UNSSACHUSETTS
BtiHMNG DEP:IRTNMNT
130 WASHINGTON STREET,3"FLOOR
op TEL (978) 745-9595
FAX(978) 740-9846
KI,,iBERMY DRISCOLL
MAYOR THOaus ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BVILDING CON06MIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name o hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
ignature of permit applicant
date
debHWrdm
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:..149601
-,Expiration: 1124/2008
Type: private Corporation
RENEWAL BY ANOERSON
JOHN ESLER -
78TURNPIKEROAO''' -
WESTBORO,MA 01581 Administrator
✓�ee �imnwmxa�uneo o�.�.aaeac�xuaella -
Board of Building Regulations and Standards
Construction Supervisor License
Licenset CS 74251
&rthdate 3/911 Q63
Expiation3/9l2009 Tr# 11065
Res$ri�tion� 00 r1 - -
JOHN K ESLER �
' 104 OTIS ST
NORTHBORO,MA 01532 Commissioner
L _
Jan 02 2007 I5: 26 JPAHCKeoneR•Ins - 734 6,62 0101 P•2
WVDDNTM
ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE
ilsnoos
PRODUCER - THIS CERTIFICATE IS ISSUED.AS A MATTER OF INFORMATION
Joseph McKeon@ - ONLY AND CONFERS .NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES .NOT AMEND, EXTEND OR
JP McKeone-Insurance Agency, Inc. ALTER THE.COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAICX
1N70RED Renewal by Anderson IrsORERA Hartford Insurance Coman
J&L Windows,Inc. INSURER B:
104 Otis St NSURER c.
Northborough,MA 01632 nsweERO:
INSURER E:-
COVERAGE$
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, EXCLUSIONSAND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS..
INSR AOM POUCYN11fil IL POLICY EFFECTIVE POLICYEAPPMTION LIMITS .
B OBMERALLJABIJTY HERS858850 917/06 9/7107 EACH OCCURRENCE f 10000
CDNMERCNL GENERAL ABILITY - R omAE i 100 ODO
CW MS MADE aOCCU0. NEO EkP PM on f 10000
PERSONAL&AOV INJURY f
GENERAL AGGREGATE i 2 0DO DO
GEN'L AGGREGATE LIMIT APPLES PER: PROOUCT9 COMP/OPAOC i - 2 000 ODD
POLICY PRO lOC
A AUTOMCBOEUABRfTY 35 MCC XD 6388 1011/05 10/1107 COMBINED i 1,000,000
ANYAUTO (EA AptMF�l)
X ALLOAWEDAUTOS - BODILY INJURY
SCHEDULED AUTOS - POf'Of1) i
HIREOAUTDS - BODILY INJURY
NON_ON AUTOS .. (PAR somol) - - 1
PROPERTYGAMAGE S
(PY ACtIOPnt)
OARAOEUASILITY AUTO ONLY-EA ACCIDENT i
ANYAUTO - OTHER THAN EAACC $
AUTO ONLY: -AGO i
ELLCnWUM 4MLMILrtY .. - EACH OCCURRENCE. S
OCCUR D CLANS WOE .. - AGGREGATE
IF
DEDUCTIBLE IE
RETENTION 1 S
A woRRFAiBcDELPNLUT1oNAND 35 WBGNC8861 1/1107 111108 WC STATU 0 -
EIILOY.wWLMBILRY El.EACH ACCIDENT S . SOD 00
ANYPROPRIETOW'PARTNEWEKECVTNE -
�FICERNEYBEREk of - E.L.DSEASE-EA EMPLOYEE f 50 000
If U bIrIN Jtl1r
IAL PRWSIONB DAI - E.L gSEASE-POLICYLMn f
O'INER
W3CMFTNIY OF OPERATIONS I LOCATIONS l VEHICLES I UCLUMONS ADDED BY ENDORSEMENT TEPECIAL PRCVIMNS -
. CERTIFICATE HO DER CANCELLATION
SHOULD ANY OF TIE ARM DESCRIBED POLJDES BE CANCELLED I EFOEIE YK EXPIRATION
DATE THEREOF,THE ISSUING,INSUR N WILL ENDEAVOR TO AWL �-DAYS WRITTEN '
INSURED COPY - NOTICE TO THE CERTIRCAT!HOLDER KWO TO THE LEFT,BUT FAILU¢E To DO 7O SHALL
IMP - O OBLUAVON OR LIABILITY OF ANY KIND UPON T NSURLR,RS AGENTS OR
ATNFA. .
- OROL R!PIESt TIME
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ogee of Investigations: .
600 Washington Street
Boston, MA.02111
twww.mass.gov/dia
Workers' Compensation.insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AAp licant Information Please Print Leeibly
o,
Name (Business/Organizali ,� .on/Individual): nt-- � I �
Address:
city/state/zip:. ^ Y�rtc� '.. Phone#:C�O� �Q' 09 cc
Are you an employer? Check the appropriate box: Type of project(required)_
1, am a ertiploycr with _
4_ ❑ I am a general contractor and I . 6. El Ne construction
employees.(full and/or part-time)." have hired the subcontractors ? emodcling
2.[1 I am a sole proprietor or partner- listed on the attached sheet t
ship`and have no employees .
These sub-contractors have 8, ❑ Demolition
working for rite in any capacity.. workers' comp.,insurance. 9. ❑ Building addition
fNo workers' comp: rnstlra cc 5. We are a corporation and its 10.❑ Electrical repairs or additions
required,].. officers have exercised their.
I am a homcowncr.doin .
rightofexemption per MGL 11.0 Plumbing repairs or additions
3. g all work .
myself. [No workers' comp. . c. 152, §1(4), and webaveAo 12.❑ Roof repairs .
• insurance required.] t employees. [No workers' 13.0 Other
comp, insurance required.]
My tpplwant that checks box#1 must also fill outthe section below showing their workers'compensation potiey intomtstiOn:
Homeowners wbo.su8nat this affidavit indice6n8 fty arc doing all work and they hire outside oontrsctors must subrrat a new affidavit stdicat**I8 Such .
"ontraeim5 tluteheck this box must atteohed an additional sheet showing the name of the Sub-om!Mctors.and then workers•Soap:policy infor-tra =.
am an emplI Oyer that is providing workers'compensation insurance for my 'employees. Below Is thepoliry and-iob site
aformadorc
osurance Company Name: P I n�Ct ll Coo e —J;')
'olicy'#or Self ins. Lic. q: Z` I t��`D G✓) C/ g(a ( Expiration Date,
ob Site Address-- _�� ( 2Z�1)i 1 �' .C� v n ( City/state/zip-�l QM A U1 9
ittacb a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailurc to secure coverage as required under Section 25A of MGL C.152 can lead to the.imposition ofcritnina]penalties of a
ine 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
fup to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OfficPi of
oyestigations of the DIA for insurance coverage verification.
do hereby ce un r the ni'/s andjyenalties of perjury that the information provided above is true and eorre�i
7orc,aturc: 6L C/ Da tl: '
pfir'eial use,only- Do not write in this area, to be completed by city or town officiaL
Information and Instructions
Massachusetts General Laws chapter 152 requires all.employers to prdvideworkers'compensation for their employees.
Pursuant to this statute, an employee is defined as."..:every person in the service of another under any contract of hue',
express.or implied, oral or written•"
An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two.or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of art individual;partnership,association or other legal entity, employing employees. However the.
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall,not because of such employment be deemed to be an errrployer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for.atny
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor,any of.its political subdivisions shall
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary, supply sub-contractors)name(s),'addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Corwanies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required.to carry workers' compensation insurance. If an LLC or LLP.does have
etrtployees;,a policy is required.. Be advised that this affidavit maybe submitted to the Department.of:Industrial
Accidents for confirmation of insurance coverage. Also be surtio sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pernut or license is being.requested, not the Deparimentof
Industrial'Accidents. Should you have any questions regarding the law or'if you areiequuedto obtain aworkers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter* their
self-insurance license number on the appropriateline. -
City or Town oMdals
Please be sure that the affidavit is complete and printed legibly. TheDepartment has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office oflnvestigations has to contact you regarding the TcanL
_ g g r
Please. n a
be.sure to fill in the permit/licensc number which will be used as a reference number. In addition, an'app3icant
that Must submit multiplepermidlicense applications 'many given year,need only submit one affidavit indicating current
Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city.or
mean)-"'A'copy ofthe affidavit that has been officially stamped or marked bythe city or town may be provided to the
applicapt as proof that a.valid affidavit is:on file-for future pernuits or licenses. A new affidavit must be filled out each
Ycar-a'bcrc a home owner or citizen is obtaining a license orpermit not related to any business or commercial venture
a dog license or permitto burn leaves etc.).said person is NOT required to complete this affidavit
The Office Oflnvestigations would like to thank you in advance for your cooperation and should you have any gts estions;
Please do not besitate to give us a.call.
7oc Department,s.address, telephone and fax number: .
The Colmnonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street.
Boston. MA o2111
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PJalara�Fer�sv.3GoD WoodNinyl Composite Frame
Ra;nlg CamciT, Dual Argon Low
-- --- Double Hung
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)/I-P. Solar Heat Gain Coefficient
OM 0 ., 33
ADDITIONAL PERFORMANCE RATINGS _
Visible Transmittance
OwN
Manufacturer stipulates that these ratings conform fo applicable NFRC procedures for detairshing whole product -
pntornnnce. NFRC mlirs,ere ads,mined fora fixed set of environmental conditions and a specific product size
NFRC does not recommend any product and does not warrant the suitability at any product for any specific use.
Consult manulncmrer'•litersiure for aMar product pedormenca intaentess.
www.nfrc.org
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