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6 LORING HILLS AVE - BUILDING INSPECTION (4) �1.. s� The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 ' Building Permit Application To Construct, Repair, Renovate Or Demolish a f, One-or Two Family Dwelling This Section For Official Use Only Building Permit Number: : Date pplied• p z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATIO I Property Address: 1.2 Assessors Map&Parcel Numbers b L 6,- ' tAve—) tit 1 :nD Q5 S '• 3L'A 1.1 a Is this an ccepted street?yeses no Map Number Parcel Number 1.3 Zoning Information 1.4 Property Dimensions: tY7Li 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP 6 Lnr;clg kl lfs -Ave-, q14- 94, Iglq No.and Street V Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': 0 s�mecs� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ `j 1. Building Permit Fee: $ 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 $ ; Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ S 5g r.oa ❑Paid in Full " ❑ Outstanding Balance Due: ` I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 11 JR I ThD.r,�� -t' �xan L ce— ns�Ib—,r Expiration Date Name of CSL Holder r , r� List CSL Type(see below) y No.and Street Type Description �)ob 1�(1 1_ Trg� , U Unrestricted(Buildings u to 35,000 cu.ft.) /Y) CJ R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry G RC Roofing Covering �/ wA4L WS Window and Siding -r- _ SF Solid Fuel Burning Appliances �'j •c� � �MJy n Qp -jr_d �t� m I Insulation Telephone Email address D Demolition �5.2 Registered Home Improvement Contractor(HIC) IV6tAtAr�, JiG . HIY*1g N um Expiration Date LUC Cv � HLtu -F �nta- Nq d Street ail ad ess f t1Obo/c) P -A al 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 ....\,Q] No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT I,as Owner of the subject property,hereby authorize L�4]m t/J ,-,T�7 CQ- to act on my behalf,in all matters relative to work authorized by this buildi g permit app 'cation. Non n; qit� 6- 14-Q) Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'ORAUTHORIZED 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. 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.mass. og v/oca Information on the Construction Supervisor License can be found at 1v .mass.gov/dns 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" MA Reg#146589 From our Home to nsia- CT Reg#0605216WLWPAG Contract# RI Reg#26463 Enargy Saying Home lmprovemenrr Federal ID#20-2625129 Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.cwm 66683 ,THIS/,'CONTRACT MADE THE < day/of ' \ 20 l between (Home Owners) (Home Phone) ` (Bus/Cell Phone) ,rel (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! NEWPRO WINOOWOPTIONS: j WINDOWS SERIES# � 1�.-'� Grids:LJ YES •NO LJCONTOUR LJSDL []EUROLJDIAMOND Window Color CITY Window Color OTY OBS I TMP: (ro ation) []TOP []BOTTOM I nt: 4.)r0• Int: Screens: (Exterior color Full Screen Standard) HALF„ LL Ext: !J)/ ❑ �FrUExt: /O Vent Latches: ❑-YES -A.no Capping Color t°L/LJ <?(s' DOORS_:xMn s_4A MODEL,.CITY Please Initial- 17�- -..-`. PVC ' Smooth NoMar No Capping Sliding Glass Door, " t s, MODELNAME ,a'P:,. :� t... MODEL,#a „. OCITYsf Color In: Out: Customer understancs that NEWPRO® Double Hung 755 Active: Left Center Right does nordo any.�_painting orstaining. 2 Lite Slider 757 HDWR: SN BB will BGE (ie:when removing or replacing interior 3 Lite Slider (1/4.1rz.114) 753 Entry Door Style"+bw "'-"v " stops or trim). NEWPRO®is not respon- 3 Lite Slider (113,913,113) Color In: ,Out: sole for conditions or circumstances be- Casement(Hinged Right) f 851 Fiberglass / Steel yond its control including condensation result- Casement(HingedLeft) 8527 HDWR: SN BB,' AGB AB ORB ing from or due to pre-existing conditions. Twin Casement 853 Sidelite St a ;:" :'. (circle one): Stationary Casement 856 color In: f Out: I(/� �C+A-S�H^�--^-- Triple Casement (1/4,112,114) 859 - Storm Doo. Ie„b0 "n Balance paid to installer at completion Triple Casement (1/3,113,113) _860 ,,,.al^ color Picture Window 7,y1< HDWR:/ SN BB AGB AB .FINANCE Sash Only _Z752 i Left Hinge Right Hinge Bank completion form signed at installation Hopper / 491 / Entry or Style NR! ,*, Awning / 35,Y / Color In: ova TOTAL,x Garden Window �/ 79g Fiberglass $feel 4h,,CASH 4 Bay Window(Roof/song r / HDWR: SN BB /,GB AB ORB " .PRICES'. �. Bow Window(Roof/soffit / Other Door Txraa ,.„ am._ DEPOSIT y 0[ / Other ` / color In: out: WITH / � / l � Other J HDWR: ;ORDERfI. DESCRIBE WORK&PROMOTIONS APPLIED: TOTAL`� _ AT�C -e•! .� ..,r�-._ . _.� , < ,.,.'f !"Ti.ir�J i '1�NST�/ALLv.', /'� Est. Start Date. / //� Est. Comp. Date: { Customer understands this is an"estimated dav 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. • 1, t ,t (Rhode Island Sales Only): Notice to buyer. (1) D #t sign this�Agreement if any of the spaces intended for the agreed terms to the extentof then available in 1 hon 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 payoff 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 premises 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 p sled 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,pot 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 materials. Owner's initials By: /(1 c4f �/ A r ///r�Y1:` r_. JI EIN# Signed:✓i/ x l-. Product Specialist(Printed Name)• // / Owner By: Signed: NEWPPRO Operating,LLC(Signature) / Owner WHITE: Branch Copy YELLOW: Customers Copy PINK: File Copy GOLD: Finance Copy us isR1012 ADDITIONAL TERMS AND CONDITIONS r- Warranties: Any 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 tiom a delay in NEWPRO performing under this Agreement,or (e)unintentional damage to Owner's personal property,it being understood that it is Owner's responsibility to removelsecure 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, finctional 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 mast 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 pennits or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A Any deposit required under 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 a until the contract is completed to the satisfaction of the parties. (Rhode Island Sales Only): THIS IS A NON-NEGOTIABLE CONSUMER NOTE.During the tern 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.niainc.gov/ag) to gather current information on how to enforce their rights when constructing or repairing their homes. 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 Maitre 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 not accept the arbitrator's decision and to seek satisfaction through other means; including a lawsuit; or O Mediation, with the parties agreeing to enter into good faith negotiations through 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 From OurHane to rwr ._. JOB R LEAD PAINT STATUS Yr Built: ✓tea LSWP; ONE MUST M' ore, p��pt� EXEMPT; BESELECTE CUSTOMER EMAIL 3 S/ i3 (�isy HOME PHONE /•fry �r/ �y��� OATS ADDRESS f (� `' / WORI(ICELI PHONE �G' s� /�7 ZIP BEST DAY TO INSTALL: .M T W 7H F circle one) CITY.STATE �i PRODUCT SPECIALIST ESTIMATED START DATE Zee !/ TOTAL!OF t OF SOWIBAY/ GRID COLOR GARDEN n 2!e Umka I CAP DOLOR WINDOWS d OF DOOR P OL MPG; rugvto r Norenaex r �Y�BOW Storm Other ,' cdeen_ _ stee conga `JiYi p Preine (drrJe one) a w soar Diamond Smooth (circle one)) Looks&Keepers(drule one):�h Almond Bronze Brass ltlmre onel /y' (r//•I''�C Handles&NIBbt La[chee(prole all Met apply): hlte Almond Bronze No Bottom Handles Nignt Latches(Nigh Larches era NOTa stanearp memm) InaMe Color(Circle one): ^ite' Natural Oak London Walnut Colonial,Cnerry Muskoka Oak Barrister Oak Outside Color(circle one): Univ.Brown Wicker Forest Green. Wedge Blue Sandstone Burgandy Bronze Custom OPENING SIZE STOPS NO. STYLE W x H U.I. LOCATION RID SCR IN OUT CONY ADDITIONS OPENING CUT X` s7 xs x x % % x x a , r S' x x / x x L x x ail ex� x x r Y J x x x x x x Meesurem x CTB Ind ' k to Crew Size Needed TimeFra tocompeteJob Special Installation Instructions: v / C1 m 1 `'� CERTIFICATE OF LIABILITY INSURANCE 5/1/2013YYn 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: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) 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 endorsement(s). PRODUCER CONTACT Melissa Pflug g Mackintire Insurance Agency Inc PHONE (508)366-6161 A Not (508)366-5202 11 West Main Street EA -MIL E��,melissap@mackintire.com INSURERS AFFORDING COVERAGE NAIC# Westborough MA 01581-1931 INSURER A:Peerless Insurance Co. 24198 INSURED - INSURERBAcadia Insurance Co. Newpro Operating LLC INSURER C: 26 Cedar St. INSURER O: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:12 - 13 Master w/13 WC 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. INSR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD YYY MMDD YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE If 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT D 100,000 - PREMISES Ea occurrence $ A CLAIMS-MADE OOCCUR BP 8589577 2/31/2012 2/31/2013 MED EXP(Any one person) If 5,000 PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED t SINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED - 8584174 2/31/2012 2/31/2013 AUTOS X AUTOS _ BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per ccidenl Uninsured molonst Bisplit limit $ 250,000 X UMBRELLA LIAB X- OCCUR EACH OCCURRENCE - $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X RETENTION$ 10,00 O 8582578 2/31/2012 2/31/2013 $ B WORKERS COMPENSATION I WC STATIJ OTH- AND EMPLOYERS'LIABILITY V/NCRYANY PROPRIETOWPARTNER/EXECUTIVE EL EACH ACCIDENT $ SOO O00 OFFICERAIEMBER EXCLUDED? MIA (Mandatory In NH) . C-20-20-003506-01 /1/2013 /1/2014 E.L.DISEASE-EA EMPLOYE IS 500,000 If yes,describe under DE SCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE -EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T Moynagh/MAAIAN ACORD 25(2010/05), ©1988-2010 ACORD CORPORATION. All rights reserved. r , The Commonwealth of Massachusetts Department oflttdustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers e Applicant Information / Please Print Legibl L Name (Business/Organization/Individual): A)e(A?r ) lZ�pr , i LC I / c q Address:_e OfzefrT City/State/Zip: �),ob u m t/-r)A C)l a o I Phone#: 2?/ 9 3::k-c j l n D Are you an employer? Check` the appropriate box: Type of project(required): J LEJ I am a employer with O 4. ❑ I am a general contractor and I 6. ❑New construction .employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. t y Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑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' comp. insurance required.] 13.❑ Other *Any applicant that checks box#I 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, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: MCI ]C)n ncy Policy#or Self-ins. Lie. #: (,t JC - Expiration Dater Job Site Address 6 Lnr;�,_ )IzAs y City/State/Zip&iCM h))q d% )0 Attach a copy of the workers' ompensation 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 certify u ider the pains and penalties ofperjury that the information provided above is tru and correct. Si nature. Date: - Phone#: 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#: uu1 ffrce of Consumer Affairs&Business Regulation License or registration valid for individul use only „PME IMPROVEMENT CONTRACTOR before the expiration date.If found return to: PRegistration: 146589 Office of Consumer Affairs and Business Regulation - Type: 10 Park Plaza-Suite 5170 Expiration: 5/5/2015 Supplement=;:ard NEWPRO OPERATING,LLC. Boston,MA 02116 THOMAS FOXON - 26 CEDAR ST. -� WOBURN, MA 01801 LJ� _ Undersecretary Not valid without sig lure Massachusetts -Department m Public Safety Board of Building Regulations and Standards Construction Supcn'isur ''�""" a .. - license CS-029090 ti P'rrS lJA". q THOMASPFOkON 230WALNUT'STx 'a READINGIY�A Commissioner Expiration - ENERGY Quallped In all zones NEWPRO MANUFACTURING RC SERIES G NEWPRO 2000 L CASEMENT Cellular PVC frame,Triple glazed, NatbnalFenealmDon Low E coatis a=0.027 S2&5) nap Dcoundl® Krypt o I i on/air filled DEV•K•29.00D30.00001 ENEI GY PERFORMANCE RATINGS -Factor( .SA-P) Solar Heat Gain Coefficient 0, 16 0.22 DDITIO AL PERFORMANCE RATINGS Visible Tran mittance Air leakage(U.S./1-P) 0,16 0A Con ensatio Resistance 74 MenuteogaermlpWatath�dleee manoeaunf rmmepplkeNe NnlDprocedumaludalermWnp whale .. pmtlud ppMtmv¢e,NFN letlnpe ae tleMm�nedMafhwdeel Nernlronmenhl nntlmam enda epecMa pIOtlIRt d16�ffNC�oee not reoammen1 7 mndaal and dose n.wamm dro eu�mamy a em product ruryapaclAcurol Oauwmpwpmuwawievn0 hr alAerpmduel perromiemelidonne0on,