9 MALL ST - BUILDING INSPECTION The Commonweal-ih of Massachusetts
Board of Building Re;ulations and Standards FFORMassachusetts State Building Code, 780 CMR, 7'h edition Y
Building Permit Applicat on.To Construct, Repair, Renovate Or Demolish ay
One-or Two-Family Dwelling
This Section For Official Use Only .
�J Building Permit Nu I Date Applied:
Signature: �"'i� — e ti J/ 3AD
` . Building Commiss' er/Inspector ofBuildings Date
SECTION 1:SITE IAFORMATION
1.1 Property Adress: 1.2 Assessors Map &Parcel Numbers
�i�tl ST
1.1 a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 3.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fi)
I.S Building Setbacks (ft)
Front Yard Side Yards Rear Yard _ -
Required Provided Required I Provided Required - Provided
1.6 Water Supply: (M.G.I.c.40, §54) 1.7 Flood Zone Information: I.S Sewage Disposal System:
Pub]: ❑' - Private O Check i f es❑
Zone: _ Outside Floyod Zone? Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record
�Z� 4 &�\((Vc4 1AQcAr.�e Ct l�wll '�'T Sw�tir� 1tit< CIS o
Name(Print) 1 �� Address for Service -
`l(�tr 50'�— Cl9 o� — �lo`'l 10
Signature Tclephone
SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply)'
New'£cns4 ct cn ❑ I E s' urtdu^❑ Or. ^ upi d ❑ ` P.epa s^s/ .❑ "^.a9mtiu,(s) ^� ^ 'd ❑
Demolition ❑ Accessory Bldg. ❑ Ntnnber of l knits I Other t Spc if;•:_. ., e .�CC.�E.Brief Description of Proposed GJorl:: H+
I'A n STr u LT's 1 Fr ( C � ✓�e-�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ �r (J o 1. Building Permit Fee: S Indicate how fee is determined:
2.Electrical - $ ❑Standard City/Town Application Fee
.[2 Total Project Cost (Item 6)x multiplier x
3.Plumbing $ i, Other Fees: S
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ .
Suppression) Tot?l All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S �5'-a 1,013 - 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTI.QN SERVICES .
t
S.1 LicensedttCC�onstruction Supervisor(CSL) q5 a 3-( C1_G;L
License Number Expiration Date.
Nam-{e of CSL-Holder 1' II -
TJ J(A\Vt S'1T9n 4Ue List-CSL (see low)
. A ess T e ;'? Description . .
U I Unrestricted(up to 35,000 Cu.Ft.)
r R Restricted 1&2Fami] Dwelling
Si,, ature
�iC/19 �a 4C Masonry Only
� - RC Resid-=tial Roofing Covering
Telephone. WS" Residential Window and SOin '
SF Residential Solid Fuel Burning Appliance Installation -
D Residential Demolition
5. Ree tend Home Imp/r\ovement Contractor(HIC) NchLd I
FCLv.Pa c k )'-Yllc�i C01) .
HIC Com anyName or 1C R istra, e Registration Number
I D�1 /�?! i ST {�ordtrorc(x� Vow I�IS �
Ad ss n
A-s� (� Expiration Date
fffnature _. Telephone .,
SECTION 6:WOR'rLGRS' COIvIPENSATTON II\TSUR-41\TCE AFFIDAVIT(Mf.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 Attacbed? Yes ........... No...........❑
SECTION 7a-.OW\TER.kUTH[!,=4 TION TO BE CGhU'LETED YITEN.. .
OVJATER'S_AGENT;OR CONTR4C.T4DR APPLIES FORBUILkirsDING PERIS�IT
I, Crla C t L as Owner of the subject property hereby
_
authori `air Crn to act on my behalf,in all matters
ze ��it _
relative to work authorized by this building permit application.
Si 2nat0a of Owner- Dat6 -
-SECTLONM-OWNERt:'OR_41'li wR p 4GEI\T IEk L4RATI(3N ',
ar.Ovmrn ror'Authnnzed ALenldlefehV
diai the statcinents and infoIInatlon Oh.the foregoiuu apetieatiun teuue'and accurate, to the best of my}kpo lejee and
bi ' 1L
.Print iJ f 2 cqj,(Opt' ( A.ft� y�3V V
Signat e of Owner or Authorized Agent Date
(Signed under the pains and cnalties ofncriu ) - -
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 Horne Improvement Contractor(HIC)Program),will not liave access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780`ClvIR Regulations I I O R6 and 11D.R5,respectively.
2. When substantial work is planned,provide the information below: -
Total floors area(Sq.Ft.). (including garage,finished basement/attics, deck or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haMaths
Type of heating system Number of deck/porches
Type of cooling system inclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost" (j, }a
DEBRIS FORM
TTus form is to ba submitted auth building permit applications wh;never theme is debris to be
disposed of.
Prop�tyAddress: q AAAi ST. �AI�M W� C)k97�..
In accordancs with the provisions of MUL.c.40, §54,:a condition of the Building Permit
Numb=is that the debris rcmulting from this work shall be disposal of in a pr operiq ficcnsed .
solid wast-disposal facility as d lined by Il�iGL c. III § 150.k
This debris will be disposed of in .
t, tC, ro, yvk-�. CLUD
(Location ofFacality)
Signamm of Permit kopl cant
Date
104 Otis St.,Northborough,MA 01532 J&-I-WlnvDws,INC.,D/B/A MA Home Improvement Contractor
(,508)919-OYOO-Fax:(77,1)987-3013 Renewal License#149601 (Expires 1/24/2012)
byA ldersen. Federal Tax ID#83-0404201
WINDOW REPLACEMENT MA,a mG pm
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyerlsl Name / Dale of Agre ment
,r/ n �( �y
Buyerlsl Street Address,Ciry,Slate,.zip Coda
qf1 _ a/cam o197c.
EMail Address Home Telephone Number Wark Telephone Number
74
Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen
("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').Buyers)hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
-'') Method of Pymm:Cl Cash heck ❑Mastercard O VISA
Total Job Amount: / �61 Estimated Start'ing Date:
❑Discover ❑Financed,App#:
Deposit Received(33%): 07, On
o Name on Credit Card:
Balance at Start of Job(33%):/ O , 6timmed Completion Date: Credit Card#:
Balance o Substantial/ —Z
Completion off Job(33% 7�): 7�, / J CC Exp. Dote: -�'�- CC Security Code----
By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initial ` ' of Job cannot be made by credit card and must be umde 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 fast
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.
J&L Windows,Inc.d/b/a Renewal by Andersen Buyer(s) Buyer(.) ,
By: fS /�Signacu rod Mana—ger^
c.E �
y� ) Sign re Signal re
Print Name of Product Manager PtiIPNatne Print It e
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.
_.--- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ -gc_ _ _ _ _ _ _ _ _ _ _ _ _ _ _�
NOTICE F ELATION X NOTICE OF AN,ELLATION
Date of Transaction �'� . You may cancel Date of Tronsaction - /. You may cancel this transaction,witho a nalty or obligation,within this transaction,withot any enally or obligation,within
three business days from the above date.If you cancel,any three business days from th 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 nesotiable instrument executed Contract of Sale,and any nesotiable 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, by the Contractor ("Seller") of your cancellation notice,
and any security interest arising out of the transaction will l 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 return shipment of
shipment of the goods at the Seller's expense and risk. 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 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 our 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 any further obl ignition. If you fail to make the
make Hie goods available to the Seller, or if you a@ice goods available to the Seer,or if you agree to return the
to return the goods to the Seller and fail to do so, then Dods to the Seller and fail to do so,then you remain liable
you remain liable for performance of all obligations under rod
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. J l notice,or send a telegram to Contractor.J &L Windows,
&L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis Inc. d/b/a Renewal by Andersen, 104 Otis Street,
Street, Northboroug 01532, BY NOT LATER THAN Northbo u MA01532,BY NOT LATERTHAN MIDNIGHT
MIDNIGHT OF J ',9 .(Date) OF�� (fie)I HEREBY CANCEL IS SACTION. I HE C CEL THIS TRANSACTION. -
Buyer's Signature Date Buyer's Signatrre Date
RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink '�I
104 Oris St.,Northborough,MA 01532 J&L WINDOWS,INC.,D/B/A MA Home Improvement Contractor
P08)919-0000•Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012)
SIX
bY.�llCl21'S0f1. Federal Tax ID#83-0404201
wixaoW REPLACEMENT ..m,d....,,�m,�.,v
WINDOW SPECIFICATION SHEET
Buyers)Name Date of A ream nt
l
The Buyer(s) listed alaw hereby jm.V1y and severally agree to purchase from J&L Windows,Inc. d/b/ Renew 1 by Andersen ("Contractor") 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 DEPAIL,S
I. Co ltractor will Install a total of=windows in Buyer's home,using the following individual quantities:
rj Double Hung(DB) 0 Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom)
—� Casement(CM ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement(CDW) ❑ Standard handle ❑ Metro handle
Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Wte 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. JJ Yes ❑ No Qty of Windows to be Custom Fit Replacement:
3. ❑ Yes O( No Qty of Sills to be replaced by Contractor:
4. ❑ Yes Og-No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings)
Exterior casings: ❑ Fine ❑ Maintenance-free material ❑ Factory applied 908 Fibres,brickmold
5. Glazing to be: [ja HP Low-E®SmartSunro IT"CreditLkVhle) ❑ Other If other,please specify:
6. Exterior color to be: 0 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be: g 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 Buyer.
S. Estate Hardware:Style
9. ❑ Yes PS No Install Lifts with Double Hung Windows
10. Screens: windows to have: Jg Half or ❑ Full screens Screens to b g/ Fiberglass ❑ Aluminum ❑ TruScene
GRILLE DETAILS
11.Windows have grilles: ❑ Yes J'No If yes:❑ Grille Between Glass aaG) ❑ Removable Interior Wood cenwr❑ Full Divided Light emir
Qty: Qty: Qty: Qty: Qty: Qty: Qty
or on oe on ne, caw o,cw.
Draw grille patterns above 'Use additional sheet if needed Buyer approved(initials):( 1
ADDITIONAL WORK DEPAELS
12.❑ Yes No Contractor will remove metal frames of windows. Qty of Units:
13.❑ Yes No Contractor will install new paint-ready or stain-ready casings.
Interior casing city of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material
14.❑ Yes q No Contractor will install new paint-ready or stain-ready inside or outside stops city of openings:
Interior stops qty of openings: Exterior stops ty of openings: ❑ Pine ❑ Maintenance-free material
15. Buyer is f Of No
that Contractor does not do any painting." Buyer Initials
❑ O
16. Yes 1 No Contractor will wrap exterior casings with aluminum coil stock of color.
Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing.
17.® Yes ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.
184kj Yes ❑ No A limited warranty shall be issued to Buyer upon completion of the job and payment in full.
19.K Yes ❑ No Building;Pernut---contractor will secure any and all necessary permits. The fee for the permits)is not
included in the Contract Price and se ara check is rJequired at the time a sale for this fee. /
20. Additional'oppcietails: f!/ 2 d �!!C eo Cie Q ea'L���(� All 4/SAY
�jL�4 f JbPRn �p
21.k Yes ❑ No Buyer agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shag be dernanded until the contract is completed to the satisfaction of ell parties.
It is agreed and understood by and between the parties that this Specification Sheet, along with the CUSFOM 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 modified or varied in any way unless such changes are
in writing and signed by both the Buyer(s)and Contractor. Buyer(a)hereby acknowledge that Buyer(s)has read this Specification Sheet.
J&L w:odos,Inc.d/b/a Renewal by Avdersev u er(s) _ Bu•er(s)
By: d l i
Svdfirre product Manager Sign® Ire - / Signat e
�/65 A��y'f SN/��v /SiGP 46,J
Print Name of Product Manager PgAt Name t Name
RBA Copy- White Buyer Copy-Yellow
1
V
Renewal
byAndersen. NOR
.®®®
WINDOW REPLACEMENT mAndersen Company
PROPERTY OWNER MUST COMPLETE&S SIGN THIS SECTION IF USING A BUILDER -
P/F as Owner of the subject property hereby authorize
Renewal bven .a. -J &c L Windows) to act on my behalf,in all matters relative to
work authorized by this building permit application for:
//{/ Address of Job
1-oC_ irol�n �c�J Jpf
/1 - Home er Signature - Dat
OWNER OR Buir-DERR�(As AGENT OF OWNER)MUST COMPLETE&t SIGN THIS SECTION
Owner/Authorized Agent hereby declare that
the statements and information on the foregoing application o
Address of Job
Signed under thee\pains and penalties of perjury.
`,� (Vr1
Print Name j
Qlav
Signature of Owner/Agent r Date -
l-
104 Otis Street
Northborough,MA 01532
Phone: (50B)919.0900
Fax (508)919.0903 _
www.renewalbyandersen.com
The Commonwealth oflrfassaehusetts
Department of Industrial Accidents .
office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Pleasericia Print mb rs eglv
ARolicant Information
Nanle(Business/Organizationllndividual): aC�no�JG � �34 !-1ndeYS 1'I
�1
Address:
n/ 1J Phone,'#:
/V C�bS� /�l� 4fO0
City/State/Zip: Df1" bo ro 0/53�
Are you an employer? Check the appropriate boa:
'Type of project(required):
4. ❑ I'am a general contractor and I 6. ❑New construction
1.aI am a employer with 0 D have hired the sub-contractors
employees(full and/or part-time). 7. modeling
listed on the attached sheet #
2.❑ I am a sole proprietor or partner- These sub-contractors have 8. Demolition
ship and have no employees workers' comp.insurance. 9. ❑Building addition
working for me in any capacity.
[No workers' comp.insurance 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL ❑
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
-Any applicant that checks box 91 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 hive outside coatrecton must submit a new affidavit indicating such
�contmctots that check this box must attached an additional sheet showing the name of the sub-contra tms and then workers'comp.polity information.
I am an employer that es providing workers'compensation insurance for my employees. Below is the policy and job site
information. ^n K J
Insurance Company Name: , I l'/C— �o '� f'1�iF r'
Policy#or Self-ins.
.LLic.
ExpirationDate:
Job Site Address: 1 I �< �\ Sl City/State/Zip:�` 1 e r^ ,A,
Attach a copy of the workers' compensation poiiay declaration gage(showimmg 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
Sae 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer1*_U_ftdrr the pains and penaldes.of'perjury that the information provided above is true and correct.
Date: Li--2,6
Signature: -Phone J� (, F) �/� 0/rQJ
FOther.
only. Do not write in this area, to be completed by city or town ofjtcial
n: Permit(License#
issuinghority(circle one): A.Electrical Inspector 5.Plumbing Inspector
Health 2.Building Department 3.City/Town Clerk P
rson: Phone r.
3
•*-� Massachusetts - Department of Public SafetN
Board of Buililim1 Rc1ulations and Standards
Construction.Supervisor License
License: CS 101952 -
• Restricted to: 00'
DAVID BANCROFT
5 JOHNSTON AVENUE
WHITINSVILLE, MA 01568 .
Expiration: 311912012
('ummisioner Tr,-: 101952
i
t
e -
Oi:¢e of Consumer Affairs ar.Bnsi¢ess Regulation h.
OME INl?ROV BENT CONTRACTOR C
' 1
Regis`.ratioc�-49601 $
j�`2—Mgc.,.E5 Gard
RENEWAL BY j
DAVE BANCROF-3j -
g
104 OTIS STREc^ ,--.�\ _
NORTHBOROUGH,1 1 2 Undersrrerary
DATE IR°JAfJDn'7YT,
ACOR CERTIFICATE OF LIABILITY INSURANCE 0211012M
PRODUCER THIS CERTiFICk7E IS ISSUED AS A MATTER OF INFORMATION IFICAE
Joseph f hcKEone 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 Nktc a
Ann Arbor, Ml 48106-0333 INSURERS AFFORDING COVERAGE
INSURED Renewal by Andersen INSURERti a ord Insurance Co an
J and L Windows,Inc. INSURER a: Nautilus
INSURER OI
104 Otis St
Northborough,MA 09532 INSURERD.
INSURER e.
1
COVERAGES
NG
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED TO THE IRESNSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.MAY
BE ISSUED S O
ANY REOUIREMENT. TERM OR CONDITION OF ANY MAY PERTAIN. HE INSURANCE AFFORDED BY THE POLICIES CDESCRIBED HEREIN ST OR OTHER ESUB SUBJECT 7NT WITH
0 ALLCT�TO E NS EOH KCLUSIONSFAND CONDRIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EF-ECTIVE PDA GY ESPIRATDH uwrs ^
IkSa v PLI P w e POLICY NUMBER EACH.C..CURREXCE f 1 000 000
B I Gv1 RA Lvsn rY 6dC958461 9 W0112009 10/01/2010 PREY6ES[Ee� S 100,000
COMtaERCIAL GENERAL LPSILITY MED ESP IM oIx P vonl $ _ S U,DO
CLAIMS MAOE. 0 OCCUR PERSONAL AAOV INJURY f 1000000
GENERAL AGGREGATE - S 2000.000 a.
PRODUcrs-CDMPAP AGO If 2 OOO.DDOD _..
I u-PE -rr APxi_ PLI l =rotcY Ir
901Q1/2009 90101/2010 coMeINED SINGLE LIMIT Is t,000,DD0
AAUMoBNELU"HUTY 35MCC XD 6390
(En ncPnany
ANYAUTO
(P.,,pe=11 RY S
I k ALL OWNED AUf0.S _ —
sCieOU:ED MUTEST
,,RED AUiCS (Pot INJURY S
(Por>a=zany
I NONdYNdED AUTOS
I SPROPERTY AMAGE S
Spot a oang
AUTO ONLY-EAACCID-W S
DARAGELNBILITY OTHE IT HAN EAACC I S
�•A�O AUTO0N AGO I S
EACH OCCURRENCE I S ---
ETCESBiUaBRieju L AzIu-v AGGREGATE f
OCCUR O MAINE MADE S
S
DEDUCTI31.e S
RETEHTiOk 5' V+G STATU• Oi H• _.
TOR P.IRS_ I I R
A WORK9SCJJISASONANo 35 VdECPP 1444 02197/2010 02117/2099 EL SOH=_I s O ,D00
EELPLOYERS LN3'L+CY
ANYPRDPRIETDRIPARTkERr."EDU'Ydc E,L,0 SEASE'EA EMPLOYEE S 500.000
OmCERMi;4BER EXCLUDE" E.L.OSEASE•PDLICYLIMR S 500000
I(Ia'Oo5molP o
HS
SPECIAL PRONEIO yelou I I
OiIiUR
0 Es:RIP In0N OF aPERATI0RS I LOCCAM0HS f VEHIQ=S!Ewr^LOSfOkS ADDED BY FADOP539E1LT 15PEClAL PROV410NS -
CANCELLATION
----------------
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANC'LLED BEFORE THE EXPIRATION
DATE STSEREOF, THE ISSUWG INSURER 547LL ENDEAVOR TO MAIL 12 DAYS WRITTEN
INSURED COPY NOTICE TO THE CERTIFICATE HOLDER NAMEED TO THE LEFT,BUT FARURE TD DO SO SHALL
U pOSE NO OBLIGATION OR LIASILriY OF ANY KIND UPON THE INSIIP`P.ITS AGENTS OR
REPRESENTA11VES.
AUTHORQCO REPP,FSENTATIVE �nn C/
•'( tDCACORD CORPORATION 1988
ACORD 25(2001108)
i
i
Renewal 'AMEN
byvAndersenn
WINDOW REPLACEMENT xn-Mde,=CnmTany
Wood/Vinyl Composite IF
Dual Ngon Low E4 Smart
Sun
f�"3�'"'1.1 Double Hung
100-00473518-010
ENERGY PERFORMANCE RATINGS
U-Factor(U.S)/1-P Solar Heat Gain Coefficient
019 omig
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
OA2
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WINDOW REPLACEMENT znAndeisenCornparty
To Whom It May Concern, .
Enciosed 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 greatly helps us in
our process.
We have also enclosed a self addressed and postage paid envelope and
®t��d request that when permit application has been processed, that you
would mail it back to ens.
Enclosed for you review in this package is:
❑ Permit Application
❑ Home improvement Contractor License
❑ Construction supervisor License
❑ Proof of Insurance
❑ Proof of Energy Efficiency Rating
❑ signed Contract from customer
❑ Permit Fee (if accepted at time of applying)
if you have any question regarding this application please call Free at (508)
919-0992.
Best Regards,,
Kelley Donahue
Permit Coordinator
104 Otis Street
Northborougb,MA,01532
Pbone(508)919-0900 -
Fa (508)919-0903
Website: "v w.renewalbNmndersen.com