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HomeMy WebLinkAbout0298 STONEY CLIFF ROAD i a , t 4 Town of Barnstable Lill g .. . ., s �. Post h Card So That rt Is Visible;From theStreet ApprovedPlans Must be�Reta�ned on Job and this Card Must be=Kept �= • ' iPosted Until Final Inspection Has Been Made. Permit W g c 11�1 Where a Certificate;of Occupancy is Requi�redsuch Building shall Not be Occupied until a Final lnspect�on has been made I Permit No. B-19-2520 Applicant Name: Elvis Verdezoto Approvals Date Issued: 09/04/2019 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 03/04/2020 Foundation: Location: 298 STONEY CLIFF ROAD,CENTERVILLE Map/Lot: 170-043 Zoning District: RC Sheathing: Owner on Record: KEGLEY,MICHELE&MARTUCCI,LAURETTA. Cor Tractor Name;,.""-,,SCOTT VEGGEBERG Framing: 1 Address: 298 STONEY CLIFF ROAD Contractor License: CSSL-103832 2 CENTERVILLE, MA 02632 _ Est. Project Cost: $3,839.00 Chimney: Description: Residential weatherization/air sealing. No structural changes. Permit Fee: $85.00 i Insulation: Project Review Req: Fee Paid:, $85.00 - Date: / 9/4/2019 Final: �� - Plumbing/Gas G Rough Plumbing: --- - �- Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the`approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning bydawsand codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,public inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the,Building and Fire Officials are provided on this Permit. Minimum of Five Call Inspections Required for All Construction Work:`T; Service: 1.Foundation or Footing 2.Sheathing Inspection A - Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: t Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT oW` � Final: r►A�c. SEA� . ,=-' Town of Barnstable i ing � eAK� he��i„i Post This Card So That it is Visible From the Street-.Approved Plans Must be Retained on Job and this'Card Must be Kept Posted Until Final Inspection Has Been Made. Eorear"°f0 f Where a Certificate of Occupancy is Required, such Building shall Not be Occupied until a Final Inspection has been made. Permit N0. B=17-43U3 Applicant Name: SOUTHERN NEW ENGLAND WINDOWS LLC. Approvals Date issued: 12/14/2017 Current Use:. Structure Permit Type: Building'-Siding/Windows/Roof/Doors Expiration Date: 06/14/2018 Foundation: Location.: :298 STONEY CLIFF ROAD,.CENTERVILLE Map/Lot: 170-043' Zoning District: RC Sheathing: Owner on Record: KEGLEY;MICHELE& IVIARTUCCI,:LAURETTA Contractor.Name: ., BRIAN D DENNISON. Framing: 1 Address: 298 STONEY CLIFF ROAD Contractor License: CS-095707 2 CENTERVILLE, MA 02632 Est. Project Cost: $8,450.00 Chimney: Description: replace 3 windows.29 u-value. Permit Fee: $43.10 Insulation: Project Review Req: ` Fee Paid: S 43.10 Date: 12/14/2017 Final: Plumbing/Gas Rough Plumbing: . - Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structure sshall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street.or road and shall be maintained.open for public inspection for the entire duration of the work until the completion of the same. Electrical f The Certificate of Occupancy will not be issued until all,applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: Rough: 1.Foundation or Footing 2.Sheathing Inspection ` Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5. Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final:. 7.Final Inspection before.Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,`and Mechanical Installations. Work shall not,proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not.have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT- ISSUED RECIPIENT aF Town of Barnstable *Permit# E�prres 6 ntorrilrs from issue date Regulatory Services Fee `( aAmsTABi.S, 9cb iMAS& Richard V.Scali,Director Bnildiny Division �► Tom Perry,CBO, Building Commissioner , 200 Main Street,Hyannis, VIA 02601 I c www.town.bamstable.ma.us 'A 1 3 Office: 508-862-4038 roo/N Fax-508-790-6230 EXPRESS PERiVLiT APPLICATION - RESIDENTIAL' L)i Nut Valid witirout Red X-Press Inrptzrrt ltitap/parcel Number /70 ,• �/,/ Property Address q Re., �: F'�' � / �Q��t� V,/ [Residential Value of Work$ � n LMinimum fee of$35.00 for work under$6000.00 Owner's Name&Address i L(P K.Q f�3 Z Contractor's Name Telephone Number(Yo f) 22 Home Improvement Contractor License#(if applicable) 73 { s Email: Construction Supervisor's License#(if applicable)-� 5 7 CNorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I m the Homeowner I have Worker's Compensation Insurance Insurance Company Name E f pd,'A'1e- ci ti� In stjca,-- a Workman's Comp.Policy# C A 31 5"i9 7 2_9 — Z Q Copy of insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ stde Replacement Windows/doors/sliders. 0-Value . Z 9 (maximum.32)#of windows _ of doors: ❑ Smoke/Carbon ibtonoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical& Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e_Historic.Conservation,etc. ***Note: Property caner must sign Property Owner Letter of Permission. A copy the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content0utlook\21`10I DHR\EXPRESS.doc Revised 040215 i Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England Michele Kegley Legal Name:Southern New England Windows,LLC 298 Stoney Cliff Rd RI#36079,MA#173245,CT#0634555, Lead Firm#1237 Centerville lle,MA 02632 wIxoo 10 Reservoir Rd I Smithfield,.Rl 02917 - - C:(508)272-1899 Phone:866-563-2235 1 Fax:401-633-6602 1 sales@renewaisne.com . Buyer(,)Name, Michele Kegley Contract Date: 12/01/17 Buyer(s)Street Address: 298 Stoney Cliff Rd, Centerville MA.02632 Primary Telephone Number: Secondary Telephone Number: (508)272-1899 Primary Email: michelekegley@comcast.net Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any othei document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement'). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $8,450 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check-,bank check,credit card,or cash. Deposit Received: $4,225 Balance Due: $4,225 Estimated Start: Estimated Completion: 8 to.10 weeks; 8 to 10 weeks Amount Financed: $8,450 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date.Rain and extreme weather are the most common causes for delay. Notes: Depo 50% gsky Bal 50% gsky tax Barnstable Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will,be valid without the signed,written consent of both the 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. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at.the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT: OF 12/05/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.: Legal Name:Southern New England Windows,LLC dbai Renewal 13 ndersen of Southern New England Buyers) Signature of Sales Person Signature . ' 'Signature Cory Scanlon Michele Kegley Print Name of Sales Persona Print Name Print Name UPDATED:'12/01/17. " Page 2 / 10 I Massachusetts Department of Public Safety � Board of Building Regulations and Standards Wlfl License: CS-095707 Construction Supervisor BRIAN D DENNISON ' 7 LAMBS POND CIRCLE CHARLTON MA 01507 �i � Expiration: Commissioner 09/08/2018 \..L 6;� ,��GI QIJQGY Office of Consumer Affairs nd Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home ImprovenL&'nt Contractor:Registration Registration: 173245 ` I --�rkft 'Type: Supplement Card } l I r Expiration: 9l19l2018 SOUTHERN NEW ENGLAND WINDOL' `,' BRIAN DENNISON 26 ALBION RDA' m' LINCOLK RI 02865 iC* 'Update Address and return card.Marl-,reason for change. scA 1 c tom 05n+ [I Address [j Renewal ❑Employment Lost Card .N J/c��nciunnruni/!/��Cv�fi+3mc/a:;rtJ, -fLce of Consoorer Aff i &Business Regal do. Registration valid for individual use only before the OMEIMPROVEMENTCONTRACTOR expiration date.If found return to: q Office of Consumer Affairs and Business Regulation Reglstradon�73245s - Type; 10 Park Plaza-Suite 5170 - Expmdticrt 9/19/2Q7.8�t Supplement Card :Boston.MA 02116 SOUTHERN NEW Ei G&INIJXRDOWS LLC. RENEWAL BY ANDE.iPSQNr,_?,;,; MR— BRIAN DENNISON UNCOLN,AL02865 d` — Not valid without signature l The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 s% www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PER-WTT 'qG ALTHORITI'. Applicant Information G Please Print Legibly Marne- (Business/Organizmionlndividual): e� L— Address: 2& , jDA) :R�j City/State/Zip: Phone 4: Are you an employer?Cbeck the appropriate box: Type Of project(requited): l &fi am a emplover-,mth !O femplovees(full and/or par-time).- 7. New construction 2.71 am a sole proprietor or partnership and have no employees working for me in S. Remodeling any capacity.pNo workers'comp.insurance required.] 9..El Demolition ;.O I am a homeowner doing a!work myself.(?do workers'comp.insurance required.] 10 Ej Building addition 4.❑]am a homeowne-and will be hiring contractors to conduct all work or:my property. I will ensure that al;contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with nc emplovees. 12. Plumbing repairs or additions f.❑I am a genera],contraetor and I have hired the sub-conLracton listed on the attached sheet. 13_ Roof repairs These sub-contractors have emplovees and have worker'comp.insurance. 14.rZOtlter E.F1 we are a cor poration and iu officer have exercised the right of exemption per MGL c. 1 jt:F 1(4).and we have ne emplovees.(No workers'comp.insurance requirec.i 'Any applicant that checks box r1 mast also fill out the section below showing their worker compensrjon policy infgrmation. 'Homeowners whc submit this affidavit indicating they are doing all wort:and.then hire outside contractors must submit E new affidavit indicating such. +Contactors that check this box must attached ap.additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Lithe sub-connector hove employees:they must provide their workers'comp.policy munben I am an emplover that is providing workers'compensation insurance for MY employees_ Below is the polici-and job site information. Insurance Company Name: -Fire LQ S — Policy 1 or Self-ins.Lic. : 2-0 0 — 2-0 Expiration Date: Job Site Address: .2 ale City/State.%Zip: C P�t"�P/ .�� 0 Attach a copy of the workers' compensaition policy declaration page(showing the policy number and exlfir2tion date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violatiop punishable by 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_A copy of this statement may be..-.forwarded to the Office of Investigations of the D1A for insurance coverage verification. �do hereby certify under the sins and penalties of perjun°that the information provided above is true and correct ature: Date: ��'�� Phone P: official use only. Do not write in this area,to be completed by city or town official City or Town: Per-mit/License g 4 Issuing Authority(circle one): 1.Board of Health 2.Building Depat tment 3.City/Town Clerk 4.)Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ESLERCO-01 SANDERSO DATE(MMIDDIYYYYI CERTIFICATE OF LIABILITY INSURANCE 0wo7,2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS HIS C CERTIFICATE DOES NOT AFFIRMATIVELY MAT 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 have ADDITIONAL INSURED provisions or 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). COMEACT PRODUCER PHONE 303 988-0804 CoBiz Insurance,Inc.-CO (AIC,No,Eid:(303)988-0446 FAX Nor-( 1401 Lawrence St,Ste.1200 E-MAIL COMail@cob-m7insurance.com Denver,CO 80202 ADDRFss: INSURERS AFFORDING COVERAGE' NAIC is INSURER A:Acadia Insurance Company 31325 INSURED INSURERS:Firemens Insurance Company of WA D.C. 21784 Southern New England Windows,LLC.dba Renewal by INSURER c:LibertV Surplus Insurance 10725 Andersen of Southern New England INSURER D 26 Albion Road,Suite 1 Lincoln,RI 02865 INSURERE: I INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: BEEN THE INSURED THIS IS TO NOTWITHSTANDING RTFYTHTE POLICIES REQUIREMENT, TERM OF INSURANCE T LISTED CONDITIONDWHAVE OF ANY CO ISSUNTRACOT OR OTHER DOCUMENT ED BWITH RESPECT TOOVE FOR THELIWHIOD ICH RTHIIS INDICATED- CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. uMns INSR'I ADDL SUBR POLICY EFF POLICY EXP L TYPE OF INSURANCE INSD UVVD POLICY NUMBER MMIDD MMIDD 1,000,000 A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 01/0112017 01/01l20Is DAMAGE TO RENTED 300,000 CLAIMS-MADE OCCUR CPA3158728 PREMI E Ea oculnence _ 5,000 MED EXF An one erson S I,000,000 —I PERSONALS ADV INJURY S 2,000,0001 r•— GENERAL AGGREGATE S 2,000,000� ! N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG !S X POLICY❑jECT ❑ LOC EBL AGGREGATE s 2,000;000 OTHER: - COMBINED SINGLE LIMIT S 1,000,000I A i AUTOMOBILE LIABILITY Fa accdent I j ! X I ANY AUTO CPA3158728 01101/2017 01/0112018 BODILY INJURY Per e,sbn 5 ~J OWNED SCHEDULED BODILY INJURY Per accident 15 PROPERTY DAMAGE AUTOS ONLY AUTOS Per accident S NON-0WNF_[.) S AUTOS ONLY AUTOS ONLY _ - 1;0D0,UUDI i A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S CPA3158728 01/0112017 01/01/2018 AGGREGATE S CLAIMS-MADE EXCESS LIAB Aggregate'' s 1,000,000 I DED X RETENTION 5 0 PER 1OTH- B WORKFRSCOMPENSATION X STAT E' R 1,000,00D AND EMPLOYERS'LIABILITY YIN WCA3158729-20 01/0112017 01/0112018 E.L.EA9t ACCIDENT t ANY PROPRIETORIPARTNERIEXECUTIVE I N 1 A 1,000,0001 %FICERIMEMBER EXCLUDED? `_ EL.DISEASE 2 FA EMPLO I S 1,000,DOO (Mandatory in NH) It yes,describe under E.L.DISEASE-POLICY LIMIT 5 1,00(3,000 DESCRIPT ION OF OPERATIONS below CA3158730-20 01/01/2017 01/0112018 B Worker's Compensatio 1,000,000 117 01l0112017 01/01/2018 DESCRIPTION Workers OF OP mA-noNs I Ln ATION I VEHICLES Stat(ACORD s O 101pt Additional OH IWA WV,S WYete,may be atlached'rf more space is required) r I I , CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATHE CCORDAN E WITH TDATE THEREOF,HE PCLLJ6 PROVISIJONSCE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE - F R f r n I P PS ©1g88-2015 ACORD CORPORATION: All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD �„mV 2013 Town of Barnstable *Permit V610 - Regulatory Services Expires 6 months from issue date Fee- 9 1639 �� Thomas F.Geiler,Director Epp Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601. www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number . Property Address z$ / �Y�t'(/E residential Value of Work$ r Minimum fee of$35.00 for work under'$6000.00 ' Owner's Name&Address - Ve,5 Contractor's Name �/ _ Iv1 lRA�1 A,3on7Telephone Number ✓v0_� �S ' 61315- Home Improvement Contractor License# (if applicable) 7 Email: Construction Supervisor's License# (if applicable) ['�Workman's Compensation Insurance ' Check one: ❑ I am a sole proprietor ❑�-,�I am the Homeowner Lg I have Worker's Compensation Insurance Insurance Company Name it"�1_ C'�/t71.✓� �J -` C(� F Workman's Comp.Policy# A-1 7 S 3 �5� 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken'to ❑Re-roof(hurricane nailed)(not stripping.'Going over existing layers of roof) ❑ side 22 Replacement Windows/doors/sliders.U-Value O a .d (maximum.35)#of windows' #of doors: . , ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and,inspections required. Separate Electrical&Fire Permits required.- 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. *,**Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is. equir SIGNATURE:C:\Users\decolU\AppData\Lo.cai\N4icrosoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 Y T Southern New England Windows -, d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Ccinstructiun Super%isor License: CS-095707 BRIAN D DENNISON �•r 7 LAMBS POND EIRi5C E Charlton MA 01507 �` " " "' Expiration Commissioner. 09/08/2014 b ad/ u,�eG� ^ Office of Consumer Affairs n B/lusessa4�aui egulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: •173245 - e. Type: Supplement Card .. SOUTHERN NEW ENGLAND WINDOWS LC Expiration: 91`19n014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 ` Update Address and return card.Mark reason for change. - sce+0 z Yll LI Address ❑Rtdewal Employment Lost Card - u<ofCovsvmer ARaLieanse or registration valid for Individul aft only OIMENT before the expiration date.iffound return to: Ofce of Consumer Affairs and Business Regulation f1r. e0I.-If n. 173245 Type: 10 Park Plane-Suit,5170EapiraOon:9M9f2.14 SupPlameru:;ard Boston,MA 02116 - r - SOUTHERN NEW ENGLAND WINDOWS I.I.C. RENEWAL BY ANDERSON BRIAN 1137 PARK +\ 1137 PARK EAST DRIVE ��s--,�•>- '° y\�J\—�_ ' � _ ' WOONSOCKET•RI 02895 Uvdersecsmry - Not valid without siganture . f The Commonwealth.of Massachusetts J Department of Industrial Accidents Office of Investigations 600 Washington Street Q. Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �N d LLC Address: o2 (o I oJI/ h&d City/State/Zip: 41A/CO& , g,_r, viSbS Phone#: ynl 1;;) 2- �Y-00 Are you an employer?Check the appropriate box: Type of project(required): 1.tip I am a employer with 02 0 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 []New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LD Plumbing repairs or additions myself.(No workers'comp. right of exemption per MGL 12.1-1 Roof repairs insurance required.] t C. 152,§1(4),and we have no / employees. [No workers' 13.[]'Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their worker;'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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 5UranAu C'�,mol'tV0 Policy#or Self-ins.Lic.#: i' a3 Egg.? Expiration Date: IIg //x Job Site Address: �' v 1 i6e City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). >6 3 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 cerdA under the pains and penalties of perjury that the information provided above is true/and correct; Signature: Date: _ Phone# �! d o� v'Z V? ' NYC/y 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#: Client#:30124 SOUTNEW DATE°(MM/DD/YYYY) A00RD,. CERTIFICATE Of LIABILITY INSURANCE 8/0612013 -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 NCON AME T Anita Little Willis of New Jersey,Inc. PHONE g56 914-4660 856-914-1881 AIC No Ext: A/C,No 1015 Briggs Road,PO Box 5005 E-MAIL s:'anita.little@willis.com, ADORES PO BOX 5005 i INSURER(S)AFFORDING COVERAGE NAIC# Mount Laurel,NJ 08054 INSURER A.Selective Insurance Co of the S 39926 INSURED INSURER B E Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER C:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen INSURER D 26 Albion Road INSURER E Lincoln,RI 02865 I INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD MM/DD/YYYY A GENERAL LIABILITY S202945900 8-10/2013 08/10/2014 EACH OCCURRENCE $1,000,000 NGEN'L MERCIAL GENERAL LIABILITY MA�E7 RENTED POEMlr'SEST' Eaoccurrence $100 000 CLAIMS-MADE 51OCCUR MED EXP(Any one person) $1O 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GREGATE LIMIT APPLIES PER: �" PRODUCTS-COMP/OP AGG $3,000,000 POLICY PET LOC $ A AUTOMOBILE LIABILITY S202945900 8/11 O/2013 08/10/201 (CEO accidentMBINED SINGLE LIMIT 1,000,000 X ANY AUTO _ BODILY INJURY(Per person) $ ALL OWNED SCHEDULED, I AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per.accident $ $ A X UMBRELLA LIAR OCCUR S202945900 08f1012013 08/10/2014 EACH OCCURRENCE $5 000 000 EXCESS LIAR HCLAIMS-MADE j AGGREGATE s5.000.000 - - DED RETENTION$ 1 $ C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/201 X;WC STATUS1 JOTH- AND EMPLOYERS'LIABILITY . ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N AIC927818352394 8l21/2013 08/21/201 E.L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? � N/A- , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below ) - E.Li DISEASE-POLICY LIMIT $1,000,000 f DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) f - CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 i AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved: =t .,ACORD 25(2010/05)q-'D 1 .of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL~~ Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)?Ume Datee(Agreemeni c e I I C Kcs e. IM,Ml- 8uyer(s)Street Address.:Gt.Sate.and Z)p Code/P.O.Banc fie n e r 1 E•MailAddress Home Telephone Number Wor*Tcleah neNumber Buyer(s)hereby.jointly and severally agrees to purchase the products and/or services of Southem-New England Windows,LLC d/b/a Renewal by Andersen of Southern New England("Contractor"),in accordance%vith the terms and conditions described on the front and the reverse of this agreement and on the attached:specification shccl(s)(collcctiwcly,this"Agrcement")• ❑ Historic ❑ Condo ❑ HOA? Total job Amount: Estimated Sinning pace: Method:of Payment: J Check 0 Cash financed. Deposit Received(33t): Credit Cards are accepted for deposit.only-maximum 1/3 of the Balance at Start of job(33%): project cost(Rens.e see Gedh Card Payment Fonri.)By signing.dhis Estimated Completion Date: Agreement.you acknowledge that the Balanceat Start of job and the Balance on Substantial Balance on Substantial Completion-of job cannot be made by credit Completion of job(33S): Jew G :card_and must be made by personal check,bank check,orcash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that "there are no verbal understandings changing any of the terms of this Agreement. Buyer(s) 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 Ageeement,.includiag 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 BLANKSPACES. (Rhode Island Sales,Only)Notice to Buyer:(1)Do not sign this Agreement if.any of the spaces intended for the agreed terms to the extent of then-available ii6orn iatioa 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 pay oft'the frill 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 signed at the slain office or a branch office of the seller,provided you aotafy wile seller at his or her main office or branch office shown in the Agreement by registered.oi certified mail,which shall be posted notlater 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 not made.See the accompanying notice of cancellatiiOn forms for an explanation of buyer's rights. Buyers)r&& d the consumer education materials prof ided by the Rhode Island Contractors lkegistratiolt.Board. (Brryer!r Inifurls) Renewal by Andersen of Southern New England Buyers) Buyer(s) By. Qr ignature Product Manager Sigma ro. Signature .AA 41 lit Name of Pt+oduct 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 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — LAZION —X NATICE_91 E ACAHACELLAIX1'1l —� Date of Transaction .You may cancel I Date of Transaction .You may cancel this transaction,without or obigation, within this tmnsahction,.without any penalty or.obigation, withill three business days fi+om a above date.if you cancel,arty I three business days from the above date.if you cancel,airy property traded In,any payments made by you under the I properly traded in,any paymts en made by you under the Conlrx Sale,and or Sa and any negotiable instrument executed I Contract or Sale,--and any negotiable instrument executed by you wiH be returned within ten business days following. I by you will be returned within ten business days following. receipt by the Seller of your cancellation notice,and any I receipt by the Seller of your cancellation notice,and any security intetestt arising out of the transaction will be -security interest 4rising out, of the transaction will be cauicded.lf you cancel,you must tmake available to the Seller I caneded.lf you caneel,you must make avaibble.to the seller at your reddegcey in substandally-as good condition as when' I at your residence,in stubslantiapy as good condition as when deceived,any goods delver"to you under this Contract or I received,any goods dowered to you.under this Contract or Sala,or you may,if you wish,colmply with the instrauctions of I Sale;or you now,,if ye+ vAs_j nomply with the instructions of the Seller regarding the return shipment of the goods at the the Seller regarding the return shipment of the goods ak the Seller%eigrerise and risk.If you do make the goods' x Seller's LoWense and risk.If you do makethe goods avaibhble to the Seller and the Seller does not pick them up within I to the Seller and the Seller does not pick them up within twenty days of the date of cancellahtion,you may retain or I twenty days of the date of cancellaition,you may retain or dispose of the goods without any further obligation.K'you I dispose of the goods without any further obligation.K you fsil to make the goods available to the Seller,or if you agree hid to make the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do s%then I to return the goods to the Seller and fail to do so,then you remain iable for performance of all obligations under I you remain cable for performance of all obligations under M.w !".ww*rs..i_.Tw e�wr�h Mhie �hwevi:ww ..�-ti — dwCv #L-- V^ 4-60. .r•.1r ~i AmZwm r