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17C-175 (10) 26 FAIRFIELD AVE BP-2021-1534 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 175 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2021-1534 Project# JS-2021-002555 Est.Cost: $7947.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 090125 Lot Size(sq. ft.): 5314.32 Owner: BARR DOROTHY Zoning: URB(100)/ Applicant: RENEWAL BY ANDERSEN AT: 26 FAIRFIELD AVE Applicant Address: Phone: Insurance: 30 FORBES RD (508) 919-0900 WC NORTHBOROMA01532 ISSUED ON:6/25/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. .161440&, )2 • 6 Certificate of Occupancy signature:0 FeeType: Date Paid: Amount: Building 6/25/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ON 24 IL, The Commonwealth of Massachusetts' �r <949/ ��,,-,,��� 4 Board of Building Regulations and Standard�; u,10 r � Massachusetts State Building Code, 780 CM12�9''r,rnE N/A,,s.4441 S ALITY Building Permit Application To Construct, Repair, Renovate Or Demo 400/vsRevis.Id Mar 2011 One-or Two-Family Dwelling ,/ This Section For Official Use Only Building P rmit Number: 6"'a/16)� Date A plied: lb 6.zs-zozi Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 26 Fairfield Ave /?[+r / 7,5- 1.1 a Is this an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Dorothy Barr Florence, MA 01062 Name(Print) City,State,ZIP 26 Fairfield Ave 617-461-0559 dorbarr2agmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other la Specify:replacement Brief Description of Proposed Work'-:Replacement of 4 windows SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: - Official Use Only (Labor and Materials) 1. Building $7,947.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $0 ❑Standard City/Town Application Fcc ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $0 2. Other Fees: $ 4. Mechanical (HVAC) $0 List: 5.Mechanical (Fire $ Suppression) 0 Total All Fee 1� Check No. s Check Amount: f Cash Amount: 6.Total Project Cost: $7,947.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs-090125 10/06/2022 Jaime Morin License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 86 Gardiner St No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Lynn,MA 01904 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-351-2277 rbabostonpermitting@andersencorp.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170810 12/22/2021 Renewal by Andersen HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 30 Forbes Rd rbabostonpermitting@andersencorp.com No.and Street Email address Northborough, MA 01532 508-351-2277 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 0 No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Jaime Morin to act on my behalf,in all matters relative to work authorized by this building permit application. Dorothy Barr see contract 06/22/2021 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED 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 nd accurate to the best of my knowledge and understanding. Jaime Morin 06/22/2021 Print Owner's or Authorized gent's ame(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 H1C Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton at H�MPio -4D,"0 ti: 1� SNS .ram Si,,„ Massachusetts (7 DEPARTMENT OF BUILDING INSPECTIONS '. r` x C..: f"+ 212 Main Street • Municipal Building v� �ii \ '`/ Northampton, MA 01060 'Ps.�:jy ����4's. CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all 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 disposed of in: Location of Facility: 4 Technology Dr Westborough,MA 01581 The debris will be transported by: Name of Hauler: Waste Management Signature of Applicant: PI- Date: 06/22/2021 • The Commonwealth of Massachusetts 144�:,..._....,Y.,.ram. r,r Deportment of Industrial Accidents `lgill w �= I Congress Street,Suite 100 t'. �4 ••"13,_ :; Boston. MA 02114-2017 www mass.gov/dia -- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lreibls Name(Business'()rranization:lndtviduall: Renewal by Andersen Address: 30 Forbes Rd City/State/Zip: Northborough, MA 01532 Phone#: 508-351-2277 Aro you an employer?Clerk the appruprlate two: Type of project(required): 103 lam a employer with 30 employees(full aiming par tune t• 7. CI New construction 20 I ant a sure pnopietin or purtncnhip and have rat employees working for nine in S. Q Remodeling my'capacity_]No workers'comp.insurance ironed.) 30 1 ant a homeowner doing all%nth myself.INo wcark:as'conc.'lima-ante required"e 9. ❑Demolition 4.0 1 am a homeowner and will be hiring contractors to conduct all w t'rk on my property. I will 1 Q❑Building addition ensure that all contractun either have workers'eonrpetesutrurt insurance or are style 1 1.0 Electrical repairs or additions prirprie[on w lilt no employees_ 12.0 Plumbing repairs or additions 50 1 ant a h2mc-rai contractor and I bat a hind the sub,conrraetun list.:a on the attached,greet l3.0 Roof repairs These sub-cuntaactun have employee*and have workers'comp.insurance.: 6.0 We are a t avocation and its otrteen have exenined their right of exemption per MU c. 14. Other replacement 152,i]1(4),and we have no employees.[No women'comp.insurance required.) '.An}applicant that chocks hot a i mead abo till uut the section below shi.w ing their workers'compensation policy infornnatio n_ 'Homeowners who submit thus afticiasrt indicating they are doing all wink and then hire outside contractors mint submit a new aftidaa it indicating such. Contractors that check the,.box must attached an additional sheet show ur.!the name of the suer-contractors and state whether or not those entities have employees. lithe sub-contractors base employees.they must pros ide their wvrleers'c nnp.lx.liey 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: Old Republic Insurance Co Policy#or Self-ins.Lie.#: MWC31415820 Expiration n:to: 10/012021 Job Site Address: 26 Fairfield Ave City/State:Zip: Florence, MA 01062 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152. y25A is a criminal violation punishable by a fine up to SI,500.00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a teas against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance :oEeiage verification. I do hereby cer ' ,r the pains and penalties of perjure that rho information provided above is true and correct. Signature: Date: 06/22/2021 Phone 4: 08-351-2277 II Official use only. Do not write in this area,to be completed by city or town official i fits or Town: Permit/License# : Issuing Authority(circle one): I. Board of Health 2.Building Department 3.C'it r Fown Clerk 4.Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: Phone#: City of Northampton aTHAM o c S,S s�C Massachusetts �? 'lam * t .. DEPARTMENT OF BUILDING INSPECTIONS r t; e . 212 Main Street • Municipal Building v4., a . .-, Northampton, MA 01060 Nh; -)% HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born _ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) Allli/ Agreement Document and Payment Terms 4, dba:Renewal by Andersen of Boston Dorothy Barr Legal Name:Renewal by Andersen LLC 26 Fairfield Ave RENEWAL HIC#170810 Florence,MA 01062 IVrsANDE0RSEN 30 Forbes Road I Northborough,MA 01532 C:(617)461-0559 Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbooking@andersencorp.corn Dorothy Barr 06/16/21 Buyer(s)Name Contract Date 26 Fairfield Ave, Florence, MA 01062 (617)461-0559 Buyer(s)Street Address Primary Telephone Number Secondary Telephone Number dorbarr2@gmail.com Primary Email Secondary Email Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen LLC d/b/a Renewal by Andersen of Boston("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 other 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: $7,947 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: $2,649 Balance Due: $5,298 Estimated Start: Estimated Completion: Amount Financed: $0 12 weeks 1 day Method of Payment: Check 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: 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 ANYTIME NOT LATER THAN MIDNIGHT OF 06/19/2021 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. ezeseg Signature of Sales Person Signature Signature Christopher Sweet Dorothy Barr Print Name of Sales Person Print Name Print Name UPDATED: 06/16/21 Page 2 / 26 Itemized Order Receipt dba:Renewal by Andersen of Boston Dorothy Barr Legal Name:Renewal by Andersen LLC 26 Fairfield Ave RENEWAL HIC#170810 Florence,MA 01062 byANDERSEN• „Al,,,MOM DOOR Q,OM 30 Forbes Road I Northborough,MA 01532 C:(617)461-0559 Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbooking@andersencorp.com ID#: ROOM: DETAILS: 101 dining room Window: Double-Hung (DG), 1:1, Slope Sill, Insert Frame, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Standard Color Recessed Hand Lift, Screen: Aluminum, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 102 dining room Window: Double-Hung (DG), 1:1, Slope Sill, Insert Frame, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Standard Color Recessed Hand Lift, Screen: Aluminum, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 200 guest bedroom Window: Double-Hung (DG), 1:1, Slope Sill, Insert Frame, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Standard Color Recessed Hand Lift, Screen: Aluminum, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 201 guest bedroom Window: Double-Hung (DG), 1:1, Slope Sill, Insert Frame, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Standard Color Recessed Hand Lift, Screen: Aluminum, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. WINDOWS:4 PATIO DOORS:0 SPECIALTY:0 MISC:0 TOTAL $7,947 Renewal by Andersen is committed to our customers'safety by complying with the rules and lead-safe work practices specified by the EPA. UPDATED: 06/16/21 Page 3 / 26 iii If Using a Builder , dba:Renewal by Andersen of Boston Dorothy Barr Legal Name:Renewal by Andersen LLC 26 Fairfield Ave RENEWAL HIC#170810 Florence,MA 01062 brANDERSEN 30 Forbes Road I Northborough,MA 01532 C:(617)461-0559 wu MIL IOWalwiltrwui 9 Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbookingOandersencorp.com Property Owner Must Complete & Sign This Section If Using A Builder I,as Owner of the said property,hereby authorize Renewal by Andersen LLC to act on my behalf,in all matters relative to building permit application for the property/address indicated on this agreement. C((--eq .) ..0., , (3.-c— Signature of Sales Person Signature Signature Christopher Sweet Dorothy Barr Print Name of Sales Person Print Name Print Name UPDATED: 06/16/21 Page 13 / 26 The Commonwealth of Massachusetts p Department of Industrial Accidents i , ;� Office of Investigations -.6 1'1 =, ji/ Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ib1y Renewal by Andersen Name (Business/Organization/Individual): Address: 30 Forbes Rd. City/State/Zip: Northborough, MA 01532 Phone #:508-351-2277 Are you an employer? Check the appropriate box: Type of project (required): IN I am a employer with 30 4. ❑ I am a general contractor and 1 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 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions m self. [No workers' comp. right of exemption per MGL y p 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.1K Other Replacement comp. insurance required.] *My applicant that checks box#1 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 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: Old Republic Insurance Co. _ Policy#or Self-ins. Lic. #: MWC 31415820 Expiration Date: 10/01/2021 Job Site Address: 26 Fairfield Ave City/State/Zip: Florence, MA 01062 Attach a copy of the workers' compensation 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: /��d1.u' Date: 06/22/2021 Phone#: 08-351-2277 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 2❑Building Department 31:City/Town Clerk 4.1:Electrical Inspector 5E lumbing Inspector 6.❑Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, 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 an 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 employer." 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 any 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-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(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 employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any 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 town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. -- -< The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 Revised 7-2019 www.mass.gov/dia 1 CossnewrisMits of 0111111141ChUnitli Construction Supervisor I # DlULOO of kelessionst Osmium . Unrestricted-Buildings of any use group which contain j �d of aid Shmderds Ma than 36,000 cubic lest psi cubic meters)of enclosed Cis fh+ also? epees. � � -.��. CS-Oio126 4, rera:lOfO012022 JAMIE 1. .° { • : : is . MB MA r 1' '' Ni.,;;;;"' i Failure to possess a current edition of the Massachusetts sale Budding Cods Is cause for revocation of this license. C4ommi.prtsr K. +ciao For Inforindlon about this license Call(M7)7l7.UN mu or vI$t www� sso l _,., ,y _ • Jute W....a ?QIaeAaóe1t Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registraffon . Tjipe: Supplement Card RENEWAL BYAI4DERSEN LLC 1 I • Ar _- Registration: 170810 90 FORBES RD } Expiration: 12/22/2021 NORTHBOROUGH,MA 01832 1 i ▪ __ » pi iti \ r Update Address end Ratum Card. SCA 1 ,5 20M05117 CAR 1?-) gicadiaoi.- OleosstCo suaeerMaks a Suisun Reeissash COME IMPROVEMENT CONTRACTOR Regiekation wild for individual use only TYPE:Sunads n it Card before the expiration deb. if found return to: BsQistre11oo llealcallen Office of Consumer Atfsirs end Business Regulation 170810 12J12j2021 1000 Washington Street -Ouse 710 RENEWAL BYANtERSEN Lie Boston,MA 0111e JAIME MORIN _ ` +/ 90 FORBES RD (,,asta.gifois 4- NORTHBOROUGH,MA 01502 Undersecretary �='`f Not valid ithout signature Page 1 of 1 A�R0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/21/2020 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 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). PRODUCER CONTACT Willis Towers Watson Certificate Center Willis Towers Watson Midwest, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd IA/C.No.Ext): INC.No): P.O. Box 305191 ADRL ADD DRESS: certificates@willis.com Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAICN INSURERA: Old Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC 30 C Forbes Road INSURER C: _ Northborough, MA 01532 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W17904932 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSO WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 MWZY 314161 20 10/01/2020 10/01/2021 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE OMIT APPUES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT (Ea accident) $ 5,000,000 X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED MWTB 314159 20 10/01/2020 10/01/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS!JAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER A ANYPROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No NIA MC 314158 20 10/01/2020 10/01/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 H yyes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1:1- Evidence of Insurance 1- // ce/` ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 20103273 BATCH: 1820957 D o u b l e Hung -- xc 'Andersen.:Renewal ; : t11INDOM' REPLACEMENT PmAmktawlGompanp y Wood/Vinyl Composite IF Ca. * Du DoArgon RR Low E4 Sin ' •�, 1 00-0047351 8-01 0 ENERGY PERFORMANCE RATINGS U-Factor(U.S)/I-P Solar Heat Gain Coefficient 0........ is2 9 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 e 42 . rain Anwar I.r tfl.:1 soft.corato a ls.ppwbft i M poormar,.la d.Is,wl;;ftp,yeat pneao.t .ds doss ow ow or**tinsid s dssoo.ft.dIr•Sod set of MYWWIIIYYOON�Y sod•N.pio P� (.YL Omni r.ra`atwr.Atw[w fermi nd dear sot wansiall Ile dw product tr ray specific.... snwr dal& $14I TW product rs.res.s 6.M....ie-Head iii.i P. l.o a I 4 :atanAsea e,:z.ne ..:; 3. , �.'.,-t'`'^siA 4'IA.Iiam.S .Y F .+•• II:• DESIGN PRESSURE(PSF) \V fIly`Af] RbA DB Sloped Sill DH IN • Awisia atcmieunCwuicstsWtotot It . .T , .-a..,:-,.�,,A n,• ...s._,.c�A 4..1.or exceeds YEC.CIA.&I.E.C.C.Alt idthuides wgoieloWs WAWA MaMdrerlN¢uk.payny.