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35-271 (8) 165 WEST FARMS RD BP-2021-1377 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -271 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP-2021-1377 Project# JS-2021-002298 Est. Cost: $10074.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 170810 Lot Size(sq. ft.): 165092.40 Owner: OMASTA JOHN P &FAYE A Zoning: Applicant: RENEWAL BY ANDERSEN AT: 165 WEST FARMS RD Applicant Address: Phone: Insurance: 30 FORBES RD (508) 919-0900 WC NORTHBOROMA01532 ISSUED ON: TO PERFORM THE FOLLOWING WORK:REPLACE 4 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. , Q (4 ,/• X1 - 51-1"I Certificate of Occupancy Signa�� e: FeeType: Date Paid: Amount: Building 5/24/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner 1 ,I The Commonwealth of Massachusetts 0 Board of Building Regulations and Standards FOR w "i Massachusetts State Building Code, 780 CMR MUNICIPALITY USE o Building ermit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 1 One-or Two-Family Dwelling -1 This Section For Official Use Only Building I erW mit Nw r:5p Zo2(-j,,77 Date A plied: F/21 f 2-02.1 _l v,i s 4 os-5 1/ 5- 2011 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 165 West Farms Rd M_99623_895538 35-271-001 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'Lone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Faye&John Omasta Florence, MA 01062 Name(Print) City,State,ZIP 165 West Farms Rd 978-852-4186 faomasta@gmail.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 0 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 $10,074.00 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fcc 2.Electrical $0 ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $0 2. Other Fees: $yip°= 4.Mechanical (HVAC) $0 List: 5.Mechanical (Fire Total All Fees: $ Suppression) 0 c_ Check i f '8793 Check Amount:I/O Cash Amount: 6.Total Project Cost: $10,074.00 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 Lynn,MA 01904 U Unrestricted(Buildings up to 35,000 cu.ft.) 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. Faye&John Omasta see contract 05/03/2021 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 applica ' is true and accurate to the best of my knowledge and understanding. Jaime Morin 05/03/2021 Print Owner's or Autho d 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.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 ua- MP>o ,s , si 1 ''t �`` Massachusetts N,f' Cs, bi .f N` �`.of .- 4- 4; DEPARTMENT OF BUILDING INSPECTIONS is ;, , . 4-°w r a ' 212 Main Street • Municipal Building " \ y'` Northampton, MA 01060 sst%,y `^'`'' arj 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 6P202-1.(3Y) 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: 4 Technology Dr Westborough,MA 01581 Location of Facility: The debris will be transported by: Name of Hauler: Waste Management Signature of Applicant: Date: --5- 4-/P. 2---i The Commonwealth of Massachusetts t'_#....T't Deportment of Industrial Accidents 1 Congress Street,Suite 100 =' =�t_io.. Boston,MA 02114-2017 www ntass.gov/dia Workers`('uuipensation Insurance Affidavit:Builders Contractors/Eketrkinns/Piundrers. 10/ HE t 11.t:D WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leelbly Name(Rusin s'Organaration:lndn7dual): Renewal by Andersen Address: 30 Forbes Rd City/State/Zip: Northborough, MA 01532, Phone#: 508-351-2277 Arc yuo an employer°Check the apprnprlaic but_ Type of project(required): 1.Ir I am a emplaycz with 30 employees(full arrd'cx part-time I• 7. a New construction 20 I am a sole proprietor or partnership and have mi enploy s working for me in B. 13 Remodeling any capacity-(Nu workers'cutup.insurance required.) ',{J i am a lwrrnxw g rnet doin all work myself.[No workers`curter insurance re p re d_I 9. 0 Demolition [,I am a!minnow-no.and will be hiring contractors to conduct all w ink.on my property. I will 10 Q Building addition y t•�erwur that all ooniraelun citbet hs1 c workers.cxxnpczrwclrun atm:rum::ur all:sule 1 l.0 Electrical repairs or additions proprietors with no employee!, 12.13 Plumbing repairs or additions 50 I am a general conttactor and I has c hired the sub-eunwracioes listed on[lie attaee,e,d street. I ❑Roof repairs Three sub.contractots have employees and have workers'camp.insurance.. 6.0 We ern a corporation and its L.rti;cr,ha%a exercised their right of excmpinrr per wit.e. 14.C/otber replacement 152,41(4),and we have no employee:,[No wurkeni'comp.insurance required.] 'Any applicant that checks box u I moist also fill out the section below showing their worker, compensation policy information_ +Homeowners who submit thus aftulasit indicalrny they are doing all work and then hire outside ec ilracton must subnut a new alli day it indicating sueh- C'ontractun that check this box must attached an additional sheet ahow'ina the name of the sub-contractors and state whether or not those entities has c. employees. lithe sub-contractors base employees.they mull pms ids their workers'comp.policy number. I on,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.#: MWC31415820 Expiration Date: 10/012021 Job Site Address: 165 West Farms Rd CityiStalelLip: Florence, MA 01062 Attach a copy of the workers'compensation policy declaration page(showing the policy number aad expiration date). Failure to secure coverage as required under MGL c. 152, ;25A is a criminal violation punishable by a fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ,rider e pains and penalties of perjury that the information provided above is true and correct. Signature: I Dale. 05/03/2021 ['hone#: 508-351-2277 11 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: r City of Northampton 4�0.?H . ros SNs. Si ice''' Massachusetts ��? ee I 4, & t i DEPARTMENT OF BUILDING INSPECTIONS y, \ 212 Main Street go Municipal Building p� CD Northampton, MA 01060 i"friv- ;7‘� 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) "qv Agreement Document and Payment Terms dba:Renewal by Andersen of Boston Faye&John Omasta Legal Name:Renewal by Andersen LLC 165 W Farms Rd RENEWAL HIC#170810 Florence,MA 01062 brAND fuivmcE MuoaMeroa MOW MIM 30 Forbes Road I Northborough,MA 01532 H:(978)852-4186 unn 9 Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbooking®andersencorp.com C:(978)500-5543 Faye & John Omasta 04/09/21 Buyer(s)Name Contract Date 165 W Farms Rd, Florence, MA 01062 (978)852-4186 (978)500-5543 Buyer(s) Street Address Primary Telephone Number Secondary Telephone Number faomasta@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: $10,074 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: SO Balance Due: $10,074 Estimated Start: Estimated Completion: Amount Financed: 10 weeks 2 days $10,074 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: 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 04/13/2021 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. Signature of Sales Person Signature Signature William Abdelnour Faye Omasta John Omasta Print Name of Sales Person Print Name Print Name UPDATED: 04/09/21 Page 2 / 26 Itemized Order Receipt y _ dba:Renewal by Andersen of Boston Faye&John Omasta Legal Name:Renewal by Andersen LLC 165 W Farms Rd RENEWAL HIC#170810 Florence,MA 01062 PALMING 11110010011111X1111111 rANDEoRSEN 30 Forbes Road I Northborough, MA 01532 H:(978)852-4186 Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbookIng@andersencorp.com C:(978)500-5543 ID#: ROOM: DETAILS: 101 Living rm Window: Gliding, Double, 1:1, Active/ Passive, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: Fiberglass, Half Screen, Grille Style: No Grille, Misc: None 102 Bed1 Window: Gliding, Double, 1:1, Active/ Passive, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: Fiberglass, Full Screen, Grille Style: No Grille, Misc: None 103 Bed2 Window: Gliding, Double, 1:1, Active/Passive, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: Fiberglass, Full Screen, Grille Style: No Grille, Misc: None 104 Plants Window: Gliding, Triple, 1:1:1, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Standard Color Extra Lock, Screen: Fiberglass, Full Screen, Grille Style: No Grille, Misc: Mull Deduct, Per opening. WINDOWS:4 PATIO DOORS:0 SPECIALTY:0 MISC:0 TOTAL $10,074 Renewal by Andersen is committed to our customers'safety by �Fai; complying with the rules and lead-safe work practices specified by the EPA. UPDATED: 04/09/21 Page 3 / 26 The Commonwealth of Massachusetts Department of Industrial Accidents , Office of Investigations 3. Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Renewal by Andersen Name (Business/Organization/Individual): Address: 30 Forbes Rd. City/State/Zip: Northborough, MA 01532 Phone #:508-351-2277 Are you an employer? Check the appropriate box: Type of project(required): 1. ►�1 I am a employer with 30 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 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 myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.�Other Replacement comp. insurance required.] *Any 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. Contractors 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: 165 West Farms Rd 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 p ' that the information provided above is true and correct. Signature: ' 2 GI L Date: 05/03/2021 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): I❑Board of Health 20 Building Department 31:City/Town Clerk 4.1:Electrical Inspector 5E:Plumbing Inspector 6.0Other 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 Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 165 West Farms Rd The debris will be transported by: Renewal by Andersen Installers The debris will be received by: Waste Management 4 Technology Dr, Westborough, MA 01581 Building permit number: Name of Permit Applicant Jaime Morin - Renewal by Andersen 05/03/2021 Date Signature of Permit Applicant , S. Cornmonweelth se blessschimeitil Construction Supsndsor 1 ��!! DiViision of Uces 1 Unrestricted- army use group which contain Board of Building R uletlons aid Standards less thin 36.000 cubic feet(U1 cubic meters)of enclosed :-,NoG l )1'. . 1e01 M cS-00012$ 4 ' 3 iran:$IOW2022 ; LEI Mit ', ✓_ Failure to possess a current edition oldie MassachusettsI e,� State Building Code is cause for ntiocahon of this license. C50 NNIST 4 r+cr l tent�lon this'corm (` j CM p17►JD MN or visit wwwaness4oeldpt&"1,6 T „� Woolwitootetieeza figAzdazdafizeat Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home improvement Contractor Registration `(1. _ j 'type: 8upplernent Card RENEWAL BY ANDERSEN LLC =t' i -- • 170810 30 FORBES RD :v A��: 12/22/2021 NORTHBOROUGH.MA 01532 1 L w I, I.at _.....7_---- Updde Address and Return Cord. SCA 1 Q 2OM-OSH7 cm..ei Consumer Maks i Oueefeee Rpiastwe HOME IMPRO`-YMNT CONTRACTOR Registration wild for individual use only TYPE:Suoolernern Card before the expiration date. E found return to: 170810Basletratlen 1 1 Office of Consumer Affairs and Badness Regulation 1000 Washington Street -Suits 710 RENEWAL BY ANDERSEN LLC Boston,MA 02118 42"------ ..---".714// NORTHBOROUGH,MA rilSW lk)deftleCf Y� Not valid t hout signature a Page 1 of 1 ACORO` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) y,,.,� 09/21/zo2o 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 Willis Towers Watson Midwest, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd Mr.E7tt) (A/C.No): P.O. Box 305191 ADDRESS: certificates@willis.com Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIC0 INSURERA: Old Republic Insurance Company 24147 INSURED INSURER 8: Renewal by Andersen LLC 30 C Forbes Road INSURER C: Northborough, MA 01532 INSURER D: 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. ISUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP men (MM/DD/YYYYI X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE X I OCCUR PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 NNZY 314161 20 10/01/2020 10/01/2021 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY 1 YET- LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 1411T8 314159 20 10/01/2020 10/01/2021 BODILY INJURY(Per accident) $ f _ AUTOS ONI V I AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OT PERTUTE AND EMPLOYERS'LIABILITY A ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 1,000,000 OFFICER/MEMBEREXCLUDED? piNIA MWC 314158 20 10/01/2020 10/01/2021 E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000' If yes,describe under 1,000,000 UESCHIP I ION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 it Evidence of Insurance 9- '! ,,,/-- ©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 1 Do ret=We impuica.top libetirtorinknot • • 13 Cunha .44 WI r;i1 tit I g I tairs tar • • .11.#11Pawspe • 111.1.0111.41.tiftwakt. • I • th.ti • ' feilf **Pt- • 1.11..1%. .11 . r• • . vows' issruatramit N1044-111 . • iff= WoodNtyl Coropods•FF Avpn Low-si UMW • Porduerrypc War maw ruiromunct salvias U-Fiplar rsaler Hest Gain Costealent 6.2911.65 0.21 , 61,11.A-11 • ADDITIONAL PUtallklAita MUMS .** VINibis.iluneinktance • 0.49 . ,1•1111,10114 .1,1111/1 •Vaum. • • ••••11.411 •— *Ik! A I vatri II=*44 . amid • Wog • • 01161WNIMIIIIIMILMOSIONS.1.--...or . • • - 061444 - • •