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16a-020-044 BP-2024-1374 314 FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 16A-020-044 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-1374 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2024 Contractor: License: Est.Cost: 7680 RENEWAL BY ANDERSEN 090125 Const.Class: Exp.Date: 10/06/2026 Use Group: Owner: KENNETH STOW Lot Size(sq.ft.) Zoning: URA Applicant: RENEWAL BY ANDERSEN Applicant Address Phone: Insurance: 30 FORBES RD 508-351-227 MWC314158 NORTHBOROUGH, MA 01532 ISSUED ON: 10/22/2024 TO PERFORM THE FOLLOWING WORK: REPLACEMENT WINDOW 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: 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.Signature: 1/2. Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner YIeet . 1W-i (., i saved -v wi ii- renews\vmu -sen @ oao xmits ors RECEIVED IZ., The Commonwealth of MasiachusettsO CT 1 8 2024 FOR . iti. Board of Building Regulations nd Standards M ICIPALITY Massachusetts State Building C e,7RRCMR USE ryr..,r .,_ Building Permit Application To Construct,R it Renovate` 't i iii:fir$,-qs Revised Mar 2011 One-or No-Family Dwelling i This Section For Official Use Only Building Permit Number: e 4(/, / 3 7 7 Date Applied: S7z%- /if/1 ? < /d 0/ aY Bwlding Official(Print Name) Si Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 314 FAIRWAY VLG,Leeds,MA 01053 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Kenneth Stow Leeds,MA 01053 Name(Print) City,State,ZIP 314 FAIRWAY VLG (413)320-8964 krstow®gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: TO REMOVE AND REPLACE(1)WINDOW.LIKE FOR LIKE:NO STRUCTURAL ALTERATIONS. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building S 7,680 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire S Suppression) Total All Fees:$ 4/. Check No.6513/Check Amount: U D Cash Amount: 6.Total Project Cost: $ 7,680 0 Paid in Full 0 Outstanding Balance Due: ` keCSC/ OVRI 1, lSSkecf o'rntt At•- Yepetkal b.s ea' e 90 ''rv`its .019 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 10/06/2026 JAIME MORIN CS-090125 License Number Expiration Date Name of CSL Holder 30 FORBES RD List CSL Type(see below) U No.and Street Type Description NORTHBOROUGH MA 01532 U Unrestricted(Buildings up to 35,000 cu.11.) City/Town,/To State,ZIP R Restricted I&2 Family Dwelling h wn, M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 860-952-4112 RENEW ALBYANDERSEN@GOPERMITS.ORG I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170810 12/22/2025 RENEWAL BY ANDERSEN@GOPERMITS.ORG HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 30 FORBES RD RENEWALBYANDERSEN(u;GOPERMITS.OR,3 No.and Street Email address NORTHBOROUGH MA 01532 860-952-0112 ' �Q fiy7, 1 City/Town,State,ZIP Telephone (-a - 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 B 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/RENEWAL BY ANDERSEN to act on my behalf,in all matters relative to work authorized by this building permit application. SEE SIGNED CONTRACT 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 true and accurate to the best of my knowledge and understanding. JAIME MORIN 10/14/24 Print Omier's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at w .mass.gok 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 halflbaths 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 oPi HAMpj0, Massachusetts W 3 ( 4 DEPARTMENT OF BUILDING INSPECTIONS �';�"• ,, P' 212 Main Street • Municipal Building vj OD Northampton, MA 01060 SSj.„, 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: 30 FORBES RD NORTHBOROUGH MA 01532 The debris will be transported by: Name of Hauler: WASTE MANAGEMENT/RENEWAL BY ANDERSEN 10/14/24 Signature of Applicant: .-t��•. Date: Go Permits, LLC 105 Buttonball Lane 430, , Glastonbury, CT 06033 PERIM'S Scott Doughman Phone: 860-952-4112 Fax: 860-430-6719 scottdoughman@gopermits.org Re: Building Permit Application - Licenses Good day, Please find attached permit application, licenses and supporting documents. Renewal by Andersen sold the job and is the G.C. and CSL - CSL #CS-090125 — Exp. 10/06/26 - HIC #170810 -- Exp 12/22/2025 - Workers Comp -#MWC 314158 24 — Exp. 10/01/25 Old Republic Insurance Co All licenses and insurances are attached. Once the permit is ready: • Please fax or e-mail a copy of the permit and receipt to the below address and mail the original to the homeowner: Fax: 860-430-6719 Email: renewalbyandersen@.gopermits.orq • If you unable to mail the permit to the homeowner please send to the below address and we will ensure the permit is at the home posted at the time of installation: Go Permits, LLC 105 Buttonball Lane Glastonbury, CT 06033 If we are required to pick up the permit in at the building department, please call 860-952- 4112 once it's ready and we will come to get it. Thank you, Go Permits Unice or Lonsumer Attair's ana Business Kegulatlon 1000 Washingto rpt- Suite 710 Bosto 118 Home Imgro Lz v;t �F,;:,•-:.••: e istration 1L �ir7r trn� 1 I,. '= ~T~ ;, Type Supplement Card we >....= 1�: atlort 170810 RENEWAL BY ANDERSEN LLC M E lion. 12/22/2025 30 FORBES ROAD ,, = ,fir NORTHBOROUGH,MA 01532 ' f w 71t� ! 7 -'-'.- _ . _ .. Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:St,pplemerd Lirr1 Office of Consumer Affairs and Business Regulation Registrati9Il L P1Itien 1000 Washington Street -Suite 710 110810 ' 12/22/202.5 Boston.MA 02118 2ENEWAL BY ANDERSEN LLC • ' 7 ..- .. ir...t."114..___.__ IAIME MORIN tO FORBES ROAD ` ORTHBOROUGH,MA 01532 Undersecretary Not valid withT7trt sige ® Commonwealth of Massachusetts Construction Supervisor Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. Const ontee rvisor �` 8 • CS-090125 .. spires: 10/06/2026 JAIMELMOION .-:Mi ' 64 NOTTING(iAM RD i 5. RAYMOND Ng,..._03077 t C il) b 1t rtL V�l f'I'v`i'13' Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner \ .1 eW s Contact OPS1:(617)727-3200 or visit www.mass.govldpllopsi 4filRENEWAL - 1 brANDERSEN /�' "i115fItMC six.l0034ItkiUElr To Wnom It May Concern This letter will authorize the follow•ng personls) to act as agent(s)on behalf of Renewal by Andersen LIC, 9900 Jamaica Ave South, Cottage Grove MN 55016 to pull for per-nits and inspections with respect to the installation, maintenance and repair of windows and entry rinnrc unite. MaccMhimetts State Home Improvement Contractor license number 170810 and Construction Supervisor License number CS-09012S. If you have any questions, please call me at 508 351,2277 ext 6 Authorized person(s): Go Permits Lt.0 Sarah Hammad David Anderson Maureen Kivel Scott Doughman Ryan B ondo Sovannara Kuy Mark Foster Glynn Norgan Jennifer Wirke Wendy Holden Herald Cramer Nick Rago Darrel Vickerman Stepher Wilder Katie Grocott Bonnie Myers Carrie Fol gno Michael Rogers Rachel Orloff -'Jamie Morin Renewal by Andersen LLC HIC 170810 CSl -CS090125 Local District Office Address 30 Forbes Rd Northborough, MA 01532 Renewal by*ndensen Ltd: 9900 Jamaica Ave South.Cox a Grove MN S5016 Page 1 of 1 ACCORD DATE(MMID0/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/17/2024 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 POUCIES 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 endors«nent(s). PRODUCER CONTACT NAME: WTW Certificate Center Willis Towers Watson Midwest, Inc. - c/o 26 Century Blvd P Ho,Esp: 1-877-945-7378 FAX 1-888-467-2378 EDIAIL oertificat-alvtvoo.ao. P.O. Box 305191 ADMEN; Nashville, TN 372305191 USA PI3URER(8)AFFORDS..COVERAGE MAICO P SURERA: Old Republic In.vrerwe Company 24147 INSURED INSURER S Reawal by Andersen LLC ----- - -. .._----30 Forbes Road INSURER C: _ Northborough, WA 01532 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1/34713245 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 REDUCEDDUCY BY PAID CLAIMS. • ADOL SOAR eL R TYPE OF INSURANCE Yap 1MY I POUCY NUMBER YYF YI M(M�!O DWI LIMITS X COMMERCIAL GENERAL MOWN EACH OCCURRENCE $ 10,000,000 DAMAGRENTED CLAIMS-MADE ;x OCCUR PREMISES TO ) f S00,000 A MED EXP(My on.person) $ 10,000 MMZ7 314161 24 10/01/2024 10/01/2025 PERSONAL A ADV INJURY $ 10,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 x POUCY n JPrei I LOC PRODUCTS.00MPIOPAGO $ 10,000,000 I OTHER: $ AUTOMOBILE LIABILm COMBINED SINGLE LIMIT $ 5,000,000 (Ea accidence X ANY AUTO BODILY INJURY(Per person) >t ` OWNED SCHEDULED lads 314159 24 10/01/202. 10/01/2025 BODILY INJURY(Perslxldent) f AUTOS ONLY AUTOS HIRED NON-OWNED I PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAW CLAIMS-MADE AGGREGATE L _ GED I I RETENTIONS pER $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY A ANYPROPRIETOR/PARTNER/EXECUTIVE Y(N El.EACH ACCIDENT I f 1,000,000 OFFICER/MEMBEREXCLUOED? No NIA INC 3141SS 24 10/01/2024 10/01/202S (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE f 1,000,000 I1 yes describe under 1,000,000 DESCRIPTION OF OPERATIONS bolew E.L.DISEASE-POLICY LIMIT $ 1 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if mo,s sped le rpaied) 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 Evidence of Insurance " ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR in. 26438395 BATCH. 3623681 ts/97RENEWAL brANDERSEN wusenKE MOW&oat maw Re:Massachusetts Solid Waste Affidavit Good day, Please find attached location where the installers will bring their debris from the jobs.These are all Renewal by Andersen location. • WASTE MANAGEMENT—30 FORBES RD,NORTHBOROUGH,MA 01532 When filling out any solid waste affidavit, it's the installer whom will be removing the garbage and dumping the trash at the Renewal by Andersen dumpster locations closest to that job. Thank you, Go Permits RENEWAL BY ANDERSEN SPECIFICATION a TECHNICAL MANUAL TECHNICAL INFORMATION PERFORMANCE RATINGS AND TEST DATA NFRC Total Unit Performance Fw t by Andersen": Illefiiiithipiiiiti � � SHBC Type (BTD(hr ft2 oF)) VT • Product Air HP Gas Blend Air HP Gas Blend Without Grilles 0.42 0.41 0.51 0.51 .82 Clear Full Divided Light Grilles 0.43 0.41 0.46 0.46 Without Grilles 0.31 0.28 0.28 0.27 .72 Low-E4' run urvweu ugn[urines U.31 u.zs u.c3 0.25 [ Casement Without Grilles 0.32 0.29 0.17 0.17 .40 & Low-E48 Sun Fixed Full Divided Light Grilles 0.33 0.30 0.16 0.15 Without Grilles 0.31 0.28 0.19 0.18 .65 Low-E48 SmartSun'" Full Divided Light Grilles 0.32 0.29 0.17 Oil Low-E48 SmartSun Without Grilles 0.26 0.24 0.18 0.18 .63 with Heatlock." Full Divided Light Grilles 0.26 0.24 0.17 0.16 Without Grilles 0.43 0.41 0.51 0.51 .82 Clear Full Divided Light Grilles 0.43 0.41 0.46 0.46 Without Grilles 0.31 0.28 028 0.27 .72 Low-E4° Full Divided Light Grilles 0.32 0.29 0.25 0.25 Without Grilles 0.32 0.29 0.17 0.17 .40 Awning Low-E48 Sun Full Divided Light Grilles 0.33 0.30 0.16 0.15 Without Grilles 0.31 0.28 0.19 0.18 .65 Low-E48 SmartSunl" Full Divided Light Grilles 0.32 0.29 0.17 0.17 Low-E4'SmartSun Without Grilles 0.27 0.25 0.18 0.18 .63 with Heatlock"" Full Divided Light Grilles 0.27 025 0.17 0.16 Without Grilles 0.46 - 0.58 - .82 Clear Full Divided Light Grilles 0.46 - 0.52 - Without Grilles 0.33 0.30 0.31 0.31 .72 Low-E48 Full Divided Light Grilles Q.34 0.31 0.28 0.28 [ Double-Nang D8 Without Grilles 0.33 0.30 0.20 0.19 .40 (Al Frames) Low-E4'Sun Full Divided Light Grilles 0.35 0.31 0.18 0.17 Without Grilles 0.32 0.29 0.21 0.21 .65 Low-E4'SmartSun'" Full Divided Light Grilles 0.34 0.30 0.19 0.19 wwCl•C AIIC,. Withturi Grilles n 27 1125 11211 [12(1 R9 with Heatlock." Full Divided Light Grilles 0.30 0.27 0.18 0.18 09-9 COMPANY CONFIDENTIAL-REVISION AA-0l �_ The Commonwealth of Massachusetts Department of Industrial Accidents —'� Office of Investigations =1:761Y Lafayette City Center C°« 2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Renewal By Andersen 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.® 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. ❑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 workingfor me in anycapacity. employees and have workers' P tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 Wi„ r Replaceent employees. [No workers' 13.�Other �„„� m 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 314158 24 Expiration Date: 10/1/25 Job Site Address: 314 FAIRWAY VLG City/State/Zip: Leeds, MA 01053 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: 77rl.,� Date: 10/14/24 Phone#: 508-351-2277 Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 41:1 Electrical Inspector 5falumbing 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,arc 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 arc 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 DIAL RINIWAL BY ANDIRSIN OF BOSTON Kenneth Stow A Maria Stow Legal Name:Renewal by Andersen LLC 314 Fairway Village HICB 170810 Leeds,MA 01053-9753 30 Forbes Road I Northborough,MA 01532 H:(413)320-8961 RENEWAL Phone:(508)351-2200 Fax:(508)9867072 I rbabostonbooking®andersencora.com C:(413)320-8964 by ANDERSEN Thank you for your order Please find, enclosed for your convenience,the contents of your agreement with Renewal by Andersen LLC d/b/ a Renewal By Andersen of Boston Table of Contents Agreement Document and Payment Terms 2 Itemized Order Receipt 3 Payment Authorization Form 4 Notice of Cancellation 5 RbA 20-5-10 Warranty 6 MA Addendum 8 RbA Insurance 11 Terms and Conditions of Sale 12 Waiver 15 If Using a Builder 17 Electronic Consent 18 Project Preparation Expectation 20 Release Agreement 22 Price Presentation Discounts .24 09/30/24 Page 1/ 24 Agreement Document and Payment Terms DBA:RENEWAL BY ANDERSEN OF BOSTON Kenneth Stow•Marla Stew Legal Name:Renewal by Andersen LLC 314 Fairway Village RENEWAL HICe 170810 Leeds,MA 01053.9753 byANDERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)320-8961 Phone:(508)351-2200 Fax:(508)986-7072 I rbabostonbookingOandersencorp.com C:(413)320-8964 Kenneth Stow&Marie Stow 09/30/24 BUYERS)NAME comma DAM 314 Fairway Village,Leeds,MA 01053-9753 (413)320-8961 (413)320-8964 BUYERS)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER krstow@gmail.com PRIMARY EMAIL - - SECONDARY EMAIL - - - NOTES: 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: $7,680 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: $0 BALANCE DUE: $7.680 Estimated Start: Estimated Completion: 8 to 12 weeks 1 day AMOUNT FINANCED: $7,680 We schedule installations based on the date of the signed contract and secondarily on the date METHOD OF PAYMENT: Financing 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 10/03/2024 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 Timothy Ayers Kenneth Stow Marie Stow PRINT NAME 01 SALES PERSON PRINT NAME PRINT NAME 09/30/24 Page 2/ 24 Itemized Order Receipt D6A:RENEWAL BY ANDERSEN OF ROSTON Kenneth Stow&Marie Stow Legal Name:Renewal by Andersen LLC 314 Fairway Village RENEWAL HICi 170810 Leeds,MA 01053-9753 brEN RENEWAL L AN ERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)320-8961 auwwwPhone:(508)351-2200 I Fax:(508)986-7072 I rbabostonbooking@andersencorp.com C:(413)320-8964 ID#: ROOM: SIZE: DETAILS: PRICE: 201 office Window: AcclaimTM Casement Double Vented, Base Frame, Exterior Terratone, Interior Canvas, Performance Calculator: PG Rating: 40 I DP Rating: + 40/ - 40 Glass: All Sash: High Performance SmartSun Glass, No Pattern. Hardware: Canvas, Screen: TruScene, Full Screen,Grille Style: No Grille. Mlsc: Standard, Replacement of window frame and sash, includes casing from standard options. WINDOWS: 1 PATIO DOORS:0 ENTRY DOORS:0 SPECIALTY:0 MISC:0 TOTAL $7,680 F Renewal by Andersen is committed to our customers'safety by • complying with the rules and lead-safe work practices specified by the EPA. 09/30/24 Page 3/ 24 If Using a Builder r DIA:RENEWAL BY ANDERSEN OF BOSTON Kenneth Stow A Marie Stow RENEWAL Legal Name:Renewal by Andersen LLC 314 Fairway Village HIC#170810 Leeds,MA 01053-9753 ENL row rRSEN 30 Forbes Road I Northborough,MA 01532 H:(413)320-8961 Phone:(508)351-2200 I Fax:(508)986-7072 I rbabostonbookingOandersencorp.com C:(413)320-8964 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. 4117P /e/ii SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Timothy Ayers Kenneth Stow Marie Stow PRINT NAME Of SALES PERSON PRINT NAME PRINT NAME 09/30/24 Page 17/ 24