18C-158 PRODUCT PEERFORMANCE
Andersea'MIRC Cauffied Total Und Performance{continued)
Andersen'Product Glass Type U-factor' SHGCI VP
Clear Dual Pane 0.45 _160 0.63
Clear Dual Pane vath GA. 0.45 0.54 0.56
I-111-wash LowE 0.30 0.32 0.55
Dniable•"ung Window Low E with Guiles 0.30 1129 1-49
HP Low-E4 SmartSun 0.30 011 149
HP Low-E4 SmanSim w/Gdlles 0.31 0.19 0.43
-Clear Dual Pane 0,45 461 0.64
Narroline, --Clear Dual Paire with 0.45 0.5_1 0.57
Double-hung Window Low-E 0-30 032 0.56
Low-E with Grilles 0.31 029 6_50
Clear Dual Pane 0.44 0.63 0.66
Narralln.' Clear Dual Pane-tft Galles 0.44 157 159
Transom Window Low-E 0.27 034 0.58
Lary-Evidth Galles 027 030 0.52
Clear Dual Pam 0.45 0,59-om
Clear Dual Pane with Grilles 0.45 154 0.56
Lnw-E 0.30 032 0.5.9
Gliding Window
Law-E with Galles 0.30 029 0A9 _7 I
Ljaw-E Sorenson _0.30 U21 0.49
Law-E SmaTtSun with Gifflas 031 0.19 0.43
Meer Dual Pane 0A3 161 165
Clear Dual Pane with Grilles 0A3 0.5r:I 0.58
Fixed,Tranininni Low-E 0.28 033 0.56
T- _J
clivie Top'Window Law-E M Galles 0-28 030 0.50
Lm E SmanSun 027 0-22~ 0.51
Zanwfth Galles 027 D-20 0.45
Clear Deal Pane 0.44 0.61 0.64
Clear Dual Pane with Gilles 6:4E_i om 0.56
LOWE 129 032 0.56
Narroffna, Low-E with Galles 030 us 0.49 Q
Gliding Patin Dom UrwE Sun 0.29 cio 0.31 m ;I m
Lnw-E Sun with Grilles 0.31 0-18 027, 9 �
low-E imartSun 128 Ul 0.50
Low-E SmarlSun wft Galles 0,30 0_19 0.44
Clear
Dual Pane 0.43 9.51 0,64
"""
Clear Dual Pane with Galles 0.43 0.54 0.56
0.28 0.32 56
perma-sh"I"Id'. Galles 0-30 1):?q U-49
_._S _d_
Gilding Patin Do- Lnw-E Sun 0.29 119 (1.30
Sun
_
Patio
Lm*-E Sun with Grilles 0.30 IA7 0.27
Low-E Smartsull 0.27 )_22 0-50
.a, ,
Law-E SmartSan with Galles 029 119 0.44
_Clear Dual Pane 0.43 0,45 G.47
Clear Dual Pane with Galles 0.43 039 0.4_0_-
Low-E 0.32 (124 0.41
Hinged laswing Law-E with Grilles e33 0.21 0.35
Patin Duars Low-E Sun 032 0,15 0-23
_Low-E Sun with es 0.34 0713 0.19
_
LixwE SnaartSun 092 0-16 037
Lo.-E SamdSurr with Gilles om G.14 0.31
W I Ntprpt,'Ut��a,���W'"yy#1S"D OTft(1 R 5 n d m W Arr�" tl�4n
I
Andersen'NFRC Certifleaf futal Unit Performance (conrinuelp I 9
Attderseo'Product Glass type U Factor' SHGC' Vi' r Andersen'Product Glass Type U-(:actor' I SiLGC' VP
---- - ------ err':
400 Series -`- -, Architectural
lip Low-Ell 0.27 035 I - 4 T - E
wiIt'Low les 78 031 0.5 HP Imv-E4 with 0.32 025 -0.42
Circle Top tip low-E4 Sun 0.27 0.7,1 0.33 R: _ TIP Lour-E4 Sun 0132 0.17_ 0.26_ [Tj
Casement Window
Casement Window HP Low E4 Sun with Galles 0.29 0.19 0.30 lit'Lour-E4 Sun with Gilles 0.32 0.16 0.23
lip Lmw-E4 SmartSun 0.26 023 0.54 R"-' !It'Low-E4 SmonSun 031 0.18 0.42 ;r T'y
HP Lux E4 Samatin w/Grtlles 0.28 021 0.49 R UP low E4 SmartStm w/Gdllls 0.31 OAT 0.38
_lip Low E4 0._27 03_5 0.60_ _ HP Low-E4_ 0.32 0.28u 0.47 '
HP Lew E4 Willi Galles 0.28 0.310 54 -- -- tip iovr E4 With Gilles 032 025 0.42 ` sl
n'.
_ LIP Lour E4 Sun 0.77 021 0.33 e _ French Casement _ (it'Low-174 sun 0.32 0.17 0.26 C
Circle&Oval Window - - -- -- ")
IIP low-E4 S if with Guiles 0.29 0.19 0.30 Window Hp tow- Sun with Grilles_ 0.32 016 0.23 - h
-._- - --- - -----
lip Low EA SmmiSnn 0.26 093 0.54 r lip Low-E4 SmadSun 0.31 018 0.42 F]
- _ tip Low 14 SmartSun w/Galles _0.78 0.71 _0.49 �.ti _-- -- IIP ton E4 SmarLSun w/Grilles 0.31 047 6.58-------I
---Hp Low-E4 U.28 0.33 0.58 - --- _-`tip Law-E4 0.32 0.28 0.47 I'
I IP Low E4 wit)Grilles 0.29 0.30 0.52 GIP low F4 with Galles 0.32 0.25 0.42
IIP Law E4 Sun 0.28 0.70 0.31 IIP low E4 Sun 0.32 0.17 0.26
Arch Window - --...-.--_� -_ _-_- ..-�.-. _ Awning Window
HP Low-E4 Sun with Gilles 0.29 0.18 0.28 i fit'Low-Ell Son Will Grilles 0.32 0.16 0.23 )�'{
Gip low E4 5mart5un 027 HP Low E4 Snar(Sun 031 0,18 0.42 ;
IIP Law-EA SmarlSmt w/Grilles 029 0.21 0.46 Hp Low.E4 SmaitSun w/Grilles 0.31 0.17 0.38 h '
fit'Low-E4 0.27 0.33 17.58 Hp Low E4 0.31_ 032 0.55
P
Flexiframe'Window II Lo lip 4 lip L
la E4 5uSort 0 27 -0 20__-0 31-`'.``(a Caoement/Awning - o lip Law E4 Sur' 0.3Yi 0,20` i 0 31' t
Hp Lora-E4 Sun with Galles 0.29 0.18 0.28 R"i Picture Window lip Low F4 Sun with Gilles 0.31 018 0.28 �
flp Low E4 SmartSun 0.26 0.23 0.52_ lip Low-E4 Smart5w; _0.31 ___ 021 0.50
HP Low-E4 SmartSun w/Guiles 0.28 0.21 0.46 ~' �:; lip Low E4 Stnartson w/Giles 031 0,19 0.44
NP Low-E4 0.31 D.33 0.58 Hp LOW-E4 030 0.37 0,64
IIP low E4 with Grilles 0.32 0-30 0.52 lip Law-174 with Galles 0.30 0.33 0.57 {`-
lip Low E4 Sun 0.31 0_20 0.31 '1 lip tow E4 Sun 0,31 022 0.36
Springiine`Window -I IP taw-E4 Sun Witt Grilles 0.33 0.18 0.28 q_-- S eclally Window I IP Low E4 Sun with Galles 0.31 020 0.32
Hp Low E4 Smatt5un w/Grilles 0.32 021 0.46 R'' HP low-E4 SmartSun U.3U 0 24 0,56 �.,.
lip low E4 SmartSim 0 30 0-23 0_52 ' Ri
,y HP low E4 SmartSun w/Gilles 0.30 0.22 0.52 r
lip few E4 0.30 0.21 O 45 tip Imv E4 0.32 022 0.37
HP tow G4 with Grilles 0.32 0.23 0.39 ! �`) HP IM-E4 Willi Grilles 0.33 020 0.33
Frenclwaod" HP LOW-E4 Sun 0.31 0,16 0.25 Ringed Inswing UP Lmv-E4 Sun 0.33 014 0.21_
Oliding Patio Door I IP Low-E4 Sun with Grilles 0.3_2 0,14_ 012 French Door lip Law-E4 Sun with"as 0.34 0.13 0.18 -
11 lmr-E45marlSun 0.30 0.18 0.41 IIP Lmv-134 SmonSun, 0.32 -0,15 GM
tip Law-E4 StartSun w/Gaffes 0.31 0.16 0.35 ` �'I LIP Lmv F4 SmanSun yr/Grilles 0.33 0.14 0.30 ca
UP Law C4 0,31 0.24 0.41 UP Low EA 0.33 025 0.41 m
IIP Low E4 Witt Gates 0.32 021 0,35 1 tP Luw14 with Grilles 0.34 0.22 0.36
Frenclwood'Hinged -_-.,_-- --_-.GIP frnr-FA Sun_--`0,31 `---0_15 0.23 i!" 'Plit }tinged Dols" TIP lo'N E4 Sun 0,33 0.16 0.23 - p
Inswing Patio Door TIP low-E4 Sun wilt Guiles 0.32 0.13 0.19 French Door UP Low E4 Sml with Grilles 0.35 0.14 0,20 -
lip Low-E4 SmarlSun 0.30 0.16 0.37 " V4 tip Lear-E4 Strwasun 0.32 _ 017__ 0.37
TIP tow-E4 5ntartSun w/Gilles 0.31 0.14 0.31 (�'•'.i� UP Low-E4 SmmtSun w/Galles 0.34 0.15 0.32 -Q 0
IIP lmr-t'4 0.31 0.25 0,41 F-1 IIP Law-EA 0.39 0.23 0.38
tip Low-FA with Grilles 0.32 U.21 0.35 'ua fit'Law-E4 Wilt Gilles 0.33 U21 0.3M1 -
Frenchwood-(tinged Hp 1mr-E4 Sun 0.31 0.15 0.23 ' _ w�?r. Fixed French Door- HP Low-E4 Sun 0.33 014 021 -
Outswing Patio Door tip L uw-E4 Sun with Grilles 0.32 0.13 0.19 !`C{ Ali, SideBght tip low-E4 Sun with Grilles 0.34 0.13 0.19 -
_ _lip low-E4SmartSun 0.30 0.17 0.37 R't7_ HPLnwi4Smar(Sun 0.32 0.15 0.34 -
I1P law-E4 SmartSun w Galles 0.31 0.15 _0.31 tit'tax-Ell SmattStm w/Grilles 0.33 0.14 0.30 -
--
lip Inw-F4 0.31 022 0.37 1 -- HPhow-E4 0.32 0.25 0.41 -
Hp Ltw-E4 With Galles 0.32 0.7.0 4.33 F 4 Hp Imv-E4 With Grilles 0.33 0.72 0.37 -
-.. :.r- -------------
Frencharead' tip lour-E4_Sun_ 0.32_ _0.14 0.21 'G:Iar_ Fixed Transom ___ UP Low-E4 Sun_ 0.32 0.15 0.23_ -
gi - -_lit'tow-E,4 Sun with Grilles--0.32 0.13 0.18 ('k:�R French Door --HP Low-E4 Sun with Gilles-_033 - 0.14-�0.2D -- ------
Patio DaorSWelt It _
lip Low-E4 SmartSun 0.31 0.15 0.33 'Fill lip Law-F.4 SmartSon 0.32 0.16 0.37 -
HP low E4 SmartSun vi/Grilles 0.32 0.14 _0.29 Phi Gip Low E4 SmarlSun yr/pilles 032 0.15 0.33
-_---- - HP LOw-F.4 0.30 0.24 0.40 i`3 'Ri` lip Luw-E4 035 026 0A4 - -
FIP Low EA with Gnites 0.30 0.21 0.35 Hp Law E4 with Grilles 036 023 038 -
Freuchwood" HP low-F4 Sun 0.30 0.1.5 0.22 -i )') TIP Lira E4 Sun 0.35 0.16 0.24 --
Fabling Door
Patio Door Transam lip low-E4 Sun wild Galles 0.31 0.13 0.20 R Tip Iva-F4 Sun with Grilles 0.36 0.14 0-21
Hp Low E4 Srnarlsun _ 0.29 D.16 0.36 {"_',
lip low-EA SmartSun 0.34 0.17 0.39 --
HP Lavr-E4 SmarlSun w Guiles 0.30 0.14 032 tip Imv-E4 Smarisun w/Galles 0.36 0.15 0.34 --
------.� _.._..----_- 'ry_ -._..-_- ----------- -
rnaGmred an nert page
°For NFRC certified total unit perfomlance an units with capillary breather takes for higir altitudes,please visit andersonvdndows_cmn.
°"High-Performance"tow-F4"(lit'(mv-E4),"High-Performance"law-E4-SmartSun"'(I!P 1 aw-E4 SmartSon)and"II1gh-Performance"LOW F4'Sun'(IIP Low-F4 Sun)are Andersen trademarks for"Low-E"glass.
' 11-Factor defines the amount of heat loss through the total unit hi OfU/Itrsq-fL"F.The lower the Yoffie,the less heat is last through fire entire product Window values represent non-tempered glass.Use of tempered glass can
increase U-Factor ratings.See andefsenWinduws.rom for specific performance values.Dear values represent tempertvi gh iss.
' Solar flea(Gain Coefficient(SRGC)defines the fracUnn of solar radiation admitted through the glass both directly transmitted and absorbed and subsequently released inward.The lower the value,the less heat is transmitted
through the product.
' Visible Transmittance(VI)measures how much light rnmas through a praducL(glass and(mine).Via higher Om value,tram 0 to 1,the more daylight the product lets in over flip product's total unit area.Visible transmittance
is measuted over the 380 to 760 mummeter portion of the solar spectrum.
•NFRC ratings are based an madefing by a third party agency as validated by an f nferiendent test lab in compliance with NFVC program and nrocedurai requirements.
This data is accurate as of December 2010.Due to angoing pmuum changes,updated test results or new industry smndards of Maeirements,this data may change over Orne.Ratings are for sizes specified by NFlIC far
testing and cerlifhraton-Ratings may vary depending on use of tempered glass,different grille options,glass forhipih altitudes,etc.
Passwesun"'glass values are ava ilabte online at anderserhwindnws.com
277
Renewal - - -- ---- ----- ---
MA Home Improvement Contractor'
byAndersen. Renewal b Andersen Corporation License Federal (Expires 12/23/2015)i 9184 3
wrx sow RE►MCE MENT A,.I .en C'ump;n y h Federal Tax ID#41-19184131.
104 Otis St. Northborouah.MA 01532
(508)351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date:
DONALD BOUTHILETTE - AUGUST 8, 2014
Buyer(s)Street Address City State Zip Code
36 WARBURTON WAY NORTHAMPTON MA 01060
Email Address Home Telephone Number Work/Cell Telephone Number
DON ELBOOTSCaCOMCAST.NET 413 586-0493 413 218-8901
Buyer(s)hereby jointly and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("Contractor'),in accordance with
the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s)(collectively,this"Agreement").
Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Est.Start Date Method of Payment
Total Job Amount $ 4,817.00 Amount Financed$ 0.00
Deposit Received(33%)$ 1,605.67 10-12 weeks V Check/Cash
Balance Start of Job(33%)$ 1,605.67 Deposit at signing$ 0.00 Check# 1622
Balance on Substantial At Substantial Est.Install Time Credit Card
Completion of Job(33%)$ 1,605.67 completion$ 0.00
1-2 days If credit card is selected,please
see Credit Card Payment form
Buyer(s)agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings
changing or modifying any of the terms of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed,written consent
of both Buyer(s)and Contractor. Buyer(s)hereby acknowledges that Buyer(s)1)has read this Agreement,understands the terms of this Agreement,and has i
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 1
orally informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
'Renewal by Andersen Corporation Buyer(s) Buyer(s)
Signature of Project Manager Signature Signature
THOMAS KELLEY DONALD BOUTHILETTE
Printed Name of Project Manager Printed Name Printed Name
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT.
`------------------------------------^--------------------------------------i
NOTICE OF CANCELLATION NOTICE OF CANCELLATION I
Date of Transaction 8/8/11 You may cancel this I Date of Transaction S/S/Id You may cancel this
transaction,without any penalty or obligation,within three business days from the I transaction,without any penalty or obligation,within three business days from the 1
above date.If you cancel,any property traded in,any payments made by you under I above date.If you cancel,any property traded in,any payments made by you under
!..the Contract of Sale,and any negotiable instrument executed by you will be I the Contract of Sale,and any negotiable instrument executed by you will be
returned within 10 days following receipt by the Contractor("Seller") of your I returned within 10 days following receipt by the Contractor("Seller")of your
cancellation notice,and any security interest arising out of the transaction will be I cancellation notice,and any security interest arising out of the transaction will be
canceled. If you cancel,you most make available to the Seller at your residence,in I canceled. If you cancel,you must make available to the Seller at your residence,in j
substantially as good condition as when received,any goods delivered to you under I substantially as good condition as when received,any goods delivered to you under
this Contract or Sale; or you may,if you wish,comply with the instructions of the 1 this Contract or Sale;or you may,if you wish,comply with the instructions of the
Seller regarding the return shipment of the goods at the Seller's expense and risk. 1 Seller regarding the return shipment of the goods at the Seller's expense and risk.
If you do make the goods available to the Seller and the Seller does not pick them up If you do make the goods available to the Seller and the Seller does not pick them up
within 20 days of the date of your Notice of Cancellation,you may retain or dispose I within 20 days of the date of your Notice of Cancellation,you may retain or dispose
of the goods without any further obligation. If you fail to make the goods available i of the goods without any further obligation. If you fail to make the goods available
to the Seller,or if you agree to return the goods to the Seller and fail to do so,then I to the Seger,or if you agree to return the goods to the Seller and fail to do so,then
you remain liable for performance of all obligations under the Contract.To cancel I you remain liable for performance of all obligations under the Contract.To cancel
this transaction,mail or deliver a signed and dated copy of this cancellation notice I this transaction,mail or deliver a signed and dated copy of this cancellation notice
or any other written notice,or send a telegram to Contractor:Renewal by Andersen,I or any other written notice,or send a telegram to Contractor: Renewal by Andersen,
104 Otis St. Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT OF 1 104 Otis St.Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT OF
8/12/11 .(Date) I HEREBY CANCEL THIS TRANSACTION. 8/12/11 .(Date) I HEREBY CANCEL THIS TRANSACTION.
1 I
Buyer's Signature Print Name Data Buyer's Signature PrMn Name Data
Renewal Renewal by Andersen Corporation MA Home Improvement Contractor
byMidetsen.ra 104 Otis St. Northborough,MA 01532 License#170810 (Expires 12/23/2015)
WINDOW RE PLACEMENT (508)351-2200 Fax:(508)-986-7072 Federal ID#41-1918413
Window Specification Sheet
Buyer(s)Name Date of Agreement
DONALD BOUTHILETTE FRI, AUG 8, 2014
The hover
(s)listed above hereby,jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms
described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING
AGREEMENT,of which the Specification Sheet is part.
WINDOW DETAILS
Approx. Exterior/Interlor Color Hardware Hardware LowE4/ Grille Grille Glass
Room X U.I. Window/Door Style Detail Casings Ext-Int Color style Screens Smartsun Grilles Sash t/3 Sash 2 Lifts Options
Kitchen 1 6 PS-C Ext./Int.Pine TT/WH Stone Standard FFG SmartSur None ----- ----- ----- No
Total 1 BAY&BOW DETAILS *See Bay/Bow Measure Sheet
Style Detail/ Approx. Approx. Number Frame Window End Center LowE/ Root/ Hardware
Room Count style Flankers U.I. Casings Angle Lftes Interior Ext/Int Color Grilles sashes sashes Screens smartsun Soffit Color
SPECIALTY WINDOW DETAILS
Full/ Approx. LowE/ specialty BAY/BOW ADDITIONAL WORK NOTES
Room Count Style Insert U.I. SmartSun Grilles Grille Style Ext/int Color Customer is aware that with ba y/how windows node,72 inches
there will be significant gla,s lose.
ADDITIONAL WORK DETAILS:
Thr>e mashicld door is to has-e the foot lock and an wcrim ke,,lock ad&d.'Fhc im,nor and exterior casin rs arc to match what is there now.
I No Contractor will wrap exterior casings with coil stock color of
Owner is aware that Contractor does not do any painting/staining or removal/installation of alarm system or window treatments/hardware.It is the
responsibility of the homeowner to have the alarm system and window treatments/hardware removed prior to installation. We make no guarantee as to
`, "1 whether alarms or window treatments/hardware will fit after replacement. Customer is also aware in some cases there will be glass loss. If there is,the
amount will be dependent on the type of existing windows,type of installation and window style.We make no guarantee as to the amount of glass loss.
Customer Is aware and understands any and all unseen rot is not included in this contract.Should any rot be found there will be an additional charge for
time and materials unless so stated In this contract.
Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration.Removal and disposal of all job related debris,
windows,doors,storm windows and vacuum nightly included. Upon completion of the job and payment In full,a limited warranty shall be Issued.
a Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is not Included in the Contract Price and a separate
check is required at the time of sale for this fee. Check# 1623 $ 35
5 yes All discounts have been applied to this agreement.
e a Yes No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s).
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODI-1ANG AGREEMENT,constitutes the
entire understanding between the parties.and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms
'modified or varied in any way unless such changtes are in writing and sighed by both the 11 1 r(s)and Contractor. Buyer(s)hereby acknowledge that Buyers)has read this Specification
Sheet.
Renewal by Andersen Corporation Buyer(si Buyer(sl
Signature of Project Manager � Signature Signature
THOMAS KELLEY DONALD BOUTHILETTE
Print Name of Project Manager Print Name Print Name
Renewal
by, ndrser ,
WINDOW REPLACEME'N'T �� �rYdraestCcxit�l�ttt
CONPOMINIUM PERMISSION FORM FOR BUILDING PERMIT
W i,AAovv.-are,c ws, o o-rdzred,a*,.&fkZ and e r will, Kat-b* fa-f kt,f cL�y
v*4 1.Appraval.f orkw i y Sig v t4 ana4 ruzwe&f ro-vw fk e,-6�W A
We, Ham-,k i e-Pror-xi� Ma"e ink-Groin b," fk.&al.wl,,y au,!-k uz.e&rWeV---tu�of
Pro ,et+WooaLy,
Halle.re vs e weob fly�iQny for fa-
36 Warbm�Way
Ow•.z& 6yy Pa-zL .&Bavui4n.i l vffv
Tin-?i Ayso•�ia�io•w or Ma.H.agewtewf-Cot^^Jlaawy a9reeti tltial-fitie�move-aw•�.ery ln-cw��.rwwyyi,o-w
fo 5,"pe.irm4k a&L�•to-carry at 4-fln,prapos e d work
Siy e,of AsS�i.a�l�.ow Repreyuulwti�v�a�.d)Tr�i,�tz Dc�he.
(to-,Li e w 0f f orvw, O.Le Hf mla4-j� aY aA>o-v�, o-w fkt-
Ma-.age -Com.rka" Pt�ry w�a y bl-p-y,�deal )
I
30 Forbes Rd.
Northborough,MA,01532
Phone(508)351-2233
Fax(508)986-7072
Website:www.renewalbyandersen.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
V
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 ROAD
City/State/Zip:NORTHBORO, MA 01532 Phone#: 508-351-2200
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 F-1 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance.:
9. E] Building addition
[No workers' comp. insurance P•
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box 41 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 INS. CO.
Policy#or Self-ins. Lic. #:MWC 30293800 Expiration Date: 10/01/15
Job Site Address: 3(0 City/State/Zip: — S,r-Jr�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).Ot6(06
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 1AA for insurance coverage verification.
I do hereb c of e e pains and penalties of perjury that the information provided above is true and correct.
Si ature: Date:
Phone#: 508-351-2200
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: JAIME MORIN 90125
License Number
86 GARDINER ST.Z91 MA 01905 10-06-16
Address Expiration Date
617-966-0412
Signature f Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
RENEWAL BY ANDERSEN 170810
Company Name Registration Number
30 FORBE/Rol NORTHBORO MA 01532 12-23-15
Address Expiration Date
Telephone 508-351-2214
SE N 10-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.
ff
Signed Affidavit Attached Yes....... No...... ❑
11 - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own 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 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apOicable)
New House ❑ Addition ❑ Replacement ndows Alteration(s) Roofing
Or Doors 1E I
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Other[O]
Brief Description of Proposed
Work: REPLACE 1 DOOR NO STRUCTURAL CHANGE
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If Now house and or addition to existina housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
DONALD BOUTHILETTE as Owner of the subject
property
JAIME MORIN
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
i JAIME MORIN as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of erjury.
JAIME MORIN
Print Name
70`-2
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:'_ L: _. R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,a);oavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only,
t� City of Northampton tatus€�fl�ermit
Building Department Curb Cut/Drivewaype�t,
212 Main Street Sevver/Septic Avati i
Room 100 ater allAvaiiability
-1 orthampton, MA 01060 T Sats 011,Structural Plans
actions
s G ao ne 4 3-587-1240 Fax 413-587-1272 PIt tISi Ply:
Electric,pw��
,t tJ,F
Noha Ft�,�. Other Si
P
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -'SITE INFORMATION
1.1 Property Address: This section to be completed by office `
36 WARBURTON WAY NORTHAMPTON; MA 01050 Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
DONALD BOUTIIIFTTE 36 WARBURTON WAY NORTHAMPTON,MA 01060
Name(Print) Current Mailing Address:
413-586-0193
Telephone
Signature
2.2 Authorized A-gent:
JAIME MORiN 30 FORBES ROAD NORTHBORO,MA 01532
Name(Print) Current Mailing Address:
50€3-351-2214
Signature Telephone
SECTION 3 ST ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building $4,817.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fes
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) $4.817.00 Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature
Building Commissioner/inspector of Buildings bate
36 WARBURTON WAY BP-2015-0507
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 158 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-0507
Project# JS-2015-000956
Est. Cost: $4817.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN 090125
Lot Size(sq. ft.): 0.00 Owner: BOUTHILETTE DONALD D TRUSTEE
Zoning: URB(100 Applicant: RENEWAL BY ANDERSEN
AT. 36 WARBURTON WAY
Applicant Address: Phone: Insurance:
30 FORBES RD (508) 919-0900 WC
NORTH BOROMA01 532 ISSUED ON.1013012014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT DOOR
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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/30/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner