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31A-061 2 LANGWORTHY RD BP-2018-0393 GIS#: COMMONWEALTH OF MASSACHUSETTS Mg.Block: 3 1 A-061 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=laced BUILDING PERMIT. Permit# BP-2018-0393 Proiect# JS-2018-000698 Est.Cost:$34820.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 090125 Lot Size(sg.ft.): 6403.32 Owner: TOPAL SAMUEL&CATHY W Zoning:URA(99)/URB(l) Applica t.- RENEWAL BY ANDERSEN AT: 2 LANGWORTHY RD Applicant Address: Phone: Insurance: 30 FORBES RD (508) 919-0900 WC NORTHBOROMA01 532 ISSUED ON.-1011812017 0:00:00 TO PERFORM THE FOLLOWING WORK:20 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. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/18/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner ISI Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability. Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Ske Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION t5 p—j 9—'--5�'-� 1.1 Property Address: 2 Langworthy Rd., Northampton,MA 01060 This section to be completed by office Map 64 Lot CJ//��kLj _--Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Samuel and Cathy Topal 2 Langworthy Rd.,Northampton, MA 01060 Name(Print) C rre t Maili1 gMail A dress: See Attached Contract Telephone Signature 2.2 Authorized Assent: JAIME MOR 30 FORBES ROAD NORTHBORO,MA 01532 Name(Print) Current Mailing Address: _ 508-351-2277 Signature Telephone SECTION 3-ES MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 34820 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 34820 Check Number This Section For Official Use Only Building Permit Number: DateIssued: Signature: Ing Commissioner/Inspector of Buildings 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 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bIdg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� NO �_�� YV �_�� D0N7KNOY[5 �_� iFYES, date issued: IF YES: Was the permit recorded atthe Registry ufDeeds? �� NO ��DONT KNOW �_� YES v^� IF YES: enter Book Page and/or Ducument# �� B. Does the site contain o brook, body nfwater orvved ��wetlands? NO �_� DONT KNOW �_� YES �_� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tpbeobtained \^_//�� Obtained /~^+�� Date Issued: ' C. Duany signs exist onthe property? YES \�� 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 0 |FYES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,orfilling)over 1acre oriahpart ofacommon plan that will disturb over 1acre? YEG [��) NO (��> IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aggfiqa_b_1e) I New House F-1 Addition F_� Replacement windows Alteration(s) Roofing F_� Or Doors rM I Accessory Bldg. F� Demolition ED New Signs [0] Decks [M Siding[0] Other[0) Brief Description of Proposed Work: Replace 20 windows 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 existing housing, complete he 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 . 1. 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 1, Samuel and Cathy Topal 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. SEE CONTRACT 10/10/17 Signature of Owner Date 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 perjury. JAIME MORIN Print Name 10/10/17 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: JAIME MORIN 9 012 5 License Number 30 Fg?pes Rd. , Northborough, MA 01532 10-06-18 Address Expiration Date ()n? 508-351-2277 Signat 7 Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 RENEWAL BY ANDERSEN 170810 Company Name Registration Number 30 FO ROAD NORTHBORO,MA 01532 12-23-17 Address Um Expiration Date Telephone.5 0 8 3 5 1-2 2 7 7 SECTION 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. Signed Affidavit Attached Yes....... It No...... 0 1. - 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 Renewal Agreement Document and Payment Terms bYAndC'I'S m dbas Renewal by Andersen of Boston Samuel rlw Lathy Topal Legal Name:Renewal by Andersen LLC 2 Langworthy Road rr:�r H1C#170810 Northampton,MA 01060 WINDOW Ott LAOrMENt 30 Forbes Road I Northborough,MA 01532 H:(413)5$4-1169 Phone:50$-351-2200 1 Fax:(50$)9$6.7072 1 rbaboston@gmail.com Buyer(s)Name: Samuel & Cathy Topa) Contract Date: 10/06/17 Buyer(s)Street Address: 2 Langworthy Road, Northampton, MA 01060 Primary Telephone Number: (413)584-1169 Secondary Telephone Number: Primary Email: setopal*comcast.net 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: +$34,820 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: S0 Balance Due: $34,820 Estimated Start: Estimated Completion: Amount Financed: $0 8-10 weeks 3-4 Days Method of Payment•. Credit Card 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: AMEX exp 4/20, $11605 deposit. 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 10/10/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEsVER DATE IS LATER SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Renewal by Andersen LLC dba:Renewal by Andersen of Boston Buyer(s) Signature of Sales Person Signature Signature David Flynn Samuel Topal Cathy Topal Print Name of Sales Person Print Name Print Name UPDATED: 10/06/17 Page 2 / 31 Now Renewal Itemized Order Receipt byAndersem dba:Renewal b Andersen of Boston Y Samuel&Cathy Topal man." Legal Name:Renewal by Andersen LLC 2 Langworthy Road HIC#170$10 Northampton,MA 01060 30 Forbes Road I Northborough,MA 01532 H:(413)584.1169 Phone:508-351.2200 1 Fax:(508)986-7072 1 rbaboston*gmail.com r• ROOM: DETAILS: 101 Kitchen Window: Double-Hung, Equal, Slope Sill Insert, Traditional Cherkrail, Exterior White, Interior White, Glass: All Sash High Performance Srnart5un Glass, No Pattern, Hardware: White, Screen: TrUSCene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash Colonia( 3w x 2h, Misc: Aluminum, Wrap, Aluminum Wrap 102 Kitchen Window: Double-Flung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SrnartSuo Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All SashColonial 3w x 2h, Misc: Aluminum Wrap, Aluminum Wrap 103 Kitchen Window: Double-Flung, Equal, Slone Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash Nigh Performance SrriartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash Colonial 2w x 21h, Misc: Alurninurr: Wrap, Aluminum Wrap UPDATED: 10/06/17 Page 3 / 31 Renewal Itemized Order Receipt byAndersen. dba:Renewal b Andersen of Boston Y Samuel&Cathy Topal M Legal Name:Renewal by Andersen LLC 2 Langworthy Road HIC#170$10 Northampton,MA 01060 30 Forbes Road I Northborough,MA 01532 H:(413)584-1169 Phone:508.351-2200 1 Fax:(508)986-7072 1 rbaboston*gmaii.com • • • DETAILS: 104 Kitchen Window: Double Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Grass: All Sash High Performance Sn'jartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash. Colonial 4,N x 2h, Misc: Alunlinurn Wrap, AluminUrn Wrap 105 Kitchen Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Cirrlles Between Glass (GBG), Grille Pattern: All Sasha Colonial 2w x 2h, Misc: Aluminum Wrap, Aluminum Wrap 106 Kitchen Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash Nigh Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Mat(h, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash; Colonial 2vr x 2h, Misc: Aluminum Wrap, Alurmnurn Wrap 107 Kitchen Window: Picture-•, Insert Frarne, Exterior White, Interior White, Glass: All Sash High Performance SrnartSun Glass, No Pattern, Grille Style: Grilles Bemeen Glass (CIBC), Grille Pattern: All Sash C olomai 5w x 4h, Misc: Aluminum Wrap, Aluminum Wrap UPDATED: 10106/17 Page 4 / 31 Renewal Itemized Order Receipt byAndemil dbs:Renewal b Andersen of Boston Y Samuel&Cathy Topai M.. 1 Legal Name:Renewal by Andersen LLC 2 Langworthy Road HIC#1708101 Northampton,MA 41060 30 Forbes Road I Northborough,MA 01532 N:(413)584.1169 Phone:508.351-2200 1 Fax:(508)986-7072 1 rbabostonOgmail.com r • ROOM: DETAILS: 108 Kitchen Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SrnartSUn Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash. Colonial 2w x 2h, Misc: Aluminum Wrap, Alurninrim Wrap 109 Hallway Window: Double Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior-White, Interior White, Glass: All Sash_ High Performance SrnartSun Glass, No Pattern, Hardware: Waiter, Screen: TrttScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash: Colonial 3w x 2h, Misc: Aluminum Wrap, Alummurn Wrap 110 Living ROOM Window: Double Hung, Equal, Slope Sill Insert, traditional Checkrail, Exterior White, Interior White, Glass: All Sash, High Performance SmaitSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash Colonial 3w x 2h, Misc: Alurninum Wrap, Aloniinum, Wrap UPDATED: 10/06/17 Page 5 ! 31 Renewal Itemized Order Receipt byAndersen. dba:Renewal b Andersen of Boston Y Samuel&Cathy Topal AW, Legal Name:Renewal by Andersen LLC 2 Langworthy Road HMC#170810 Northampton,MA 01060 WIMU30 Forbes Road I Northborough,MA 01532 N:(413)584-1169 Phone:508-351.2200 1 Fax:(508)986-7072 1 rbabostonogmail.com 'O• DETAILS: 111 Living Room Window: Double Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: JruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash, Colonial 3w x 21), Mist: Aluminum Wrap, Aluminum Wrap 112 Living ROOM Window: Double-Flung, Equal, Slope Sill Insert, Traditional (heckrail, Exterior White, interior White, Glass:All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: 1rr Scenc- with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash; Colonial 3w x 21), Misc: Aluminum Wrap, Aluminum Wrap 113 Living Room Window: Double-i-lung, Equal, Slope Sill insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sa0i High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash. Colonial 3w x 2h, Misc: Alufninum Wrap, Altsrninum Wrap UPDATED: 10/06117 Page 6 1 31 Renewal Itemized Order Receipt byAndemn. dbac Renewal b Andersen of Boston Y Samuel&Cathy Topal Mao Legal Name:Renewal by Andersen LLC 2 Langworthy Road HIC#170810 Northampton,MA 01060 30 Forbes Road I Northborough,MA 01532 N:(413)584.1169 Phone:508-351.2200 1 Fax:(508)986.7072 1 rbabostonOgmaii.com t 11• tr 214 Bath 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: Sash t High Performance SmartSun Glass, Obscure, Sash 2 High Performance Sr-nartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, bull Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: Alt Sash Colonial 3w x 2h, Misc: Aluminum Wrap, Aluminum Wrap 215 Bed 1 Window: Double-Hunq, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SniartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior ColorMatch, Full Screen, Grille Style: Grilles Between Glass ((--IBG). Grille Vattern: Alf Sash Colonial 3w x 2h, Misc: Aluminurn Wrap, Aluminum Wrap 215 Bed 1 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: T-ruScene with Exterior Calor Match, Full S(reen, Grille Style: Gilles Between: Glass (CABG), Grille Pattern: All Sash. Colonial 3\)v x 2h, Misc: Alummum Wrap, Aluminum Wrap UPDATED: 10/06/17 Page 7 / 31 Renewal Itemized Order Receipt byAndemn. dba:Renewal by Andersen of Boston Samuel&Cathy Topal r�rr legal Name:Renewal by Andersen LLC 2 Langworthy Road �rrrr HK#170810 Northampton,MA 01060 WINNOW RE IACEMENT 30 Forbes Road I Northborough,MA 01532 H:(413)584-1169 Phone:508.351-2200 I Fax:(508)986-7072 1 rbaboston*gmailcom ROOM: DETAILS: 217 Bed 2 Window: Double-Hung• Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, interior White, Glass: All Sash High Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: TruScene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash. Colonial 3w x 2h, Mist: Aluminum Wrap, Alurninurn Wrap 218 Bed 2 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash_ High Performance SrnartSun Glass, No Pattern, Hardware: White, Screen: 'TruScene with Exterior Color Match, Full Screen. Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash: Colonial 3w x 2h, Misc: Aluminum Wrap, Alurninurn Wrap 219 Bed 2 Window: Double Hung, Equal, Slope Sill Insert, Traditional Checkrail, Exterior White, Interior White, Glass: All Sash High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruSeene with Exterior Color Match, Full Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash; Colonial 3w x 21h, Misc: Alr.rminum Wrap, Aluminum Wrap UPDATED: 10/06/17 Page 8 / 31 Renewal Itemized Order Receipt by-Andersen. dba:Rtnewal b Andersen of Boston Y Samuel&Cathy Topaf ♦>�� Legal Name:Renewal by Andersen LLC 2 Langworthy Road " HIC#170810 Northampton,MA 01060 wiNoow RE LACEMENT 30 Forbes Road I Northborough,MA 01532 H:(413)584-1169 Phone:508.351-2200 I Fax:(508)986-7072 1 rbaboston*gmail.com D• ROOM: 220 Bed 3 Window: Double-Hung, Equal, Slope Sill Insert, Traditional Checkrad, Exterior White, Interior White, Glass: Al( Sash High Per#ormance SmarlSun Glass, No Pattern, Hardware: White, Screen: 'TrcjScene with Exterior Color Match, FUll Screen, Grille Style: Grilles Between Glass (GBG), Grille Pattern: All Sash. Colonial 3w x 2h, Misc: Alurninun) Wrap, Aluminum, Wrap WINDOWS:20 PATIO DOORS:0 SPECIALTY.0 MISC:0 TOTAL $34,820 ' Renewal by Andersen is committed to our customers'safery by complying with the rules and lead-sae work practices specified b the EPA. UPDATED: 10106/17 Page 9 f 31 The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 r� www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED V►7TH THE PERMITTING AUTHORITY, 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.E1 I am a employer with 30 employees(full andtor part-time).' 7. New construction 2.Q 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity [No workers'comp.insurance required.] 9. ❑Demolition 3.Q 1 am a homeowner doing all work myself [No workers'comp insurance required)f 10 C]Building addition 4.3 1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I i TJ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 a I am a general contractor and 1 have hired the subcontractors listed on the attached sheet. 13.oRoof repairs These sub-contractors have employees and have workers'camp,insurance 14.[Z)Other Replacement 6.[]We are a corporation and its officers have exercised their right of exemption per MGL c. —` 152,§1(4),and we have no employees (No workers'comp insurance required 1 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 show ing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,the}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.Lie.#:MWC 311129 00 Expiration Date:10/1/2018 Job Site Address: 2 Langworthy Rd. City/State/Zip: Northampton, MA 01060 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,§§'25A is a criminal violation punishable by a fine up to$1.500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificat I do hereb ertify under thg1pains andpenalties of perjury that the information provided above is true and correct: Sien Date: 10/10/17 Phone#:5 1-2277 Official use only. Do not write in this area,to be completed by cit)=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#• Page 1 of 1 ACCOR0CERTIFICATE OF LIABILITY INSURANCE F °09/27/2017ATE Y' 04J27J201T 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(les)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 NAME:__ ---- - ----.. -- -- -- �.- Willis of Minnesota, Inc. PHONE 1-877-945-7378 FAX 1-868-467-2378 c/o 26 Century Blvd -- -- .__-. --. - lA+� .. _- P.O. Box 305191 E-IL certificatos*willis,com Nashville, 737 372305191 BSA INSURE, S AFFORDING COVERAGE NAIC8 INSURERA: Old Republic Insurance Company 24147 INSURED INSURER B Renewal y Anderson LLC - - 30 Forbes Road INSURER C Nortbborougb, ILII 01532 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:W3762206 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 REOUIREMENT, 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. MSR. _.__-...._.AI�t'SUgR-_.-____._._----_._.._- ----'-'POL�YEFF POLICYE%P_... _ -..__.....-`—. LTR TYPE OF INSURANCE POLICY NUMBER M D/E IYYYY WARS ',. X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE5 1,000,000 _ �gMAGETOTtENTE15_ --- -- CLAIMS-MADE _.x_.OCCUR PREMES(Ea occurred S.- 500,000 _ A MEO EXP(Any one person) $ 10,000 WWZY 311132 10/01/2017 10/01/2013 J PERSONAL b ADV INJURY $ 11000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 4,OOD,000 X POLICY PRO ' PRODUCTS-COMPlOP AGG 5 _._._. JECT _. .:LOC 4,000,000 OTHER. $ .AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 5,000,000 -_. ca student X ANY AUTO BODILY INJURY(Per Person) S SCHEDULED AUTOS ONLY AUTOS b WTS 311130 10/01/2017 10/01/2018 BODILY INJURY(Per atudenti S HIRED PROPTV DAMAGE AUTOS O Ei't - -_ AUTOS ONLY :AUTOS ONLY _LPer aCCid-t 5 S UMBRELLA I" OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATIONX PE O7H- AND EMPLOYERS'LIABILITY STATUTE _ER A ANYPROPRIETORIPARTNERJEXECUTiVE YIN 1,000 000 MWC 311129 OQ 20/O1J2417 10/Ol/2013- OFFICERAAEMBEREXCLVDED� NO N/A E.L.EACH ACCIDENT--- S -------- -- --- - --- (Mand my M NHI E.L DISEASE-EA EMPLOYEE S1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS be[. E.L.DISEASE-POLICY LIMIT $ -_1.000,000 DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be enact-ad It 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 Eby' Evidence of Insurance �• '/�� C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD SR M 15126106 SATM 459145 MaSsachusetts Departrne,nt Soard of; :7-1 � � a"114 stallodiolu L ensu. I2 Construction s r JANWE L MORIN 86 GARDNR ST LYNN MA 0 1905 `w . +' MIS IMPROVEMENT CN`fi RA TO R Registration 170810 . 4Type. Expiration, 1 / 31 }17 Supplement nt Card RENEWAL BY ANDERSON LLC. JAIME MORIN 30 FORBES RCS NORTHBOROUGH, MA 0153 t . nullersecretar fO , .1 (A to � �- OAJ It-s�. �' � . i�$ ..: 7 {' � �' i� - •� +fig fp q. ri F31 ••� Aatlk:u�=plbta -kit- =Yimood i Argv� 4avwEat£lmart�'3un R+3duct Type. Picture U-Pactor SKEW Haat Gain C oefflole t AVOrTK>NA4 Pw F-oPJ -vmcr= #%A*nN" Vi+sibi�Tray»mittanc� i`"' i a ■ /M!lWai rlll+ }14�NA1!*iVMbIMYli1��1'�'� •. paasl(awllAl. RIMS GM41pl r�l1ilf+l MRP�OY4/frllKiM NtN'�slw'.�•�Ii Mtf�4iM"khMw�'J901. N$IIOY/171111RV11�sA•ar Mah�ElRae't<*'Wi!!t*l��IK vl0t/MicR*YI►djlesMY WIl. wr�+oawi.Ys■•rAw r-•afar iM.H.at,Mrb.•ap�t RM,aela;dan. . rruemxslt s 3.v 3Tr • 4 FjAF M a AAMAN*4A1R':L41ftU—.QV4S-W DP;m( F^1,:SO SCA'Csorift News y�,3 etaa�eesarr� au an r.l.rarar..�r..y/.Inala , t `�1akul�Rarkaal/� '�'�'��Ti�►� I.aurtrWr aalwrtnaa 100-00611007 Masco ., ienaNrmO:.& ad Ws�x City of Northampton 212 Main Street,Northampton,MA 0106+0 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: 2 Langworthy Rd.,Northampton,MA 01060 The debris will be transported by: Renewal by Andersen The debris will be received by: Renewal by Andersen Building permit number Name of Permit Applicant Jaime Morin 10/14117 Date S` ature of Permit Applicant