29-103 (15) 454 RYAN RD BP-2021-1515
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 103 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-2021-1515
Project# JS-2021-002524
Est.Cost: $13262.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN 170810
Lot Size(so. ft.): 31450.32 Owner: CUMMINGS CLAY
zoning: Applicant: RENEWAL BY ANDERSEN
AT: 454 RYAN RD
Applicant Address: Phone: Insurance:
30 FORBES RD (508) 919-0900 WC
NORTHBOROMA01532 ISSUED ON:6/21/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 5 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 NORT . AMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ( / .).9 51511a,
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 6/21/2021 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
t-.
v
.
-_, -�(E) N The Commonwealth of Massachusetts
! Board of Building Regulations and Standards FOR
v n a % / Massachusetts State Building Code,780 CMR MUNICIP
U EALI
TY
Building Permit Application To Construct,Repair;Renovate Or Demolish a Revised Mar 2011
a Fa One-or Two-Family Dwelling
This Section For Official Use Only _
ks"- Lig Pe7itNumber: it— I.. Date Applied: b/2-1/2-O2-
iktu1 1/17-
ZI Z
N ass / a-2 i
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers •
454 Ryan Rd 29-103-001
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(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,i54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ID Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIP1 .
2.1 Owner'of Record:
Clay Cummings Northampton, MA 01060
Name(Print) City,State,ZIP .
454 Ryan Rd 413-774-0307 '
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building 0 Owner-Occupied 0 'Repairs(s) ❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other Specify: Replacement
Brief Description of Proposed Work2: replacement of 5 windows
SECTION 4:ESTIMATED CONSTRUCTION COSTS
. Item Estimated Costs: Official Use Only
(Labor and Materials) .
1.Building $13,262.00 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee -
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing S -2. Other Fees: $
• 4.Mechanical (HVAC) S List
5.Mechanical (Fire $ se
Suppression) Total All Fees:$ 40 o0
13 262.00 Checks ol9/9Y Check Amount: I/D.— Cash Amount:
6.Total Project Cost: $ 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
86 Gardiner St List CSL Type(see below) U,
No.and Street Type Description
Lynn MA 01906 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 rbabostonpermittin9Crx?andersen.com I Insulation
Telephone Email address D Demolition •
5.2 Registered Home Improvement Contractor(HIC)
Renewal by Andersen 170810 12/22/2021
HIC Compan Name or HIC Registrant Name HIC Registration Number Expiration Date
30 Forbes 2d rbabostonbermittinq(a).andersen.com
No.and Street Email address
Northborough, MA 01532 508.351.2277
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(1VLG.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 )4 • No O
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.
Clay Cummings 6/9/2021 •
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application nd accurate to the best of my knowledge and understanding. •
Jaime Morin • 6/9/2021
Print Owner's or Authorized A t' Name(Electronic Signature) Date
• NOTES:
I. 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 CHIC)Program),will nor 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.rmv/dns
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
1
FRONT:SETBACK_ _ 4
•
FRONTAGE •
1
i
The City of Northampton
. „,-) % , Building Department
p;:;: 212 Main Street
' Northampton,Massachusetts 01060
• Phone(413) 529-1402
Fax (413) 529-1433
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance with the provisions of MGL c40, s54, a condition of Building Permit
Number6e-2b21-ISicis 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 Facili 4 Techology Dr Westborough MA 01581
The debris will be transported by:
Name of Hauler Renewal by Andersen
6/9/202
Signature of Applicant :_ __ _ ___ ___ ___ _ Date:_6/9/202
•
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
v ►= 1 Congress Street,Suite 100
= Boston,MA 02114-2017
— www.mass.gov/dia ,
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print 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):
1.2:1 I am a employer with 30 employees(full and/or part-time).' 7. 0 New construction
2.0I am a sole proprietor or partnership and have no employees working for me in g
8. Remodetin�,
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself(No workers'comp.insurance required.]t
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per 1vIGL c. 14. ]Other replacement
152,§I(4),and we have no employees.[No workers'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.Lie.#: MVVC 3145819 Expiration Date: 10/01/2020 .
Job Site Address: 454 Ryan 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$250.00 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 and• :1, 'us and enaldes of perjury that the information provided above is true and correct
Signature: Date: 6/9/2021
Phone#: 508.3 .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(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: •
City. of Northampton
Massachusetts 4.' ..
DEPAR2'1ENT OF BUILDING INSPECTIONS
u t -. h•:
,r 212 Main Street • Municipal Building
j Northampton, Na, 01060 ' a
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 qualifij 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)
•
•
DocuSign Envelope ID:3C215057-B43F-4CC6-807D-6DAE6EE99E53
Agreement Document and Payment Terms
Adip-w-al
dba:Renewal by Andersen of Boston Clay&Robert Cummings
Legal Name:Renewal by Andersen LLC 454 Ryan Rd
RENEWAL HIC#170810 Florence,MA 01062
�S W(1.D 00011911011011
ERS1E N 30 Forbes Road I Northborough,MA 01532
H:(413)774-0307
Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbookingeandersencorp.com C:(413)230-8921
Clay &Robert Cummings 05/14/21
Buyer(s)Name Contract Date
454 Ryan Rd , Florence , MA 01062 (413)774-0307 (413)230-8921
Buyer(s)Street Address Primary Telephone Number Secondary Telephone Number
clayton.t.cummings@gmail.com rcummings@amben.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: $13,262 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: $4,420
Balance Due: 58,842 Estimated Start: Estimated Completion:
Amount Financed: 10-12 weeks 1-2 days
SO
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: Cc; 1/3 deposit $4420; 1/3 start $4421; 1/3 sub.complete $4421
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 05/18/2021 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.
-
DocuSigned by: - -- DocuSigned by:
(Ayr__ CustotitiAls
Signature of Sales Person at*OBFFA4BA_ :laribifif4620C456...
Marc Festa Clay Cummings Robert Cummings
Print Name of Sales Person Print Name Print Name
UPDATED: 05/14/21 Page 2 / 26
DocuSign Envelope ID:3C215057-843F-4CC6-807D-6DAE6EE99E53
— Itemized Order Receipt
4
— dba:Renewal by Andersen of Boston Clay&Robert Cummings
Legal Name:Renewal by Andersen LLC 454 Ryan Rd
RENEWAL HIC#170810 Florence,MA 01062
b>vaNDERSEN 30 Forbes Road I Northborough, MA 01532 H:(413)774-0307
ItglMU OWL 00011MBINI
Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbooking@andersencorp.com C:(413)230-8921
tD#: ROOM: DETAILS:
100 repeat sale Misc: Misc, repeat Sale, Notes repeat sale Robert Cummings3
Cotton Farm RdNorth Hampton NH
101 front hall Window: Double-Hung (DG), 1:1, Full Frame, EJ Frame,
Traditional Checkrail, Exterior White, Interior White, Glass: All
Sash: High Performance SmartSun Glass, No Pattern,
Hardware:White, Standard Color Extra Lock, Standard Color
Recessed Hand Lift, Screen: TruScene, Full Screen, Grille
Style: No Grille, Misc: None
102 front hall Window: Double-Hung (DG), 1:1, Full Frame, EJ Frame,
Traditional Checkrail, Exterior White, Interior White, Glass: All
Sash: High Performance SmartSun Glass, No Pattern,
Hardware:White, Standard Color Extra Lock, Standard Color
Recessed Hand Lift, Screen: TruScene, Full Screen, Grille
Style: No Grille, Misc: None
103 front hall Window: Double-Hung (DG), 1:1, Full Frame, EJ Frame,
Traditional Checkrail, Exterior White, Interior White, Glass: All
Sash: High Performance SmartSun Glass, No Pattern, Tempered
Glass, Hardware: White, Standard Color Extra Lock, Standard
Color Recessed Hand Lift, Screen: TruScene, Full Screen, Grille
Style: No Grille, Misc: None
104 front hall Window: Double-Hung (DG), 1:1, Full Frame, EJ Frame,
Traditional Checkrail, Exterior White, Interior White, Glass: All
Sash: High Performance SmartSun Glass, No Pattern, Tempered
Glass, Hardware: White, Standard Color Recessed Hand Lift,
Screen: Fiberglass, Full Screen, Grille Style: No Grille, Misc:
None
UPDATED: 05/14/21 Page 3 / 26
DocuSign Envelope ID:3C215057-B43F-4CC6-807D-6DAE6EE99E53
~ /~ Itemized Order Receipt
dba:Renewal by Andersen of Boston Clay&Robert Cummings
Legal Name:Renewal by Andersen LLC 454 Ryan Rd
RENEWAL HIC#170810 Florence,MA 01062
brANDERSEN H:(413)774-0307
fW%MONO.B001m11QilQ1 30 Forbes Road I Northborough,MA 01532
Phone.508-351-2200 I Fax:(508)986-7072 I rbabostonbooking®andersencorp.com C:(413)230-8921
ID#: ROOM: DETAILS:
105 stair well Window: Double-Hung (DG), 1:1, Slope Sill, Insert Frame,
Traditional Checkrail, Exterior White, Interior White, Glass: All
Sash: Hlh Performance SmartSun Glass, No Pattern, Tempered
Glass, Hardware: White, Standard Color Recessed Hand Lift,
Screen: Fiberglass, Full Screen, Grille Style: No Grille, Misc:
None
WINDOWS: 5 PATIO DOORS:0 SPECIALTY:0 MISC: 1 TOTAL S13,262
Renewal by Andersen is committed to our customers'safety by
k:r ra complying with the rules and lead-safe work practices specified by the EPA.
UPDATED: 05/14/21 Page 4 / 26
DocuSign Envelope ID:3C215057-B43F-4CC6-807D-6DAE6EE99E53
���777777 If Using a Builder
" dba:Renewal by Andersen of Boston Clay&Robert Cummings
Legal Name:Renewal by Andersen LLC 454 Ryan Rd
RENEWAL HIC#170810 Florence,MA 01062
brANDERSEN H:(413)774-0307
30 Forbes Road I Northborough,MA 01532
Phone:508-351-2200 I Fax:(508)986-7072 I rbabostonbookingOandersencorp.com C:(413)230-8921
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.
112 v 0 --ebt - DocuS by: e—�/yp"�c ne N1(�/►/�7
Signature of Sales Person gA60BFFA4BA signrawm24620C456...
Marc Festa Clay Cummings Robert Cummings
Print Name of Sales Person Print Name Print Name
UPDATED: 05/14/21 Page 14 / 26
12. The Conmtonwealth of Massachusetts
.— Department of Industrial Accidents
,., " ,= .f Office of Investigations
-' 'r`
�
r_ 60Bo Wtoasnh ing
,MA0n2 Stre et
111=' 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.
Cit /State/Zi 1:Northborough, MA 01532 Phone#:508-351-2277 _
Are you an employer?Check the appropriate box: Type of project(required):
1.IN I am a employer with 30 a 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. Remodeling
2.❑ I am:mile propzietor or partner-ship and have no employees Mace sub-contractors have 8. 0 Demolition 1
working for me in any capacity. employees and have workers'
[No workers'comp.insurance gyp.insurance.: 9. ❑Building addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 MMGL12. Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.®Oita Replacement
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 ell work and then hire outside cofactors must submit a new affidavit indicating such.
ZCmtrectors that chock this box must attached an additional sheet showing the name of the sub-contractos and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam 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 Expo Date:10101/2021
454 Ryan Rd Florence Ma 01062
Job Site Address: City/state/zip:
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify arm a par s and penalties of perjury that the information provided above is true and corn
6/9/2021
st
Sir] ttr ' '` Date'
Phone :508-351
IIOfficial use only. Do not write in this area,to be completed by city or town official 1
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
at. Corraeorrwiealtte of Massadarsetts
Construction Supervisor DMsicn of pra1sion 1 Ucens re
Unrestricted-Buildings of any use group width OOntain Board of aumeng Watkins M ut Standards
1
less than 91000 cubic fastblc meters)of enclosed 7,;N :e�„g.' ,.�. ,;�• jisor
C'S-00012$ ce, ' . pirea 1OlOOI2022
Jil111R£t•. +
/y ^ QK
LYNN iiiit ' . ..\ ,..ii4: A . _ T._ ' .
Failure to possess a current edition of the Massachusetts e,�
State Betiding Code Is cause for revocation of this license. � K.
For ieamrn�ien about Ids Home,
CM'Am 7V.3200 or visitvrraL. _ -..
Q'ie w eaI/ Cy9gAloosaCklAle,42.
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts 02118
Home Improvement ant ctor Registration
T Supplement Card
RENEWAL BY ANDERSEN LLD f ReRegistration: 170610
4 a0 FORBES RD - -t _ - r Eqdridion: 12/22/2021
NORTHBOROUGH,MA 01532 3 _ �_
# : = e*j
. r
L. Waists Address end Return Card.
SCA 1 A 20M-05117
Mu of Conauner Malts S Scsbtsse Regulation
HOME IMPROVEMIMT CONTRACTOR valid for indtvidusl use wry
TYPE:Suodnrn ert Cord be ,th. tuep ruUon date. If found return to:
Hass trader, n Ofllesof Consumer Affairs end Business Rsoulatlon
170810 12 2021 1000 WeehIntlton Street -Suits 710
RENEWAL BY ANDErRSEN Lie Boston,MA 02110
ORRTHBOROU(3H,MA ,7,15S2 under g �;: Not valid Without signature
Page 1 of 1
AC R� DATE(MMIDD/YYYY)
�r� CERTIFICATE OF LIABILITY INSURANCE 09/21/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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
AMC t..
Willis Towers Watson NidweSt, Inc. PHONE 1-877-945-7378 Nol. 1-888-467-2378
c/o 26 Century Blvd --- -- - - -
P.O. Box 305191 Applig certificatesi>:wil1ia.cos
Nashville, TN 372305191 USA
, INSURER(8)AFFORDING COVERAGE NAIL if
INSURER A: Old Republic Insurance Company 24147
INSURED INSURER 8
Renewal by Andersen LLC
30 C Forbes Road SURER C;
Nortbborougb, NA 01532 INSURERD:
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER:W17904932 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 'AWL:WSW. POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTRyt1;0;IUD, POLICY NUMBER =JMWDD1YYYYI'IMW0D1YYYYI. LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE1G"RENTED 500,000
r _;CLAIMS-MADE X OCCUR '' I ! PREMISES(Ea occu renal .$.—.___.
A i I -MED EXP(Any one person) `3--- --_ 10,000
MWZY 314161 20 '10/01/2020 10/01/2021 I PERSONAL&ADVINJURY $ 1,000,000
I GEM.AGGREGATE UNIT APPLIES PER: I GENERAL AGGREGATE $ 4,000,000
X I POLICY 1,71917 1 I LOC I PRODUCTS-COMP/OP AGG $ 4.000,000
.$
OTHER: COMBINED SNGLE I.MT
AUTOMOBILE LIABILITY (Eay I$ 5,000,000
x ANY AUTO Ir BODILY INJURY(Per parson) i{$
A ' ;OWNED I I SCHEDULED NWTB 314159 20 j 10/01/2020 110/01/2021 BODILY INJURY(Per accident)!$
AUTOS ONLY I ;AUTOS
I HIRED NON-OWNED I PROPERTY DAMAGE k
, AUTOS ONLY AUTOS ONLY , -'Per accdW*I $
I
UISRELLA LU1B i«�� _EACH OCCURRENCE $
EXCESS LIAR i ; ' t
,_ f. . __.? i CLAIMS-MADE .._AGGREGATE $
I DED RETENTIONS $
WORKERS AND EMPLOYERS'LIABILITY I PENSATION T - +,X:STATUTE ER
A A CERIME�RIPAR DEEXECUTIVE No NIA E.L.EACH ACCIDENT $ 1,000,000
NBC 314158 20 10/01/2020 10/01/2021`
(Mandotory In NH) i !E.L DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under y
1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached If more apace Is requited)
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 REPRESENTATIVEEvidence of Insurance c J'
0 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
SR ID, 20103273 sATcar 1820957
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