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17C-108 (11) BP-2022-1638 87 HIGH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-108-001 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-2022-1638 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2022 Contractor: License: Est. Cost: 13140 RENEWAL BY ANDERSEN 090125 Const.Class: Exp.Date: 10/06/2024 Use Group: Owner: J KLOC STEPHEN S III &LISA Lot Size (sq.ft.) Zoning: URB Applicant: RENEWAL BY ANDERSEN Applicant Address Phone: Insurance: 30 FORBES RD 508-351-227 MWC31415820 NORTHBOROUGH, MA 01532 ISSUED ON: 12/22/2022 TO PERFORM THE FOLLOWING WORK: 2 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I ,ec) Tit • • Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • gEC 2 0 2022 • AJ, • The Commonwealth of Massachusetts _ _ !�- Board of Building Regulations and Standatda �LJt n!�:,INSPEC-IONS FOR . .�a moe`lvN/ Massachusetts State Building Code,780 CMI� ' • •• ' - USENlCiPALTTY • Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only ' Buildin Permit Number: 6/9. d " /`/ Date Applied: hEu Z-35 //& )2-ZZ.zoz2: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: • 1.2 Assessors Map&Parcel Numbers • • 87 High Street 17C 108-001 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private❑ Zone: Outside Flood Zone? Municipal CI On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Lisa & Chip Kloc Florence,MA 01062 Name(Print) City,State,ZIP 87 High Street (413)575-3323 . Ikblaiser@ao'I.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building JR Owner-Occupied ❑ `Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg.0 Number of Units Other tx Specify: Replacements Brief Description of Proposed Work2: Replacement of 2 windows."No structural changes. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Casts: Official Use Only (Labor and Materials) I.Building $ 13,140 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ -2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All F e : Suppression) Li 6.Total Project Cost: $ Check No.yj I Check Amount# Cash Amount: 13,140 0 Paid in Full ❑Outstanding Balance Due: • • • • • 'SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-090125 10/06/2024 Jaime Morin • License Number Expiration Date • Name of CSL Holder List CSL Type(see below) •• U 30 Forbes Rd. No.and Street Type Description Northborough, MA 01532 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry • RC Roofing Covering • • WS Window and Siding SF Solid Fuel Burning Appliances 508-351-2277 rbabostonpermitting@andersencorp.com I Insulation Telephone Email address - D Demolition • 5.2 Registered Rome Improvement Contractor(HIC) • 170810 12/22/2023 Renewal by Andersen HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 30 Forbes Rd. rbabostonpermitting@andersencorp.com No.and Street Email address Northborough. MA 01532 508-351-2277 . City/Town,State,ZIP Telephone • SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) • Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached?' Yes /ii( . No I] 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. • Lisa&Chip Kloc(See signed contract attached) 12/16/2022 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 accura the best of my knowledge and understanding. • Jaime Morin 12/16/2022 Print Owner's or Authorized Agent's Name tc 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(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at . www.mass_gov/oca Information on the Construction Supervisor License can be found at w^ww.mass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.It) (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" • The City of Northampton Building Department t.0.1g r 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 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.LNorthborou_gh, MA 01532 The debris will be transported by: Name of Hauler Renewal by Andersen 1 2/16/2022 Signature of Applicant:_ _ Date:_ ' I , The Commonwealth of Massachusetts Department of Industrial Accidents Lit—Mt 1 Congress Street,Suite 100 '%:11111c Boston,MA 02114-2017 www.massgov/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.®I am a employer with 30 employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in g ❑ 8. Remodeling any capacity.[No workers'comp.insurance required.) 3.0 I am a homeowner doing all work myself.[Na workers'comp,insurance required.]t 9. ❑Demolition 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct ail work on any property. I will ensure that all contractors either have workers'compensation insurance orate 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.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.®Otl2er R e pl a ce l71@n t ffi 152,§I(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box ltl 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 22 Expiration Date: 10/1/2073 • . Job Site Address: 87 High Street cityistate/zip: Florence, MA 01062 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 certt;fy under the pains and penalties rjury that the information provided above is true and correct Signtature: Date: 12/16/2022 Phone#: 508-351-2277 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(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 DEPARTMA'NT OF BUILDING INSPECTIONS • 212 Main Street • Municipal Building vs •ly` Northampton, MA 01060 ...5 rbC 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 ,Q_P • ,20_ • (Signature) City of Northampton 212 Main Street,Northampton,MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 87 High Street, Florence, MA 01062 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 12/16/2022 Date Signature of Permit Applicant +� ......=.i Agreement Document and Payment Terms�:.�...I' DBA:RENEWAL BY ANDERSEN OF BOSTON Lisa&Chip Kloc RENEWAL Legal Name:Renewal by Andersen LLC 87 High Street HIC#170810 Florence,MA 01 62 bRANDERSEN + � ,. 9" 30 Forbes Road(Northborough,MA 01532 H:(413)575-33 3 oalex Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmail.com Lisa &Chip Kloc 10/11/22 BUYER(S)NAME CONTRACT DATE 87 High Street,Florence, MA 01062 (413)575-3323 BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER Ikblaiser@aol.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 Al�dersen 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: $13,140 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: $13,140 Estimated Start: Estimated Completion: 10-12 weeks 1-2 days AMOUNT FINANCED: $13,140 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 a providing at this time is only an estimate.We will communicate an official date and time at a la r date.Rain and extreme weather are the most common causes for delay. NOTES: 1/3 contract signing; 1/3 start of install; 1/3 sub completion 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,u derstands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices f 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 10/14/2022 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. (414glitiyiv,-- (51„.„,Qtalc. 1.4 -4,:kle,-4P) SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Rebecca McCallister Lisa Kloc Chip Kloc PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 10/11/22 Page 2 / 25 J 'LJ' Itemized Order Receipt DBA:RENEWAL BY ANDERSEN OF BOSTON Lisa&Chip Kioc R E N E WA! Legal Name:Renewal by Andersen LLC 87 High Street HIC#170810 Florence,MA 01062 yANDERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)575-3323 ANAKk WNW S UVMAIRYI11M Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmail.com ID#: ROOM: SIZE: DETAILS: PRICE: 101 Room 1 Window, Gliding, Double, 1:1, Passive / Active, Base Frame, Exterior White, Interior Pine, Performance Calculator, PG Rating: 30 I DP Rating: + 30/ - 30, Glass, All Sash: High Performance SmartSun Glass, No Pattern, Tempered Glass, Hardware, Oil Rubbed Bronze, Estate Finish Extra Lock, Screen, TruScene, Full Screen. Grille Style, No Grille, Misc, Construction - Lower/Build-In Opening, Includes framing, siding, drywall and one coat mud &tape. 102 Room 1 Window, Gliding, Double, 1:1, Passive/ Active, Base Frame; Exterior White, Interior Pine, Performance Calculator, PG Rating: 30 I DP Rating: + 30/ - 30,Glass, All Sash: High Performance SmartSun Glass. No Pattern, Tempered Glass, Hardware, Oil Rubbed Bronze, Estate Finish Extra Lock, Screen, TruScene, Full Screen, Grille Style, No Grille. Mlsc, Construction - Lower/Build-In Opening, Includes framing, siding. drywall and one coat mud & tape. WINDOWS: 2 PATIO DOORS: 0 ENTRY DOORS: 0 SPECIALTY: 0 MISC:0 TOTAL $13,140 Oftlittz Renewal by Andersen is committed to our customers'safety by ` complying with the rules and lead-safe work practices specified by the EPA. 10/11/22 Page 3 / 25 If Using a Builder '1rc�J11- DBA:RENEWAL BY ANDERSEN OF BOSTON Lisa&Chip Mot RENEWAL Legal Name:Renewal by Andersen LLC 87 High Street HICK 170810 Florence,MA 01.62 ayANDERS£N 30 Forbes Road I Northborough,MA 01532 H:(413)575-3323 Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmail.com 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. Civjayh,. otu,d? SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE Rebecca McCallister Lisa Kloc Chip Kloc PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME 10/11/22 Page 18 / 25 Page 1 of 1 7 AC AR Q� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/21/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center NAME: Willis Towers Watson Midwest, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd (A/C,No,Ex0• —_ (A/C,No) P.O. Box 305191 A csrtificatas8willis.can ADDRESS: Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIC It INSURER A: Old Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC -- - - 30 Forbes Road INSURER C: Northborough, MA 01532 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W26007651 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 TYPE OF INSURANCE IN p SYWR D LTR POLICY NUMBER (MM/DD/YYYYL(MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY ,000,2000 EACH OCCURRENCE _ S DAMAGE TO RENTED CLAIMS-MADE X I OCCUR PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 MWZY 314161 22 10/01/2022 10/01/2023 PERSONAL&ADVINJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED MUTE 314159 22 10/01/2022 10/01/2023 BODILY INJURY(Per acciden $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE Z EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X ;MUTE EMPLOYERS'LIABILITY STATUTE ER Y/N A ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No NIA MWC 314158 22 10/01/2022 10/01/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 8 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance • 'J,- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID. 23076070 BATCH• 2676324 Commonwealth of Massachusetts 11, Division of Occupational Licenstire Board of Budding Re,suratabons and Standards "..,•)nstoittia VA4trtsor CS-090125 * Kijoirsor 10/0012024 JAtMELMO - 84 NOTTWO RAYMOND NO 41"0/1v4O, Commissioner Comatucsan StotaMIMM Umaimattsil-11111salamporSsOsisifiliffridOlkesollin • Ins Ow SS**awesat alas weistatolawitstiod 0111100- paws* mallidrad00*filat Sh10.101110101001 1 SSW Cob is sum far sensillen eft*ilessos. Fee Istfierandien moot sflassost Oaf OM?mum at ytoti ttow.ttaisomosio THE COMIONWEALTH OF MASSACHUSETTS Office of Consumer Affebik&Business Regulation Registration valid for individual use only before the HOME IMPROVEMND1ON1RACTOR expiration date. If found return to: TYPE:&u mont Card Office of Consumer Affairs and Business Regulatio Ritn ' /43:811ffoll 1000 Washington Street -Suite 710 1/0010 12/22/2023 Boston,MA 02118 RENEWAL BY ANDE JAMAS MORIN Et: ? 30 FORBES RD NORTHBOROUGH,MA Ot Undersecretary Not lid without s ge4riStoce Page 1 of 1 ACQRO0 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/21/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center NAME: Willis Towers Watson Midwest, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd (A/C,No.EMS: (A/C.NO P.O. Box 305191 A ADD DREDRE SS: certificates@willis.com Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE i NAIC INSURERA: Old Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andersen LLC 30 Forbes Road INSURERC: Northborough, MA 01532 INSURER D• INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W26007651 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSO WVD (MM/DD/YYYY) (MM/DD/YYYY) LTR POLICY NUMBER LIMITS X COMMERCIAL GENERAL LIABILITY 2,000,000 EACH OCCURRENCE $ C LNMS-MnDE x OCCUR DAMAGE 10 RENTED 500,000 PREMISES(Ea occurrence) $ A MED EXP(Any one person) $ 10,000 MWZY 314161 22 10/01/2022 10/01/2023 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POUCY JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED MWTB 314159 22 10/01/2022 10/01/2023 BODILY INJURY(Per accident) $ AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS • $ WORKERS COMPENSATION X I PERTUTE OTH- AND EMPLOYERS'LIABILITY STA ER Y A ANYPROPRI ETOR/PARTNER/EXECUTIVE f N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? n NM MWC 314158 22 10/01/2022 10/01/2023 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t. Evidence of Insurance '47-- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 23076070 BATCH 2676324 • • • • .w.. tllltrl • • • ritt,-41-basti d0 ,,mlrfRgS 11.MiiNMlitill .. • IOW PRIM* y:r+a�.a�YfM�wif� +Y�r riOtY�lr.���s, •. L '""!' *.+Ww�. l,4rsrr aiw�s�*1r,/+�rw�j��.�.sarrtt��.aa...�rae' - 61 •O arIUMPARKRU.1:04ittA swum IM M UIC14tii 7MRQLLw uogfesi _ 1 - varlpioupo mpg, - Jil +�v*�t-r+� rrrarae�srua� r+�un�1r • ft I., a ..r .