5 RIVERBANK RD - BUILDING INSPECTION (3) 23 CY, C1 6D-] 33
The Ciiiintonwealth of Massachusetts
Board of Building Regulations and Standards u CITY OF
Massachusetts State Building Code, 780 cm?J1 bi NOV 2 2 P 3- 1 FALEM
Revised Afw 2011
Building Permit Application To Consftuct,Repair,Renovate Or Demolish a
One-or Two-Faintly Dwelling.
:� c orfics ;o
7
SECTION 1:SrM AV ORMATIONl
1.1 Property Address; 1.2 Assessors Map&Parcel Numbers
5 RIVERBANK ROAD 31-0247-0
1.1als this an accepted street?yes_ no�_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R 1
Zoning District Proposed Use Lot Area(sq ft) Fruitage(ft)
1.5, Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Pxqumd Provided
1.6 Water Supply-(M.G.L c,40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 13 Private 13 Zone: Outside Flood Zone? M
Check if unicW 0 On she disposal system D
yesE3
2.1 Owner'of Record:
ROBERT& LINDA DOUGHTY SALEM, MA 01870
Name(Print) city,SmIC6 ZIP
5 RIVERBANK ROAD 978-224-2211 lindadoughty(cNive.com
No.and Stud Telepbom Email Address
$RPN 3:,DESCRIP`MN OF PROPOSED (choc :all tiint apply)
Now ConsftftwWbon 13 Existing Building F( Owner-Occupied kl( Repairs(s) 13 1 Alteration(s) 13 Addition E3
Demolition E3 Aceemory Bldg.0 Number of Units I Other Specify:Replacement
Brief Description of Proposed Word: Replacement of 2 windows-no structural work to be performed
SEC'MN.4:FSTIMATED-OONSMUCMONjCOSTS,t,
Estimated Costs:( End Materials ' - — I -�
Item ofl:dal use 0alyi,U" )
1,Building $ 3819.00 1, Building Permit Fee $ 10111:916 hw*fee is ddermined"
— 13 86ndird,eliynawAw#_Ciim red
2.Electrical $ E.3 Total Pr-6jed Costa(Itain 6)x=14her x
$
3.Plumbing $
4.Mechanical (HVAQ $ List
Tmechartical a% Total All
I SUDDreSSiOn)
ChadL No. - Check Arriount. QA Amount:
6.Total Project Cost: $ 3819.00
1(1 _-'C) MaoLIED tt"N
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125
10-06-18
Jamie Morin License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
30 Forbes Road
No.and StreetIY)o: Description
Northborough, MA 01532 U Unrestricted(Buildings up to 35 OW cu.fL
R Restricted 18:2 Family Dwelling
CityfFown,State,ZIP M Masonry
RC Rooling Covering
W S window and Siding
SF I Solid Fuel Burning Appliances
508-351-2244 rbabostobpermitting(a)andersencorp.com I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Rome Improvement Contractor(HIC) 170810 12-23-17
Renewal by Andersen HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
30 Forbes Rd rbabostonpermittinq@andersencorp.com
No.and Street Email address
Northborough, MA 01532 508-351-2244
City/Town,State,ZIP Telephone
SECTI614'6:WORKERS'COMPENSATION E4SURANCE AFFIDAVIT(M.G.L.e.ISL§ 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.......... No...........O
SECTION 7a:OWNER AUTHORTZATION'TO BE COMPLETED WHEN
z " OWNER'S AGENT OR CONTRACTOR:APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf;in all matters relative to work authorized by this building permit application.
See Attached Contract 11/19/16
Prim Owner's Name(Electronic Signature) Date
II, _ . SECTION11i:OWNER'OR AUTHORIZED AGENT DECLARATION•
By entering my name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained in this application is true and accurate of my knowledge and understanding.
Jaime Morin < / 11/19/16
Print Owner's or Authorized Agent's Name(El is Signature) Date
NOTES: . sr.
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.nov&m Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 SALFAI, MISSACHUSETTS
8t.�M94G DEPARTMENT
120 WASH1NGeoN STEW,r PLOOR
TEL(979)74S.9595
FAX(978)740-9846
1uat8R4r PY DRTSCOI.L
MAYOR THOMAS ST.PERM
DmEcroa oP Pl.'mm PROPEtt7Y/ LIMING COMMI ONM
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CMR section It 1.5
Debris,and the provisions of MGL c 4o,S 54;
Building limit# is issued with the condition drat the debris resulting$van
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 transported by.
Renewal by Andersen
(name of hauler)
The debris will be disposed of in
Renewal by Andersen
(Dame of fuility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
C�
si of permit awlieam
11/19/16
data
debrinf.doc
Renewal Agreement Document and Payment Terms
byAndersen. dbw Renewal by Andersen of Boston Linda and Robert Doughty
Legal Name:Renewal by Andersen LLC 5 Riverbank Rd
HIC#170810 Salem,MA 01970
WINDOW ae uosrnr 30 Forbes Road I Northborough,MA 01532 H:(978)224-2211
- - - - Phone:508-351-22001 Fax:(508)986-7072 1 RbABoston0perations®AndersenCorp.com C:(978)270-6541 -
Customers)Name: Linda Doughty and Robert Doughty Contract Date: 11/12/16
Customer(s)Street Address: 5 Riverbank Rd, Salem, MA 01970
Primary Telephone Number: (978)224-2211 Secondary Telephone Number: (978)270-6541
primary Email: Iindadoughty@live.com 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,Notice of Cancellation, Itemized Order Receipt,Warranty,Terms and Conditions of Sale,Lead-Safe Form,If Using a Builder,and
an 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: 53,879 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: f 1,272
Balance Due: $2,547 Estimated Start: Estimated Completion:
Amount Financed: 40 8-10 weeks Iday
Method of Payment: Credit Card We schedule installations based on the date of the signed contract and secondarily on
Notes: the date in which we complete the technical measurements.The installation date that
1/3 down $1272 card visa we are providing at this time is only an estimate.We will communicate an official date
7723 exp 03/18,1/3 start and time at a later date.Rain and extreme weather are the most common causes for
$1272 , 1/3 comp $1275 delay.
Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal
understanding 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 OWNER: 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 11/16/2016 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.
Legal Name Renewal by Andersen I.I.0 Customer(s)
dba:Renewal by Andersen of Boston n
Signature of Sales Person Signature Signature
Greg Arsenault Linda Doughty Robert Doughty
Print Name of Sales Person Print Name Print Name
11/12/16 Page 2 / 11
Renewal Itemized Order Receipt
byAndersen. dba:Renewal by Andersen of Boston Linda and Robert Doughty
Legal Name:Renewal by Andersen LLC 5 Riverbank Rd
HIC#170910 Salem,MA 01970
wrao.. ae uosraNr 30 Forbes Road I Northborough,MA 01532 H:(976)224-2211
Phone:508-351-22001 fax:(508)986-70721 RbABoston0perations®AndersenCorp.com C:(978)270-6541
s • ROOM:
101 Kitchen Window: Casement- Single, Casement, Left, Base Frame,
EXTERIOR White, INTERIOR White, Glass: Sash All: High
Performance, No Pattern, Hardware: White, Screen: TruScene
with Interior Color Match, Grille Style: No Grilles, Misc: Non
102 Kitchen Window: Casement - Single, Casement, Right, Base Frame,
EXTERIOR White, INTERIOR White, Glass: Sash All: High
Performance, No Pattern, Hardware: White, Screen:TruScene
with Interior Color Match, Grille Style: No Grilles, Misc: Non
WINDOWS:2 PATIO DOORS:0 SPECIALTY:0 MISC:0 TOTAL $3,819
UPDATED: 11/12/16
Renewal by Andersen is committed to our customers'safety by
a complying with the rules and lead-safe work practices specified by the EPA.
11/12/16 Page 4 / 11
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Workers' Compensation Insurance Affidavit:Builders/Contractors/Electncisas/Plambers
Aoolkant Information please print i wily
Name(B RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
Ci /Stste/Z : NORTHBOROUGH MA 01532 Phone#: 508-351-2082
Are you an=plyer?Cheek the appropriate boa: Type of project(required):1.�I am aemployer with 4. ❑ I am a generel contractor and I
employees(dill and/or pert-lima}e have hired The sub-wagons 6. ❑Now conahucamn
2.❑ 1 am a sole peapzWm or partner- listed on the attached sheet 7. SfRemodeling
ship and have no employees Tbeae subiwntrectors hate 8. ❑Demolition
waking for me in any any. employees and have workers'[No workers'comp6 tnmu®ce comp.imre anse.= 9. ❑Building addition
required.] 5. ❑ We are a corpondion and its 10.11 Ehtcaical repairs or additions
3.❑ I am a homeowner doing all wok officers have exercised their 11.❑plumbing repairs or additions
myself[No wort as,camp. a 1ght o ¢I(4)e d we have no 12.❑Roof repairs
insurance requhedl
employers. [No workers' 13.❑Other
cons .insurance repaired.]
•noreppliaotthatdeola box#1 mud aim sn out aemcdonbdowslowivg1nirwalmes'aompmemna policy iamm em.
tAameowmowhonhmlt*bs &vat BUY=doles an Wok cad thm him ouWdowa4 egoo;augeamiTaamvatsdevkbxficwiossoad P
,coraamms 0.0 dtedrthia burr mod dtad:od ao edOdug abed dawiogthesame oYfio eab.mNwpn n detdo%terhe of=spm mdit have
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buommoe Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#or Self--ice.Lia#: MWC30823100 Expiration Dete: 1 0/0 11201 7
Job SiteAddreaT: 5 Riverbank Road
City,&IdeJ21p: Salem, MA 01970
Attach a copy of the workers'compeunden policy dabradon page(shumeg the policy number and cWhation dato).
Failure to secure coverage as required user Section 25A of MOL c. 152 can lead to the*odtion of criminal penshlea of a
fine up to$1,500.00 and/or one-yew imp boat,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to SM.00 a day against the violator. He advised that a copy of this statamest may be forwarded to the OMM of
Investigations ofthe DIA for insimuloo coverage verification
I der haeby cer*andleraiepahn maepannl . a ry ab�a'e bar p��d aboveissae cad tartars
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1111911(i
Pboee#: 50S351-2082
W
ly. Do nogg tradte by Akawra,to be oen�edby c4 or terrorVidaL
p ity(drde one):LBoardalm 2.BuildingD"artment 3.CityjT0Waclerk 4.Elect ical Inspector S Plumbing bVecter: Phone#.
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RENEWAL BY ANDS KeL C':�l
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JAIME MORIN �
30 FORBES RE)
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NORTWBOROUGN, MA 01 $32 Undersecretary
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