22 SUMMIT AVE - BUILDING INSPECTION (8) 35 cl<
MW ComMonwealfb ofMewsohoseas
�✓� Board of Building R%pflsd s end Siaederde MY OF
Massaaheseas Slate Building Code,780 CM R. MEW
RepbedAhv;2011
C(� Building Permit AppUcadon To Ca�Repair,Renovate Or Domolioh a
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1.1 Prop"Address: Z 1.Z Aesasee Map&Pared Nmbm
22 Summit Avenue 33_p.139.802
1.181adiom staal? x ao MepNodar PraeplNmbm
13 Zoabglofforoatlm: IA PrapartyDbaradonm
ZmisaDbakt PropoWtTac LatA=(sg8) proctw(tt)
115 BWMbgS (2)
FrootYwd 6ik Yards Rea YaN
Requhed Prodded Rogebed Frartdea RoWW Piavmw
1.6 Wda Sappy:pact c.40,5 54) 1.7 Flood Zeaa lafineatleu: I.S Samp Duped System:
pd&a Pdv m O Z=c: ` Oatelae Road Zaae4 1 0ab s(te dhposat eYarm O
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31 Owner-ofRaosrd:
Kathleen Casale Salem,MA 01970
Name(P" Cf4'.Sa E
22 Summit Avenue 781432-6958 kathleen5698@verimn.nst
No.®d Read 7elepbone REM Adhm
3:DF8LRMWN01' Offle decksOSasapp _,
New Construction 13 Fxistlng B�M OwnarOeoopiod N Rapen 4s) O Abandon(s) ElAddition D
D O Aasaemy Bldg O 1 Numbs ofUne O&W ® %Mdfv.Replacement
Brief DaersipliorrofPmpaod Wort' Replacement of 2 windows-no structural work to be eerforrned
SPG'PIOP).AE=Mi[A:76- ODTBIRUC1iaN 70i318.v
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1.Bmldlog S 3711.00 1. it 14tsmiped'r
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3.Pbabmg S 2 t)rtierFeee S
4.Awl (VAC) S I st
S.)wrsi (Firs 5 To>olABFeeo'S
6.Toml PtoJaet Cat S 3711.00 CU&NM Qmck A Cat A t
a Paid io Fall O Oaletind'mg ft--bM* [:
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CITY OF SAm4 W ACHUSETTS
St.'tUMO DEPASTUENT
120 WASHOW OtV Stttssr,r FLOOR
T6L(TM 745-VAS
coii PAX(>f7�700046
taa�eextstt>�s
MAYOR 7NOsrus Sr rawue
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Construedou Debris Dlsposai AtBdavit
(required hr all dammWition and rtmovstica work)
In accordam with dw six&edition of the State Building Code,780 C R medoa l I I-s
Debris,mrd the proovielons of MOL o 40,S 54;
Bwhftg Permit# m issaed with the condition that tha debris rosnhigg Snmt
this work loll be disposed of in a pwpmly licensed waste disposes tborlity es deed by MOL c
111,S I50A.
The debris will be trangmdod by.-
Renewal by Andersen
(wme ol'ewlarl
The debris will be disposed of in:
Renewal by Andersen
(Ulm 4pf6daw
30 Forbes Rd, Northborough, MA 01532
(addraa at'acWty)
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
JAIME MORIN License 90125 Expiration Date 10-06-18
NameofCSL Type Description
86 GARDINER ST. LYNN , MA 01905 U Unrestricted(up to 35,000 Cu.Ft.
Address R Restricted 1&2 Family Dwelling
M Masonry Only
Signature RC Residential Roofing Covering
WS Residential Window and Siding
508-351-2214 SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5.2 Home Improvement Contractor Registration(HIC) 12—23—17
RENEWAL BY ANDERSEN Registration 170810 Expiration Date
HIC Company Name or HIC Registrant Name
30 FORBES ROAD NORTHBORO, MA 01532
Address
Signature
508-351-2214
Telephone -
SECTION 6: WORKER'S COMPENSATION INSURANCE AFFIDAVIT(M G.L.c. 152.§ 25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit.
Signed affidavit attached? Yes N No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR
CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Kathleen Casale as Owner of the subject property,
hereby authorize JAIME MORIN to act on my behalf in all matters relevant to work
authorized by this building permit application.
(see contract) 11/11/2016
Signature of Owner Date
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I JAIME MORIN ,as Owner or((luthorized Agent))iereby declare that the statements
and information on the foregoing application are true and accurate,to the best of my knowledge and belief.
(see contract) 11/11/2016
Signature of Owner or Authorized Agent (Signed under the pains and penalties of perjury) Date
SECTION 8: DEBRIS DISPOSAL
All dumpsters of six(6)cubic yards or more are required to have a permit from the Marblehead Fire department:call 781-639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work performed shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 11,§
150a.
DEBRIS DISPOSAL LOCATION 30 FORBES ROAD NORTHBORO,MA 01532
SIGNATURE OF APPLICANT laima Mnrin
NOTE
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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.
yr
Renewal Agreement Document and Payment Terms
bYAUldemm dba:Renewal by Andersen of Boston Kathleen Casale
N.,
Legal Name:Renewal by Andersen LLC 22 Summit Ave&115 atlantic ave
HIC#170810 - - Salem/Marblehead,MA 01970/01945
wraaor 30 Forbes Road I Northborough,MA 01532 H:(781)632-6958
Phone:508-351-2200 1 Fax:(508)986-7072 1 RbABostonOperations®AndersenCorp.com
Customer(s)Name: Kathleen Casale Contract Date: I1/08/16
Customer(s)Street Address: 22 Summit Ave & 115 atlantic ave, Salem/ Marblehead, MA 01970101945
Primary Telephone Number: (781)632-6958 Secondary Telephone Number:
primary Email kathleen5698Qverizon.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,Notice of Cancellation, Itemized Order Receipt,Warranty,Terms and Conditions of Sale,Lead-Safe Form,Waiver,If Using a
Builder,and any other document attached to this Agreement Document,the terms of which are all agreed to by the patties 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: $5,212 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 0
Balance Due: $5,212 Estimated Start: Estimated Completion:
Amount Financed: $5,212 8-10 weeks 1-2 days
Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on
Notes: GS Ian 2531 the date in which we complete the technical measurements.The installation date that
P we are providing at this time is only an estimate.We will communicate an official date
1/3 $1,737 deposit and time at a later date. Rain and extreme weather are the most common causes for
1/3 $1,737 start delay.
1/3 $1,737 full completion
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 11/11/2016 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION,
WHICHEVER DATE IS LATER SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN
N 471M RIGHT. cnatons"(s)
ba:Renew b�y A/�n�ee(se��n o///{���B/,�o/s/ton L
Signature of Sales Person Signature Signature
Stephen Waitt Jr Kathleen Casale
Print Name of Sales Person Print Name Print Name
11/08/16 Page 2 / 13
Renewal Itemized Order Receipt
brAndemn.
dbw Renewal by Andersen of Boston Kathleen Casale
Legal Name:Renewal by Andersen LLC 22 Summit Ave a 115 atlantic ave
HIC#170810 Salem/Marblehead,MA 01970101945
WIN— ne uoeacar 30 Forbes Road l Northborough,MA 01532 H:(781)632-6958
Phone:508-351-2200 1 Fax:(508)986-7072 1 RbABoston0perations®AndersenCorp.com
a • ee DETAILS:
101 Kitchen Window: Double-Hung, Equal, Slope Sill Insert, Traditional
Checkrail, EXTERIOR White, INTERIOR White, Glass: Sash All:
High Performance SmartSun Glass, No Pattern, Hardware:
White, Screen: Fiberglass, Half Screen, Grille Style: Full
Divided Light (FDL with spacer), Permanently Applied Interior
Wood Grille, Grille Pattern: Sash 1: Colonial 3w x Oh, Sash 2:
No Grilles, Misc: L tri
201 Kitchen Salem Window: Double-Hung, Equal, Slope Sill Insert, Traditional
Checkrail, EXTERIOR White, INTERIOR White, Glass: Sash All:
High Performance SmartSun Glass, No Pattern, Hardware:
White, Screen: Fiberglass, Half Screen, Grille Style: No
Grilles, Misc: L tri
202 Bathroom Salem Window: Double-Hung, Equal, Slope Sill Insert, Traditional
Checkrail, EXTERIOR White, INTERIOR White, Glass: Sash All:
High Performance SmartSun Glass, No Pattern, Tempered
Glass, Hardware: White, Screen: Fiberglass, Half Screen,
Grille Style: No Grilles, Misc L tri
WINDOWS:3 PATIO DOORS:0 SPECIALTY:0 MISC:0 TOTAL $5,212
UPDATED: 11/08/16
Renewal by Andersen is committed to our customerr'safety by
.� complying with the ruler and lead-.cafe work practices specified by the EPA.
11/08/16 Page 4 / 13
The Co ne twwM ofMasasebamew
DeAMM"ent of In dusW al Aeddewtr
Offlw Olin
600 waawnstan Sheet
Roston,MA 02111
wwi%a*ax gor/dia
WoNu re' compensation Insurance Affidavit:Haffdere/Contracton/Elat idrnt/Plambere
AuN[caat Information ��e]Flint leaibl.,
Name F RENEWAL BY ANDERSEN
Address. 30 FORBES ROAD
NORTHBORO,MA 01632 Rhone# 508-MI 2214
Are you an employer?Check the appropriate box-
Typo adptoJad(rogedrsd):
1.0 I am a�pktyer with 30 4. ❑I am a geoersl contractor and I
employees(fall and/or part-time).• haw hired the sus 6. ❑Now contraction
I❑ I am a solo pmpriator orpartmr- listed on the attached sheet. 7. FL]Remodeling
ship and have no employees Those sub-connaetma have g. ❑Dozolitim
working for me is any capacity. employees and have workers'
[No workers'comp.inamsnce camp•imarBneO.t 9. ❑Building addition
required-1 5. ❑ We an a ration and its 10.❑Electrical repairs or additions
3.❑ I an a homeowner doing all work officers have mmised their 11.❑Plumbing repairs or mWitiow
Mwz[No Mudcars'camp• right of aaemptionper MOL 12.❑Roof repairs
imoraxe required)t 0.152,610),and we have no 13.❑Offiar
amployees.[No workers'
coup.inearaoco required.] 11
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fHmmwamevdmabodilis a All it farmodoinaBvrod:audtbmhbemeldscmoarmn mudzubo tanewe>ild"hhtSm-& each.
$ontmot ed,trkakthiehm<amtamtfedse eMdmel dint[dmwiq msommoffee 6.,om mom and soeewlaaa'Qnm faro aowleubave
oft&yem. Hieeob•affiamonfummpsyccm6*w mad pmvWetlair wofm'cemp.puBoyamber.
Imes as aarker thin Is pmvlft warners'campasaaHen aarwmaae for my ealpfyem Below 6 alepoft aadlob r6e
WilpmadmL
Insurance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#or Salf-im.Lic.#: MWC30823100 Eapindica Date: 10/01/2017
Job Site City/SMdZip:_ Salem/MarhIphPad 01970/45
Attach a copy of the workers'eampeasathm poticy decleration page(dwwfpg the Polley number and capintlan date).
Fail=to"me coverage a inquired under Section 25A ofMOL o.152 can lead to the imposition of criwinal penalties of a
fine up to$1,5M.00 and/or me-year impaieo>m>aoy a woo as civil pemltim in the Sam of a STOP WORK ORDER and a fine
of up to$250.00 a day against flee violabr. Be advised data copy ofthis statement maybe finwwded to the Office of
Inveatigetiuns for iamaoce coverage Venficaten.
I de ea* dwpains andPeadCa 00alars alert ire Von wailonpvwed86M 6 am erJ earned
11/10/2016
Phone 8-351-2214
t7(iWd use oa(p. Do sot writs In Air mina,to be camy& d by dry or Mon og7dal
City or Tows: Permlt/Idoena#
Iadog Authority(drele one):
L Board of]Health L Building Department 3.C4y/fown Clerk 4.Mw ial bapecam, s Pp®icing Iaspwtm'
6.Other
t.eutact Pare=• Phase
ANDECOR-01 SALWAN3V
.�`4�RQ. CERTIFICATE OF LIABILITY INSURANCE �"S"'06
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),AUTHORLED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. -- —
IMPORTANT: N the =it cats holder is an ADDITIONAL INSURED,the polley(ies)must be endorsed. N SUBROGATION IS WANED,aubleet to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certlneab does not confer AVMs to the
cwditate holder in lieu of such ardomeme s.
PRODUCER CONTACT
NAME: Willis Towers Watson CePo&cate Canter
Wildolis of Minnesots,20Ce�nturyBhrdlne E S 94ST37B Np. 888 467-2378
P.O.Box TN 87280.9191 ADDRESS;�cales@wRibLcom
I
ONAURN AFFORDING COAERAGE MA:p
INSURERA:01d Republic Insurance Comparry 24147
INSURED INSURER a:
Renewal by Anderson INSURER C:
30 Forbes Road INSURER O
NaAhborough,MA 01532
eaURERE:
919UREIt P:
COVERAGES CERTIFICATE NUMBER: 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. TERRA OR CONDITION OF ANY CONTRACTOR 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.
INSIR
LLTR TYPE OF INSURANCE POLICY NUMBER LaaTO
A x COIaElUTAL GENERAL LU16LrrY j 991NAIRY
CEre y 1,000,00
CwM84AADE QOCCUR WZY 3082M 'IOA7/2016 IWOJIM17500,00
$ 10,00
a 100010044
GENLAGGIEGATELSIRAPPUESPER GENERAL AGGREGATE $ 4,000,00
X POLICY El ❑Loc PRDDl1CT8-COtAPANAGG s_ 4,000,00
OTHER: S
AUTOMOSLE LIA ILITY I rAmewD smM LIIITT $ 5,000,00
A X ANYAINO MW7T13082a2 10/01I2078 10101/M17 eoD%YE%wNYGPerpxw:) s
ALL OWNED SCHEDULED
ANOS AUTO$ SMLYINIURYIPrr S
HIRtD AUT00 NOW-Odd®
AUTOS i Pera _ S
�S
,nmun,�LU,a OCCUR EACH OCCURRENCE S
EXCESS WASClAIM3-MADE AGGREGATE $
I DEO RETEN-nIMIs S
WORKERS COMPENSATION
ANDEMPWYERI'LWSIrY YIN x ST TUIE FR
A ANY PROPRIErORIPARTNERIFJ¢CURJE C30923100 1010112016I10/01f2017
o yRR E=LOED7 Fk]N/A ELEAf77ACCID@lI s 1,000,000
e, in 00 EL DISEASE-LA ERPLO $ 1,000,00
o'EBCNIPrIOH OF�OPERATIWA hNw EL DISEASE-POLICY UMn a 1,000,00
DEWWTIONOPOPENATaMLSILOCATIONS/VEMCLES TACO IGI.Ad=onel Rem ft&hem..m TWA hadenrore ApAn Ie rt@,trtl)
L
f
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Proalfafinsurance %• '✓��
01983.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Sdarty
Board of Building Regulations and Standards
License:CS-090125
Construction Supervisor
JAIME L MORIN
86 GARDINER HT
LYNN MA 01905
ZCX- CA- Expiration:
CoMmissioner
Construction Supervisor
Restricted to:
Unrestricted-Buildings d any use group which contain
less then 35,000 cubic feet(901 cubic metals)of
enclosed space.,
Failure to possess a current edition ofthe Minsachusaft
State 3""Code Is cause for revecallen of this times.
DIPS Licensing information v[oR-.111111111101N.11110UNINGOVIOPS
cc of Cowumer Affairs&1111twinm ftulatioa
ME IMPROVEMENT CONTRACTOR
Reg Type:
Expi Supplement Card
RENEWAL BY AN
JAIME MORIN
30 FORBES RDA
NORTHBOROUGH,MA 01532 Uudltremmtary
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100-00473518-010
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ADDITIONAL'PERFORNIANCE RATINGS
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