42 WARREN ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts FOR
° Board of Building Regulations and Standards
TY
Massachusetts State Building Code,780 CMR, 7" edition USE
n� Revfsed Janua
Building Permit Application To Construct Repair,Renovate Or Demolish a rY
V g P
p P
One-or Two-Family Dwelling 1, 2008
1P This Section For Official Use Only
Building Permit Numb Date Applied: b• (� U L�
�( 1 Signature: Oj 2
JJJ Build' gCommissioner/InspectorofBuildings Date
SECTION 1:SITE INFORMATION
J.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Sc em Olq-lo
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)
`i
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❑ - Private❑ Zone: _ Outside Flood Zone?. Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
`Se n We SS l`fian u 1 .mac,rren Sl SGk�e ,,,. IMA
Name(Print) Address for Service:
Ct - 5�tq - 51 � �
Signature Telephone
SECTION 3-DESCRIPTION OF PROPOSED WORK2S(check all that apply)
ti gBuil Constru ❑ . "le :cm(s) Add'.icn ❑d O u P
Demolition ❑ Accessory Bldg. ❑ Number ofl1 nits._._-_
Other -❑ Specify:... .. .._...
Brief Description of Proposed work':
V-'S <1 .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
].Building $ O 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑.Total Project Costa (Item 6)x multiplier x
3.Plumbing $ Q 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List.,
5.Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6..Total Project Cost: $ 03 ❑Paid in Full ❑ Outstanding Balance Due:
J
SECTIONS: CONSTRUCTIONSERVICES t;
5.1 Licensed Construction Supervisor(CSL) Ct
i0I License Number Expiration Date.
Name of CSL-Holder
List CSL Type(see be I ow)
Ad es _ T e Desciition -
U Unrestricted(up to 35,000 Cu.Ft.
Signature • - R Restricted 1&2 Family Dwellin
M MasonryOnly
RC Residential Roofing Covenn
Telephone. WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance lnstallanon
D Residential Demolition
5.2 Registered Home Impr 7,;nt Cont actor(HIc�,
t=il e —Jc. l R-N (l ait=.z Sesl++ N�` I I° olt t( 1
HIC Company Name or HIC Registrant Nafti Registration Number
,✓447Lwyn AAA o+S3d
,Sa7-'117-6YCja � Expiration Date
- Signature vTelephone .
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 ........... M- . No...........❑
SECTION 7a::OWNER AUT73ORIZATION TOM:COMPLETED
OWNER'S AGENtbki dONTRAC.TOR APPMES FORBUILDING]- ERMiT
I. as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner - Date -
SECTION 7b::OWNER' OR AUTI30RI2ED AGENT DECLARATION
} v"� ae�uver or Authernzed Avert 41*erehy jecl:ire
tliat the stay rneuts and information on the foregem .application are true and accurate, to the best of m,,know be and
belialf.
CU+ P ` ` `
i
.Print . • ne
Signature of Owner or Authorized Agent - Date
(Signed under the pains and penaltiesofpa 'u
NOTES:
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 and
Construction Supervisor Licensing(CSL)can be found in 780`CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below: 111.
Total floors 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 ofhalf/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"
DEBRIS FORM[
This form is to be submitted with building permit applications whenever there is debris to be
disposed of.
Property Address: l/ )� U 1g1 I U
in Accotdance with the provisions of MGL cA0, §54,a condition of the Building Permit
Number is that the debris resulting from this work shall be disposed of in a properly licensed .
solid waste disposal facility as defined by MGL c. 111§ 150A.
This debris will be disposed of in: .
�e.n-P.t._,a►' � � �^at�S�� 1 0�-( C��:is S-l. �Uo%f-� bc� MA o�s��
(Location of Faclriy)
Siguabue of Penmt Applicam
Date
95 ' Massachusetts-- Department of Pub lie Safetc
V Board of Building Re,ulations and Standards
V Construction Supervisor License
s License: CS 92256
Restricted to: 00
SCOTT PHILLIPPI
58 0 STREET
WHITINSVILLE, MA01588
Expiration: 617/2011
<,,rnrn.,inner - Tr;#• 92256
Restricted to: 00
00- Unrestricted
LG-1 2 Family Homes ,
Failare to possess a current edition of the
Massachusetts State Building Code _
is cause for revocation of this license.
Referto: VVWW.Mass.Gov/DPS
,per ✓he -�omnzanuiea�ca�./��ancor/weetQ .
�\ Board of Building Regalatians and Standards
lug HOME IMPROVEMENT CONTRACTOR
Reg
iatrafioisy 149601
E1—xptrataota 1/ 412010
�,Tjrpe=Supplement Card -
RENEWALBYANDER5015 }=
SCOTi PHILLIPPG,
ISS STREET`or �='�
NORTHBOROUGH, MA�01532 -Administrator
ACORDy CERTIFICATE OF LIABILITY INSURANCE °"'E'"B"°D"Y"
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC 0
INSURED Renewal by Anderson INSURERA HilEtLord Insurance CQMpany
J&L Windows, Inc. INSURERS: Herrnita e
H 104 OUS St INSURER C:
Northborough,MA 01532 INSURER D.'I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUREMENT. 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
WSR USUR11POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
B GENERAL LIABILITY HCP 507 404 09/07/2008 09/07/2009 EACH OCCURRENCE f 1,000,000
COMMERCIALGENERAL LIABILITY S f:a E.0 S 100000
CLAMSMADE ®OCCUR MEDEXP! "penml f .__ ._.., $QiQO
PERSONAL&ADV INJURY S ..600.001)
GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2000000
POLICY PRO• F I LOC
A AUTOMOBILE LIABILITY 35 MCC XD6310 10/01/2007 10/01.2008 COMewEDeINGLELIMIT S 1.000,000
ANY AUTO (Ea emMent)
X ALLOWNEDAUTOS
80DILYINJURY ' S
SCNEOULED AUTOS _ (Per pnnpn)
OIRED AUTOS
BODILY INJURY S
NON OWNED AUTOS IP"eceiam)
PROPERTYDAMAGE S
IP"--m)
GARAGE LINBGJTY AUTO ONLY-
FA ACCIDENT S
ANY AUTO I OTHER THAN EA ACC S
AUTO ONLY: AGO S
EXCESMIABRELlALIABILFTY EACH OCCURRENCE Is
OOCUR CLAIMS MADE AGGREGATE S
f
DEDUCTIBLE
f
RETENTION f - f
A wowreRs COMPENSATION AND 35 WEC PP 1444 02/17/2008 02/17/2009 WC S TAN• OTH
EMPLOYERV UABMY
ANY PROPRETOWPARTHERIEXECUNVE E.L.EACH ACCDENT I S 500000
OFFICERMEMBER-EXCLUDED? E.L.DISEASL -EA EMPLOYEE S 500,000
SgS.Me¢nbe VII¢er
SPECIAL PROVISIONS balm EL.CISEASE•POLICYLIMIT I fSoo onn
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ESPBIATION
INSURED COPY DATE THEREOF.THE ISSUING INSURER VALL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE BNUREA IT$AGENTS OR
REPRESENTATNES.
AUiNORREO REPRESENTATIVE
ACORD 26(2001/08) - 0 ACORD CORPORATION 1988
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
U1V 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name(Business/Organizadon/Individual): Wene Lial 29A de-rS a
Address: �-
0 i e a City/State/Zip: A/orI bo ro , A, M,3.Z- Phone#: w' Ut�� Jc%J- 0/00
Are you an employer?Check the appropriate box: Type of project(required):
LEE I am a employer with 00 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• modeling
ship and have no employees These sub-contractors have S. rj Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomration.
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 subcontractors and their workers comp,policy information.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information,
Insurance Company Name:
/
Policy#or Self-ins.Lic.#: &Ji IJ e ' Expiration Date: ,:2—/
Job Site Address: U) Ct f'-en City/State/Zip: Sode✓vI ,M U l q,) O
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 ce u erthe pains and penalties ofperiury that the information provided above is true and correct.
Signature: IrIy Date: ] O —0-4 T
Phone# 0
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#:
OGt 20 2008 8: 11f1M MIKE SIDMAN 6039345514 P. 1
VliW.Agreement-Pagel of 2
104 pill It,NortbborouBM MA 01532 JaL Windows,Inc.,d)bla MA Homs Improvmant contractor
(tiffs)still•Fax:late)919-0s03 Lleanao#149501(ExPlree 1447010)
Customer Service Renewal F" nal Tar ID#034404201
(800)$73.7608 byAfldersen, Inely.Lke,wn. ,lane salon(Ca#7a]el),
NaWeen 91enUero(elxsa0l)
M wresow
Product Mermper. {'/i'k-4 1 rigs n n w ;Indow Aareement Conirsct Dam: IO/Y-0
Narawwnec "owner"s Nam ar Ta C 13SM+_
Street Addrasa: �/.. .�< C Rown: Sti t Stato: zip;O/
Nome Phone; 2
2 rl Work Phons: f 11
Job She Address(k dlftarent): E,rnoll Address:
Materials to be provided and work to be performed by Renewal by Andersen "Contractor" :
Contractor will furnish and install Renewal by Andersen proved materials to the following specifications:
1. Date onrehich Work Is Scheduled to Begin: I;- j Expected Date of Substantial Completion: /✓w..L.
2. C.ontractor will Install a total of_2_windows in Owner's home,using the following individual quantifies:
Double Hung(OB) []'Equal sash 0 Cottage sash(113 top,2l3 bottom) 0 Oriel sash(213 top,18 bottom)
Casement(CW) 0 Hinge right O Hinge left(as viewed from exterior):OStandard handle OMetro handle
Double Casement(CDW) OStandard handle []Metro handle
_Casement I Picture!Casement(CPW) O 1:1:1 or 0 1:2:1 []Standard handle OMetro handle
_2 Lite Gliding Window(GW)
_Glider f Picture f Glider(GPW) O 1:1:1 or 0 1:2:1
_Awning Window(AW)
_Picture Window(PW)
Bay or Bow Window:
3. &Yes 0 No #Windows to be Custom Fit Replacement:_
4, 0 Yes IANo #of slits to be replaced by Contractor:
5. ❑Yes I$'No #Windows to be New Construction Full frame(includes new Interior 8 exterior casings): -
Exterior caaings: ❑Pine 0 Maintenance-free material O Factory applied 908 Fibrex bricknnold
8. Glazing to be: WHlgh Performance 0 Other If other,please specify:
T. Exterior color to be: White 0 Sand O Canvas 0 Tarratone
8, Interior color to be: WWhite 0 Sand 0 Canvas O Te matone 0 Woad
Nuts:Interior color can only be white,wmtl or same valor as exterior. Woad Interiors need t fl y O
9. Hardware: gYWhita O Stone 0 Canvas O Braes Double Hung: Install fifls7
10. 0 Yes m'No Contractor will remove metal frames or grilles. #of units:
11. 0 Yes 6d'No Contractor will Install new paint-ready or stain-ready casings.Inside or outside stops#of openings:_
Interior casing#of openings:_ Exterior casings#of cpe n'ngs:_ 0 Pine 0 Maintenance free material
Owner Is ay'ere that Contractor does not do any painting. tbP Owner Initials
12, 0 Yea Ill Contractor will wrap exterior casings with aluminum coll stock of oolor.
Note:Requl ed with storm window removal;removal of atom)windows will leave slew holes In casing.
13, New,windows to have: []Has or J RTull screens Screens to be: Wlborglass O Aluminum ❑TruScene
14. Windows to have grilles: ❑Yes EMo If Yes: O Grille Between Glass(GBG) 0 Removable Interior Wood(INTW)
❑Full Divided Light(FOL) 0011e patterns:
F1 P P m
DH DH DH OH CWlPicture Glider CPW or GPW
'use additional sheet if deeded Owner approved(initials):
15.$•4es 0 No Contractor will insulate,caulk and seal windows with 3-point system to proventwater and air Infiltration.
16. OrYes []No A limited warranty shall issue to Cwner upon completion of the job and payment in full tree reverse aloe),
17. 1111 O No Sulld(na Permlt-Contractor will secure any and all necessary permits.The fee for the perrnit(s)Is not
Included In the Contract Price and a separate check is required at the time of sale for this fee. li
18. Addlgonaljob details:
19. NI O No Owner has reviewed the Additional Terms and Conditions governing this Contract on the reverse side.
20. Total Contract Price:$ 3103 y Regular Retell Price:,S # A l evmaele aleeounm Pi'+P!md:1p�'fee ❑No
21. Deposit(113):$ paid b ❑Cash Inane Account feo34re253ow59038• )
Second(1/3)$ to be paid by Cash at start of job on !d--/Y-a b' (Esfimated Mad date),
Final 113)$ to be paid by Cash at completion ofJob on 1 L /1-DY (Estimated mmplelion date).
22. ❑No Owner agrees to be present on the Mel day of Installation for final inspection and to deliver final payrl ent.
No Thal am shall be demanded until the connect is com tad to fne satisre0f10n 0 elf ernes.
NOTICE: AIl•home Improvement contractors sad suncantractors must bo regmmrod. Any Inquiries about a contractor or
subcontractor relating to a registration should be directed to:Registration Division,Program Coordinator,One Ashburton Plpcp,
Room 1201 Boston MA 02108 Tol: 617 727.3200 eat.25239.
The Parties.Itersily mutually agree in advance that shoulda dispute arise regarding this contract,Contractor may
..:filRtmit euch�di9Putat a Irate arh(,t(at oB service tiler has been approved by the OfAce of thaZorlsommffairs
A-Suslness ltd ulafio,and Owner shayll_ "required to submit to such arbifrallgon asSprovided In MGL c.142A.
Contractor Signature; 9�_Lrl Owner Signature
NOTICE: The signatures of the pa les above apply only to their agreement to a(Wriate dispute resolution Initiated try
Contractor.Owner may Initiate alternate dispute resolution even where this section Is not signed separately by the parties.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
J&L Windows,Inc.dlWa_Rene9{al byyAndliusae
ey: Tvil"�.a
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Product Manager - or 8l�aturo
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Praducl Manager(Print Name) Ow Slglatun
W011e-ReneweleyAndalsen YeffDw-este0ation Pink-Homeowner
Renewal .;1
R byAndersen. -%-
WINDOW REPLACEMENT PnA de C.PanT
IUarahal6eres6aLDty WoodMtryl Composite IF
gl� Dual Argon Low E
Double Hung
100-00414585-007
ENERGY PERFORMANCE RATINGS
U-Factor (U.S)A-P Solar Heat Gain Coefficient
0 . 30 Ox3lADDITIONAL PERFORMA
Visible Transmittance
0m53
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