B-19-1142 - 0019 BARCELONA AVENUE - Building Permit ,ry 'PECT11 ,t
" The Commonwealth of Massachusetts
Board of Building Regulations and Standard g � ! A1.F.CrrY OMF
Massachusetts State Building Code,780 C Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
'One-or, Two-Family Dwelling
This Section For,Offtcial Use_ Only o
Bwldmg Permtt<Number gDate Applied
guil ... ot>z ding cial(PrmtName) _ s Date
Signatiue A'` - l ER
SECTION•i:'SITEINFORMATION.
1.1 Property Address: 1,2 Assessors Map&Parcel Numbers
1 19 Barcelona Ave. 08-00010
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(s 'ft) Frontage q age(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:
Zone: Outside Flood Zone?
Public 0 Private 0 — Check if yes13 Municipal❑ On site disposal system 0
" $ SECTION 2t PRO-PERTY,OWNERSHW1`7,
2.1 Owner of Record:
George Weil Salem, MA 01970
Name(Print) City,State,ZIP
19 Barcelona Ave. 978-998-0602 _patcarpenterl9@comcast.net
No.and Street Telephone Email Address -
1 f9N 3:DESCRIPTION&OF PROPOSED WORK-(check all t!q aPP Y);, '. .d
New Construction❑' Existing Building M, Owner-Occupied,M Repairs(s) O Alteration(s) M Addition [3
Demolition ❑ Accessory Bldg.O Number of Units Other 0 Specify:_Replacement
Brief Description of Proposed W6rk2: Realarement of 2 windows
t
SECTION 41 ESTIMATED GONSTRUCTIONICOSTS .
Estimated Costs:. T
Item z
t O>tlicial�Use Only
(Labor and Materials -
1.Building $ 11.Biuldntg Permit Fei f$ Indicate how'fee is determined"
8 421 p StandsrdCity�wnApplicationFee
2.Electrical $ '13 Total',.Project Cod(item 6)x multiplier x
3.Plumbing $ 2 Other Fees $ T11 '+
4.Mechanical (HVAC) $ ;List: , -�
5.Mechanical (Fire $
S ion Total All Fees
6.Total Project Cost: $
Check No. x Check Amount Cash Amount ' '+
'
8,421 13 Paid n Full El Outstanding Balance Due:`l
SECTION:5:.C6N§TRUCTI034 SIJRVICES t
5.1 Construction Supervisor License(CSL)
90125 10-06-20
Jamie Morin License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
30 Forbes Road
No.and Street Type Descriptions x.;.
Northborough, MA 01532 U Unrestricted uilga s up to 35,000 cu.R
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofint Covering
- `WS Window and Sidra
"SF Solid Fuel Burning Appliances
a
508-351-2277 rbabostobpermitting(cilandersencorp.com I Insulation
Telephone Email address D Demolition
5.2 Registered Rome Improvement Contractor(HIC) 170810 12-22-19
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/TOW13,State,ZIP_ Tele' one- _
SECTION 6:WORKERS COMPENSATION,INSURANCE AFFIDAVIT(M-G.L.c.152 §,' 25C(�)
s
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...........❑
SECTION 7a;OWNERAUTFIORTZATION_O_BE COMPLETED WHEN `
0 Nld S'AGENT OR CONTRACTOR APPLIES FOWBUILDING PERNIIT'
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 10/8/2019
Print Owner's Name(Electronic Signature) N Date "
SECTION;7b UWNERIORAUTHORIZE rAGENT.DECLARAT..IONy
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 accurate to the best of my knowledge and understanding.
Jaime Morin 10/8/2019
Print Owner's or Authorized Agent's Name(Electronic Signature) = Date
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.gov/oce Information on the Construction Supervisor License can be found at www.mass.g vo /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
P. "Total Project Square Footage"maybe substituted for"Total Project Cost"
" Cn Y OF SALEM, MUSACHUSEM
BL'II.MG DEPAAI TENT
120 WASHINGTON STREET,r FLOOR
TIIL(978)745-9595
PAX(978)740-9846
luaGWERLEY o1<tscaLi.
MAYOR 'IkOe�As 5T.P[ERRB
Di1 wmiL Of PUKX PROPEM/'SCII.DING COMOMONER
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 111.5
Debris,and the provisions of MGL c 40,S 54;
Building Permit# is issued with the condition that the debris resulting fiUm
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
(name of facility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
$IBM of permit appl cant
10/8/2019
date
dcbrisafrdoc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
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.
City/State/Zip:Northborough, MA 01532 PhoneA 508-351-2277
Are you an employer7Check the appropriate box: Type of project(required):
1.® I am a employer with 30 4. 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6: ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• Demolition
workingfor me'many capacity. employees and have workers'
Y P h' 9. 0 Building addition
[No workers'comp.insurance comp. insurances
required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
3:0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c: 152, §1(4),and we have no Re lacement
employees. [No workers' 13.Z Other P
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 sin 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 31415819 Expiration Date: 10/112020
Job Site Address: 19 Barcelona Ave. City/State/Zip:Salem, MA M 5110
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 under the sins d penalties of perjury that the information provided above is true and correct
Signature: Date: 10/8/2019
Phone#:508-351-227
Official use only. Do not write in this area, to be completed by city or town official
�
Cior 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#:
Page 1 of 1
AYM
`� o9/le/2/2 0�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM0o1919
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 endonzemen s.
PRODUCER CONTACT
NAME:
Willis Towers Watson Midwest, Inc. PHONE
c/o 26 Century Blvd 1-877-945-7378 No: 1-888-467-2378
E-MP.O. Box 305191 ADDRESS:• Certificatee@willie.com
Nashville, TN 372305191 USA INSURE S AFFORDING COVERAGE NAICN
INSURERA: Old Republic Insurance Company 24147
INSURED INSURER B:
Renewal by Andersen LLC
30 C Forbes Road INSURER C:
Nort:hborough, MA 01532 USA INSURER D:
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:W12663065 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.
�TRR TYPE OF INSURANCE A SUB POLICY NUMBER MOLICY EFF POLICY EXP LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000
F;_171 DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES Eaoomnence $ 500,000
A MED EXP(Ary one person) $ 10,000
MWSY 314161 19 10/01/2019 10/01/2020-PERSONAL BADVINJURY $ 11000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000
X POLICY❑JJECaT LOC PRODUCTS-COMP/OP AGG $ 4,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea $ 51000,000
- ac ant
X ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED MW`rB.314159 19 10/01/2019 10/01/2020 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTYntDAMAGE $
AUTOS ONLY AUTOS ONLY Per aeeitle
$
UMBRELIALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE -- $
DED I I RETENTION $
WORKER COMPENSATION X ST TUTE ER
AND EMPLOYERS'LIABILITY 1,000,000
A ANYPROPRIETOR/PARTNERIEXECUTIVE YIN - E.L.EACH ACCIDENT $
OFFICERIMEMBEREXCLUDED7 No NIA NWC 314158 19 10/01/2019 10/01/2020 1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
H yes describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N 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 Insurance9•
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
art Ia, 18532909 BAWH- 1372547
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Commonwealth of Massachusetts
4 t Division of Professional Licensure
Board of Building Regulations and Standards
Construction supervisor Constr t--%6pervisor
-
Unrestricted Buildings of any use group which contain i
less than 35,000 cubic feet(991 cubic meters)of enclosed 6
spac CS-MI25
e. rres 10t06l2020
11!
JAIME L MOWN 'a
86GARDIMER. TREET ; •1
i LYNN MA fliall 1� �
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(�JivS _tZfi s
1 Failure to possess a current edition of the Massachusetts Commissioner
cz
State Building Code Is cause for revocation of this license.
For information about this ricense
Call(617)721-Uoo or visit www.mass govldpl
G�
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston', Massachusetts 02118
Home Improvemehx Coritractor Registration
Type: Supplement Card
!� /
RENEWAL BY ANDERSON LLC. ? Registration: 170810
30 FORGES RD Expiration: 12/22/2019
/M
NORTHBOROUGH,MA 01532
i
t Update Address and Return Card.
SCA 1 0 20M-W17 �y p
JX. O/�717dJ/1LlJN4 ✓ (JCG9JCI.C/!a'.GJ'Pl� -
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:Suimlement Card before the expiration date. If found return to:
Reglstr>rtion Ex6kAon Office of Consumer Affairs and Business Regulation
170810 12/22/2019 1000 Washington Street Suite 710
RENEWAL BY Ai "I.M. Boston,MA 02118
JAIME MORIN:
30 FORBES R[) ,,,efQ.�iGf,A.k'
NORTHBOROUGH,MA 61532 Undersecretary Not"lid out signature
Renewal Agreement Document and Payment Terms
byAndersen. dba:Renewal by Andersen of Boston George Weil
A
Legal Name:Renewal by Andersen LLC 19 Barcelona Ave
HIC#170810 Salem,MA 01970WIND 30 Forbes Road I Northborough,MA 01532 H:(978)998-0602
Phone:508-351-2200 1 Fax:(508)986-7072 1 rbabostonbooking@andersencorp.com
Buyer(s)Name: George Weil Contract Date: 09/13/19
Buyer(s)Street Address: 19 Barcelona Ave, Salem, MA 01970
Primary Telephone Number: (978)998-0602 Secondary Telephone Number:
Primary Email: patcarpenterl9@comcast.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,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: $8,421 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: $2,806
Balance Due: $5,615 Estimated Start: Estimated Completion:
Amount Financed: $0 8-10 weeks 1 day
Method of Payment: Cash/Check 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: Chk 872 $2806; Start$2806; Subcomp $2805
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 09/17/2019 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 LLC
dba:Renewal yAnder en f Boston Buyer(s)
)9 Q/�r t2, `-)� J
Ij
Signature of Sales Person Signature Signature
Steve Duff George Weil
Print Name of Sales Person Print Name Print Name
UPDATED: 09/13/19 Page 2 / 24
Renewal Itemized Order Receipt
Andersen. dba:Renewal by Andersen of Boston George Weil
ALACEMENT
Legal Name:Renewal by Andersen LLC 19 Barcelona Ave
HIC#170810 Salem,MA 01970
wINDO 30 Forbes Road I Northborough,MA 01532 H:(978)998-0602
Phone:508-351-2200 1 Fax:(508)986-7072 1 rbabostonbooking®andersencorp.com
• ROOM:
101 dining Window: Gliding, Triple, 1:2:1, Insert Frame, Exterior White,
Interior White, Glass: All Sash: High Performance SmartSun
Glass, No Pattern, Hardware: White, Screen: Fiberglass, Full
Screen, Grille Style: No Grille, All Sash: , Misc: Aluminum
Wrap, Aluminum wrap of exterior trim.
102 living Window: Gliding, Triple, 1:2:1, Insert Frame, Exterior White,
Interior White, Glass: All Sash: High Performance SmartSun
Glass, No Pattern, Hardware: White, Screen: Fiberglass, Full
Screen, Grille Style: No Grille, All Sash: , Misc: Aluminum
Wrap, Aluminum wrap of exterior trim.
WINDOWS:2 PATIO DOORS:0 SPECIALTY:0 MISC:0 TOTAL $8,421
h
• Renewal by Andersen is committed to our customers'safety by
complying with the rules and lead-safe work practices specified by the EPA.
UPDATED: 09/13/19 Page 3 / 24