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143 FORT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts FOR Board of Building Regulations and Standards MUNICIPALITY y i Massachusetts State Building Code, 780 CMR, 71°edition USE. Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised January or Tw amily Dwelling 1, 2008 This Sectiot For Official Use Only Building Permit Numb Date Applied: C.- Signature: Buildin Cnmmi$Si ea/Inspe ofB dings Date TION 1:SITE INFORMATION a.. 1.1 Property Address: � ��..j nn 1.2 Assessors Map &Parcel Numbers 1� !Y�✓�17 a`e 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 fi) Frontage(fi) 1.5 Building Setbacks (ft) Front Yard _ Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.Lc.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone2 Munici al❑ On site disposal stem ❑ Putilic❑- Private❑ - Check if yes❑ p p SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[RR(Record 1 / /) /�/�� y /J_ hl�x �lr�/IPe �knaC- %y3 f6 1�Vei ////T Name(Print) - Address to Service: Signature Telephone SECTION 3:.DESCRIPTION OF PROPOSED WORK2(check all that apply) wens[ ^t ❑ Exis E r'uild it❑ ) 0 pied ❑ repairs( ::' id. :ci: ❑ r .vt• .. .. . .. _ Demtilitinn ❑ AccessnrryBldg. ❑ 1Jumberofllnils Other ❑ Spceilj.: " ., ......: . __._..___. _ Grief Lcscriptxm of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate bow fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ D ❑.Total Project Cost' (Item 6)x multiplier x 3.Plumbing $ O 2. Other Fees: $ 4.Mechanical (HVAC) $ /% List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ /(f� �� 0 Paid in Full 0 Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5(.1�1 Liccense"d'�Construction Supervisor(CSL) J JL,22/ License Number Expiration Date. H r Name of CSL-HoIde 111 I List CSL Type(see below) Address - - / - e '" ;.r - Descri lion - /0� U Unrestricted(up to 35,000 Cu.Ft. S"gn tore R Restricted 1&2 Farnily Dwelling M Masomy Only RC Residential Roofing Covering Telephone. WS Residential Window and Siding - "SF Residential Solid Fuel Burning Appliance lnstallation D Residential Demolition- 2 Regis d Home Improve t Co tra for(HICq e /1 HIC Compan N e or IC Regis nt Na a Registration Number S r l ro Address Expirati nDat'e - . Signature- - 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 .......... No...........❑ SECTION lac OWNER 9,UTHORIZAT'ION TO BE COMPLETED,WHEN. . ' OWNER'S AGENT OR CONTRACTOR APPLIES F.ORBUILDI G PERMIT I, as Owner of the subject In hereby authorize to act on my behalf,in all matters - relative to work authorized by this building permit application. - Signature of Owner - Date - - SECT.ON 7b: OWNErtI QR AUTOORIZFIp AGENT°DECLAR4TIOIN hat thenlat'emetits and information on the 11,3 _ oim applicatiai hrefrue and accurate, toile best of niy know ledge and behalf. . `d i`eh -Print Narnc - - aid Signature ofowner o F.uthorczed— gen Date (Signed under the gins an enalties operjury)' 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 I MR5,respectively. 2. When substantial work is planned,provide the information below: 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 ofbathrooms 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" r i DEBRIS FORM This form is to be submitted with building pemut applications wbenever there is debris to be disposed of. Property Address: In Accordance with the provisions of MGL c.40, §54,:a condition of the Building Pemut 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: (Location of Facmlity) Signature of Pemrit Applicant /�rla g Date The Commonwealth of Massachusetts ( T Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n/� I Please Print Legibly Name (Business/Organization/Individual): �E'1�PJc.� �V Y1llr�erSeY1 Address: %d/N Ofi 5 L1fYec City/State/Zip: ldh bo ro/ A4 L7/�3� Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.5+1 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.❑ I am a sole proprietor or partner- listed on the attached sheet. I 7 modeling ship and have no employees These sub-contractors have 8. 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 ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 most 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 most 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. J Insurance Company Name: 1 �&0 Je J/Z ✓GYICL' Policy#or Self-ins. Lic. #: &S Gt/j!'''L �? /yYJ Expiration Date: 2 J yd9 Job Site Address: ✓�,�J '6// / nno' _/ _ City/State/ZipAl�ez�j Aq 01IF70 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 cer a er the pains and penalties ofperjury that the information provided above is true and correct Signature: _ J Date: Phone#: 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#: NI-Machusett.s Department of Public Safety Board of Building Regulations and Standards_ Construction Supervisor License +, License: CS 99256 Restricted to: 00 SCOTT PHILLIPPI 58 D STREET WHITINSVILLE, MA 01586 Expiration: 6f7/2011 ('unm�ivxioner Tr#:,99256 Restricted to: 00 - 00- Unrestricted 1G-1 2 Family Homes Failure to possess acurrent edition of the Massachusetts State Building Code is cause for revocation of this license. ' Refer to: WWW.Mass.Gov/DPS ✓lie 'fOavNmzoose�ea c�./�aeaac/uroellb Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: RegistratioMN 149601 - Board of Building Regulations and Standards EXJtu hWT--4 /2010 One Ashburton Place Rm 1301 -= /1* Boston,Ma.02108 J'A' „yp `pm pleent Card RENEWAL BY A1D_SOf .1>1 CAROL O' E'�. .jNNY 104 OTIS STRTREET ,1 NORTHBOROUGH,MA Oi532 Administrator Not valid without signature ACORD� CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDMYp 02/13/2008 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. AT ER THE HCOVEIS RA COVERAGE FORDATE ED BY THEE OLDICIESS BEL OR OR OW. P.O. Box 333 Ann Arbor, MI 48106 0333 INSURERS AFFORDING COVERAGE NAIC# IxsuxeD Renewal by Anderson INSURER A: Insurance Company J&L Windows,Inc. INSURER B: Hermitage 104 Otis St INSURER C: Nonhborough,MA 01532 INSURER D NSURER e COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 7EUTY INSURANCP POUCYKUMBER- POLICY EFFECTNE POLICY EXPIRATION ILITY HCP 507404 09/07/2007 09/07/200$ EACH OCCURRENCE UMITBE 1 0 Ooo CIAL GENERAL LIABILITY PREMI ES Ea em1 nm S 100 D IMS MADE ©OCCUR - MEO EXP( Crro pelaen) E $000 PERSONALSADVINJURY E . 1 0000 GENERAL AGGREGATE 5 2 000 000 ATE LIMIT APPLIES PER: PRODUCTS-COMPIDP AGG E ZDOO D00 PRO. LOC . LIABIUTY 35 MCC XD 6390 10/01/2007 10101.2008 COMBORDSiNGLE LIMB (ERecdeeny I E 1,000,000 X ALL OWNED AUTOS SCH[OULEDAUTOS BODILY INJURY 5 (PW Pemn) HIRED AUTOS NON•OWNEDAUTOS BODILY INJURY S (Pal ACMeni) PROPERTY DAMAGE E (PeraWdenll GARAGE LIABILITY AUTO ONLY•EA ACCIDENT S ANYAlnO OTHER THAN EA ACC S . AUTOONLY AGG $ EXCESSRIMBRELLA LIABILITY EACH OCCURRENCE M. 111 OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLERETENTION EA ��YSCOLMMPBury ON AND 35 WEC PP 1444 02/17/2008 02/17/2009 u' DTANY PROPRIETORIPARTNERIEXECUTVE E.L.EACH ACCIDENT OFFICEP/MEM8ER EXCLUDED, IIyae aeacOeuMer E.LOISEASE•FAEMPLOYEE S 500000 SPECNL PROVISIONS OeIwi E.L.DISEASE-POLICY LIMIT S OD OO oTxER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT ISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WALL 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 KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATNEL ' AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ACORD CORPORATION 1988 Window Agreement-Page 1 of 2 r— J&L Windows,Inc.,d/b/a i 104 Otis St.,Norlhborough,MA 01532 Renewal .♦ MA Home Improvement Contractor (508)919-0900•Fax:(508)919-0903 {,,, �� License#149601(Expires 112 412 01 0) Customer Service:f80e11 573 4 606 Andersen. Federal Tax ID#83-0404201 �7 (' p qW'"OaW eE OWMe a Andersen G+mpvny Product Manager: ✓ (/!D J /I I/v Window Agreement Contract Date: 6 ' Homeowner("Owner).Name(.): 10,< Street Address 3 /-0 2T ✓ City/Town: Q Stat Zip:G/ 7 Home Phone: c?--7 —3- / -7 Work Phone: Job Site Address(if different): .] /.+7 2/ E-mail Address: Materials to be provided and work to be performed by Renewal by Andersen("Contractor"): Contractor will furnish and install Renewal by Andersen-approved materials to the following specifications: p 1. Date on which Work is Scheduled to Begin:67oR Cv/tJ Expected Date of Substantial Completion. OS lC 2.�ontractor will Install a total of-7 windows in Owner's home,using the following individual quantities: / Double Hung(DB) Z Equal sash ElCottage sash(1/3 top,2/3 bottom) ❑Oriel sash(2/3 top, 1/3 bottom) Casement(CW) 00 Hinge right O Hinge left(as viewed from exterior):OStandard handle OMetro handle Double Casement(CDW) OStandard handle OMetro handle Casement/Picture/Casement(CPW) ❑1:1:1 or 0 1:2:1 OStandard handle 0Metm handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or 0 1:2:1 Awning Window(AW) _Picture Window(PW) Bay or Bow Window: 3_4�_Yes 0 No #Windows to be Custom Fit Replacement: 4. ❑Yes-![4 No #of sills to be replaced by Contractor: 5. ❑Yes o #Windows to be New Construction Full frame(includes new interior&exterior casings): Exterior casin s: ❑ Pine 0 Maintenance-free material ❑Factory applied 908 Fibrex brickmoid 6. Glazing to be?N High Performance 0 Other If other,please specify: 7. Exterior color to bf5Z White 0 Sand ❑Canvas 0 Terratone 8. Interior color•to b White 0 Sand ❑Canvas ❑Terratone 0 Wood Note:Interior color can only be white,wood or same color as exterior. Wood interiors need to be finished by Owner. 9. Hardware ,White 0 Stone 0 Canva55 Brass Double Hung: Install lifts? ❑Yes�No e�L/�( (,¢�,v+ob t0 1R�Yes ;9L..,V.No Contractor will remove metal frames or grilles. #of Units: .S "t;VV 7 11. O Yea-45-No Contractor will install new paint-ready or stain-ready casings. Inside or outside stops#of openings: Interior casing 4 of openings: Exterior casings#of ❑Pine 0 Maintenance free material Owns Is aware that Contractor does not do any painting, wrter initials 1 Z. 0-lfea No Contractor will wrap exterior casings with aluminum toll stock of color. Nate:Required with storm window removal;removal of storm windows will,f@ave screw holes in casing. 13.New windows to have: 0 Half or �'Full screens Screens to be: R Fiberglas ❑Aluminum - 14. Windows to have grfles�'Yes 0 No If Yes:�f"[I Grille Between Glass(GBG)�Removable Interior Wood(INTW) , F�Divided Light(FDL)— 6 F2oNT Grille patterns: B B ❑ m DH - DH DH DH CW/Picture Glider CPW or GPW use difional sheet if needed - Owner approved(initial ): 15 es 0 No Contractor will insulate,caulk and seal windows with 3-point system to prev and air infiltration. Yes 0 No A limited warranty shall issue to Owner upon completion of the job and payment in full(see reverse side). 1Z_3a Yes 0 No Building Permit-Contractor will secure any and all necessary permits.The fee for the permit(s)is not included in the Contract Price and a separate check is required at the time f sale for this fee. �b . 18. Addition .ob details: 5- 4,A, .w S, /O G 2 W, N 00 Cd S v . 19_C7les 0 No Owner has reviewed the Additional Terms and Conditions governing this Contract on the reverse side, including Owner's Three-Day Cancell n�ighis pursuant to MGL c.93 48, .140D�§JA-or C.255D§14(See Se 25). 20. Total Contract Price:$/O 7 Regular Retail Price:$ 7 0 All available discounts applied: Yes 0 No 21. Deposit(1/3):$. 5�7-/_ - paid by 0 Cash ❑ Finance (Acco m#: ) Second(1/3)$3�"7 /. - to be paid by Cash at start of job on (Estimated start date). Final(113)$ -3.S�to be paid by Cash at completion of job on (Estimated completion date). 22>Yes 0 No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shall be demanded until the contract is completed to the satisfaction Of all Parties. NOTICE: All home improvement contractors and subcontractors must be registered. Any inquiries about a contractor or subcontractor relating to a registration should be directed to: Registration Division, Program Coordinator, One Ashburton Place, Room 1301,Boston,MA 02108,Tel: 617 727-3200,Website:hftp://www.mass.gov/dps The parties hereby mutually agree fnoalbr th ould a dispute arise regarding this contract,Contractor may submit such dispute rivate orbiter�y� that has been approved by the Office of the Consumer Affairs &Business Regulatio �i1 r sf L,j d t mn to such arbitration as provided' GL C. A. Contractor Signature: Owner Signature: ��� NOTICE:The signatures of the parties above apply only to their agreement to alternate dispute resolution initiated by Contractor.Owner may initiate alternate dispute resolution even where this section is not signed separately by the parties. YN IS THIS CONTRACT IF THERE ARE ANY BLANK SPACES ,_n al by An eri- P uct M a at wner gnature � �� SU l/✓CN Product Manager(Print Name) Owner Signature White-Renewal by Andersen Yellow-Installation Pink-Homeowner re al WoodNinyl Composite Frame ' RMilp'CcuKfc•+ - Dual.* Argon Low E Double Hung ENERGY PERFORMANCE RATINGS U-Factor(U,S)/1-P IsOiar Heat Gain Coefficient 0 ., 32 133' ADDITIONAL.RERFORMANCE RATINGS Visible Transmittance 0 5 '_ M.mrineluryi rtllM•1•IV.IIA.ri miry.e•nTim ls.PVA:•ObP!'PLq:o.aw•r hr<•FTidy'•MFp•Iw . MII^nvnv..N<MC'raN.yl•1vy.wwnir.d ardnnds.nl.rv•Ironm.nnl•ewH:.nr Mdvyw.l(pNw�rrt. ' - - '. - NPof,d•u Mf gc•ar1!ynJ•nrp-•due4nd Nn n•I bingl�e nAmOeYm el•Iy peNelbnq.q•eRr w. -- ' C•n•M MCv4cWni•Awnan•b cUvgadwlyrrynnMy wbmxrwv,' .. . . Df SIGN PPESSUSE'(PSF) H -IC25 , Mr0027 21t. ! .. "1.rJv�Ar4C M.� '.D. loin ix: 1Y111 • • MPb s•.R+.d.M6.L�C.EL A♦ C.q.AY 1i ""P MTM+vnMy OMA M•AI &C.,O Aw by/M. - " Renewal byAndersen. WINDOW REPLACEMENT an Andersen Company To Whom It May Concern, Enclosed is a permit application package for a project we have been town. Thank you in advance for receiving this contracted to do in our to g Y Y package by mail. As we work in every town in the state, it greatly helps us in our process. We have also enclosed a self addressed and postage paid envelope and would request that when the permit application has been processed, that you would mail it back to us. Enclosed for you review in this package is: ❑ Permit Application ❑ Home Improvement Contractor License ❑ Construction Supervisor License ❑ Proof of Insurance ❑ Proof of Energy Efficiency Rating ❑ Signed Contract from customer ❑ Permit Fee (if accepted at time of applying) If you have any question regarding this application please call me at (5013) 919-0992 or e-mail www.cobrien@renewalboston.com. Best Regards, Carol O'Brien Permit Manager 104 Otis Street 1 Northborough,MA,01532 Phone(508)919-0900 Fax(508)919-0903 Website: www.renewalbyandersen.com