13 HILLSIDE AVE - BUILDING INSPECTION 17tS
GK 01(po3Z23
Q The Commonwealth of Massachusetts t
Board of Building Regulations and Standards INSPECTION, df.7-OFSALEM
Massachusetts State Building Code, 780 CMR]] IISS pplleviwd-Af�2011
Building Permit Application To Construct,Repair,Renovate O�r7?03o -!h`a
One-or Two-Family Dwelling,
This Section For Official UseO.
4[�h.Jar P `- "i—
Building Permit Number:` Date A w
Building Official(Print Nam) t=" 4 _
1 d . w ( ) &t f l$nelure A s M t} Date
lll� SECTION1 SiTEINFORMATION'S ., ,,,.,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
13 HILLSIDE AVE 15 15-0407-0
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R SINGLE FAMILY
Zoning District .Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yesD Municipal❑ On site disposal system ❑
SECTION 2s'PROPERTY OW �'"„ NER$HIP'
2.1 Owner'of Record:
WIMPYS&JUANA FERNANDEZ SALEM, MA 01970
Name(Print) City,State,ZIP
13 HILLSIDE AVE 978-401-1056
No.and Street Telephone Email Address
'S'KWTJON 3:DESCRIPTION OF PROPOSED WORK=(check all that apply),,;
New Construction❑ Existing Buildin Owner Occupied Rcpairs(s)41 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other Specify: REPLACEMENT
Brief Description of Proposed Work : REPLACE 15 WINDOWS &2 DOORS&2 STORM DOORS
SECTION A:ESTIMATED CONSTRU711mcogr S
Item Estimsled Costs:
i)f8ektl UB®Onlyr
(Labor and M
1.Building $ 29,461.00 1 Building Permit Feb ^S:�Indicate how fee is determined
❑Saanda d Crty4own Application Fce
2.Electrical $ ❑Total Project Costs(item 6)x muhipliei = x
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ List.
5.Mechanical (Fire $ �'
Suppression) Total All Fees:$
Check No. Amount:Amt: Cash Amounf
6.Total Project Cost: $ 29,461.00 p Paid in Full 17 Outstanding Balance Due:
?
SECTION&`'CONSTRUCTION SERVICES,;
5.1 Construction Supervisor License(CSL)
90125 10-06 16
JAIME MORIN License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
86 GARDINER ST
No.and Surd - lype Descnption �, }:
U Unrestricted(Buildings up to 33,000 cu.ft.
LYNN, MA 01905 R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 I Insulation
Telephone Email address D Demolition
5.2 Registered Rome Improvement Contractor(HIC) 70810 12-23-15
RENEWAL BY ANDERSEN HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
3n Ft7RRFC ROAn
No.and Street Email address
NORTHBORO MA 01532 508-351-2214
City1rown,State ZIP Tel hone
SECTION 6c WORKERS'COMPENSATION INSURANCE AFFRIAVIT(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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN '
OW$TEWS AGENT OR CONTRACTOR APPLIES FOR BUII DING PEitMIT T
1,as Owner of the subject property,hereby authorize JAIME MORIN
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW,OR AUTHORIZED AGENT DECLARATION
By entering my name below,I by atte under the pains and penalties of perjtay that all of the information
contained in this application' true and eci rate to the best of my knowledge and understanding,
04/14/15
Print Ownef s or Au A s Name(Electronic Signature) Date
NOTES: :
1. An Owner vftooMains 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.mlig.eovloca Information on the Construction Supervisor License can be found at mmngg". y/dus
2. When substantial work is plumed,provide the information below:
Total Door 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 haWbaths
Type of heating system Number of decks/porches
Type of cooling system Encloser! Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SM EN1, NUsSACHUSEM
• Bt mmo 13EPARTamaT
I M W ASIMOTON STRSET,r MOOR
TBi.. (978)745.9595
PAX(979)740-9846
KIMBERLEY ORMOLL
MAYOR Thomas ST.PmKxa
DmECT08 OF PUBLIC PROPEM BUTIM NG CONINU StONER
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 a 40,S 54;
Building Permit# is issued with the condition that the debris resulting from
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 NORTHBORO,MA 01532
(address of facility)
llna opt applicant
04/14/15
date
d6tiofrdoe
__ ------`_.-_.--------- ---
M
Renewal _.-.--------._._ _-
A Home Improvement Contractor.
License 9170810(Explrest IM 2015):
�7Andet yen Renewal by Andersen Corporation Federal Tax 10 941-1918413
wraoove oacuaa«rxr N,n,_."a,.ct. ><
30 Forbes Rd. NorthtHIrougfi,MA 01532
(508)351-2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
1.Buyer(s)Name Date:
WIMPYS FERNANDEZ - JUANNA FERNANDEZ MARCH 16, 2015
6u r(s)Street Address City State Zip Code
13 HILLSIDE AVE SALEM MA 01970
(Email Address Home Telephone Number Work/Cell Telephone Number
WI M PYS FERNANDEZQAOL.COM 978-401-1056 978-745-1753
Buyers)hereby)amoy,and severally agrees to purchase the goods and/or services of Renewal by Andersen Corporation("Contractor'),in accordance with
the terms and condi itens described on the front and the reverse of this agreement and on the Downed specification sheets)(collectively,this'Agreement"). I
Buyers)hereby agrees to sign a oompletion certificate after Contractor has completed all work under this Agreement.
Total Job Amount S 29,461 swum cad S 22 500 Est.Star!Date Method DF Payment
Rnaa
Deposit Received(33%)$ 0.00 oopryt at eeek,y$ 11,250,00 ChecktCasn
12-16 weeks '
Balance Stan OfJob(33%)$ 0.00 Chack a
Balance OR Substantial Ai Saavpu v ESL Install Time Credit Card
Completion of Job(33%)$ 6,961.DO c.daw.S 11,250.00 4.5 days tf credit card is sdected,please
w M1"N .at•.zaee oemvmed lrse an a.zee are aeestea see Crmdlt Card Payment form
;Buyer(s)&grass and understands that this Agreement constltutes the entim understanding between the parties,and that there am n,verbal understandings
.changing or modifying any of the tams of this Agreement. No alteration to at deviation from this Agreement will be valid without the signed,wrmen consent S
tot both Buyertst and Contractor. Buyer(s)hereby acknowledges that Buyers)1)has read Mi.Agreement,understands the terms of this Agreement,and has
received a winptated,signed and dated ropy of this Agreement,including the two attached Notices of Cammilailon,on the data first carmen above and 2)was
orally informed of Buyers right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Rerrewal by Andersen Corporation
4 ' r.
signature of Commatant Signature Signature
X WILLIAM SALEM WIMPYS FERNANDEZ JUANNA FERNANDEZ
lrvved Namaof Can i rt Firmed Name Pursed Name
',. YOU.THE BUYERtak NAY CANOE/THIS THANSAODON AT ANY TIME PRIOR TO MIDNIGHT OF ME Times SUSIPIESS DAY AFTER THE DATE OF TH6 TRANSACTION.
e E THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF TH6 RKU T.
".___ ____________________________________________ __ ___________________________`
NOTICE OF C&NCELLATION j NOTICEOF(1kNcFLI.ARON ,
I
Dare er Teaasaedoa LI+/IS .Ymmnyrum,A04Y Dwrof Traacaeuaa 3^till': -Yua maycnord this
trao.ardon,without my pensltywstdrgw wit6ia threeiwdaea.dayaftom the uaeau+reu,wlehoat a,ty peaaity rn ohl[gatbn,within tht<e lmxiaeaaa}c fromthe
'eDax darn If ynu<aece4'auY Pr P-M graded rah my paym made by under abvvn ibus If ynn"v J,"pruprny wiubul b4 imY PAYm by"a ueder
.the Comeau0 Sale,and a,vtvdad< by you veal be thrCmttan of Soh,aaaany n<gadahh' teareaeed 6Y}oo will be
:retnr«e.dwtn ro eat•&rwm„atg..rdp.uy the eoarraa art^s<n<r)ar your .<t..AYAW.10 day.rdl..Ing r<r<ip,by.h<.e„mrannr("s<tw") nr}a.er
.uHmI..vork.,amt any xec by iat.,arising am attic tranaaninn wid be I eaa.rnatioa mrlce,nod any security im mruiaiag out of Hae rraasacUonwnl be
aaaaehd, IL you eamd,yvn atoar makc.vanaM<tb the senrr at Ya,a r<ddma<,la I ehd. Ir yin ra,t<d,yen maatmaA.awllaNnm tW Sea<r at}aur.ealaenre,m
xeh taat:aOY ax Sand mvdieon axtabev rordved,aa good a de4r<rod en}'au ender xnhuaaHaliy nx good candirwn ovrhea raedvwl,xay goads,hHverrd to yon,mdar
'thxi Cnamrt m Salei m}an maye if}au wh:h,."I,«itb the insrrunlons of the I tbix Caarraer or Sale;ac yon.nay,V y«o w:»h,emuyly with the.iaxtruatia.�of the
iseucr regaNtng the rnum.bipmem or the goodserthe Sell<r'e aapmzc It il-k I S<ner rcgvrtlfo,WrrerM.aUpmrnror tbe .a..deherft Nde ..tP lhr..
'(L you do mahe due gatda aaa0aitle terbe Seller and th<a<nm does nit pith them upl 3(rne du make sae Sunda muasMeta the Seller and theae.Der duex dot phk them
'':wvdrin TD day.ef the dar<of yuw NmicruT fanvellacioq}rove may rttaiumd'wposa 1 u+thia TU da}s vt ehe.date.of yom Notice ofCm<e0atyea,you tray rauainar dispree i
,aP the gaudx without aaY funberoUDgadw. Vymr fylWvvhe the goodA arailehle I of the goeda withnue uny fuller obiigadnn. V}au fail ra mdte the gandaavaOahle
.te the Seller,arV yauage<e ro recurs th<geWx brW Sallee sod Gare da xe.lice i to ehe.aeiim,oe Vyau agr«tontnrn rim ga.dcto the Selhr and fdl to do w,then
}un aratain Habh 6epmfnrmaure of all ebtigadnua under We Contract.Tu. YI I. you rcuvaitt liaLt<.6r peK mv,ee of as„bligaJuus andu rite CouOaa. To tit
':•this tranwcifoq maB or,, r exig Nt,.r.C. N.Reoncullatiohnotlee thfslraaaeedoq ma0 wdellveru sfgeed avd dv«dcopy d'tbix<aaaOndau mdce
say ether«eittea aai:re.,nr aeadutete;ram to Cmuraavm:tl<ne.val bYAederxegl nr anyother wriann awhe,orcendae<t<gran.to Covrrannr. th«ewwi lrYAuda,v<a,',.',�Pvebes Rd. Nuedatwrc.ngh,AfAMeaT. I aDfbrhec ltd.Yorthhorougb,kfA DISDT.
'I HEREBY f:ANCEt'[f1t91'144NSACCION. i I HEBE&Y CANCELTHis Tatrism..noN.
I
'.. &.}cre5y'at¢ Wire Wm Lme I auryt:5araere Sv'.:tlNrm ese '..
Renewal Renewal by Andersen Corporation nnn Homa Improvement coniraaor
byAndersen, 30 Forbes ed Nodhbarough MA 01532 License 817081D (Expires 1 212312 0 1 5)
"r�aoavr errucamerrt .,,n,.o.,.,,a.:.+'°"° (508)351-2200 Fax:(508)-986.7072 Federal lD#41--1918413
Window Specification Sheet
lBuvedsi Nance Dale,or Agrtrmcnt
WiMPYs FERNANDEZ JUANNA FERNANDEZ MON, MAR 16, 2015
l hr hnrcr(sj Baled aixwe hcusDy jointly and nevvrallp itgnr to put,Il:uo dw goods nu(il"n snrirrs listed bola"";in air ondan,0,"tilt the ptioc,mrl tar nr'60iibr;d
rG tin.sto:611'abmt Shut and the lh'ml and fhr levelsetd ill,.aoramp:urwnv; C:LMO)'I IVIM)CAV OAU UGOR RiS01CDELt1C i(>IttiFliLti'I;aY"uhidt
flhrr NI I, i6rautal Shad pan. ..
WINDOW&DOOR DETAILS
A+P t4F� N4+ 6>1WlWAaINdOr color H:aNRarO fkNswa LawLJ: Gi%Ae crop Gluz
RWm I 000, t,,oi ndow/ a $ Dat Ca E.WhtC 5 Samns snwfqun Grilles Sash s+3 S.uh2 Lift. Our.
L—
LMngg I00 ',to 50 80 DS so rail equal lnsen sloped sat L-Tarn WfVWH1 White Standard FFG Low.E4 G6G 3.2 W2 No No
Ltv' 101 30 30 pp OB rellegoalfisensYnpodaef L-Tome WWH White Standard_FFG L4w-E4 Can 3.R V2 No No
L 103 gill 50 80 DB rdi equal finnan st ad aVV L-Trim NKNOH White Standard FFG Low.E4 am 3B 3/2 No No
Kitchen 103 30 50 80 GW Insert late L-Trim NIW,H While Etarbard FFG Low-F4 Gee 213 2J3 No No
Kitchen f01 30 50 80 DBsel#0 uaInserts loped s4 L-Trim NIVINH White Steward FFG Lev-E4 can 112 X2 No No
Kitchen 10l, 'Al 51) 80 DB scroll equainsed sloped sill L-Trim NHPNH WhiteW Standard FFG Lom£4 Gm M 3/2 No No
Dini lot; 311 1 .`i(1 I 80 DB WYd7 al ina9rt slpPad sill L-Thm NHMJH White Standard FFG Low-E4 use 3/2 3/2 No No
Dfreng 107 30 50 1 80 DB sq rail equal need sloped sift L-Trim NKPWH White Standard FFG Low-E4 role 312 312 No No
Sold 200 :40 :i0. 80 be an no opeal insert stoped sift L-Trim KHWH, White Standard FFG_ Lovr.E4 am 32 3+'2 No No
Bed -)Of 30 5tl W W ease one evoin skeperia nit L-Trim vVKMH White Standard FFG 1ow-E4 Gm 31 N2 No No
Bed 12(12 3i) 14 70 OB nail equal!nsoR slapad sill _ L-Trim VKM7H White standard FFG Lov,E4 use N2 3n2 No No
Bed 2013 :}0 at) 70 D8 solely uat insert slareed iel L-Trim VKVH White Standam FFG Low-E4 eaGL3= N2 No No
Bed 2 201 10 80 80 Da^ rode at Insert sta ed sort L-Trim VHMtH White Gtawam FFG Low-E4 Gno W2 No me
SathI 20h 30 4 34 DB raN xgualinsertsloFed via L-Trim H White Standard FFG Lm E,I C&s 3/2 Na No
Bed3 20G :ill 50 80 DS sq fall uai used sloped sill L-Tilm VfirWH White Standard FFG low-E4 Gat; 3/2 No No
Taal 15 BAX BOW&BUILD OUT DETAILS
accent A
pPmx
$C}I xxotM Acores. Number Franc Willow End C¢ntar LnwEi Knot! 14ardwara
Rwm Cam" Style Fill en rod ht Ce3lrps Lite, Le. latarar E:rGmtic:a Glhtna io her sasrraa 5✓exms Sn'znsun :whit Capsr
SPECIALTY WINDOW DETAILS
fell Apo., taws: sprx:ult RAY/HOW ADDITIONAL WORK NOTES
Roam Cwnl ffiy10 "hurt UJ. amanSun Gr21oa Grille&file ExVIN GobY t It .n 1 b:2 fndia
vul h. a4 Mbw Lr
AUDI'C10NAL WORK DETAILS,
No contractor will wrap exterior cash s wilfi call stock aalor of
Owner is aware that Contractor does net do anypavairlgistalning orlemov-77astaulerion of atenn system a window It is the respon%pery at
the homeowner to have the alarm system and window liaafinenta/hardware removed prior to installation. M make no guarantee as to wnetheralamis M window
haiamanfeeiteardware wit fit after replacement. Customer is also aware in same cases there will be glass loss. it Utem is,the amount will be dependent on the type
of existing windows,type ofinstafWtion and window style.I"make no guarantee as to me amount of glass ions.Customer is aware and understands any andall
unseen mr is not Included in this contract-Should any rot be found there will be an additional charge tot time and naterne,unless so stated in this contrect.
3 yes Contractor will Insulate,caulk and seal windows with 3-pdm system to prevent water and air infiltration.Removal and disposal of all job related debris.
windows,doss,storm windows and vacuum nightly Included. Upon completion of the job aril payment in Nil,a limited warranty shall bA issued.
t'I Yes Building Permit.-Contractor will secure any and all necessary permits. The fee far the funniest to Included in the lanai contract price.
Yes All discounts have been applied to this agreement.
`=a ✓ Y, Vo Owner agrees to be present an the final day of installation for final inspection and to deliver final payment/finance fine ).
-Ln:ryr rdnnd rl Amw<xal by-rind l4.t n•ent6r µhrh tt�tdmlivaif,arcn5k n,.d.rr"+nh t�C11,CIY)A{WlNlif)1vl\UUCHlR la4\EOPIJ,Iu:q(.11t111I_�-Ii romur u:.A�rcuurr
ally i rtay;l t h l ti nLi a ..m t t I i sled y 1 y dl y I n . ' I'I hw,M man�`#irl ri ;err;, I r str n.n" II dr n.rrcd n
nt"uaY... archrLaups are in edinftf4okiuu a in Nile its line xitmvvm4n lS "ror;n,h'.i et1, 1ft'dvIft l+,- I tiv.�px 61i"4",M r:l.
IReaewal by Andersen Corporation p 1S nvrEi "� Tiu
c�4~4f-{� ~
i Signature of Consultant- Signature ! - Sigrtafu 4 �7r
WILLIAM SALEM WIMPYs FERNANDEZ JUANNA FERNANOET"
Print Name of Consultant Print Name Print Name
RenBwal by AnderSBn COrporatlon MA Hame Improvement Contractor
30 Forbes rd Northborough,MA 01532 license#170610 (Expires 1 2123120 1 5)
(508)351-2200 Fax:(508)-986.7072 Federal ID#41-1918413
Provie Door Specification Sheet
jBu e.r`>)Name, Date of Agrecinent
WIMPYS FERNANDEZ - JUANNA FERNANDEZ IMarch 16,2015
'11c hntrr listrct alxxe 11"AA pindy srul amity uFrce w ourthrow.th. ¢�nde and 0.vr nun.r.hrYvd lrloq in uermd.uu w H,ev h pnu,.arut army dutinhe,l ou the
Sixx-iBraioWshrnr Ind III,,lnsm awi thr n w mx ,;f'the arc m panving Ct S1 Olt%VINDUW AND DOOR ICIiAIU )ELING:GRIN AMN 114 lii,h the
Slw<ificninn Shrcr is pan-
ENTRY DOOR DETAILS
taau,m Front Back
width 361' 32,
tf"glu Ito" 240"
lembdaFlh 4.9/16 49/16 49/16 49/16 49/16 49/16
4 tnwde sy'6 Iicr410 Hrr 430.21r
[?vlsidenYl" lirr410 Hut 410-211'
3 IruWu,olnr Sum,Xllst sirn.,Mist
Chn,de Cola, l`eilis Rid PuUis Rnri
Siddim,;fpk, None Srnu:
c trim sidr3iW \,� \u
LixtdEmhr No �n
woad,C.km, N„ No
t:Fuv rto4,. Clrtr wAow li Cca,o'/hnrli
Camh,s Nnnn None
Smooth Smooth
Opma6un HRFO HLFO
Add GrRte Colonial Cohd,ial
G,uk aptwns I`tintrd }".wnt-d
Lidt•.ah'r SAME 5.-k-ME
th,c,;d,•u,hTM s-mm it SAM fS
hnIt,cL a G--orvnin Cleofximl
1.Fiw"h Sarin Ni,:k Satin Nick
Eat xxiitstt l'hrtnmah G"ngian
as Finth Satin Nick Sohn Nick
IbmA. ld sah", Silerr
Kickpl.w No No
acx"I'ni
KJ1Si1t Nn No
aadm�ae,a White i White
1Fmcbx I No N.,
STORM DOORS
fArarst)dc I3s+3 3tl+a
Storm Colin 1'yNiy and l'alfiw RM
Handle Style Siren :iierta
Haradk Clolnr Sarin Sur" 4:,eua Nid
Additional
Job Notes:
Owner is aware that CoMmctardoes net do any paintingisG$rtstg orremovaltins daffatidn of alarm system and dow veatmentsmamwam.it is the esponsibilt y of
>
the horrreavner to have the alarm s stemand door treatmentslttaNtvare removed nor to enstasation. We make rw uaranfee as to wtwthei alarms.dow Y P, 9
treatments or hardware will fit after replacement Cusfomarts also awam in some cases[hare will be glass bss. if ttxYe Is,the amount AN be dependent on the
type of existing doors,type of instatunion and window style.We make no guarantee as to the amount of glass loss.Customerfs aware and understands any and
all unseen rot is not included In this contract.Should any mC be found them will be an additional charge tar time and materials unless so slated in this contract.
- Yes Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. Removal and disposal of all job related debris,doors,
steno doors and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shad be issued.
:t Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permii(s)a included in the total contract price.
9 Yes Al discounts have been applied to this agreement.
�ilr ✓Pis So Os vvr aortas w he pr,9e•ra t,n the final rev of i.wsalimi.+a for final map,....and m drLar final paem nr!Imanee toi osL
,tn Fim:fpanrzmishaPh�rrrmrfrd uvlildkneatmrt is uerc/.ld.im J.a mFe.l�'trnx�oGprzrtiT:
g ..3 1 k itn iix 1 .1 s 4u Sir ' t }I v+ 1rh ICa1r7HIkINIXnA AND Dtfrla AFU9Uf]JA, 1f ltttiftAt rtl _
i d 1 . tat rue• xla , i { i-.. I e, I y .q .3! a ( I . 1 SF. f 1 I 1 5''d . erns..><dda n, n
unkr noh rLamm nrr e. .,and ss+rd tg lnnh,he Burr a,v.dr vac a tFmr_ E rziry aslno olydk etr.¢Ruu.x;1. adL..e SI"*,.:r.n,naLort
1
;Renewal by Aodersen.Corporation
to 7✓Ir�llia�,r,.S�rl�� `� {' �r� —" r,�y��, li —,
l 1
, Signature of Consultant Signature
WILLIAM SALEM WIMPYS FERNANDEZ JUANNA FERNANDEZ'
Print Name of Consultant Prim Name Print Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigadons
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electiricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organizadon/individual): RENEWAL BY ANDERSEN
Address.30 FORBES ROAD
City/State/Zip: NORTHBORO, MA 01532 Phone#:508-351-2200
Are you an employer?Check the appropriate box:
Type of project(required):
I. ■❑ 1 am a employer with 30 4. ❑ I 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
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.: 9• ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I 1•Q Plumbing repairs or additions
myself. [No workers' camp, right of exemption per MGL 12.[] Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
`Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
tmployecv. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:OLD REPUBLIC INS. CO.
Policy#or Self-ins. Lic. #:MWC 30293800 Expiration Date- 10101/15
Job Site Address: 13 HILLSIDE AVE City/State/Zip: SALEM, MA 01970
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 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.
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1 do hereby c u e pains and penalties ojperjury that the information provided above is true and correct i
Date:
e: 04/14/15
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Phone#: 50 -351-220O
Ofikial use only. Do not write in this area,to be completed by city or town official.
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City or Town: PermittUcense#
Issuing Authority(circle one): !
I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector z
6.Other g
Contact Person: Phone#•
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ANDECOR-01 YADAVYO
A�Rd CERTIFICATE OF LIABILITY INSURANCE �TE 101112014
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(SI,AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must 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 endorsemen 6).
PR°DUC°` _ to COINIACT
AME: certlflca Ills.com
WildoIis of 25 Cantu Blvd Inc.IDC. _�N..EMI:(877)945-7378 F
Century NA.(888)467-2378
P.O.Box 305191 -MAI
Nashville,TN 37230.5191 Ao_owEss_._,_.-___ . __
IRSURER(S)AFFORDING COVERAGE RAID
INSURER A:Old Republic Insurance Company 24147
INSURED INSURER e: _
Renewal by Anderson Corporation INSURER C:
30 Forbes Road WSURER D:
Northborough,MA 01532 wSURet E:
MSURSRF:
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, TERM 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,
ILTR NSR TYPE OF INSURANCE
POLICY NUMBER MMIOD FI lm"Drrfyyl LSARB
A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S 1,000,0
71 CLAIMS-MADE Al OCCUR ZY302940 101011=14 1010112015 PREMISESO(V,! ner¢e) E 500,00
MED EXP(Any mN pemn) S 10,00
PERSONAL B ADV INJURY E 1,000,00
GEWL AGGREGATE LI MIT APPLIES PER: GENERAL AGGREGATE S 4,000,00
X POLICY JECT LOC PRODUCTS-COMPIOPAGG E 4,000,00
OTHER: E
N1ITONOBILE COMBINEDa�H&1 L LIMIT $ 5,000,00
A X ANWAUPO MWTB302575 10101/2014 1010112015 BODILY INJURY(PefpNepn) E
_ AUTOS
AUTOSSCHEDULED
O BODILY INJURY(Peramdm,q S
HIREDAUTOS NON-OWNED
PE,dantl GAA E S
I E
UMBRELLA UAS OCCUR EACH OCCURRENCE E
EXCESS UAB CLAIMS-MADE AGGREGATE S
DIED I I RETENTIONS E
WORKERS COMPENSATION X R O -
AND EMPLOYERS'UAORM YIN STATUTE ER
A ANY PROPRIETORMARTNERIEXECUTIYE MWC30293800 1810112014 10101/2015 E.L.EACH ACCIDENT S 1,000,000
OPFICERAIEMBER EXCLUDED? N� NIA
(Mambdory In NN) E.L.DISEASE-EA EMPLOYEEI E 1,000,00
Ira We Ibe under
OE SCRIPTIONOFOPERATIONSbM. E.LDISEASE-POUGYUMIT S 1,000,000
DESCRIPTION OF OPERATIONS MOCATIONSI WHICLES(ACORD lei,AIN UNmal Ram.M achod16Y,may W.KiN retl I..Wca is regWaCl
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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.
AITTNOROED RLPRESENTATNE
Evidence of Insurance �/ }
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01989.2014 ACORD CORPORATION. All rights reserved. i
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'iror
License:CS-090125 °
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JABS L MORIN ns s f.
86GARI)INMST
LYNNMA 01905 T "sin
Expiration
Commissioner 1tN0412018
flies of Consumer Affairs&Business Regulation
EIMPROVEMENTCONTRACTOR
�r Reglstretien. 170810
Type
f _ Eltpih'dton• 12C13J2015 _ Supplement
RENEWAL BY ANDERSON CORPORATION P
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JAIME MORIN
104 OTIS STREET Q
` NORTHBOROUGH,MA 01632 -'
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Undersecretary
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Product Type: Glider
ENERGY PERFORMANCE RATINGS
U-Factor Solar Heat Gain Coefficient
0.29 1.65 0921
U.S.A-P Metnc/SI
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
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pol.rManie.NFRC r;tngs a s,,,,,ninea for a MEa set of eMROnmental<Onaltiane and a epecift ga.1'as.
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100-00473518-010
ENERGY PERFORMANCE RATINGS
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