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43-135 (2) 45 LONGFELLOW DR BP-2019-0016 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:43 - 135 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category INSULATION BUILDING PERMIT Permit BP-2019-0016 Project# JS-2019-000020 Est.Cost: $2062.00 Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THE ENERGY STORE 178392 Lot Size(sp.ft.): 32539.32 Owner: MCGRATH JOHN H&CAROL D Zoning: Applicant: THE ENERGY STORE AT. 45 LONGFELLOW DR Applicant Address: Phone: Insurance: 17 B EAST ST WC EASTHAMPTONMA01027 ISSUED ON:71312018 0:00:00 TO PERFORM THE FOLLOWING WORKAIR SEAL ATTIC AND AIR DUCTS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeelWpe: Date Paid: Amount: Building 7/3/2018 0:00:00 $65.00 212 Main Sheet,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 0 a.-ftil#L$rak- ' Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit r 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PbVSite Plans Other Spedy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 80 /9-lG 1.1_Pro_P_arty�Address,: /' This section to be completed byyooffice SFS L-,Ac'Pef0t✓ Ar, lV(ALRIP�r Map 43 Lot 163 Unit M4. 0` V 6d- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name( dn) Current Mailing AdddMailing Addds Seg RA )d Tekplwne wa- 3 -139q Signature 2.2 Authonzed Aaentc Name(Pont) I Cunent^7Mailing Arltltlress: r Sgnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only wm leted b e"it applicant 1. Building /1 O � '1 R (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee l 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) Ix i1i ,0o Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commi bnedinspectcr of Buildings Dale .n. EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Wist Be Completed,Permit Can I Denied Due To Imuiuplete Information Existing Proposed Required by Zoning 'cuwhim.ro be filledm by Bmldiog thpannwnt Lot Sizc Frontage Setbacks Front Side L: R: L: R: RM, Building Height Bldg. Square Footage Open Space Footage ^/ (lut @tae minus bld8&p@ved hin N OMking Spaces Fill: VOlW90 ai('Iap@[Ipp A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO a DONT KNOW O YES U IF YES: enter Book page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size,type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES,describe Size, type and location: E. Will the construction activity disturb(dearing,grading,excavation,or filling)over I acre or is it part of a common plan Mat will disturb over i am? YES 0 NO a IF YES,then a Northampton Storm Water Management Permit from the DPW is Mquirod, SECTION S DESCRIPTION OF PROPOSED WORK!check all applicable) New House ❑ Addition ❑ Replacement Windows Akeration(s) ® Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolklon ❑ New Si ns D], Deeks [p Siding r Other[LSa Brief Descr Pilon of P olws c / 77'� Work: fA lir- Sa� L I� I)aA)at!L S�Yt�7j4-,_ Jia Qird,if'S t-ii6 P_4/Z Alteration of existing bedroom_Yes t No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement es lie- No Plans Attached Roll -Sheet 7 �- so.If New house and or addition to existing housing, complete the following: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of heating? Fireplaces or Weodstaves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 k.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Sepfic Tank_ City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATKIN-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Seg ,as Owner of the subject propeM ,//.�/� /ry //C/ p hereby authorize �// I�/S!'l/U!Y ////C� to act on my behak,in all matters rel We to vro authorized by this buildin pertnk a plication. See a�2 Signature/of�Owner Date I, Cpl-/ /ter' //P� as Owner/Authorized Agent hereby declare at th statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains an penalties of r'ury. Print Name Signature of Owner/Agent f Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suosrvisor: Not AppClic`/ab/le ❑ Name of License Holder: �me S� ,�,// License Number Address / Emnuion Date S_0 Signature Telephone 9 Reaistemd Nome Impmy nt Contractor: Not Applicable ❑ 17'�3ga Company Name RegistrationNu�bar Iq Address I n l�// /� qpm Expiration Dale 3 51 Alfh `aA 1 WdOW�`/- V�Telephone 000 �YUYt SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must he 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...... ❑ City of Northampton .r Massachusetts i ' l`" A x � �1 DNPARIMl:N1' OF BOILOING INSPECTIONS 212 Main sliest *municipal Building c c Q�� dortaampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: cis I,n thllt7w dl- i (Please print�n mbe� r and street name) Is to be disposed of at: fh eg ems,Y s�Ie, l Deus) s .. �,, /f?� Please pant n e an locatio of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) lq� Si ure of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. City of Northampton S Sr Massachusetts dn SaiPAnlNBMl OF BarLDIPG In3PECT10NS ;t 212 Main Btreat • Municipal Building MurthaepW., Ma 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to Performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"recanstructioo,alteration, renovation,repair,modernization,conversion, improvement,mmaval, demolition, Or 00118#1100a of an addidwi to any pre-embng owner-occupied burldirig conlainmg at Wast one but not more than four dwelling unifs....or to structures which am adjacent to such residence or budding"be done by registered contractors. Note:if the homeowner hat contracted with a corporation or LLC,that entity must be registered Type of Work: teval(IID h§/ i r-it6 i Est.CC/osttI: �. /6 2 Address of Work: 4') ILlli✓ r�f IYo�rrl'hrvm/)e.P NA G�IO..0 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 6l221Thr eLAz) 17 9'3,a Date Contractor arae HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Q,�, City of Northampton MassachusettsOSP]INTN@rr or Duz== INSPECTIONS 212 Main Stvs�i INn 070 auilAing MoctEampton, MA 01060 Massachusetts Residential Building Code Section 110.85.1.2 Homeowner: Person (s)who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.85.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The Commonwealth ofMassachusetls Department of IndmirialAccidents I Congress Street,Suite 700 Boston,MA 02774-2077 www.massgouldia 9F.irkers'Componsation Insurance Affidavit:Builders/Contractors/Eleemicians/Plumbers. TO BE FILED WITH THE PERMITTING ADTHORITY. Information Please Print Legibly Name(Business/Or,sausstion/Individuaq: The Energy Store,LLC Address: 3 Simm Lane City/State/Zip: Newtown, CT 06470 Phone#: 888-840-6641 Are sma an empmyeO Cheek me appmpmte hex: Type of project(required): 1.01 an aenii erwLh —1—employees that mM/mpan-mrc)a 7. ❑New construction 2.❑Imnamlewmnetmorpmmmbipandhavenoempmycesworking rmmein g. [—]Remodeling any capxiw.[Nowohere'come haumncc requbcd.] 3.❑lame hommwne,do,,ol work myself[No workers romp.menioree required 1' 9. El Demolition 10❑Building addition 4.0 tons Mmeownttm lase 1 hiring mnaacmrsIocoMumall work oe s, resole . Iwill name metal)conuacmrseimerhavc wokas'compenmtion insummeor are sole I1.❑Electrical repairs or additions pmprie wa with M employees. 12.❑Plumbing repairs or additions 5.❑I These ❑Roof repairs amgemnl cpmmclmeM t have hired the sub-colons-. lined on the emched shat.mbConlracmrs hove employees end have workers' mn.irsunnce+ 13-1�T 6.❑wearea corpainwound itsofter,Mve exemisramen nghl.fexonmins per MOL c 14.2Other Weatherization 152,¢1(4),and we have no emplayees.[No workers'comp.neutazrec required J 'Any�plicm[thet eM1aks box pl mu4 also all oat the section bclm':showing their uwrkeri compenselion policy infemmtion. 'Hmr�mwners who subndt Ihu emdevit iMicaang they me doing ell work and Then Lim omsitle conhecmrs muu submit a mw effidavitindicadng smh. :Canhacmrs bet[httkrhu box must anxhcd an eddinp,ml shmtsMwing the risme ohdre subcy ons000rs and amewhmhm orrmt thmemtities Mve employca. IfrM1c submmrutma Mreemployen,Mry must provide their workers'camp.polity number. I am on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site mformadon. Insurance Company Name: BNC Insurance Agency, Inc Policy N or Self-ins.Lic.#: BNUWC0131379 Expirution Dale: 4/15/2019 /{/ Job Site Address: y S Iarx4 a(;�tot✓��- City/State/Zip:�T A�� oi(Md Attach a copy of the workeVccompensa[lon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby caniffA under�theqpains an/d/p�ern sofperjwy thatthe informmionproviddealabovvee is apree andcarrect Signature: DI ' Phone#: 475-2044585 Cell 888-8406641 Office Oficial 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#: A`Ro® CERTIFICATE OF LIABILITY INSURANCE °A0413V2018 o4r3azole 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 MEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORQED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT. H the cemRcate holder is an ADDITIONAL INSURED,the policy(lea)must have ADDITIONAL INSURED provialons or be endorsed. If SUBROGATION IS WAIVED,subject to Me terms and condWons of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to A°cerdficafe holder in lieu of such endonu man4s). PRODUCER NAME- T Jeri E SBIYJ102,AAI BNC insurance Agency,In PNOHN �. (914)93]-1230 FAX NI (914)937-1124 90 South Ridge Street ADDRESS: IUIvatOreapnmgenLymm INSURHUSIAFFORDINGOOVEMGE NAICe Rye Bleak NY 10573 INSIIRERA., StaMetlNSUNI.Corn" 40045 IMSuren INSURER B'. Enelgy PRZ LLC INSURER c'. DBP The Energy SIO. INSURER D'. 3 Simm lane,Suite 1C INSURER F. Newt. CT OM70 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1844462992 REWSION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOT ATHSTANDINGANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER COCUMENTMH RESPECTTO NMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOIHN MAY HOVE BEEN REDUCED BY PAID CLAIMS. IL, TYPE OF INSURANCE sm VAD POLICYNUMBER MMN MMIppYEAP IIMRS COMMERCIALGENERALLA.I.- F OHIX6URRENCE 5 11 CIAIMSMADE -1OLCUR PREMISES Ee awv,_ 5 MEDUPIAnyam ,xnl 5 NIA IFERSONAILAADV INJURY $ GEN'LAGGREGATE UMIIFPPLIESPER. GENEMLAGGREWTE $ POLICY 1 p R LCC PRODUCTS-COMMPAGG $ OTHER AUTDMC°ILELIA°ILITY FaMeINdWINGIE LIMIT $ ANYAUTO DO°ILVINIURY(FiP ) $ .yyNED rvLv SCHEDULED WA eDOILTINIURY1Psac ASS S FII rvONAWNFD PROPERTY DAMAGE $ AUT05GNLY AUTOS ONLY cDxo E UMBRELLA OAD OCLUR EACH OCCURRENCE 5 EXCESS LNB CIAIMSMADC WA AGGREGATE S LED I I RETENTION$ S WORNERBCOMPENMPEROTT SATN STATUTE ER AND EMPLOYERS'UABILITY VIN A ANYPROParETORNIIT ERIEXECUTIVE ❑IN' BNUVJC01313T9 04I15I2016 OV15I2019EL FAID.IDENT S1000,000 OFFICERIMEMBER E%CO1,W0,000 IM,,d.M,n NHl EL DISEASECAEMPLOYEE 5 06LRIPigO.01OF Mwr 0 IOFERATIONS CePO Iw EL OISEADE- LICY LIMIT 5 "DOW WA DEBCRIPl10N OF°PERAT°HSILOf llpl5/VEHICLES IACO0.0 TUI,AGOMonel RmmeM S[MEUM,mey Se MacKJ B mon ap[e if rpui,eEl Evidence of Insumucc, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOV E DESCRIBED POLICIES BE CANCELLED BEFORE THE FSflRATON DATE THEREOF,NOTICE WILL BE DELIVERED IN """SAMPLE"' ACCORDANCE WIIN THE POLICY PROVISIONS. ♦♦"♦••♦"♦^♦ AUMORnEDREPRESENTATIYE ©1988-2015 ACORD CORPORATION. All rights deserved. ACORD 25(2016103) The ACORD name and logo am registered malls of ACORD AC /ro o® CERTIFICATE OF LIABILITY INSURANCE B41OW2018 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,MEND 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. Ifthe ca"I cats holder is an ADDITIONAL INSURED,the poliry(ies)must have ACHIMNAL INSURED proVlslons or be endomed. If SUBROGATION 15 WAIVED,subject to the forms and conditions of the policy,certain policies may require an endorsement. A statement on this ce"Ificale does not confer rights Be the certificate holder in lieu of such andonament(s). PRODUCER NAME. Wendy Ethan,CIC Vanb..k Insurance Services,CA Li¢ODBOM2 PNE.Em 1907TPUD N : 6320 Canoga Ave.,121h Floor R4fins.DORE8. wfilice@venbrookwm IxFomte81AEFOlty COVERAGE "520 Woodland Hill6 CA 9136] INSURER A: CrvmBF01s1er Spedalry 06520 INSURED INSURER B: XI Insurance CNHwny The Energy Store,LLC INMUNE.c 3 S,mrn Lana INSURER D: SWC¢1C INSURER E: Newtown CT 061 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD INDICATED. NOODNITHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LT0. TYPE OF INSURANCE Jan VARD POLICY NUMBER 1nVpDAYD" Wp LIMI LOMMERCMLGEN.UUUEIl1Y OLLUXREXLE S 1'006'000 CIAIMSMADE ®OCCUR PNEMIBES Eetvandw3 S 5D,000 MEDEXEF,—NI s 6,000 A EPK121W 032712018 OV272019 PERSONALannvmlVRY S 1,600,000 GEN'LAGGREGATE LIMITAPPLIES PER GENOMAGGRECATE E 2'000'000 X POLICY 11¢P LOC PROOUCTS.CIXAPIOPAGG S 2.0001" OTHER: S AUTOMOBILE WBILl1Y COMBIN )SINGLELIMIT S 1,000,0(/0' ee GE M ANVAUTO BODILY INJURY(AE cenm) S B GLARED SCHEDULED WP1,160406H00 OW2712018 031272019 BODRYINIUgY(P,,.,I s AUTOSCNLY ANT. HIRED NONGWNED PROPERTY MIMCE aI$onty ros orvty 1 A ULUAIiLIA od molonSl S uxaRELuuRa 11 ocCUN —C._.,._.._..a._.....,' 5,WODOO X OCCVRgEXCE S A ExCnS use CAIMSMADE EFX-110328 0312]2018 OW2]12019 AGCAEGATE $ S,WO,ow I DEN RETENTION E S WORXERSCOMPENRATIOx FER °1K AN°EMPLOYERS'UABILDI YIN STATUTE EA ANY PROPRIETONJP TNEWE%ECVTVE ❑ NIA EL EACH ACCIDENT $ 0 JDERASI EXCLUDED? (Mmdwar,In NH) EL DISEASE-EA EMPLOYEE S IOEGLAIPTION CF OPERATIONS Etlw EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES WC°RD fel,M9MOIW Ramat SNMUN,may pe Reached Nnwn yar+LL,piJM) '30 DayS Notice of Cancellation.Except 10 days for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP IUMBON DATE THEREOF,NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AYTMON6EO XEPRESEMATME " 6L. ,me✓ 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks 0 ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 i Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: LLC Registration: 178392 THE-ENERGY STORE, LLC Expiration: 04/09/2020 3 SIMM LANE STE 1C NEWTOWN, CT 06470 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 178392 04/09/2020 One Ashburton Place-Suite 1301 THE-ENERGY STORE, LLC Boston, MA 02108 i ROBERT NEAL IQC�.Cte -- 3SIMM LANE STE1C L�l NEWTOWN, CT 06470 Undersecretary Not valid without signature