42-118 (3) 29 BRISSON DR BP-2019-1193
GIS#' _ COMMONWEALTH OF MASSACHUSETTS
M=31 1 k:42. 118 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-2019-1193
Proiect# JS-2019-001935
Est.Cost: $3145.00
Fee, $65.0PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RICHARD ABTS 74666
Lot Size(sp.R.): 18600.12 Owner: LEPAGE HECTOR I&CHRISTINE M
Zoning, Applicant: RICHARD ABTS
AT: 29 BRISSON DR
Avalkant Address: Phone: Insurance:
132 PROSPECT ST (860) 306-7275 WC
EAST LONGMEADOWMA01028 ISSUED OM4/25/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR, ATTIC HATCH, RIM
JOIST
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring U.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Eire Department Fireplace/Chimney:
Rough: 0111, Insulation:
Finan 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:
FeeType• Date Paid: Amount:
Building 4/25/2019 0:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(4 t3)587-1272
Louis Hasbrouck—Building Commissioner
City of Nort am „
Building De artnt
212 Main tre App 2 d )q,9 �(JLATION
-.1 Room 00
Northampton, A 0
phone 413-587-1240 ax ".F;, ON
ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY (wrj /�
SECTION I •SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
zq Ir;55aw Tr;JC Map _ Lot � � � Unit
Flooe icce) MA d 10(e Z zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHP/AUTHORIZED AGENT
2.1 Owner of Record:
s+or Le Pe3e T. JR �Y LSOK pr.�Ffov .tet MA olo(o,
Name(Print) Cunent Mailing Atldress:
4113-320 - le41473
se.& / wlvlev" Telephone
Signature
2.2 Authorized Adept:
`T(Phno cJ Ab'Fs 13a ting doer st.j East- L.o r+. .0 encJew/NAo 02�
Name(Poop Curten�')Mailing Atltlress'.
W, a&�; p
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by pennnit applicant
1. Building ,$ (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from fi
3. Plumbing Building Permit Fee 1/
O U
4. Mechanical(HVAC) Q
5. Fire Protection
fi. Total=(1 +2+3+4+5) 4u Check Number
This Section For Official Use Only
Date
Building Permit Num er Issued.
Signature
Building Commissioneninspeolor of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor//: Not Applicable 11Name of License Holder: R�r,6&Nd ITf'$ cS
License Number
r.3x 't'.roepg�t sl East Lcr�n,.ea:Jb J MAoro2 ,Y a/s f2,0
Address Expir tion to
1",J 26 1(e6- 36( - 7275-
Signature Telephone
9.Realeterod Home Improvement Contractor: Not Applicable ❑
>=ue�SV . uc 177.zs9
Company Name Registration Number
33 G);sca H.Six
Atldres ce /.n UA1�ve i /lloouj,� GT0(,3(eQ xor�
Telephone 977- $ 300, E2fie
S
SECTION 5-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...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY]
1 Ksuulo.+e ciyfic -,Toon 'i 7" 610,,0„ cellulose isu� ix 6+a11 )DVOPdUVea+S
-.ubr,�la+2 u+fic l+c *Ck r.�t..cl PeV6loe+1 r_.i.-sec...!; 5 . 1r.6u.1 w*-e V; rJ0isi-
W i+la 6" -�-1beV51nS,5 roc�,7f
�cltaa 1 �1�i-S as Owner/Authonzed
to
Agen hereby declare that the statements and information on the foregoing application are true and accurate, the best o my nowledge
and belief.
Signed under the pains and penalties of perjury.
1�; 164 !Arts
Print Name
Signature of Omer/Agent Date
I, _ ceN 6LrJAPIV au tl,ov i7n+;nu 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
City of Northampton
`�.. Massachusetts
F
I. DEPARTMENT OF HDZZDING INSPECTIONS
212 Main Street a Municipal Building
�. North m ton, HA 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 most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneraccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: G)ea,+(.,tL +'ox�j s ( t �u Est Cast: �3 14�
Address of Work: try 'Bs Sn _Py. rPlotCe_ MA rrf062
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
—Job under S 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.G.L.Chapter I42A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH.ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury: )E 6U '-J az( i
I hereby apply for a building permit as the agent of the owner:
��� f�t5 L.
Contractor
t"Q4 1773Y9
Dat Contractor Name I 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
City of Northampton
Massachusetts �
x
u �. 3ffiPARITIENS OF BOILOING INSPECTIONS � rt
` 212 Main Street • . nicipal auiltling 3 CD
Nor'tha ton, M 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
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.R5.1.3.1
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.
10
City of Northampton
Massachusetts
{` DEPaRTHENT OF BUILDING INSPECTIONS
212 Main Street oHunicipal Building Y`Sh C
Northampton, M 01060 sbp yy6°
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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
2.9 'RN;ssou t7Y. Noo-ewce_ MA n/6ia2-
(Please print house number an street name)
Is to be disppoosed of at: / 1
1 �"uc Kiur — CJ'CTaj AIA
(Please print na and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
/(Company Name and Address)
Signature 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02714-20777
www.massgov/dia
R orkers'Compensation Insurance Affidavit:Builders/Contractors/Elect nans/Plumbers.
TO BE FILED WITH THE PERMITTING.4UTHORIT
Applicant Information Please Print Legibly
Name (Business/OrgmizatioWIndividual):
Address:
City/State/Zip: Phone#:
Are you an employee Check the appropriate box: /woron
Type of project(required):
I.❑I or a employer wah employees(full aod/ time)' 7. ❑New construction
2.❑l am a sole taximeter or partnership and have ne,emporking form g. ❑Remodeling
any c rpack, [No workers'wmp.an., reportedn
3.E]l am a homeowner doing all work myself [No worker .ins required.]' 9. El Demolition
4.01 am a homeowner and will be comments to collwor 10❑Building addition
longer eonn tort pmpem. 1 will
ore that all contractors clWcr have workers compems cor are sole I1.❑Electrical repairs or additions
propnctors with no cmplovees. 12.❑Plumbing repairs or additions
SMIvm ageueral mnuacmr end lhavehved the sultconstee on mr aMchea sneer13.�Roof repairs
These sub- mane ors have employes unit have workp.insuran -
6❑WeareaeohpomdonmditeoffcersbaveexercisedWtofesomptionper MGtc. 14.❑Other
152,51[41,end we have va employees [N.worsen' nsuraire, ood_]
Any applicant next checks box#1 most also fill out the sec n below showing the@workers pmpensation policy information_
r Hom who submit Wrs aliidavit or has Wey doing all work and Wen hire outside commcmrs must submit a new affidavit indicating such.
K'ontradurs our check Wie box muni attached an addid al sheet showing We carne now sub contractors and scot,whether or wt those entities have
employees. Pro,sub-coma,,ars have employees,the must provide Weh workers comp,policy mm�ber.
7 am an employer phut isp7777CiUY/St.pc1ziJy-
Attach
ployees. Below is the potiry and job site
information.
Insurance Company Name
Policy#or Self-ins.Lie#: Expiration Date:
Job Site Address:ttach a copy of the worker ' compensation policydeclaration page(showing the policy number and expiration date).
Failure to secure coverage required under MGL c. 152,$25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprison ent,as well as all
penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a
day against the violatar. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u der thepains and penulfies of perjury that the information provided above is true and correct
Signature: Date:
Phone#:
Oficial url only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License N
Issuing Authority(circle one):
L Board of Health 2.Building Department 7.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#;
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,ss'25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)mantels),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cavy workers compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Departments address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www,mass.gov/dia
--- City of Northampton
" Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street Municipal Building /\J.
Northampton, em OSOfio
MANDATORYFOR HOUSES BUILT BEFORE 1945
Property Address: 24 ar:sz oA.tFlnv-eU.c.e MA-
Contractor _
Name: L o %A+WK Ewe.v-5)y I..C_C
Address: $3 Glsreasipt rile
City, State: A/or__ w;� 1— CT bG36n
Phone: 877- 878'-3o04
Property Owner
Name: f40C+n,n LP_ Pa,
_ Tr
Address: 19
City, State: Flo"��o. �-
I,
M,+< (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
Permit Authorization
47T rTF-
mass save Form
s.,mq,awwnar.m.xFr•aw
Site ID:3787600
/�� p Customer: HECTOR LEPAGE IR
1, llc 4a,e L P/R L9 T ,owner of the property located at:
(o Os Nam pdnUA
29 BRISSON DR FLORENCE, MA 01062
(Pre,"StIMAddren) (CRY)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property. /,t
Owner's signatu � ,r{{
Date:
.12 A45ZNOBn6NlPeF.C�e.Sk64M1g446.a@40Vflg0f kk M1gSV4q TOp4u`e'Ynrtgatum^in&Nr>1:0g040
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
L atateVt4 tr�er� -Lc-
t +(�12A�P201
Participating Cott[ra -Date
Name: CLEAResult
Phone:800.480.7472
Email:
Paas 1 ort For oak.U..only
Rev.302015
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oj,)'ice of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/OrganimtioMndividual): LAl#hl MN ENaure: LLC-
Address: 33 lil'c us'w AtIenie-
City/State/Zi : : Phone 4: 8 27-%7R- :?60&
Are you an employer?Check the appropriate box: Type of project(required):
LM I am a employer with ;0 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' y ❑ Building addition
[No workers' comp.insurance comp. insurance.=
required.] 5. ❑ Weare a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §l(4),and we have no
employees. [No workers' 13.9 Other t/1eG4kairiZ44+is
comp. insurance required.]
iy applicant that checks box#I mug also fill out the section below showing their workers'compensation policy information.
�=Homeowrens who submit this affidavit indicating they.doing all work and than hire outside contractors most submit a new affidavit indicating such,
tContmpors that check this box mug attached an additional shea showing the none of the subcontractors and gate whether or not those entities have
employees. If the subcontractors have employees,they mug 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 sloe
information.
Insurance Company Name: Employers Mutant Catsun)ty Geame
Policy#or Self-ins.Lic.#: S H g I O 2 g Expiration Date: 12 A3L�0 19
Job Site Address: DIP i u2 City/State/Zip: 3 A& 010(e?-
Attack
10(sZAttach 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 u der the ' s aan+�dQpenaWes of perjury that the information provided above is true and correct.
Simature- c,7�q.-(.XJ% Date */23 /.2011
Phone a, (! �b-30(a-?;i,-M
Official use only. Do not write in this area,to be completed by city or town ojfrciaL
-- City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Persom Phone#:
aco^ixd CERTIFICATE OF LIABILITY INSURANCE
12/1]/21)18
THIS CERTIFICATE I8 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE GOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
S REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the DerBRcate holder If an ADDITIONAL INSURED,the pollcy(ka)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 18 WAIVED,subject to ON,terms and conditions of the policy,certain policies may require an endorsement A statement on
this certllicate does not confer rights to the certificate holder In Ilea o/each endorsemen s.
RROeuCm Shari site, CIC
Byxnas Agency, Iaa. - NII
6 Con.Usexe A... =%.seat
(860) B96-5698 FAX Mg,1111 859-5075
EMRL vkin
Norwich CT 06360-]511
INSURE BAFFOPOIXOCOVEMGE XAICY
mBUREIA:I e of Loadoo
IN... (8]]) 878-3006 IXBVRFR a: 1 • IN[Val cma1G C 21415
LoaOera ZDargy, LLC A Lantexv Electrical, LLC a
IxwREA e:sxcAHco xa.urmce c m 21407
33 Niscoacin A . IxsURBA D:
Ncxwich M 06360-1550 INSUMRE:
NSURERF:
COVERAGES CERTIFICATE NUMBER:Carr ID 20397 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED RANTED 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,
WLjp MEOFINSUMNCE U MUCYNUMBEH POLICTIFF MPS Y!%P uMmI
B Y COMeMBRCIALGWEIGLWNLnY I EACH OCCURRENCE f 1,600,000
CLAIMS-MADE O OCCUR SD81028 12/31/2018 12/31/2019 PREMISES(EarcanenwI f 500,000
MR..(Prt/aupleon) f 10,006
PERSONALBADVINJURY s 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE 5 1,000,000
PoUCY OjERC LOC PROOUCTS-COMPgPAGG $ 2,000,D00
Y OTHER:Location f
COAUTg10aaHWBIMttE1e8da,MNGI-E UNITf 1A01).000
g ANYAUTO 15881028 12/31/2018 12/31/2019 BODILY INJURY(Pw PEMm) s
OWNED BCHEOUIEO 'BODILY INJVRY(PxxGEM) f
AUTCG ONLY I I AUTO'
HIRED 7-1 NON
AIRCG ONLY AUTOS GNL0 PR PERTYW f
5
B Y UMeRF11ALMB Y OCCUR 5SB1028 12/31/2018 12/31/2019 EACHOCCURRENCE f 5,000,000
EUCE9s L1AaI amms- ALE AGGREGATE 5 51000,000
OED I % I RETENTIONS 10,000 5
WORNOISCOMPENMTpH
H YIN ANOlNPLOYEBeLWW1Y 5881028 11/31/2010 12/31/2019 Y 6TATUTE ER
ANYPROPRIETOWARTHERiEdG IVE E.L.EACH ACCIDENT S 1,000,000
OFFICERAdIAMEREV LUDED? I NIP
(MwMMay In Mle E.L.DISEASE-EAEMPLOYEE S 1,000,000
D � MM 00
OESCRIPfIONOFOPERATIONS bIvx EL OIBFJSE-POLICY OMIT d 11000,000
A Prof...innal/8G0j PGITA[08,1800 02/23/2018 02/23/1019 s 2,000,000
f
DEBCRETOX GFOPFRAIpNBILDCAIX)N81VEl11CLE8(ACGrm 10t,AEdtlavlMmIMBCRM,M,mYb McbRX,m,eapwlsnqulMl
CERTIFICATE HOLDER CANCELLATION
SHOULDANYOF THEABOVE DESCRIBED POLICIES BECANCEl ED BEFORE
BVidsnca of Insurance ME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH 111E POL OY PROVS510NS.
AUTHOR6®REPRESEXTATNE
s g1•
®1988-2015 ACORD CORPORATION. All rights rewlved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Page 1 of 1
�lze �pay�r�7,anusecz�i a�Ci�aaac>livae%ta
Office of Consumer Affairs and Business Regulation
One Ashburton Place-Supe 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Supple n d Cxtl
LANTERN ENERGY LLC. Reg sba8on. 177388
33 W SCONSN AVE E omfion: 12/01/2019
NORWICH,CT 0&W
Updit AAdn nM Realm Cxtl.
Scpt O htµp5ry]
Dolce a Oonnunw AINYe ewYir.Rpulnpon
XOYE a1PROYEYENT CONTRACTOR bolmffOonvYNfir dcff elup et9Y
TYRE:SwdRns9010 Cm! bn celhexip wAff a RAwM1 m:
121M a9 OslaxGomunx AReee euMneu RepWYbn
17/389 12412019 10 pxk PIOn-8uIb6/70
LANTERN ENERGY LLC. a n,MAW 10
RICHARD ADT8 `D�C�,
33 W ISCONSIN AVE
NORWICH,CT 00380 Undx retwy t vallo Without signature
CorrsrionwealM of Massachusetts
Division of Professional Lkensure
Board of Building Regulations and Standards
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