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35-106 (6) BP-2024-0038 80 DREWSEN DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-106-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-0038 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 5573 CLEAN TECH CONSTRUCTION 106247 Const.Class: Exp.Date: 01/05/2026 Use Group: Owner: M LEYDEN PATRICK Lot Size (sq.ft.) Zoning: WSP Applicant: CLEAN TECH CONSTRUCTION Applicant Address Phone: Insurance: 38 ELLIS AVE 508-663-7847 6hub4n60130823 WEYMOUTH, MA 02190 ISSUED ON: 01/09/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: , 924T Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED .IAN - q 2024 I91,y The Commonwealth of Massachusetts 'Board of Building Regulations and Standards FOR •nF7T. - ;!``I r►TN INSPFCTIONS Massachusetts State Building Code, 780 CMR MUNICIPALITY 9 USE _ .� Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Pirrnit Number: V—4 -• 36 Date Applied: tiE010 4-Z53 / f-9 z z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 AssessojMap&Parcel Numbers 80 Drewsen Drive 35 1 D V 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 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 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Patrick Leyden Northampton,MA,01062 Name(Print) City,State,ZIP 80 Drewsen Drive 413-858-5132 patrickleyden@hotmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.❑ Number of Units Other 0 Specify: Weatherization Brief Description of Proposed Work2: Residential weatherization and air sealing with the Mass Save Program.No structural changes. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $5573.47 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ �J Suppression) Total All Fees[ W Check No.a� Check Amount: V� Cash Amount: 6.Total Project Cost: $ 5573.47 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 106247 09/26/2026 Arianna Davidson License Number Expiration Date Name of CSL Holder List CSL Type(see below) Insulation 38 Ells Ave No.and Street Type Description , U Unrestricted(Buildings up to 35,000 cu.ft.) Weymouth,MA,02190 City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-663-7847 cleantechconstruction48@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 196071 06/27/2025 Clean Tech Construction HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 38 Ells Ave c_leantechconstruction48@gmail.com No.and Street Email address Weymouth,MA,02190 508-663-7847 City/Town,State,ZIP 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 0 No .❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. See attached Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 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. ,Auara.Zacaeelf. 1/8/2024 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton Massachusetts • ` � d DEPARTMENT OF BUILDING INSPECTIONS y:. 212 Main Street • Municipal Building vh a • Northampton, MA 01060 ss� 1/0^.\ CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all 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 disposed of in: Location of Facility: 40 Messina Drive Braintree, MA 02184 The debris will be transported by: Name of Hauler: Clean Tech Construction Signature of Applicant: 44.4.a..40.4. T>a e.L Date: 1/8/2024 The Commonwealth of Massachusetts Department of Industrial Accidents =i lw Office of Investigations Lafayette City Center e. 2 Avenue de Lafayette, Boston,MA 02111-1750 „• www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Clean Tech Construction Address:40 Messina Drive City/State/Zip:Braintree,MA 02184 Phone#:508-663-7874 Are you an employer?Check the appropriate box: I am a general contractor and I Type of project(required): 30 4. 1.❑■ I am a employer with ❑ 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 8. ❑Demolition workingfor me in anycapacity. employees and have workers' p �' 9. ❑Building addition [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 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.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no Insulation employees. [No workers' 13.■❑Other 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. 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 employees. 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:Traveler's Indemnity Co of America Policy#or Self-ins.Lic.#:6HUB6R60053223 Expiration Date:9/18/2024 Job Site Address: 80 Drewsen Drive City/State/Zip:Northampton,MA,01062 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 pains and penalties of perjury that the information provided above is true and correct Signature: 44A.a.fru 2- !/Gisrt% Date: 1/8/2024 Phone#: 508-663-7874 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(check one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT% WORK ORDER Patrick Leyden (413) 11/06/2023 409688 10304 SERVICE STREET BILLING STREET PROPOSED BY: 80 Drewsen Drive 80 Drewsen Drive Ray Dickson SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE 75% For eligible weatherization measures, Eversource is offering an incentive of 75%for insulation measures and 100%for the air sealing measures, both with no limit.You are eligible to apply for the 0% Heat Loan to finance your co-pay,applications must be submitted before the weatherization work begins. HOME AIR SEALING 8 $852.72 $852.72 Seal areas of your home against wasteful,excessive air leakage. Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics, basements,attached garages and other unheated areas (windows are not generally addressed.) DUCT SEALING 4 $392.56 $392.56 Provide labor and materials to seal heating and/or cooling ducts within designated unheated areas. TRANSITIONS 60 $448.80 $448.80 Provide labor and materials to air seal the transitions of your home against wasteful,excess air leakage. WEATHERSTRIP DOOR 2 $72.64 $72.64 Provide labor and materials to install Q-Ion weatherstripping to door(s)to restrict air leakage. DOOR SWEEP 1 $29.66 $29.66 Provide labor and materials to install a doorsweep to restrict air leakage. ATTIC FLAT-5"OPEN R-19 CELLULOSE 146 $273.02 $204.77 $68.25 Provide labor and materials to install a 5"layer of R-19 Class I Cellulose to open attic space. KNEEWALL GABLE WALL-2"RIGID BOARD INSULATION 60 $330.60 $247.95 $82.65 Provide labor and materials to install 2"rigid insulation board to the open gable wall in a kneewall attic region. KNEEWALL SLOPE-2"RIGID BOARD 360 $1,983.60 $1,487.70 $495.90 Provide labor and materials to install rigid board at R-10 or greater with the required fire rating to the sloped rafter area behind a kneewall. KNEEWALL GABLE WALL-6"FIBERGLASS BATTS 60 $150.00 $112.50 $37.50 Provide labor and materials to install R-19 faced fiberglass batt insulation to the open gable wall in a kneewall attic region. Document Ref:KWZLR-KJVCK-PBRSE-6FERH Page 2 of 5 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT* WORK ORDER Patrick Leyden (413) 11/06/2023 409688 10304 SERVICE STREET BILLING STREET PROPOSED BY: 80 Drewsen Drive 80 Drewsen Drive Ray Dickson SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL KNEEWALL SLOPE-6"FIBERGLASS R19 360 $900.00 $675.00 $225.00 Provide labor and materials to install a 6.25"layer of R-19 fiberglass batts to the sloped rafter area behind a kneewall. VENTILATION CHUTES 23 $107.64 $80.73 $26.91 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow from the soffit ventilation. INSULATED BATH EXHAUST HOSE 4 INCH 1 $32.23 $24.17 $8.06 Provide labor and materials to install an insulated 4"exhaust hose to existing bathroom fan(s). ATTIC CONTINGENCY An attic area in your home that could benefit from weatherization work (initials) has been identified. Although your home would benefit from weatherization work in this area,we have to remember the safety of the workers who will need to enter this space. The insulation contractor may need to inspect this space prior to scheduling the work to verify their ability to accomplish the scope of work. HIGH CO SEALED SYSTEM Have your sealed combustion heating system serviced by a . (initials) professional HVAC technician.The undiluted flue gasses should not exceed 400 parts per million(ppm)air-free of carbon monoxide.The existing high level of carbon monoxide in your system's exhaust fumes are a symptom of a combustion inefficiency. Your initials are your acknowledgment of these conditions,and agreement to proceed. Total: $5,573.47 Program Incentive: $4,629.20 Client Total: $944.27 I.DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the above work at the Client's Address in a professional manner and in accordance with the terms of this Contract: II.PAYMENT Client agrees to pay the Contractor for the Work,the Client Share of the Contract Cost is payable to the Independent Installation Contractor(IIC)upon satisfactory completion of the Work.Client understands that they will not be required to pay the Program Incentive Share of the Contract cost.Changes to the individual line items and/or previous incentives may increase or decrease the size of the Program Incentive Share. d eo RISE Representative Client Signature Ralean Dickson 11-08-2023 Printed Name Date of Acceptance Document Ref:KWZLR-KJVCK-PBRSE-6FERH Page 3 of 5 400k mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Patrick Leyden owner of the property located at: (Owner's Name) 80 Drewsen Drive Florence (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. This form is only valid with a signed contract. The permit will be secured by the subcontractor, at no additional cost. Owner's Signature 11-08-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: rQ2G � Z7 d_ew. 01/08/2024 Participating Contractor Date Document Ref:KWZLR-KJVCK-PBRSE-6FERH Page 1 of 5 •••:' •'•••.i ••• ••••• � ` • •••••.: t� `- `2 4i + . --`k--"!' ?5 j - . a -oar- -''` - .y"_,1 :,.•p c �„'3<, . c4. K:rf " S❖• c. • • Signature Certificate ��' _ - —:._ :••�. � il (-/-rr3 4, ,lam- I'- 1-_+ / - `�� i••••• .••:' Reference number KWZLR-KJVCK-PBRSE-6FERH ,?{t �h�`1 `r•• 4- -ii: .v► •�� •• ,••. 'NA' Signer _, .: T - Timestamp -• ..,tom+' Signature j, •�•:: Ralean Dickson '.•.•; Email:rdickson@riseengineering.com „v., ;••••• Sent: 06 Nov 2023 23:48:24 UTC /I G ieced � c,�d '•••••' ••••:' Signed: 06 Nov 2023 23:48:24 UTC ••••: gip•; IP address:71.192.20.71 .::::•, ...v Location:Springfield,United States '••�•;•;.••,• Patrick Leyden ;�;,, 'ANMm:. Email:patrickleyden@hotmail.comgob '••••. ..... Sent: 06 Nov 2023 23:48:24 UTC •�•.: 'PO• Viewed: 07 Nov 2023 15:07:43 UTC �•• '••i•: Signed: 08 Nov 2023 14:23:45 UTC ;••••; •.•••: :•i:' :: : Recipient Verification: IP address:73.253.171.46 4•4•; Pi Email verified 07 Nov 2023 15:07:43 UTC Location:Northampton,United States ;�•�l •••••:' ••••••' {•:°. Document completed by all parties one . s-i cx'� "It • fz . _..•?R, •.❖; '••••: 4 � ram►� _ "� j, '%�• t �•••: _.D8 Nov 2023 t4.23::45.UTD, y ••• Page 1 of 1 + ,• «; .- ,, .."�, -C 4 ?y r ,_:„. ..'...t .`�I!� '�•i'- :❖' tii 'tt -. �'✓.•-erg`':,•' .yy t }• �: _ " - '•••' _47 ,::,., J, • }. Y. �•i ••• tr •••• w► ram_- ..1r 3Q ♦zx� 'i.lir`4 "' �•�• •••• .•••i • - .'.fir• � • t sj....•" ` ••••.. • ..❖, •-,- - �'�•. "rti. ram' _ - 'ii•. .0111 ;aft •.•••• .<f,-�S 7 1••. •••• Signed with PandaDoc ■ ■ ,. • '..... m ••.�•;, PIPandaDoc is a document workflow and certified eSignature R` •, y r• ;~ :�•�•. :•:•••. solution trusted by 40,000+companies worldwide. . '` 'e. ._� Ot • }� �'.' .4 ••••••*•:':•:❖�••• i:•: :•:•i•.•:':i i i:•:•:':':':•:•i i•i•i i•i;in.• i••;' :i i•••:••••-';':'•'••i;o:•:':•:❖i i i i•:•i i•-• ••'i;:•i i i•i❖i•:'i•:•i''/•••• •��•ll"e'e!.:" - - -!.•!:!.t:••••.�•.❖.eO!:!e•.••❖•••❖.!e�:•,'!.!•.::•.::::•.:t:t.. - _ .��i:tl!ie•.•.•••.•.:•.::: !_ _ _ _ !.•.:ice.•.:•: R I S E1 Client: Patrick Leyden Address: 80 Drewsen Drive AN EMPLOYEE-OWNED COMPANY Florence, MA 01062 Energy Specialist: Ray Dickson Phone: (413)8585132 Program: EGMA-HES Client# 409688 Work Order# 10304 Work Scope DESCRIPTION Qty Notes 1 HOME AIR SEALING 8 2 DUCT SEALING 4 3 TRANSITIONS 60 4 WEATHERSTRIP DOOR 2 5 DOOR SWEEP 1 6 ATTIC FLAT-5"OPEN R-19 CELLULOSE 146 7 KNEEWALL GABLE WALL-2"RIGID BOARD INSULATION 60 8 KNEEWALL SLOPE-2"RIGID BOARD 360 9 KNEEWALL GABLE WALL-6"FIBERGLASS BATTS 60 10 KNEEWALL SLOPE-6"FIBERGLASS R19 360 11 VENTILATION CHUTES 23 12 INSULATED BATH EXHAUST HOSE 4 INCH 1 13 ATTIC CONTINGENCY 1 Diagram Main building Main Building Garage A/ KW2 12 5' OBC KW1 LI Commonwealth of Massachusetts Construction Supervisor Specially Restncted to: �� Division of Occupational Licensure �` - Board of Builr ulations and Standards 7 Construc' i.)erityar Specialty CSSL-IC-Insulation Contractor 1 CSSL-106247 ,,pires: 09/2612026. ARIANNA JAMES DAVIDSON 38 ELLS AVE WEYMOUTH MA 02190 t =r;1 a \) Failure to possess a current edition of the Massachusetts A. State Building Code is cause for revocation of this license. Commissioner ';,c•,... / ,``.-Y `:ra_.. For information about this license Call(617)727-3200 or visit www.mass.govidpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration v ll= t- . - ,:Type: Supplement Card CLEAN TECH CONSTRUCTION LLC v __ p. a ration. 196071 38 ELLS SVE "` _ Exxpiration: 06d27/2025 w WEYMOUTH,MA 02190 -_ f - i©/ sr ,-'51,4r Sy e MP Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 196071 06127/2025 Boston.MA 02118 CLEAN TECH CONSTRUCTION LW ARIANNA DAVIDSON ~/s':' // 7� s_ _ 38 ELLS AVE ° '/ ' c,.•G....r.• .<'G ' .ry 4.4 E/Ce.41• dd-i9 WEYMOUTH,MA 02190 + ' Undersecretary Not valid without signature ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/15/2023 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 endorsement(s). PRODUCER CONTACT GaryHebsch NAME: TOBMAN PARTNERS INSURANCE AGENCY INC WC.No.Ext.): (617)471-1123 FAX (NC.,y), E-MAIL hebsch tmwins.com ADDRESS: 9 C 21 MCGRATH HIGHWAY SUITE 303 INSURER(S)AFFORDING COVERAGE NAIC C QUINCY MA 02169 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: CLEAN TECH CONSTRUCTION LLC INSURER C: INSURER D: 40 MESSINA DRIVE INSURERE: _ BRAINTREE MA 02184 INSURERF: COVERAGES CERTIFICATE NUMBER: 931330 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DO/YYYY),(MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE J OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JJECT LOC PRODUCTS-COMP/OP AGG $ OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED 1 RETENTIONS �/ $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6HUB6R60053223 09/18/2023 09/18/2024 (Mandatory in NH) 1 E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ N/A I I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage- Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Clean Tech Construction, LLC ACCORDANCE WITH THE POLICY PROVISIONS. 40 Messina Drive AUTHORIZED REPRESENTATIVE Braintree MA 02184 Daniel M.Cro rl y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC C)Ra CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/VYYV) 09/19/23 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 endorsement(s). PRODUCER CONTACT NAME: Tobman Partners Insurance Agency Inc. iacoNNo.Eu)): 617-471-1123 (AC,No): 617-773-2474 21 Mayor Thomas J McGrath Highway E-MIL Suite 303 ADDRESS: Quincy,MA 02169 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Company INSURED INSURER B: Safety Insurance Co Clean Tech Construction LLC INSURER C: 40 Messina Drive INSURER D: Braintree,MA 02184 INSURER E: INSURER F: 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 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. INSR TYPE OF INSURANCE ADDLBUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR IN$D WVD (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A NN1562513 09/18/23 09/18/24 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X AUTOS SCHEDULED 5931459 09/16/23 09/16/24 BODILY INJURY(Per accident) $ AUTOS ONLY XHIRED x NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AN1293596 09/18/23 09/18/24 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 Clean Tech Construction,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 40 Messina Drive Braintree,MA 02184 AUTHORIZED R ENTATIVE ©1 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: Clean Tech Construction Name of Waste Facility Not Applicable - No Debris Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L.c.40 s.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c.111 s.150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department.If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR—6th Edition 42L;a4tot . Signature of Permit Applicant 1/8/2024 Date