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37-058 (3) BP-2024-1051 236 GROVE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 37-058-001 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-2024-1051 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 5474 CLEAN TECH CONSTRUCTION 106247 Const.Class: Exp.Date: 01/05/2026 Use Group: Owner: THEA PANETH Lot Size (sq.ft.) Zoning: URB Applicant: CLEAN TECH CONSTRUCTION Applicant Address Phone: Insurance: 38 ELLIS AVE 508-663-7847 6hub4n60130823 WEYMOUTH, MA 02190 ISSUED ON: 08/20/2024 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: Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner /q0? The Commonwealth of Massachusettsz Board of Building Regulations and Standards FO�— o VYMassachusetts State Building Code, 780 CMR MUNIUS f1}>� Y o N o Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised G,11 rn o o zOne- or Two-Family Dwelling 'Ui This Section For Official Use Only U n i Building Permit Number: '- V... gQ 6-7 Date Applied: a o 0 1--Z /--a'-// -- / ./P la.V 62.OCIL:gr----- o Building Official(Print Name) ignature Date SECTION 1:SITE INFORMATION `— 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 236 Grove Street 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 ifyes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Thea Paneth Northampton,MA,01060 Name(Print) City,State,ZIP 236 Grove Street 339-368-9729 tpaneth@gmail.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. 0 Number of Units Other 0 Specify: Insulation Brief Description of Proposed Work': 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 $5474.56 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fee :$ il) L, Suppression) J 5474.56 Check NoCheck Amount: Cash Amount: 6.Total Project Cost: $ 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 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-663-7847 cleantechconstruction48(agmail.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 cleantechconstruction48(agmail.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 0 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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 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. Arianna Davidson ,Au z.0 a• Zi'avad rn- 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 cater P c `s S., ✓ Massachusetts ��s S wi im '' �• 1. ` DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street 40 Municipal Building 1E f0� „�i Northampton, MA 01060 s'j. , golf" 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: 4,24 a- T7a. a0�e - Date: 8/12/2024 The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations Lafayette City Center 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: Type of project(required): I. ■❑ I am a employer with 30 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no Insulation employees. [No workers' 13.0 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. :Contractors 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: 236 Grove Street City/State/Zip: Northampton,MA,01060 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 44z�Z'Zf'LCL Pavi. 6fli Date: 8/12/2024 Phone#: 508-663-7874 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Construction Supervisor Specialty 1317 Division of Occupational Licensure Board of Build' '•-aulations and Standards Restricted to: COnstrUC' Ipervmor Specialty CSSL-IC-Insulation Contractor .J CSSL-106247 I ,pires: 09/26/2026 ARIANNA JAMES DAVIDSON :r 38 ELLS AVE — WEYMOUTH MA 02190 n, �� 7J7�t 3;1 3' (`. Failure to possess a current edition of the Massachusetts �/ :,._ State Building Code is cause for revocation of this license;' Commissioner :cla# Jl&m:.1c For information about this license Call(617)727-3200 or visit www.mass.gov/dpi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration u w ^' 7, Type: Supplement Card - -o — l :egistration: 196071 CLEAN TECH CONSTRUCTION LLC = Expitation: 06/27/2025 38 ELLS SVE =-- • WEYMOUTH,MA 02190 �� —w—== ?j •,' 4 — _ _iiii Ag I •,7V vow•, q1 1 0$ 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 06/27/2025 Boston,MA 02118 CLEAN TECH CONSTRUCTION LLC t,'l ARIANNA DAVIDSON .1 i�!N 3844zaedz, - Z a i-. W YMO AVE } �.t`((Writ' JZ WEYMOUTH,MA 02190 A- !� Undersecretary Not valid without signature WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT R WORK ORDER Thea Paneth (339) 368-9729 06/27/2024 563469 10902 SERVICE STREET BILLING STREET PROPOSED BY: 236 Grove Street 236 Grove Street SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 02474 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. KNOB&TUBE WIRING SIGN-OFF-FSC The wiring in the areas weatherization work is proposed will be reviewed by a licensed electrician to determine if there is any existing live knob&tube wiring. WALLS-VINYL SIDED 6" 832 $2,837.12 $2,127.84 $709.28 Install blown in Class I Cellulose to vinyl-sided exterior walls. Homeowner has received a copy of the EPA's Renovate Right Lead- Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.Your signature is your acknowledgement of receipt and agreement to proceed. WALLS-WOOD SHINGLE SIDED 6" 832 $2,637.44 $1,978.08 $659.36 Furnish and install blown in Class I Cellulose to Wood shingle exterior walls.The butt of the upper course of your wood siding is cut to drill holes into the wall sheathing behind.The holes are then plugged and the wood siding is reinstalled using exterior grade nails. Touch-up painting, if needed,will be the customer's responsibility. Homeowner has received a copy of the EPA's Renovate Right Lead- Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.Your signature is your acknowledgement of receipt and agreement to proceed. ASBESTOS PRECAUTION A blower door diagnostic test will not be conducted at your home,as a precaution for the presense of steam heating(past or present)that was most likely insulated with asbestos. LEAD PAINT Your home was built prior to 1978 and might have lead-based paint r.R (initials) present.You have received a copy of the EPA's Renovate Right pamphlet informing you of the potential risk of a lead hazard exposure from the renovation activity to be performed at your home. Document Ref:8U5RK-JZSG4-VWRQN-4JJOA Page 2 of 5 WEATHERIZATION CONTRACT EVER$ -URGE CUSTOMER PHONE DATE CLIENTI WORK ORDER Thea Paneth (339) 368-9729 06/27/2024 563469 10902 SERVICE STREET BILLING STREET PROPOSED BY, 236 Grove Street 236 Grove Street SERVICE CITY.STATE.ZIP BILLING CITY,STATE.ZIP Program Northampton, MA 01060 Northampton, MA 02474 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL PREPARE YOUR HOME Homeowner is responsible for the removal of any items stored in the r.P linilials) areas where the weatherization measures will be installed. The workers will need the space cleared to safely bring their tools and materials into these work areas. If you have any questions or specific concerns, please bring them to the attention of your subcontractor when they call to schedule your work. Total: $5,474.56 Program Incentive: $4,105.92 Client Total: $1,368.64 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. RISE Representative Client Signature Ralean Dickson 06-27-2024 Printed Name Date of Acceptance Document Ref:8U5RK-JZSG4-VWRQN-4JJOA Pape 3 of 5 :................................................... .... !❖� Signature Certificate :':'" :❖: ;.•;. �� :•:; Reference numb W 6U5RK-JZSG4-VRQN-4JJOA •: ,••;.%4. Signer Timestamp Signature .•. Ralean Dickson •••: ;:;%{ Email rdickson@riseengineering.com •❖: ••�; Sent 27 Jun 2024 22 13:06 UTC /iGG�aIri�GC.Cdo •:••'. •.:: ; Signed 27 Jun 2024 22 13:06 UTC **.. ••... :61 •• - -- --- -_--'••• i:' • �.� IP address:73.68.52.2 v.. •❖O Location.Waltham,United States ;•�•'• ••• !O•: ;;} Thea Paneth •••. �•� Email:tpaneth@gmail.com ::; V Sent 27 Jun 2024 22:13:07 UTC rhea pace ...., �.• Viewed 27 Jun 2024 22:13:07 UTC !•.•. •:: Signed 27 Jun 2024 22:13:42 UTC :•::' N. Recipient Verification: :••• • % IP address:73.69.31.74 .•4.: !•••: I Email verified 27 Jun 2024 22:13:07 UTC Location:West Springfield,United States :OS' �•-.. Document completed by all parties on: :::::: i0.; 27 Jun 2024 22:13:42 UTC ;.::!•... .••.•; Page 1 of 1 .•.,•' :. !••.. ...:. ••..••• • :.•.: .• .:• !.• . AO.. :••••• ..••. '••••, 404 :.... Signed with PandaDoc in. . CI . .; y:•; 0PandaDoc is a document workflow and certified •eSignature •, -�•' r •� ;� ;N solution trusted by 50.000+companies worldwide. 1 ;a— !•♦••• • ••...40,140:40:���14440:4OW4 •0.4It10M444It44O...444O.:�M. , .i•i i�••••••i.•••i i i0•i i i i i i'i i i:4 i i i i i i•i i i i i•��i❖i❖i i•i:•i❖itilt,•,•••. RISEClient# 563469 Work Order# 10902 RISE Rep: Name: Thea Paneth DESCRIPTION Qty Notes 1 WALLS-VINYL SIDED 6" 832 1st floor walls 2 WALLS-WOOD SHINGLE SIDED 6" 832 2nd floor mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM l Thea Paneth owner of the property located at: (Owner's Name) 236 Grove Street Northampton (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. Thea Pae/ Owner's Signature 07-02-2024 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 42a 77G:t erL 8/12/2024 Participating Contractor Date Document Ref:DILY2-SEHDQ-MDQSW-5M4ER Page 1 of 1 •.•.•:-.•:::4.❖:❖.•'❖.•.•::•O:❖:-:❖: :-:-:-:•"❖:•::❖'-:•:•'•'❖:❖:•:.•'•.•••❖.•::::❖ :❖:-:•.❖:ti•::•••"•'•::❖:•:::•••:-:•:ti-:•:-.•.•'-::❖::•, Signature Certificate '.:%:; Reference numbF- DILY2-SEHDQ-MDQSW-5M4ER ,:; ; :•i•.• ' :•i•: •••••' Signature ❖•.. ....... Signer Timestamp v.•.�• : }b•: Thea Paneth '.•••: Email tpaneth@gmaiLcom i ;:•♦♦: ' •. Sent 02 Jul 2024 11 52.25 UTC .•. 7-itear ::: •QO• Viewed 02 Jul 2024 121 518 052:25 UTC •❖.; ::::* Signed: 02 Jul 2024 12.18:22 UTC YVY ;•�$ ••:•:: Recipient Verification: IP address:73.89.31.74 '.❖ '.•A. 'Email verified 02 Jul 2024 12:18:05 UTC Location:West Springfield,United States ••O: •i i :If.;•.• •••• :•;•;� Document completed by all parties on :4; •:•:• 02 Jul 2024 12:18:22 UTC ;• p. �•:• t:.:: Page 1 of 1 •••. •❖• :❖:• '••••: '•••:• .• •• •••• IV ••••••• •••••, 'd0: .O•: •••••• •.O•: ••. ••••4.• ••••., ••i i •••••i ❖•• •••••. •••••• •• ••••• 'VW •.' i•i•i •.• ••♦• ,11.4141. :D••: •••••i '••1•: •••••: N. '•••♦• W. V Signed with PandaDoc 0 •�:�: _•• PandaDoc is a document workflow and certified eSignature ,i- T, ••• •.• solution trusted by 50''• :' 0 ,000+companies worldwide. El I CI- ••••••.*; 'WV WV ...v• .. A ♦V •••• • ••.•.•• 'J♦•. :...•• •♦•. :.,���:❖:•: ii:•:i•••�:•: i••ii•i::•i:i••iiP:i❖iiiiii•••i:i•i❖iiiiiii:❖iiii•iiii••:iiiiiiiiiii:❖•i:ti:-:••• Mass Save® Facilitated Services: Electrical Pre-Weatherization CUSTOMER INFORMATION Customer Name Thea Paneth Client #or Site ID: 563469 Site Address: 236 Grove street City: northamton State: MA ZIP: 01060 Phone Number: (339) 368-9729 Email: tpaneth@gmail.com ELECTRICAL BARRIERS (To be filled out by the licensed contractor.) Roadblocks identified at home energy assessment: K&T wiring Recessed lights Knob and Tube Wiring To determine if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mass Save® weatherization recommendations have been made: 0 Attic Floor p Attic Wall Ea Attic Slope 0 Exterior Wall t Basement I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below: m► Attic Floor p Attic Wall a Attic Slope p Exterior Wall p Basement Contractor Notes: open splice in attic,estimate repair 500.00 Recessed Lighting IC Sign-Off The contractor will evaluate the number of recessed lights in the following areas identified by the Home Energy Specialist: Company Name: Ron Desellier, Electrician Contractor Name: ronald r desellier License Number: 39916e Contractor Signature: Date: Monday,July 15,2024 My signature confirms that I have performed my inspection of the electrical systems listed above and have corrected any barriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined when submitting this form. a od e OUR KLAN[T.YOUR ROW. / • ACORLf CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/VYYY) 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 GaryHebh NAME: sc TOBMAN PARTNERS INSURANCE AGENCY INC PHONE (617)471-1123 FAX MCA,.No.Ext): WC,No): ADE esc tmwins.com ADDRESS: ghbh C� _ 21 MCGRATH HIGHWAY SUITE 303 INSURER(S)AFFORDING COVERAGE NAIC# QUINCY MA 02169 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED -- - INSURER B: CLEAN TECH CONSTRUCTION LLC INSURERC: INSURER D: 40 MESSINA DRIVE INSURERE: BRAINTREE MA 02184 INSURER F: 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. ILTTRR TYPE OF INSURANCE INSDIN $uart WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS {MMIDD/YYYY) (MMIDDIYVYM COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR -DAMAGE TO RENTED - PREMISES(Ea occurrence) $ - MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ —1 POLICY PRO- JECT 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 LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE_ S DED 1 RETENTION$ $ 1 WORKERS COMPENSATION Nwr X PER OTH AND EMPLOYERS'LIABILITY Y/NER A 'jOFFICER/MEMBERE CLUDED?ECUTIVE N/A N/A N/A 6HUB6R60053223 09/18/2023 09/18/2024 E.L.EACHACCIDENT $ 1,000,000 (Mandatory in NH) 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 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 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 n R1 DATE(MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE 09/19l23 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: FAX Tobman Partners Insurance Agency Inc. (NC,No,Ext): 617-471-1123 (A/c,No): 617-773-2474 21 Mayor Thomas J McGrath Highway E-MAIL 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. I POLICY EXP NSR ADDTYPE OF INSURANCE INSD WVDSUER (MM DD/YYPOUCY YYYV (MMIDD/YYYY)LTR INSD WVD POLICY NUMBER LIMITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $DAMAGE T 1,000,000 RENTED CLAIMS-MADE X OCCUR PREMISESO(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 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: S AUTOMOBILE UABILITY COMBINED SINGLE LIMIT y 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED 5931459 09/16/23 09/16/24 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED x NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) $ •X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,000 A EXCESS LIAB —•CLAIMS-MADE AN1293596 09/18/23 09/18/24 AGGREGATE S 2,000,000 DED RETENTIONS $ rr WORKERS COMPENSATION I SPER TATUTE I OERH AND EMPLOYERS'UABIUTY 1,I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 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 I LOCATIONS 1 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 Cc)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—66 Edition la.eA rt. Signature of Permit Applicant Date