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17A-242 (8) 72 LAKE ST BP-2019-0620 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 17A-242 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ADDITION BUILDING PERMIT Permit# BP-2019-0620 Prosect# JS-2019-001019 Est.Cost: $243781.00 Fee:$1584.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WILLIAM LABOMBARD 060247 Lot Size(a.ft.): 16160.76 Owner: Linda Adams Zoning,:URB(100)/ Applicant: WILLIAM LABOMBARD AT: 72 LAKE ST Applicant Address: Phone: Insurance: 12A PARKER AVE (413) 687-7946 0 WC NORTHFIELDMA01360 ISSUED ON:12/101201$ 0:00:00 TO PERFORM THE FOLLOWING WORK.-CREATING A 1 BEDROOM, 1 LIVING ROOM, 1 1/2 BATH WHEELCHAIR ACCESSIBLE ADDITION OFF BACK OF HOUSE CONNECTED VIA BREEZEWAY **RAMP CANNOT BE COVERED** 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: Firg j2ePartmeut Fireplace/Chimney: Rough: Qil,:, 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: FeeType: Date Paid: Amount:_ Building 12/10/2018 0:00:00 $1584.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0620 + / APPLICANT/CONTACT PERSON WILLIP d LABC'4BARD ADDRESS/PHONE PO BOX 406 NORT, FIELD (413)250-039-{) 0f& PROPERTY LOCATION 72 LAKE ST MAP 17A PARCEL 242 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Got Fee Paid Building Permit Filled out ] Fee Paid Typeof Construction:_CREATING A 1 BEDROOM, 1 LIVING ROOM, 1 1/2 BATH WHEELCHAIR ACCESSIBLE ADDITION OFF BACK OF HOUSE CONNECTED VIA BREEZEWAY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 060247 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT RE(JIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Y; L Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay /2. to 118 L Signature of Building OTficial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. yy M City of Northampton Building Department " 212 Main Street R fT r Room 100 ; Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 . � t APPLICATION TO CONSTRUC r,AL R DE OIOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION N O V 2 6 Poig } PZCy'1-" 1.1 Property Address: This section to be completed by office DEPT.OF BUILDING INSPEG Lot 1� Unit NORTHAMPTON,MA 01OW 72 Lake Street, Florence M overlay District Elm St.District CO Dla lat SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Linda Adams 72 Lake Street,Florence MA 01062 Name(Print) Current Mailing Address: 413-992-9890 d�." J Telephone Signature 2.2 Authorized Aaent: 1AVj1j;ar•t �u a.��.,rd lir1 &r /Q✓t ,NC/�6{.'t/c /IfA di36�� Name(Print) f „r Current Mailing Address: y13-6$7_7ay6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building of Dr oil (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of off ' Construction from 6 3. Plumbing /61 FAZ Building Permit Fee 4. Mechanical(HVAC) 6470 1 5. Fire Protection 6. Total=(1 +2+3+4+5) `ut791 lCheck Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date Jeff @ aipbuilders.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage V.36' :82.36' . Setbacks Front 35.3` s35.3 Side L:—'29 9 R:'15.1 L.28.9-' R. 15.1'.x_ Rear 335' + '95i Building Height 14 16 ' Bldg.Square FootageOX 928 5 76., 0 237& 14J Open Space Footage _. % (Lot area minus bldg&paved 12% '79.5 113fi 17Q.5- parking) 7Q.5kin _ #of Parking Spaces 4 4 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW E) YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW @ YES 0 IF YES: enter Book Page; and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained © , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aioplicablel New House Addition ❑✓ Replacement Windows Alteration(s) Roofing Or Doors 1711 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding 0) Other[tom Brief Description of Proposed creating a 1 bedroom,1 living room,13 bath wheelchair accessible addition off back of existing house connected via 1 breezeway. Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet ea..1f l+1ew_house and or aditbn to eXlstt l4 housim-COMWete the#oRMNInfl: a. Use of building:One Family X Two Family Other b. Number of rooms in each family unit: 4 Number of Bathrooms 1.5 c. Is there a garage attached? NO d. Proposed Square footage of new construction. 14`�O 31.5X40.5 + 11.SX 15 Dimensions e. Number of stories? 1 f. Method of heating? muusplit Fireplaces or Woodstoves None Number of each g. Energy Conservation Compliance. Yes Masscheck Energy Compliance form attached? Yes h. Type of construction f'wl', a' x6 i. Is construction within 100 ft.of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes x No j. Depth of basement or cellar floor below finished grade oe� —�4 k. Will building conform to the Building and Zoning regulations? _Yes No. I. Septic Tank CitySewer X Private well City water Supply SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /1"14 /7���"S as Owner of the subject property Aging In Place Builders, Inc. hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Dat as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name lI Jl-�8 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of license Holder: William LaBombard License Number 12A Parker Ave. Northfield, MA 01360 060247 Address Expiration Date 6/6/2020 Signet lephone f 413-687-7946 Not Applicable ❑ Company Nam Registration Number 114593 Address Expiration Date 124 f*tld- A /Y01AI0;e4C 4-f40/3.-drelephone y�j G�1-7�� 10/5/2019 SECTION 10-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....... No...... ❑ City of Northampton 'f Massachusetts { DEPARTMENT OF BUILDING INSPSCTIONS 212 Main street • Municipal Building Northampton, 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"reconstruction,alteration,renovation,repair, modernization,conversion, improvement, removal,demolition,or construction of an addition to any pre-existing owner-occupied 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: A/1, Est.Cost: 2'IL ZX Address of Work 7-� I 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.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERM SEE JNE T PAG F R MORE INFORMATION. Signed under the penalties of perjury: I'�]]h/�ereby apply for a building permit as the agent of the owner: uz.1 A '1f;�l,ar•, LA�O�1�� if Date Contractor Name 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 t„r rGyy y: ;Y DEPARTAWT OF BUILDING INSPECTIONS � r 212 Main Street • Municipal Building vyS Northampton, MA 01060 syr" 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 110.85, 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. City of Northampton Massachusetts wF =; ' DEPARMENT OF BUILDING INSPECTIONS aJ� 212 Main Street a Municipal Building Northampton, NA 01060x ,10 4 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: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: f, AR S (Company Name and Address) Signa ure of Permit Appli nt 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 Stree4 Suite 100 Boston,MA 02114-2017 r www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leldbly Name(Business/Organization/individual):Aging In Place Builders, Inc. Address:203 Birnam Road City/State/Zip:Northfield MA 01360 Phone#:413-225-3047 Are you an employer?Check the appropriate box: Type of project(required): 1.[D I am a employer with 2 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I Ln Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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 subcontractors 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:EMC Insurance Policy#or Self-ins.Lic.#:51-178682 Expiration Date:10/28/2019 Job Site Address:72 Lake Street City/State/Zip:Florence 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 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 DIA for insurance coverage verification. I do hereby certify und�erthe pain penal' perju that a information provided above is true and correct Si ature: Date: Phone#:413-225-3047 Official 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#: 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 a joint 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,§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 of this 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)name(s),address(es)and phone number(s)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 carry 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 permit/license 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 of the 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's 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-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 a joint 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,§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 of this 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 your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry 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 permit/license 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). A copy of the 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 ARo® CERTIFICATE OF LIABILITY INSURANCE DATE,M"°°°"YYY' 10/16/2018 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. H the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,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 E:CT Adina Edgett Webber & Grinnell PHONE (413)586-0111 FAX NG: (413)586-6481 8 North King Street CRESS dgett@rebberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC N Northampton NA 01060 INSURERA:Employers Mutual Casualty Company 21415 INSURED INSURER B:Citation 40274 Aging In Place Builders, Inc. INSURER C: Attn: Jeff LaBombard INSURER 0: 203 Birnam Road INSURER E: Northfield NA 01360-9526 1 INSURER F: COVERAGES CERTIFICATE NUMBER:BxP 10/19 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE S POLICY NUMBER POLICY EFF POLICY EXP TR LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR PREM SES'a€ccurrence TED $ 500,000 5D78682 10/28/2016 10/28/2019 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JC7 El LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABUM COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B ANYAUTO BODILY INJURY(Per person) $ A TO OWNED X SCHEDULED BCDR51 10/28/2018 10/28/2019 BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIREDAUTOS X AUTOS Per accident $ Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION 5878682 X YIN PER TH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE Jeffrey LaBambard, Michael E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? �N/A (Mandatory In NH) LsSombard, and William 10/28/2018 10/28/2019 E.L.DISEASE-EA EMPLOYEE $ 100,000 H yes,describe under DESCRIPTION OF OPERATIONS below LSBcabard are excluded. E.L.DISEASE-POLICY LIMIT $ 500,000 A Inland Marine 5078682 10/28/2018 10/28/2019 LeasedEquipmenl $130,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be allacMd N 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /J W Grinnell, CPCU, CIC ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) offk *Of COmmff C Aft=&BUSMom RpulaWn HOME IMPRENT CONTRACTOR. JrlCrr4ldUeJ Ent" - 10/06 a18 Vltl#taAM ilN. � _ , WILLIAM 12 A PARKER NORTHFIELD, MA 01 Undwswr fy v �cs J 94 •� i9 U J CENTER FOR V EcoTechnolo V we make green make sense- J PRELIMINARY ENERGY EFFICIENCY PLAN Project Address: 72 Lake St, Florence, MA(new accessory apartment addition revised plans) Conditioned Floor Area 1,287 ft2 not including common breezeway entry) Volume 10,472 W Building Type Attached accessory apartment Bedrooms 1 Assumptions for Preliminary Home Eneray Ratina CET has completed a Preliminary Home Energy Rating based on the construction plans you have provided. Any energy features not listed below are assumed to meet the prescriptive requirements of the IECC 2015. mi 1s'Floor Slabs R-30 foam board under slab, R-10 foam board at slab edge; haunched foundation wall to to eliminate thermal bridging R-19.3 dense-packed cellulose, all cavities fully enclosed by air barrier Exterior Walls on top&both sides; R-15 foamboard at foundation stem wall at ramp; R-15 sealed foam board at skylight shafts Windows&Glass doors U-value=0.27, SHGC=0.30 Exterior Doors(opaque) R-5 I U-0.20 Skylights U-value=.42, SHGC= .26 Flat Ceilings 14"loose-blown cellulose(R-52),sealed eave wind baffles,full insulation contact with sheetrock ceiling; Attic Hatches R-20 foam board,fully gasketed,framed edge dam to height of surrounding insulation Blower Door Test 3.0 ACH50 or better lower Rater Field Checklist,sections 2&4 Meet all Checklist Requirements as verified by a HERS rater at pre- drywall and final inspection addition and existing PT room �C r. Heating&Cooling Equipment 10.3 HSPF,20 SEER ductless minisplits; No thermostatically controlled electric resistance heat Water Heating Equipment .90 Energy Factor assumed existing electric water heater Domestic Hot Water Pipes 50 feet horizontal distance from water heater to farthest fixture All hot water pipes insulated to R-3 Whole House Ventilation Continuously operating,variable speed bath exhaust fan with boost capability, <0.3 sones, Energy Star certified Emil Lighting 100% LED,CFL,or in-based fluorescent Dishwasher ENERGY STAR certified Oven Electric Clothes Washer ENERGY STAR certified Clothes Dryer ENERGY STAR certified ENERGY EFFICIENCY PLAN Preliminary Home Energy Rating Results Based on the assumptions described above,we have calculated the following Preliminary Home Energy Rating results. Preliminary HERS Index: 54 Estimated Mass Save Rebate: $0* Alternative Features Analysis The following additional optional energy features were analyzed but not included in the Energy Rating: E nss � P r. R-6 insulated sheathing -2 Heat Recovery Ventilation: Panasonic FV-10VEC1 ERV or 8 equal(81%sensible recovery efficiency and 24 watts at 50 CFM Heat pump water heater -5 Photovoltaic system 2.5 kw or greater 5 points Renewable energy primary heating system,including clean biomass heating system,solar thermal array,or ground source 5 points heat pump Solar thermal array for domestic hot water or clean biomass 2 points stove Note that Confirmed Home Energy Rating results may vary from the Preliminary Home Energy Rating results due to changes in building plans,energy features installed in the home, RESNET standards,software changes, and other factors. *Existing electric water heater results in negative overall savings for the project. Resulting non-participation in the Mass Save Residential New Construction program means that CET will need to bill an additional$350 for lost incentives, per client agreement. Mass Save Residential New Construction program requirements and incentive amounts can change at any time without notice at the discretion of program sponsors. Preliminary Rater:John Saveson Date:Oct 25, 2018 Job A- 18-02358 Page 2 of 2-The Center for EcoTechnology-Tel(413)586-7350 ext.242-Fax(413)586-7351 --green homeAcetonline.org RESNET Home Energy Rating Standard Disclosure LU CENTER FOR For home located at: 72 Lake St, Rear Unit U ECOTECHNOLOGY City: Florence State: MA 1. ❑X The Rater or Rater's employer is receiving a fee for providing the rating on this home. 2. In addition to the rating, the Rater or Rater's employer has also provided the following consulting services for this home. A. Mechanical system design B. Moisture control or indoor air quality consulting C. Performance testing and/or commissioning other than required for the rating itself D. Training for sales or construction personnel E. Other(specify below) 3. LI The Rater or Rater's employer is: A. The seller of this home or their agent B. The mortgagor for some portion of the financial payments on this home X C. An employee, contractor or consultant of the electric and/or natural gas utility serving this home 4. NX The Rater or Rater's employer is a supplier or installer of products, which may include: Installed in this home by: OR is in the business of: HVAC Systems Rater Employer Rater Employer Thermal Insulation Systems Rater Employer Rater Employer Air sealing of envelope or duct systems Rater Employer Rater Employer Windows or window shading systems Rater Employer Rater Employer Energy efficient appliances Rater Employer Rater Employer Construction (builder, developer,construction contractor,etc.) Rater Employer Rater Employer Other(specify below): Rater Employer Rater X Employer Vendor of recycled building materials. 5. [� This home has been verified under the provisions of Chapter 6, Section 603 Technical Requirements for Sampling'of the Mortgage Industry National Home Energy Rating Standard as set forth by the Residential Energy Services Network(RESNET). I attest that the above information is true and correct to the best of my knowledge.As a Rater or Rating Provider I abide by the rating quality control provisions of the Mortgage Industry National Home Energy Rating Standard as set forth by the Residential Energy Services Network(RESNET).The national rating quality control provisions of the rating standard are contained in Chapter One 4.C.8.of the standard and are posted at http://resnet.us/standards/RESNET_Mortgage_Industry_National_HERS_Standards.pdf. The Home Energy Rating Standard Disclosure for this home is available from the rating provider. John Saveson 1911963 Raters Printed Name Certification# ' October 30,2018 Raters Signature Date RESNET Form 0300-2 REM/Rate-Residential Energy Analysis and Rating Software v15.7 This information does not constitute any warranty of energy costs or savings. 01985-2018 NORESCO, Boulder,Colorado.