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17A-129 (7) 8 FOX FARMS RD BP-2022-0024 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 129 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2022-0024 Project# JS-2022-000041 Est.Cost: $7000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CLEAN TECH CONSTRUCTION LLC 106150 Lot Size(sq.ft.): 25264.80 Owner: MOORE ZACHARY Zoning: URA(100)/ Applicant: CLEAN TECH CONSTRUCTION LLC AT: 8 FOX FARMS RD Applicant Address: Phone: Insurance: 40 MESSINA DR (617) 271-0768 WC BRAT NTREEMA02184 ISSUED ON:7/7/20210:00:00 TO PERFORM THE FOLLOWING WORK:INSULATIONNVEATHERIZATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. () 0 Certificate of Occupancy Signatur I: �( ` Jr • • , II FeeType: Date Paid: Amount: Building 7/7/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ' cFi 1rF g , The Commonwealth of Massachus- �G� . ` Board of Building Regulations and Stan a ds°F,o,, 2 F l Massachusetts State Building Code, 780 C I' '1'o,9T e0/ • C l E I Building Permit Application To Construct,Repair,Renovate Or D tiq ro o•, Revise, Mar 011 One-or Two-Family Dwelling 41 This Section For Official Use Only Building rmit Numb :6A-47 - -� D Applied: Eu►rJ 1 KOSS f/Z "7-7-Z02 1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbe� Q j� 8 FOX FARM RD FLORENCE MA 01062 /7 4 / / 1.1a 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❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ZACHARY MOORE FLORENCE MA 01062 Name(Print) City,State,ZIP 8 FOX FARM RD 603-548-5172 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': INSULATION WEATHERIZATION WORK FOR MASS SAVE PROGRAM SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 7000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: Ty. W Check No. 1a05 Check Amount: Cash Amount: 6.Total Project Cost: $ 7000 0 Paid in Full Cl Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 106150 5/24/2022 PATRICK MCDONOUGH License Number Expiration Date Name of CSL Holder List CSL Type(see below) 105 MARSHHAWK WAY No.and Street Type Description MARSHFIELD MA 02050 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State.ZIP M Masonry WieGZ9)1497 RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 617-271-0768 cleantechconstruction(1)gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 196071 6/27/2023 CLEAN TECH CONSTRUCTION HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 40 MESSINA DR cleantechconstruction@gmail.com No.and Street Email address BRAINTREE MA 02184 617-271-0768 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. AUTHORIZATION FORM 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. PATRICK MCDONOUGH 6/30/2021 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 SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton Massachusetts �§ ��_ DEPARTMENT OF BUILDING INSPECTIONS .'�ryjk.•;G.' 212 Main Street • Municipal Building ,.+-^ Northampton, MA 01060 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 DR BRAINTREE MA 02184 _ The debris will be transported by: Name of Hauler: CLEAN TECH CONSTRUCTION Signature of Applicant: /)a-t-4-4.cA kkele 6', W Date: 6/30/2021 U City of Northampton �° ti 5‘5 '"'.si Massachusetts ��: .*... c'ec 1:1 ,, DEPARTMENT OF BUILDING INSPECTIONS S: 212 Main Street • Municipal Building IJb cs- --' ." Northampton, MA 01060 4:6:;$ %'° HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, ZACHARY MOORE (insert full legal name), born (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this 30 day of JUNE , 20 21. (Signature) DocuSign Envelope ID:DAD67082-75A8-4BFB-9B02-CC448BAC724C Federal ID#05-0405629 RISE Engineering RI Contractor Registration#8186 MA Contractor Registration#120979 RISE60 Shawmut Unit#2,Canton,MA 02021 CONTRACT WZ ENGINEERING (401)7843700 FAX(401)7843710 Page 1 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE C MA-HES E ENGINEERING G AND THE CUSTOMER FOR WORK AS CUSTOMER PHONE DATE CLIENT M WORK ORDER Zachary Lipkin Moore (603)548-5172 05/21/2020 499937 57902 SERVICE STREET BILLING STREET PROPOSED BY: 8 Fox Farms Road 8 Fox Farms Road George Maha SERVICE CITY,STATE,ZP BILLING CITY,STATE,ZP Florence, MA 01062 Florence, MA 01062 DESCRIPTION QTY COST INCENTIVE TOTAL ua LEAD PAINT Your home was built prior to 1978 and might have lead-based paint / (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. RECESSED LIGHTS We have identified that there are recessed lights present in your home. unless the recessed lights are certified by a licensed electrician as being IC-rated(Insulation Contact Rated)we will create a 3"clearance space around the fixture by using fiberglass blanket insulation as a damming material,no insulation will be installed across the top and closed cavities which contain recessed lights will not be insulated. UN WATER PIPES IN ATTIC Your home has water pipes in an unheated attic and are at increasedV (initials) risk of freezing/damage during the winter.We will install protective 'pipe tenting'around your pipes to try and cocoon them to the heated space below,but we cannot guarantee this will prevent any future freezing and/or damage. Your signature is your acknowledgement of these conditions and agreement to proceed. ATTIC CONTINGENCY ,---VD. An attic area in your home that could benefit from weatherization work J A, (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. ua INACCESSIBLE ATTIC AREA VitWe have identified an opportunity to insulate an attic area in your (initials) I home that is not presently accessible.We are making our recommendations based upon an educated understanding of your home's construction, but upon gaining access to this space,your home's work-scope might need to be modified. Your contractor and our RISE inspector will guide these changes and discuss them with you prior to proceeding. OLIO STORAGE-ATTIC QQ�� Homeowner is responsible for the removal of the stored items A/ (initials) t DocuSign Envelope ID:DAD67082-75A8-4BFB-9B02-CC448BAC724C Federal ID#05-0405829 RISE Engineering RI Contractor Registration#8186 MA Contractor Registration#120979 R I S 60 Shawmut Unit#2,Carlton,MA 02021 ENGINEERING CONTRACT w CT - WZ (401)7844700 FAX(401)7843710 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE C MA-HES EESGCR6RI BELOW ANDTHE CUSTOMER FOR WORK AS CUSTOMER PHONE DATE CLIENT P WORK ORDER Zachary Lipkin Moore (603)548-5172 05/21/2020 499937 57902 SERVICE STREET BILLING STREET PROPOSED BY: 8 Fox Farms Road 8 Fox Farms Road George Maha SERVICE CITY,STATE,2P BILLING CRY.STATE,2P Florence, MA 01062 Florence, MA 01062 DESCRIPTION QTY COST INCENTIVE TOTAL blocking the installation of weatherization work in the attic. Removal must occur prior to the scheduled work start. STORAGE-BASEMENT US Homeowner is responsible for the removal of the stored items J .(initials) I blocking the installation of weatherization work in the basement. Removal must occur prior to the scheduled work start. STORAGE-CLOSET us Homeowner is responsible for the removal of the stored items in the M closet with the attic access. Removal must occur prior to the scheduled work start. va STORAGE-GARAGE Homeowner is responsible for the removal of the stored items VA. (initials) blocking the installation of weatherization work in the garage. Removal must occur prior to the scheduled work start. ATTIC DAMMING-R-38 FIBERGLASS 156 $319.80 $319.80 Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass batts for damming purposes. ATTIC FLAT- 13"OPEN R-45 CELLULOSE 1,462 $2,543.88 $2,543.88 Provide labor and materials to install a 13"layer of R-45 Class I Cellulose to open attic space. PIPE TENTING 12 $73.80 $7 �� The water lines that exist outside of the thermal boundary in your t (initials) I home will have the insulation removed from underneath the pipes v and insulation installed only over the top,to create a tent around the piping. This will cocoon the pipes from direct exposure to cold air but cannot guarantee against continued concerns with potential freezing. ATTIC HATCH-SEAL& INSULATE 2 $120.00 $120.00 Provide labor and materials to insulate the back of an attic hatch with 2"rigid insulation board.Weatherstrip the perimeter. VENTILATION CHUTES 89 $222.50 $222.50 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow. us KITCHEN VENT NEEDED GAS RANGE In order to maintain healthy indoor air quality and remove excess moisture,every kitchen should have an exhaust fan vented to the outdoors to provide at least 100 cubic feet per minute(CFM)of DocuSign Envelope ID:DAD67082-75A8-4BFB-9B02-CC448BAC724C Federal ID#05-0405629 RISE Engineering RI Contractor Registration#8186 MA Contractor Registration#120979 RISE60 Shawmut Unit#2,Canton,MA 02021 ENGINEERING' CONTRACT - WZ (401)7843700 FAX(401)7843710 Page 3 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE C MA-HES D GINEERI BELOW AND THE CUSTOMER FOR WORK AS CRSECUSTOMER PHONE DATE CLIENT N WORK ORDER Zachary Lipkin Moore (603)548-5172 05/21/2020 499937 57902 SERVICE STREET BILLING STREET PROPOSED BY: 8 Fox Farms Road 8 Fox Farms Road George Maha SERVICE CITY,STATE,ZP BILLING CRY,STATE,ZP Florence, MA 01062 Florence, MA 01062 DESCRIPTION QTY COST INCENTIVE TOTAL ventilation. Your home's kitchen exhaust fan for your gas range is not currently vented to the outside and it is our strong recommendation you consider venting this,in the near future.You will need to contact a licensed contractor to install hard,metal exhaust ductwork to a roof or wall mounted flapper vent. This is being brought to your attention to identify it as a pre-existing condition to the weatherization work planned for your home.Your signature is your acknowledgement of these conditions and agreement to proceed. HOME AIR SEALING 13 $1,105.00 $1,105.00 Provide labor and materials to seal areas of your home against wasteful,excess 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.) A reduction in cubic feet per minute(cfm)of air infiltration will occur, but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor. WEATHERSTRIP AND ADD DOOR SWEEP 3 $240.00 $240.00 Provide labor and materials to install Q-Ion weatherstripping and a doorsweep to door(s)to restrict air leakage. COMMON WALL R13 FIBERGLASS AND RIGID BOARD 130 $696.80 $696.80 Provide labor and materials to install R-13 unfaced fiberglass to a common wall. Then rigid board at R-10 or greater with required fire rating will be installed to a common wall area Seal all seams with FSK tape. BASEMENT SILLS R19 FIBERGLASS BATT 83 $161.85 $161.85 Provide labor and materials to install R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. GARAGE CEILING:8"DENSE CELLULOSE 546 $1,206.66 $1,206.66 Install 8"densely packed Class I Cellulose insulation to a garage ceiling located below a heated floor area. Holes drilled will be plugged,speckled and left in a relatively smooth condition.Finish sanding and touch-up priming/painting will be the homeowner's responsibility. DocuSign Envelope ID:DAD67082-75A8-4BFB-9B02-CC448BAC724C Federal ID#05-0405629 RI SE Engineering RI Contractor Registration#8186 MA Contractor Registration 4120979 Ri S E. 60 Shawmut Unit#2,Canton,MA 02021 ENGINEERING CONTRACT - YY�/�/ Z (401)784-3700 FAX(401)784-3710 Page 4 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE C MA-H ES EEGINEERI BELOW ANDTHE CUSTOMER FOR WORK AS CUSTOMER PHONE DATE CLIENT WORK ORDER Zachary Lipkin Moore (603)548-5172 05/21/2020 499937 57902 SERVICE STREET BILLING STREET PROPOSED BY: 8 Fox Farms Road 8 Fox Farms Road George Maha SERVICE CITY.STATE.ZIP BILLING CITY.STATE.ZIP Florence, MA 01062 Florence, MA 01062 DESCRIPTION QTY COST INCENTIVE TOTAL PRE-TEST BY CONTRACTOR Prior to the installation of the weatherization measures, your home will need to have a combustion safety test conducted by the weatherization contractor to check all the combustion appliances. This test will check the existing carbon monoxide levels in each appliance, and the amount of available air-flow in your home. I -INCENTIVE: VIRTUAL HOME ENERGY ASSESSMENT For a limited time, Columbia Gas of MA is offering an incentive of 100%on qualifying weatherization measures for customers that participate in the virtual home energy assessment. This contract must be signed and returned within 30 days of the assessment and the weatherization must be installed by October 31, 2020.The installation of your home's weatherization will be scheduled when our in-home operations resume. This proposal was created without benefit of an on-site evaluation, therefore,we expect there might be a need to modify the work-scope at the time the work begins.We will explain any alterations needed and a written change-order will be presented for your consent and approval. Total: $6,690.29 Program Incentive: $6,690.29 Customer Total: $0.00 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***00/ Dollars $0.00 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF I9.WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES.RIGHTS OF RECISION.SCHEDULING.AND CONTRACTOR REGISTRATION. DocuS! ncd by: ,---DocuSigned by.�.... 9 ���Y, (( �n r��sir f� I A.LttUA. c!�s'1UMI�"RSit,4TS�tif ie . iM AAVY RISEREPR ENTATNE ;;1f 1-fB(.9UC;m162t 5/21/2020 17:18 PM EDT NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE SIGN DAT E 30 DAYS. ACCEPTANCE OF CONTRACT-THE ABOVE PRICES.SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFED.PAYMENT WILL BE MADE AS OUTLINED ABOVE DocuSign Envelope ID:DAD67082-75A8-4BFB-9B02-CC448BAC724C RISE ENGINEERING OWNER AUTHORIZATION FORM Zachary Lipkin Moore (Owner's Name) owner of the property located at: 8 Fox Farms Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform 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. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. (r--DocuS gned by. lnbbift Qwpr gp tu ��tire 5/21/2020 I 7:18 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com The Commonwealth of Massachusetts ► r Department of Industrial Accidents t�ia au t 1 Congress Street,Suite 100 �.�� Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plnmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): CLEAN TECH CONSTRUCTION Address: 190 FEDERAL AVE City/State/Zip: Quincy,MA 02169 Phone#: 617-271-0768 Are you an employer?Check the appropriate box: Type of project(required): Xl.0I am a employer with 6 employees(full and/or part-time)" 7. New construction 20I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required] 3.01 am a homeowner doingall work myself. t 9. Demolition❑ y [No workers'comp.insurance required.] 10 Q Building addition 4.01 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 11.O Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑ROOc airs These sub-contractors have employees and have workers'comp.insurance.: INSULATION 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.®Of118r 152,¢t(4),and we have no employees.[No workers'camp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 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 mist 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 enrplot'er that is providing workers'compensation insurance for my employees.ees. Below is the policy and job site information. Insurance Company Name: TRAVELERS Policy#or Self-ins.Lic.#: 6HUB4N60130820 Expiration Date: 9/21/2021 Job Site Address: 8 FOX FARM RD 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: / I1/10.1/9/ZBG7A Date: 6/30/2021 Phone#: 617-512-1509 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#: All-bRn CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 5/13/2021 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,Molignano&Weiner Ins Agency (A/C No,Ext): 617-471-1123 FAX No): 617-773-2474 21 McGrath Highway,Suite 303 -MAIL Quincy,MA 02169 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Norfolk&Dedham Mutual INSURED INSURER B: Traveler's Indemnity Co of America Clean Tech Construction LLC INSURER C: 190 Federal Ave INSURER D: Quincy,MA 02169 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMARENTED CLAIMS-MADE X OCCUR PREMISES0(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 500,000 A P012011894 09/18/20 09/18/21 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PEFQ 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) $ A OWNED x SCHEDULED 91972894A 09/16/20 09/16/21 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS $X HIRED NON-0WNED PROPERTY DAMAGE AUTOS ONLY x AUTOS ONLY (Per accident) 1,000,000 $ X UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE U20003464A 09/18/20 09/18/21 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE V I A 6HU64N60130820 E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? 9/18/20 9/18/21 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION FLORENCE BUILDING DEPT 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 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: TROUPE WASTE DUMPSTER Name of Waste Facility 40 MESSINA DR BRAINTREE MA 02184 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 PATRICK MCDONOUGH Signature of Permit Applicai ! 6/30/2021 Date ` Commonwealth of Massachusetts igf Division of Professional Licensure Board of Building Regulations and Standards ConstructioWS r Specialty CSSL-106150 5j ires:05/24/2022 - f PATRICK E MCDONOUGH 105 MARSHHAWK WAY MARSHFIELD MA 02050 .a`' Commissioner C Construction Supervisor Specialty Restricted to: CSSL-IC - Insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call (617) 727-3200 or visit www.mass.gov/dpl Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC CLEAN TECH CONSTRUCTION LLC Registration: 6 190 FEDERAL AVE Expiration: 0 06//27/27/ 2023 QUINCY, MA 02169 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 196071 06/27/2023 1000 Washington Street -Suite 710 CLEAN TECH CONSTRUCTION LLC Boston,MA 02118 WILLIAM DAVIDSON ) WG�� �GiiG^G�db/1i 190 FEDERAL AVE QUINCY,MA 02169 Undersecretary Not valid without signature Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card CLEAN TECH CONSTRUCTION LLC Registration: 6/2 71 190 FEDERAL AVE Expiration: 0 06/27/2023 QUINCY, MA 02169 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 196071 06/27/2023 1000 Washington Street -Suite 710 CLEAN TECH CONSTRUCTION LLC Boston,MA 02118 PATRICK E.MCDONOUGH P2 rta 190 FEDERAL AVE r, 7".fr G.I QUINCY, MA 02169 Undersecretary Not valid without signa ure