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35-145 (5) BP-2021-2341 17 WESTWOOD TERR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-145-001 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-2021-2341 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 6000 ESE INC 072316 Const.Class: Exp.Date: 12/19/2023 Use Group: Owner:, CAMPBELL, SAGE Lot Size (sq.ft.) Zoning: WSP Applicant: ESE INC Applicant Address Phone: Insurance: 52 FITGERALD DR (603)532-6346 V9WC236415 JAFFREY, NH 03452 ISSUED ON:12/28/2021 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: 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. Signature:g • 11I it Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildinc Commissioner ��. 0 vdOWamp 1 / D� \: / Ca J he Cpmmonwealth of Massachusetts/..,:(jt.... oww�, �c fp..w. ••1 �Q�, B d o Building Regulations and Standards Massach setts tate Building Code, 780 CMR Ninth Edition ---,El :-B ttkdi i App cation To Construct,Repair, Renovate Or Demolish a -, ' ';rioNs / One-or Two-Family Dwelling Revised Mar 2018 n '� This Section For Official Use Only Building Permit Number: ✓l'pV' Date Applied: f\ n acticitk, Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 tgrsors Map& Parcel Numbers 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 ❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Re d• Name(Print) City,State,ZIP 17 AJi 5'rwavb ga/ec 20/-q1? .,l!9Sr Yeg?e,Avytgr/fa y nt aL c i1. No.and Street Telephone Emaif Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building lX Owner-Occupied R Repairs(s) Di Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other ® Specify: Weatherization Brief Description of Proposed Work2: install insulation,air barriers,venting **No demo or debris** SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ beQd .. 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ 1106 Suppression) ,_ Check NoCheck Amount: Cash Amount: 6.Total Project Cost: $ 6060 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-072316 12/19/2023 Caleb Aho License Number Expiration Date Name of CSL Holder U 52 Fitzgerald Dr List CSL Type(see below) No.and Street Type Description Jaffrey,NH 03452 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 603-532-6346 permits@esaverenabler.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 193253 09/30/2022 Caleb Aho dba ESE, Inc HIC Registration Number Expiration Date HIC Com any Name or HIC Registrant Name 52 Fitzgerald Dr., permits@esaverenabler.com No.and Street 603-532-6346 Email address Jaffrey,NH 03452 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 No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Caleb Aho dba ESE, Inc to act on my behalf,in all matters relative to work authorized by this building permit application. ca*,o W( laidv/g/ Print vner's Name(Electronic Signature) (authorization attached) D to 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 accu to the best of my knowledge and understanding. Caleb Aho dba ESE, Inc 1 a119l40/ Print Owner's or Authorized Agent's Name( ct n& ignSiu� 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" Permit Authorization mass save Form Site ID: 4359761 Customer: SAGE CAMPBELL Sage Campbell I, ,owner of the property located at: (Owner's Name,printed) 17 Westwood Terrace Northampton, MA 01062 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. SGt yz Cae14p+PI Owner's Signature: 11 /23 /2021 Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Ai _/)&d_ 2-5Y/;4-A-- /0-i.P /0 Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page I of 1 °cr CfFice'J_e Orly Document Ref:AZAE9-J8HIS-C7UWP-UFFTP Page 6 of 17 ,;.•:.•:�.' •'.:: 3: :" • •+. '.�:•.+i a O> l: i•:':'s•.:.i!:'••.::�:.•::.'�::':'••• Signature Certificate . Document Ref.: X9UZZ-93H0Q-BWXDK-2DAKB I Document signed by: ►r.; j :. I Sage Campbell ::: At Verified E Safe CA p :iv m sage.augusta@gmail.co .. 172.60220.202 al Dee2 a 1111111111 13111111 31111 Iill , y. Document completed by all parties on: 01 Dec 2021 14:28:19 UTC i '•:• f ,•; • a'� ! :• ;- �. V. .*.• y: . :" !{ 1 s i 1 •.: `'.;. I i V. y: :i Signed with PandaDoc.com ■ ■ •PandaDoc is a document workflow and certified eSignatur� • T .; •solution trusted by 25.000+companies worldwide. ❑ ;: •:•:• ..*.•.i••••••-••• .".ti•-'ice •i..t•*.'•ii '1•. • i sii.' i•;i•i•r :.; i iii;•'•;•i` :\.i i :•.+. ..x.. +i i .. i... CLEAResult CONTRACT CLEAResult 50 Washington Street, Customer Name:SAGE CAMPBELL Westborough,MA,01581 Email:sage.augusta@gmail.corr Phone:978-417-1951 Premise Address:17 Westwood Terrace,Northampton.MA 01062 Mailing Address:17 WESTWOOD TER Florence,MA 01062 Project ID:4359761 Date:Nov 30.2021 Job Description Contractor will perform or cause to be performed the following work on these"Premises" in a professional manner and in accordance with the terms of this Contract, including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference. Measure Description Location Quantity Unit Total Cost Customer Cost I Air Sealing at Estimated 62.5 CFM50 Per Hour 8 hr $740.64 $0.00 Door Sweep(with AS hrs) 3 each $75.93 $0.00 Exterior Door Weather Stripping(with AS hrs) 3 each $90.21 $0.00 Attic Floor-8"Open Blow Cellulose 720 SF $1,267.20 $316.80 Walls-Vinyl-4" Dense Pack Cellulose 880 SF $2,332.00 $583.01 Walls-Buffered Interior-4"Dense Pack Cellulose 144 SF $365.76 $91.44 Bath Fan-Vent to Roof 1 each $141.30 $35.32 Propavent 45 each $187.20 $46.80 Damming 34 each $81.26 $20.31 Blower Door Test 1 each $72.75 $18.19 Total: $5,354.25 ti—' Program Incentive: -$4,242.38 Customer Total: $1.111.87 ._.....�— -- ______---- Payment Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows Payment#1:$0.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs) Mail check&contract to CLEAResult,50 Washington Street, .Westborough, MA. 01581. Final Payment:$1,111.87 as the final payment for the Work shall be payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work. Customer Page 1 of 4 Document Ref:X9UZZ•93H00-BWXDK-2oAKB Page 1 o'4 understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$4,242.38. Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Dispute Resolution The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.G.L.c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the sell in writing • ordinary , ail •.sled,by telegram sent or by delivery, not later than midnight of the third business day ollo ng the sig ei 1aye • g g.J��sT SIGN THIS CQif TtCIT)E2T,f-IERE ARE ANY BLANK SPACES. •GP• Customer Signature Date Indicate your selected IIC here,if applicable Initial here if you want the Program to assign a Cotte Contractor 11,30,21 Kevin Cote Participating CLEAResult Signature Date Name of CLEAResult Representative Page 2 of 4 Document Ref:X9UZZ-93H0Q-BWXDK-2DAKB Page 2 of 4 TERMS AND CONDITIONS ASSIGNMENT OF CONTRACT BY CLEAResult Customer acknowledges that CLEAResult will,and Customer hereby requests CLEAResult to.assign this Contract to the IIC to undertake the Work on the terms set forth in the Contract.After such assignment:(a)CLEAResul;shall no longer be a party to this Contract;and(b)Customer shall have no recourse against CLEAResult for any of the performance.non-performance or deficient performance of the Work or any obligations under this Contract performed by,or on behalf of,the IIC Notwithstanding the foregoing.Customer shall provide CLEAResult with(i)such information regarding the IIC's performance as CLEAResult may reasonably request:and(ii)reasonable access to the Premises as CLEAResult may request to permit CLEAResult to inspect IIC's work,and(c)Furthermore,Customer agrees that he'she.ithey(i)shall notify CLEAResult of any dispute between Customer and the IIC concerning the Contract:(ii)shall provide CLEAResult with such information regarding the dispute as CLEAResult may reasonably request;and(iii) consent to CLEAResult's participation,at its sole election,in any arbitration or other dispute resolution proceeding between Customer and the IIC. LIMITED TIME OFFER The terms,prices,and any incentive offered in this Contract are valid for only thirty(30)days from the date of CLEAResult's presentation of this Contract to the Customer.In the event that Customer does not execute this Contract and return it to CLEAResult within such thirty(30)day period,the terms.prices and any incentive offered by CLEAResult is NULL and VOID COMMENCEMENT AND COMPLETION The IIC will not begin the Work or order the materials before the sixth(6th)day after the execution of this Contract by CLEAResult and Customer, whichever signs later(the"Contract Execution Date").Subject to the availability of subcontractors,materials and to delays attributable to the weather or "acts of God",the IIC shall begin performing the Work as soon as practical after the Contract Execution Date,and the IIC shall substantially complete the Work no later than sixty(60)days after that Contract Execution Date,barring delay caused by circumstances beyond the IIC's control,including but not limited to any delay resulting from Customer's decision to wait for a particular IIC Each of CLEAResult and the IIC reserve the right to advise the Customer of changes in the projected start and completion dates.based upon availability of materials and subcontractors. Upon completion of the Work,the IIC will leave the Premises in a neat and orderly condition but shall not be responsible to correct conditions outside the scope Of its Work. MODIFICATION Prior to CLEAResult's assignment of this Contract to the IIC set forth in Section IV(above),this Contract cannot be changed except by a writing signed by CLEAResult and the Customer After CLEAResult's assignment of this Contract to the IIC set forth in Section IV(above),this Contract cannot be changed except by a writing signed by the IIC and the Customer that has been approved in writing by CLEAResult. PERMITS In connection with the Work to be performed at the Premises by the IIC Under Contract.the following permits may be required for this project depending upon the judgment of local inspectors:Electrical.Plumbing/Gas,Mechanical,Building.The IIC shall be responsible to,and shall,obtain any and all permits required for performance of the Work.The IIC shall inform the Customer of the permits required and any Customer co-pay or cost of the required permit acquisitions. If Customer chooses to secure her his own work-related permits.and'or deal with an unregistered contractor Customer will be excluded from the Guaranty Fund provisions of M.G.L.c 142A. CUSTOMER'S DUTY Customer must prepare the Premises for the Work.Objects which obstruct areas of Work must be moved before the Work is to commence.Customer affirms that they have received no incentives(from the above-named Utility)during the last calendar year DISCLAIMER OF LIABILITY OF CLEAResult AND UTILITY Customer understands and acknowledges that the IIC is not an agent,vendor or sub-vendor of the Utility or CLEAResult with respect to the installation of any energy efficiency measures In the event of the failure of any energy conservation device to perform as expected.Customer agrees that Customer's sole recourse is to the IIC and not to CLEAResult or the Utility The Utility and its operating companies shall not maintain,remove or perform any work whatsoever on the energy conservation measures installed.Customer understands and acknowledges that its participation in the Mass Save Home Energy Services Program is voluntary and that it has consented for the IIC to install the proposec energy conservation measures. Customer agrees that it shall not hold CLEAResult.the Utility their affiliates or operating companies liable for the IIC's failure to perform its obligations under this Contract,for failure of the energy conservation measures to function.for any damage to Customer's Premises caused by the IIC or for any and all damages to property or injury to persons caused by the energy conservation measures ENERGY BENEFITS The local sponsoring Utility is entitled to 100%of the energy benefits associated with all energy conservation measures,excluding the value of energy cost savings by the Customer.but including all rights to all associated ISO-NE Energy Capacity and Reserves Products(as defined by ISO New England) and the IIC agrees to provide the Utility with such further documentation as the Utility may request to confirm the Utility's ownership of such benefits and Products. IIC REGISTRATION The IIC and any subcontractors must be registered by the director and any inquiries about the IIC or any subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,Home Improvement Contractor Registration, 10 Park Plaza,Room 5170,Boston. Massachusetts 02116.617-973-8700. Page 3 of 4 Document Ref XBUZZ-93H00-BWXDK-2DAKB Page 3 of 4 IIC WARRANTIES The IIC warrants as follows. A. Materials and workmanship will meet or exceed the specifications in CLEAResult's Materials and Installation Standards. B. The Work and the materials furnished by the IIC will conform to the requirements of this Contract. If there be a defect in workmanship or materials,or any damage caused by its subcontractors or employees is discovered within one year after completion of the Work(including cleanup),the IIC will,at its own expense,at its option,remedy,repair,correct replace,or cause to be remedied,repaired,corrected or replaced such defect or damage. CUSTOMER RIGHTS UNDER M.G.L.C 142A Customer has the following rights under M.G.L.c. 142A. A. At the time of signing this Contract,the Customer shall be furnished with a copy of it.No Work shall begin prior to the signing of this Contract by the Customer and CLEAResult. B. Any party may bring an action to enforce any provisions of Mass.G.L.c. 142A or to seek damages or the Customer may request that a dispute be decided under the terms of a private arbitration program approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations. C. Customer may have the right to be compensated from the Residential Contractor's Guaranty Fund for actual losses incurred as a result of a registered contractor's or subcontractor's conduct found by a court to be work performed in a poor or unworkmanlike manner or which violates certain laws for the protection of consumers within 6 months after the Customer has obtained a judgment or arbitration award and has exhausted customary reasonable efforts to collect the judgment or award. Page 9 of 4 Page 4 of 4 Document Ref:X9UZZ-931-100-BWXDK-2oAKB I RCS PLANVIEW DIAGRAM y [CustoMer S_ - - - ---- — ( � � -- ---; Home Fttont?: f )- Addrese i�W � � _ �C ECG 9 Work Phone Town._ n AtA�r' Cell Phone ( )- - - Any ln.trt,ons for 4CCc.s by Web.tru,:4 tgletaiC d'rCttt011s Or I.,ndm.t•4 s' No Site ID: ; p ^ _ __ _ Energy Specialist: �IGn�kn 1. a3 - --�""'d bY. _ c c, ,c (8,k os G-- 72o r Sect: ( —$�1 rS 2V‘hl I , y Vlaks V 53 -1),crstot.P I S X 3 • t \i� V- c 1141-(43 1045 CY .,00m),..k%4.p.c...yen6-es 3'-i it) ao . — No tJ F mkt-- ID 0 ii U. , s'0 try • `� i 0 A 14 aI Di ,... a • fit For Office I'se Only CI __ t3,.sr,r, _ ladder - rt Neghbor Proxtmsty Pocket Doors _ Insert Radiators ' Fence(!) Existing Conditions X=Access t, Note Inside Square R=Roof _._ - - S=SoffitG=GabeRV■Ridge Vent S=Continuous . CDE=Continuous Drip Edge T=Triangle an_ ... - - --_ - - -Instafi p= dew Access Noce.n Cade C=Ceiling w=Wall S*Sheotnav Temp Unless Noted Otherwise =Vents Note in Tria tgle R Y 8"Rods S•Safr,t G=Gable M•12-Mushroom_ _ __-_ _ .- For Access 2200.10-V115 IIIIIIIIIppn k ______.. . _ ,....7.--..., : /. t_ C30_ - 6 q 3 344_3atc,,= lip XW _ _ _ ; : /1-/g -. 0 _ x I I o%2 . r 1 E Recommended -- -- i ; • Ventilation Calculation Recommended Vcntdatton Calculation AR Se hnp Wo+n Haar ) d/ „ /era to +�� CJIGuIdt+On (0.(� Work Hours 4 6 r 10 12 14 16 (•2) Attic SO Footage <500 301-Q00 BOt-1100 1101-1400 1401-1700 1701-2000 2001-2300 Evary 300- E•:rot.ona1 AFL Hours Pnmardy Floored Attics Crumney or BF=,Hour Hutt.pl.Ch.mney/BF=2 Mows an!.w Moduirr Hours No Ch.mney =4 Hours Chimney:6 HourS F■:Kat•onat Kitt 404.0: X<20 felt•1 Four 20 tt<X c<0 ft:2 r+curs X >40 ft=4 Hours Rem J .st Or,t>Huure RJ<150 R= Hour RJ 1S0 n=2 Hours HMT Cc„W Om,MArs Cam'nq Area r 2000 so ft s 1 Hour - — _- Ce+l•nq Ateea>2.00010 ft.2 Hours ""NOTE You MUST be INSULATING RJ or Baseineett Ceieieq 10 ipict(y RJ or BHT calling ONI.v Ak seams Hours r© 1 '6 Loos.lttkMt on Cross Beet►nsulec.or Mstt..... >t M,� Lia� Batt diLOOse MKubt•ort Truss Constnxt.on 1.4rWM, 1 .. sorbs City of Northampton ' \ Massachusetts +., * • : - •'<<G ` G' I # _ rk DEPARTMENT OF BUILDING INSPECTIONS y: ;yt +.' ' p 212 Main Street • Municipal Building Northampton, MA 01060 J4iiii...4. 0� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. WO dam o c.a.- delogir The debris will be disposed of in: Location of Facility: __.34 !� NG LC r �/.L4'nfi iu 1 The debris will be transported by: Name of Hauler: 25 ltix- Signature of Applicant: ' # Y Date: /�h/111 optH: City of Northampton 5 ry s '� t Massachusetts 4``.••` * <`c " DEPARTMENT OF BUILDING INSPECTIONS y I� •. _ 212 Main Street • Municipal Building J�J`S..•• .1D Northampton, MA 01060 l'Y Hf71 Property Address: 17 1JJP lA)bd() -r4Q/t 4(s- Contractor Name: L 41-iJ /4)kd 1,64 F�� five_ Address: 52, i -l-t y-474 U 1k. City, State: -C-t-Rctt /WI b 5 2 Phone: ( 03. 5 3? •6.3 VG Property Owner Name:ame: )/6 Gen 1,0 611 Address: 11 O1Je5 uob jp 7.ea 24 i City, State: NQ► 1—mA? t b i MA. 0 L CJ 6 Z �S ' /Nc(-contractor attest and affirm that the buildingI intend to I, e4tÔ Ho d�� ) insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date ,0- I,29L,2I c* The Commonwealth of Massachusetts =, —. t. Department of Industrial Accidents �l_ 1 Congress Street,Suite 100 °°ftrr— Boston, MA 02114-2017 6 "el�!= ,,�� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Caleb Aho dba ESE, Inc. Address: 52 Fitzgerald Dr City/State/Zip: Jaffrey, NH 03452 Phone#: 603-532-6346 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 7 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.❑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 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p 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. 14.00ther weatherization 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 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: National Liability&Fire Ins Co Policy#or Self-ins.Lic.#: /V9WC236415 (3a)MA& NH Expiration Date: 03/08/2022 Job Site Address: / 7 L/UeSrwvoe rimi4Gf City/State/Zip:M/201A MIA*MA (/ 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 pain nd penalties of perjury that the information provided above is true and correct. Signature: 4. Date: /ol/ 7' /'2 1 Phone#: 603-532-6346 Official use only. Do not write in this area,to he completed hr 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#: ACC) ® DATE(MM/DD/YYYY) ��^O CERTIFICATE OF LIABILITY INSURANCE 07/23/2021 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 Lisa Nolan,CPCU NAME: FIAT/Cross Insurance PHONE FAX (603)669-3218 (603)645-4331 (A/q No,Ext): (A/C,No): 1100 Elm Street EMAIL manch.certs@crossagency.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Manchester NH 03101 _ INSURER A: Ohio Security Ins Co 24082 INSURED INSURER B: Ohio Casualty Ins.Co. 24074 ESE,Inc. INSURER C: National Liability&Fire Ins Co 20052 52 Fitzgerald Drive INSURER D: INSURER E: Jaffrey NH 03452 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 All lines 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 IADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE -INSD_WVD POLICY NUMBER (MM/DD/YYYYL(MM/DDIYYYY)- LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,DAMAGE T000 RETE CLAIMS-MADE X,OCCUR PREMISESO(a occur ence) $ 300,000 MED EXP(Any one person) $ 15,000 A BKS55684497 07/31/2021 07/31/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE T LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ B - OWNED S• CHEDULED BA055684497 07/31/2021 07/31/2022 BODILY INJURY(Per accident) $ __ AUTOS ONLY AUTOS ' HIRED —7 N• ON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) — X UMBRELLA LIAR `lC OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAR CLAIMS-MADE US055684497 07/31/2021 07/31/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE I ORTH- AND EMPLOYERS'LIABILITY 500,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE YYN NIA V9WC236415(3a.)NH&MA 03/08/2021 03/08I2022 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Caleb Aho is excluded from workers compensation coverage DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Informational Purposes Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. Informational Purposes Only AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 S ) Boston, Massachusetts 02118 •�,,�J1 k� Home Improvement Contractor Registration tt� 5x"- Type: Corporation "77.- ESE INC Registration: 193253 2 52 FITZGERALD DRIVE Expiration: 09/30l2Q20' JAFFREY,NH 03452 SCA 1 0 20M•05/17 Update Address and Return Card. Office of Consumer Affairs ii Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Redistratiory Expiration Office of Consumer Affairs and Business Regulation 193253 09/30/2020 1000 Washington Street-Suite 710 ESE INC Boston,MA 0211.$ CALEB D.AHO /7 :' fei 52 FITZGERALD DRIVE � CC�N `L.s� JAFFREY,NH 03452 Undersecretary Not valid without signature li j DvnlFitoittfifai�itie Sr Massachusetts hu6etttS I blviwion of Professional Licensees h i;irii of iluiltiing Regulations 8rlfi Jtanuards • ''trt,C2ior.Super. i ; ,• Expires: 12/18/2u r CALEB AHQ 2 62. 482 JARMANY HILL RD. u SHARON NH 03458 19 1 Cumfrdislyidnor :ZEt.+t7(( ' .... �` , 1 1 • •. v )mmaigam ffice or Affairs and Reguation HIC Registration Complaints Registration 193253 Registrant ESE Inc Name Caleb Aho Address 52 Fitzgerald Drive City, State Jaffrey, NH 03452 Zip .� Expiration 09/30/2022 Date Complaints Details No complaints found for this registrant. You can also view arbitration and.Quaranty rand history. Back_T.search site Policle; Contact U . 2018 Commonwealth of Massachusetts. 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