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31A-115 (10)
BP-2022-1656 38 VERNON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-115-001 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-2022-1656 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2022 Contractor: License: Est. Cost: 2000 EFFICIENT BUILDINGS INC 117239 Const.Class: Exp.Date: 03/15/2026 Use Group: Owner: A COFFEY KELLY Lot Size (sq.ft.) Zoning: URB Applicant: EFFICIENT BUILDINGS INC Applicant Address Phone: Insurance: 973 REED RD (508)279-1110 6H48605 DARTMOUTH, MA 02747 ISSUED ON: 12/28/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney': Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I ' >2 . TAIR `r a Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner p` --- F �, w / '- tm.- '�r Crel-k, 12-Lz c z 2. // Oe' The Commonwealth of Massachusetts i C P lt •: Board of Building Regulations and Standards/ f, ;\ MUN7t�IP R / Massachusetts State Building Code, 780 CMR ^�c°l o,. USE Building Permit Application To Construct,Repair, Renovate Or Demolisfi a oti' cT -2011 One-or Two-Family Dwelling '��,00N` , This Section For Official Use Only Building Permit Number: �L44 A- tei 6re Date Applied: Z /� /2-Z6-ZU1-2 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3 4-- y'-tr ncn SIN 1-floor ayi- I as- 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❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'l of R rd: It at/sifti-ilit)t) City,State,ZIP 3 - `PEA()Pt S i !t—(Ar- -z.s Sty C oW-ey-�9r ;c,c" No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: -*`C i n5.,tA(b 1 A. r SLc.,l -.s,„. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ -*?1 Od10.0c) 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ r j Suppression) Check No. 104/ Check Amount: Cash Amount: 6.Total Project Cost: $29 i 0 .l`f3 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS- l t E at4 Jhn LG4 License Number Expiration Date Name of CSL Holder 4 S List CSL Type(see below) l I O 1 No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu. ft.) S-1 r e..w s bw,_ Nl A C) S t/5-- R Restricted I&2 Family Dwelling , City/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding ,��f (� SF Solid Fuel Burning Appliances 5-2 j- 111 O L1'Ti G;c lob ,.. i�,G�'t,,c...AI Insulation Telephone Email address✓ D Demolition 5.2 gistered Home Improvement Contractor(HIC) l'3 to�- S 'Ci — (Ots rwL L HIC Registration Number Expiration Date HIC Compan Name or HIC Registrant Name °I1-3 T�ec�:e c Pc,c:4.44,i4:,di yi kfA.,41.c _, No.and Street Email address 4 ©2}t[?- 3bk 211-11 I O City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE A1H'}IDAVTT(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 ..........JIE 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 -bkF,--, Laud to act on my behalf,in all matters relative to work authorized by this building permit application. S'e.2 / 2//4e/26Z7-_ 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 c• t,fined in this application is true and accurate to the best of my knowledge and understanding. / z' z , .,ram. _ 2 �Da z ' nt Owner' r Authors d Agent's Name(Electronic Signature) ate 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" N M City of Northampton 47, Massachusetts „ J + DEPARTMENT OF BUILDING INSPECTIONS f� , 212 Main Street • Municipal Building vy,U .0 Northampton, MA 01060 J'{ny 3p0 _ 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: ktea, POct rJL/ .c/ The debris will be transported by: Name of Hauler: Y3 poi cs1,- Signature of Applicant: Date: /244° 2 The Commonwealth of Massachusetts ► —v, � l, Department of Industrial Accidents 11 =�1= 1 Congress Street,Suite 100 = f_i_9 Boston,MA 02114-2017 t'' t 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):Efficient Buildings, INC Address:973 Reed Road City/State/Zip:N. Dartmouth, MA 02747 Phone #: (508)279-1110 Are you an employer?Check the appropriate box: Type of project(required): 1.1 I am a employer with 15 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 4.0 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 11.❑Electrical repairs r additions proprietors with no employees. 12.❑Plumbing repairs r additions 5.0 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 area corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other Insulation 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 indica ng such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitie.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'ob site information. Insurance Company Name:Employers Mutual Casualty Company Policy#or Self-ins.Lic.#:6H48605 Expiration Date:709/01/2023 Job Site Address: Vertu S7. I Pod" City/State/Zip:Nort Ctn,p- 't o,o.o O Attach a copy of the workers'compensation policy declaration page(showing the policy number and expira;on 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 i surance coverage verific. in. I do hereby ' under the and penalties of perjury that the information provided above is true and correct. Signature• ' Date:/ -//4'/)0 2?- Phone • 08)279- 110 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#: City of Northampton \fr,• Massachusetts 1.41 41.%'n1,144414/ DEPARTMENT OF BUILDING INSPECTIONS '6fr 212 Main Street (0 Municipal Building 1.111 Northampton, MA 01060 Property Address: \ft\ir Y1JcL Contractor Name: Efficient Buildings inc 973 Reed Rd Address: North Dartrhouttk MA 02747 City, State: Phone: PropertyName: Ownery. Q. - --(4 Address: s-- vef non A: City, state: fk)goCoMirl_j.,ka V.)(..s() \ -1; (contractor) attest and affirm that the building I intend to insulate does not have any,, pen air(knob and tube)wiring in the spaces to be insulated and that I have provided the property o‘ , with a copy of this affidavit. 1/4.. Contr ct sigrpature (A, Irr \\, Date 271)7,7 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re lations and Standards Cons nui Svisor CS-117239 "'- ppires:03/15/2026 -1OHN LAVElp'Y F • re 110 FRANCISrAVE SHREWSBURY MA to 'a Commissioner ' THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Stret-Suite 710 Boston, Massachusetts-02118 Home lmorovernen Contractor:Registration Type: Out of State Corporation EFFICIENT BUILDINGS INC R Istration: 09/27/20245 973 REED RD • EXpiration: DARTMOU T H.MA 02747 Update Address and Return Ca . THE COMMONWEALTH OF MASSACHUSETTS S Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Out of Nretorporaiion Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street •Suite 710 208525 :`_'-09/27/2024 Boston,MA 02118 EFFICIENT BUILDINGS INC r--DocuSipned by JIM REARDON WMGS ,li}�'( U, 973 REED RD a % f —•4192C226691r49D... DARTMOUTH.MA 02747 ? -- Undersecretary Not valid without signature _ .___. DEBRIS FORM I � In accordance with the provisions of MGL c.40,s.54,a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.111,s.150A. This Debris will be disposed of in: 973 k. , 1AJO.elh 2a./z fr)'tovT)-. , 4' Col 7477 (LOCATION OF FACILITY) Signature of Permit Applicant Date • IF DUMPSTER I USED IN EXCESS OF SIX(6jCUBIC YARDS A PERMIT FROM THE FIRE DEPARTMENT IS REQUIRED FOR COMMERCIAL INDUSTRIAL,INSTITUTIONAL AND MULTI-FAMILY RESIDENTIAL OVER 20 UNITS DEMO, RENOVATIONS OR ALTERATIONS OF THE EXISTING BUILDING: CIRCLE ONE '• **HAVE YOU SUBMITTED TI1E AQ06 NOTIFICATION TO THE MASSACHUSETTS DEP? YES NO { uvi.0 Jlyn CnvtlIUpC IV.LouooJo L-licar-gaJo-Hroa-1 rL.000m IOLV:e Federal ID#05-0405629 RI Contractor Registration No 8186 MA Contractor Registration No 120979 CT Contractor Registration No 620120 RISE1341 Elmwood Ave,Cranston, RI 02910- CONTRACT - WZ 339-502-6335- FAX 339-502-6345 Page- 1-- PROGRAM., THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR WORK AS CMA-HES DESCRIBED BELOW CUSTOMER PHONE DATE CUENT WORK ORDER Kelly Coffey (413)687-2543= 11/04/2022E 462330E 61906E SERVICE STREET BILLING STREET PROPOSED BY: 38 Vernon Street 1 FL.'' 38 Vernon Street 1FIL Jeff Ledouxii SERVICE CITY.STATE,ZIP BILLING CITY,STATE,ZIP Northampton, MA 01060 Northampton, MA 01060._: DESCRIPTION: CITY'. COST_ INCENTIVE TOTAL INCENTIVE 75%_. For eligible weatherization measures, Eversource is offering an incentive of 75%for insulation measures and 100%for the air sealing measures, both with no limit.You are eligible to apply for the 0%Heat Loan to finance your co-pay, applications must be submitted before the weatherization work begins.. HOME AIR SEALING._ 4._ S377.32_ S377.32. Seal areas of your home against wasteful, excessive air leakage. I 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.)._ ATTIC DAMMING-R-38 FIBERGLASS:" 70:- S169.40 S127.05 S42.35 Provide labor and materials to install a 12"layer of R-38 unfaced _. fiberglass batts for damming purposes. ATTIC FLAT-8"OPEN R-30 CELLULOSE' 400::: S672.00_. $504.00_ $168.00 Provide labor and materials to install an 8"layer of R-30 Class I Cellulose to open attic space. OVERHANG R30 FG AND RIGID BOARD__ 44_. S288.64__ $216.48. S72.16_ Provide labor and materials to install 9"R-30 kraft faced fiberglass then rigid board at R-10 or greater with the required fire rating to the ._ bottom of the joists. All seams will be sealed. VENTILATION CHUTES__ 20:_" $69.80:: $52.35: S17.45_ Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow. KNOB &TUBE WIRING-OK... ,Y Because the weatherization recommendations are in readily { accessible areas and your energy specialist verified they do not contain knob and tube wiring,your weatherization can proceed without an electrician's inspection._ DocuSign Envelope ID:26985382-AESF-4536-AF63-7FC868A15209 Federal ID#05-0405629 RISE RI Contractor Registration No 81186 MA Contractor Registration No 120979 C CT Contractor Registration No 620120 RISE1341 Elmwood Ave.Cranston,RI 02910 CONTRACT - WZ 339-502-6335 FAX 339-502-6345 Page 2 PROGRAM THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINEERING AND THE CUSTOMER FOR RK AS CMA-HES DESCRIBED BELOW 1 CUSTOMER PHONE DATE CLIENTS WORK ORDER Kelly Coffey (413)687-2543 11/04/2022 46233q 61906 SERVICE STREET BILLING STREET PROPOSED BY: 38 Vernon Street 1 Fl 38 Vernon Street 1 FI Jeff Ledoux SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Northampton, MA 01060 Northampton, MA 01060 DESCRIPTION QTY COST INCENTIVE TOTAL PREPARE YOUR HOME Homeowner is responsible for the removal of any items stored in the r� (initials) areas where the weatherization measures will be installed. The - workers will need the space cleared to safely bring their tools and materials into these work areas. If you have any questions or specific concerns, please bring them to the attention of your subcontractor when they call to schedule your work. Total: $1,577.16 Program Incentive: $1,277.20 Customer Total: $299.96 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Two Hundred Ninety-Nine&96/100 Dollars $299.96 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%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. iDocuSigned by: —DocuSigned by: -4�a1n7 CO \'Yi ISER Fi... Miti RIACA°t IWO... 11/7/2022 I 6:59 AM EST NOTE:THIS CONTRACT MAYBE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE SIGN DATE 30 DAYS. ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND ONDITONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHOR TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE DocuSign Envelope ID:2B98B3B2-AEBF-4536-AF63-7FC868A15209 RISES ENGINEERING` OWNER AUTHORIZATION FORM Kelly Coffey (Owner's Name) owner of the property located at: 38 Vernon Street (Property Address) Northampton, MA 01060 (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. ,-DocuuSig ned by:{y oc 1 c"��b 11/7/2022 1 6:59 AM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com AC R® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/2/2022 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 RogersGray,A Baldwin Risk Partner PHONE FAX 410 University Ave INC.No.Ext):800-553-1801 (Arc,No):877-816-2156 E-MWestwood MA 02090 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:Employers Mutual Casualty Co 21415 INSURED EFFIBUI-02 INSURER B:Tokio Marine Specialty Insuran 23850 Efficient Buildings Inc. 973 Reed Road INSURER C: North Dartmouth MA 02747 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:141705734 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 LIMITS TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIM l A X COMMERCIAL GENERAL LIABILITY Y Y 6D47875 8/30/2022 8/30/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X PE LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 6Z47875 8/30/2022 8/30/2023 COMBINED SINGLE LIMIT $1 000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY - AUTOS ONLY (Per accident) _ _ A X UMBRELLA LIAB X OCCUR Y 6J4787 8/30/2022 8/30/2023 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION$1rlofn $ A WORKERS COMPENSATION Y 6Y47875 8/30/2022 8/30/2023 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Pollution PPK2337007 10/12/2021 10/12/2022 Per contaminant 1,000,000 Aggregate Limit 2,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) When required by written contract the following Apply: General Liability:Additional Insured Ongoing(CG 7174.3 10 13)and Completed Operation(CG 7174.3 10 13) Primary and Non-Contributory Basis(CG 7174.3 10 13),Waiver of Subrogation(CG 75 55 02 19) Auto Liability:Additional Insured(CA 7450 11 17),Waiver of Subrogation(CA 74 50 11 17) Workers Compensation:Waiver of Subrogation(AC 000313 04 84) Pollution Additional Insured,Primary Non-Contributory and Waiver of Subrogation(PICEVCP001 7/17) Thielsch Engineering,National Grid,Columbia Gas of MA,and Liberty Utilities are included as cited above. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Columbia Gas of MA ACCORDANCE WITH THE POLICY PROVISIONS. 4 Technology Drive, Suite 250 Westborough MA 01581 AU25EPRESENTA11VE USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD