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17A-157 (8) BP-2023-1045 61 FOX FARMS RD COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 17A-157-001 CITY OF NORTHA PTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGIS ERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARAN FUND (MGL c.142A) BUILDING P .RMIT Permit# BP-2023-1045 PERMISSION S HEREBY GRANTED TO: Project# insulation 2023 Contractor: License: Est.Cost: 11643 CLEAN TECH CONS RUCTION 106247 Const.Class: Exp.Date: 01/05/202 Use Group: Owner: CIAMP DOSTAL ERIC D& ELENA L Lot Size (sq.ft.) Zoning: URA Applicant: CLEAN ECH CONSTRUCTION Applicant Address Phone: Insurance: 40 MESSINA DR 508-576-1026 6hub4n60130822 BRAINTREE, MA 02184 ISSUED ON: 08/07/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Seri ice: 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 NO THAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner itk Een M'il laiLT 1g5y IL, The Commonwealth of Massachusetts ��Board of Building Regulations and Stan..rds ^ FOR W. Massachusetts State Building Code, 7:i C ' •� ICIPALITYUSE Building Permit Application To Construct,Repair, ' -no - Or olish a /'- 'd Mar 2011 One-or Two-Family Dwelling 'i oc ` 0 This Section For Official Use Onl 9):5‘6.65, (% Buildin Permit Number: 65+"^.0) 3 . iQf s Date Applied: T��> • ro �l� (1.Z55 �� '°� ,) 8-4.2a?3 Building Official(Print Name) Signature KS Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 4?\ RN. COSYYlS 1.la 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 Waterte Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public tie Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner'of Record: r‘C OoSk-QJ, A)p(- osn c r , 1 \A , O\ O(n Name(Print) City,State,ZIP (e\ c-oY )C.‘rt(IS cZ-\ _ 4• s-ilX)-301Li 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 l 'Specify: V vls v\c OvZ Brief Description of Proposed Work2: \; 14 CL\-\'\&'c iz( C V\ O.. Or Se 0.c):%v, tn.t-\k-PN i'A.G5S jc,:j-e 7cOa cs_vv\ _ JVo '-Fruc_fixc=„.i. C.=\."0-vkOr. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ r\,(Q k' (.0c21. 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 $ Total All Fees: $ Suppression) Check No. Check Amount. �I Cash Amount: 6.Total Project Cost: $\\, CQt{3 . CoC� ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) lceG qZPID License Number Expiration DateCo Name of CSL Holder List CSL Type(see belowcW \55L)`o Ov\ (2)? F\\S US No.and Street Type Description Y <�\ w �Z,Q C� Unrestricted(Buildings up to 35,000 cu.ft.) I�JC c �( � V) , R Restricted 1&2 Family Dwelling City/Towb,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances jh cac o3-7bct'l Nsi,�)cG/NCOVIS�(orkievictlh�,Ctwt\`\ ( ) Insulation Telephone Email address -Cbvv D Demolition 5.2 Registered Home Improvement Contractor(HIC) i4 ��,` L7 /�2 QA.LO3 A \C_Can l.GV15 oc-sciOV1 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name • 8 �l t S Avg- "#' C aVkk6ncOv,sk-r-uc ((.g i‘\CA k . C Owl No.and Street Email address 1\)P1.1\w oVVI r M.k c ()21q() ;tom- 1Y City/To*n,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 Isssu e of the building permit. Signed Affidavit Attached? Yes g 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 ,Sc i Q.M QC z1/4 to act on my behalf,in all matters relative to work authorized by this building permit application. See a C t� 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. v,v,a " 7:5 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" ilIK mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Eric Dostal owner of the property located at: (Owner's Name) 61 Fox Farms Road Florence (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. This form is only valid with a signed contract. The permit will be secured by the subcontractor, at no additional cost. Owner's 'gnature Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above reference proPct: _ a"----21„,-/--2. 0 ' -------/ 0 /�.5/2oz Participating Contractor Date Commonwealth of Massachusetts Construction Supervisor Specially it y Division of Occupational Licensure --- '. Board of Buil , ' julations and Standa , Restricted to: Construe nert$or Specialty CSSL-IC-Insulation Contractor :y CSSL-106247 -. L ires: 09/26/20 - ARIANNA JAMES DAVIDSON r 38 ELLS AVE — WEYMOUTH MA 02190 ter,- 1 407J,Yd:.1)' Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner ./ K. ,tjea_ For information about this license Q�t bl& Call(617)727-3200 or visit www.mass.govldpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffatP and Business Regulation 1000 Washington Street- Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration „, r" s" -l Arai t Type: Supplement Card v =:_ _ :. r ation: 196071 CLEAN TECH CONSTRUCTION LLC "', ��L— E abon: 06127l2025 38 ELLS SVE .' 1usi MEM WEYMOUTH,MA 02190 uoa?i s_ sow et,VTR a moss ji i{J1% — ,tie i Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Renistration Expiration 1000 Washington Street .Suite 710 196071 06127/202`5 Boston.MA 02118 CLEAN TECH CONSTRUCTION LLC `-z s "T 4. ARIANNA DAVIDSON ` �,, *J" fj 38 ELLS AVE t �..�GG.k' WEYMOUTH,MA 02190 .>- , ,�„,.w�. 44 Undersecretary Not valid without signature The Commonwealth of Massachusetts i 4 Department of Industrial Accidents _' ► 1 t Office of Investigations talk Lafayette City Center � 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/ndividuat): Clean Tech Construction Address:40 Messina Drive City/State/Zip: Braintree, MA 02184 Phone#:617-271-0768 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 6+ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10.0Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13 ®fir Insulation 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:Traveler's Indemnity Co of America Policy#or Self-ins. Lic.#:6HUB4N60130822 Expiration Date:9/18/2023 Job Site Address: 6, Fo Y VA-S P\c 1, City/State/Zip:A t1( `0i 0 G Z Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjary that the information provided above is true and correct Signature: �€:€0,lsa D.�zr.e4 P Date: g / 3 /20 23 Phone#: 617-271-0768 Official use only. Do not write in this area,to be completed by city or town ojficiaL City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: MIIIIDomrY) A`CORE, DATE( MAXNY CERTIFICATE OF LIABILITY INSURANCE lorz 6/2022 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 pollcy(les)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: Gary Hebsch TOBMAN MOLIGNANO&WEINER INSURANCE AGENCY INC _i, "4.0,y: (817)471-1123 FAX EMAIL ADDREss; ghebschet n vIns.com 21 MCGRATH HIGHWAY SUITE 303 INSURERS)AFFORDING COVERAGE NAIc QUINCY MA 02189 OIIIUmA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURERS: CLEAN TECH CONSTRUCTION LLC INSURER C: INSURER D: 40 MESSINA DRIVE INSURERE: BRAINTREE MA 02184 INSURER F COVERAGES CERTIFICATE NUMBER: 828667 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. 'NW POUCY EFF POLICY EXP TYPE OF DURANCE INSD W VD POLICY NUMBER IISTKIDIYYYYI RNIIDD/YYYY) Lis COMO1MINALMINERAL LUla1L TY EACH OCCURRENCEDAMAGE TO RENTED - $ CLAIMS-MADE OCCUR PREMISES Ms occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV MJURY $ GEL AGGREGATE UNIT APPLIES PER GEMERAL AGGREGATE $ POLICY JFERcT LOC PRODUCTS-COUPIOPAGO $ OTHER: AUTOMOBILE LIABILITY SINGLE LIMIT $ (Es scddent) ANY AUTO BODILY NJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per so:Want) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per sodderU f UIBRE LA LIAB _ OCCUR EACH OCCURRENCE s EXCESS LIAR CLAIMS.IItDE N/A AGGREGATE s DED RETENTJON$ $ WORRIERS COMPENSATION x PER OTH- STATUTE Eft AND EMPLOYERS LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE El.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? NIA NIA 6HUB8R60053222 09/18/2022 09/18/2023 (Mandatory In NH) E.L.DISEASE-EABrPLOYEE $ 1,000,000 If yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT f 1,000,000 i N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govflwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Boston ACCORDANCE WITH THE POLICY PROVISIONS. 1 City Hall square AUTHORIZEDREPRESEMATNE Boston MA 02201 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACOROt DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09/09/22 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 pollcy(les)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 PHONE Ext): 617�71-1123 FAX No): 617-773-2474 21 McGrath Highway,Suite 303 E�AIUL Quincy,MA 02169 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC INSURER A: Norfolk&Dedham Mutual INSURED INSURER 8: Clean Tech Construction LLC INSURER C: 40 Messina Drive Braintree,MA 02184 INSURER D: 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. LTR TYPE OF INSURANCE s n BWvo POLICY NUMBER (MIDD/YYYTY) (MAEFF /DO//YYCY EXVFY) LIMBS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED CLAIMS-MADE X OCCUR I PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A — P012011894 09/18/22 09/18/23 PERSONAL a ADv INJURY $ 1,000,000 yGEN'L AGGREGATE UNIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 POLICY a JECT I I LOC PRODUCTS-COMP/OP AGO $ 2,000,000 I OTHER: $ AUTOMOBILELIABILJTY (COOMBEs IeEnD(SINGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED accident) $ AUTOS ONLY X X UTOS 91972894A 09/16/22 09/16/23 BODILY INJURY(Per accident) X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ X UMBRE—r A UAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS UAB CLAIMS-MADE U2003464A 09/18/22 09/18/23 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) The City of Boston is an additional Insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Boston ACCORDANCE WITH THE POLICY PROVISIONS. 1 City Hall Square Boston,MA 02201 AUTHORIZED NTATIVE ®1 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: Clean Tech Construction Name of Waste Facility Not Applicable - No Debris Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L.c.40 a.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 41,e.QILfZCL T7Gi 68rL Signature of Permit Applicant /Zo2- Date City of Northampton ,�o..- ff.;I. SAS^'—S.0 '•''" Massachusetts �4?. K. •!<. t` 1 k Y` DEPARTMENT OF BUILDING INSPECTIONS �`. j„ " 212 Main Street • Municipal Building 1- .cam �=. Northampton, MA 01060 *54 ,.• 60. CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: k,o\_ 001ic ,47j(Q C.,_,,_ a c\AQA ) The debris will be transported by: Name of Hauler: /30\- cj cc-3,0 2_ Signature of Applicant: •,(-4n� .� Date: S%3/2 GZ WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT WORK ORDER Eric Dostal (036)500-3014 07/26/2023 450802 61604 SERVICE STREET BILLING STREET PROPOSED BY: 61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux SERVICE CRY,STATE,ZIP BILLING CRY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE 75% For eligible weatherization measures, Eversource is offering an incentive of 75%for insulation measures and 100%for the air sealing measures, both with no limit.You are eligible to apply for the 0%Heat Loan to finance your co-pay,applications must be submitted before the weatherization work begins. HOME AIR SEALING 18 $1,918.62 $1,918.62 Seal areas of your home against wasteful,excessive 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.) WEATHERSTRIP DOOR 2 $72.64 $72.64 Provide labor and materials to install Q-lon weatherstripping to door(s)to restrict air leakage. DOOR SWEEP 2 $59.32 $59.32 Provide labor and materials to install a doorsweep to restrict air leakage. ATTIC DAMMING 50 $139.00 $104.25 $34.75 Provide labor and materials to install an approved damming material in the attic ATTIC FLAT-5"OPEN R-19 CELLULOSE 2,072 $3,874.64 $2,905.98 $968.66 Provide labor and materials to install a 5"layer of R-19 Class I Cellulose to open attic space. RECESSED LIGHT COVERS 1 $56.89 $56.89 Install recessed light covers over existing recessed light fixtures. Up to 6 at no cost. WHOLE HOUSE FAN COVER 1 $222.03 $222.03 Provide labor and materials to fabricate and install a rigid foam insulating cover for the whole house fan. WALLS-CLAPBOARD SIDED 4" 1,460 $4,292.40 $3,219.30 $1,073.10 Install blown in Class I Cellulose to clapboard sided exterior walls. Touch-up painting,if needed,will be the customer's responsibility. Homeowner has received a copy of the EPA's Renovate Right Lead- Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.Your signature is your acknowedgement of receipt and agreement to proceed. WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Eric Dostal (036)500-3014 07/26/2023 450802 61604 SERVICE STREET BILLING STREET PROPOSED BY: 61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux SERVICE CITY,STATE,ZIP BIWNG CITY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL WALLS-INTERIOR DRILL AND PLUG 4" 184 $540.96 $405.72 $135.24 Provide labor and materials to install blown in Class I Cellulose to exterior walls through an interior surface drill and plug method. Plugs will be spackled and left with a rough finish. Finish sanding and touch- up priming/painting will be the customer's responsibility. Homeowner has received a copy of the EPA's Renovate Right Lead-Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.Your signature is your acknowedgement of receipt and agreement to proceed. BASEMENT SILLS-6"FIBERGLASS 88 $268.40 $201.30 $67.10 Provide labor and materials to install R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. VENT BATH FAN TO ROOF OR OTHER 1 $166.53 $124.90 $41.63 Install an insulated exhaust hose to a flapper vent to exhaust existing bathroom fan(s). Fan will be vented through the roof or an acceptable alternative if contractor cannot vent through the roof. INSULATED BATH EXHAUST HOSE 4 INCH 1 $32.23 $24.17 $8.06 Provide labor and materials to install an insulated 4"exhaust hose to existing bathroom fan(s). WEATHERIZATION CONTRACT EVERSWURCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Eric Dostal (036) 500-3014 07/26/2023 450802 61604 SERVICE STREET BILLING STREET PROPOSED BY: 61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 3 DESCRIPTION QTY COST INCENTIVE TOTAL PREPARE YOUR HOME 1 Homeowner is responsible for the removal of any items stored in the 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: $11,643.66 Program Incentive: $9,315.12 Client Total: $2,328.54 I.DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the above work at the Client's Address in a professional mamer and in accordance with the terms of this Contract: II.PAYMENT Client agrees to pay the Contractor for the Work,the Client Share of the Contract Cost is payable to the Independent Installation Contractor(IIC)upon satisfactory completion of the Work.Client understands that they will not be required to pay the Program Incentive Shar of the Contract cost.Changes to the individual line items and/or previous incentives may increase or ecrease the size of the Program Incentive Share. Representative Client Signature rj...(s) Printed Name Date of Acceptance Client: Eric Dostal R I S E8 Address: 61 Fox Fauns Road AN EMPLOYEE-OWNED COMPANY Florence, MA 01062 Energy Specialist: Jeff Ledoux Phone: (036)500-3014 Program: EGMA-HES Client# 450802 Work Order# 61604 Work Scope DESCRIPTION Qty Notes 1 HOME AIR SEALING 18 2 WEATHERSTRIP DOOR 2 3 DOOR SWEEP 2 4 ATTIC DAMMING 50 5 ATTIC FLAT-5"OPEN R-19 CELLULOSE 2,072 6 RECESSED LIGHT COVERS 1 7 WHOLE HOUSE FAN COVER 1 8 WALLS-CLAPBOARD SIDED 4" 1,460 9 WALLS-INTERIOR DRILL AND PLUG 4" 184 Interior drill exterior wall in garage. 10 BASEMENT SILLS-6"FIBERGLASS 88 11 VENT BATH FAN TO ROOF OR OTHER 1 Preferably soffit 12 INSULATED BATH EXHAUST HOSE 4 INCH 1 13 PREPARE YOUR HOME 1 Diagram 9 12 /11//il 61 10 I ® 5 BF BF 5 Garage 5 WH 5 28 23 El 5 5 1\ 32 23 1\ 2,3 2,3 Test hole