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31A-028 (3)
BP-2023-0478 9 BANCROFT RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-028-001 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-2023-0478 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 8576 POTENTIAL ENERGY LLC 106184 Const.Class: Exp.Date:04/27/2025 Use Group: Owner: KNAPP AARON Lot Size (sq.ft.) Zoning: URA/URB Applicant: POTENTIAL ENERGY LLC Applicant Address Phone: Insurance: 1 HARTFORD SQ, SUITE 216 (413)798-0273 we 9083282 NEW BRITAIN,CT 06052 ISSUED ON: 01/09/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI ON 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: 01 • If >2 " I i5 Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Ck.) -o I't ek.: $ 36- -,� Ca rl,� 3 y - pilHcjt'Lc�f+c 1 / k Cr , ,,17 The Commonwealth of Massachusetts ® Board of Building Regulations and Standards qp9 � FOR Massachusetts State Building Code, 780 CMR of, �0c,ii MUNICIPALITY USE Building Permit Application To Construct, Repair, Renovate.,QD,,Aemolish a Revised Mar 2011 One- or Two-Family Dwelling ,, This Section For Official Use Only "' BPermit Number: ,Q-},3- eV7" Date Apolied: Buildin tv,,._)(1Z, /// l - 9-ZOzy Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors 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: Lift j- U 2eh - rat..µ 4e,+Nik, i 1 '3u'`9' `7 Zoning District Proposed Use Lot Area(sq ft) Fron age(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided Ni l& ti( N A- ,u iA- w f 4 iv, d 1.6 Water upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zo ? Public Private 0 Check if yes[ Municipal$ On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: `Cil_- a \ cNck R.e 1Qa' b ' n l- cob(.0 Name(Print) City, State,ZIP CI-11 `3G.CCe-a - (4. (-{I2-921-t bC1 GC3.SD(\1<n(1pp€ OIL 1 k • wyl No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Er Owner-Occupied ❑ Repairs(s) 0 Alteration(s) Er; Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units .- Other .a Specify: \c-Nri\G--1.;on Brief Description of Proposed Work': (-c- ae(2\; onti j i;'Gc ;_rN (�;C sock 3c ?'n�+•'�ti �,•n.c6.4.0 v,n r C i) , L�tcfz, ►) `dos rc 2_j..sf n -1 Jc p;� 14._I W.10 12_w".�..1e)t n 1,1 S'' FC-�'1 t �(r, C 4-:e -F-'►Der•(Z.4) .t Co" _�: C4 -Nate- (?I`-I ��;ia fadp„ue, cd: Co '' o)4- t T" Pal 1 ac• ,(1, L. (L((Lk-a\lf-, to`,Fe) c \Y_L1 +ems ..%,[Jcui cl (t,,. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ S-ko :if cl 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2. Electrical $ (''' 0 Total Project Cost; (Item 6)x multiplier x 3. Plumbing $ () 2. Other Fees: $ 4. Mechanical (HVAC) $ 0 List: 5. Mechanical (Fire $ O _Suppression) Total All Fe (rs�,� g q Check No.iAI,tT Check AmounCtt:66 Cash Amount: 6. Total Project Cost: $ 8 s-7(, 0 Paid in Full 0 Outstanding Balance Due: % 7otg S' SECTION 5: CONSTRUCTION SERVICES Construction Supervisor License(CSL) 106184 04/27/2023 Nicholas Meister License Number Expiration Date Name of CSL Ilolder R List CSL Type(see below) 344 Andrews Street No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Southington,CT 06489 NIC Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 860-620-4433 nick@potentialenergyus.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(H1C) 192284 6/21/2024 Potential Energy, LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 1 Hartford Square Suite 216 Box 2E info@potentialenergyus.com No.and Street Email address New Britain,CT 06052 413-798-0273 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 Potential Energy, LLC to act on my be Kin all relative to work authorized by this building permit application. 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 app ation is accurate to the best of my knowledge and understanding. Li- Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 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 When substantial work is planned,provide the information below: Total floor area(sq.ft.) -2 212. (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) 5Lt(,p y'( Habitable room count Number of fireplaces a— Number of bedrooms 6 Number of bathrooms a— Number of half/baths U Type of heating system (.:1q,S k14 Se G„to Number of decks/porches Type of cooling system (J. t.:) Enclosed Open Z.-- "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton SMA _s Teti\ AS { SIC Massachusetts �,? r. 'e -' 1.... *.k ` 'y4 , DEPARTMENT OF BUILDING INSPECTIONS 4*'F ` 212 Main Street • Municipal Building y°tip Ohs`, Northampton, MA 01060 :r. , 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: k7V4 r-Dol,T,1/4yPt-- s CcM,,,nc„) .3 ei y) s mac. maaf\ Si ? sv',l ce ,CT Otok-C 9 The debris will be transported by: Name of Hauler: 1%ireccii. FnPly,(,1. Signature of Applicant: Date: .41)Z177,2`\ The Commonwealth of Massachusetts t�� Department of Industrial Accidents ia. - Office of Investigations ,= Lafayette City Center ..• ram' 2Avenue de Lafayette, Boston,MA 02111-1750 t''� www mass.gov/ilia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): Potential Energy, LLC Address: 1 Hartford Square Suite 216 Box 2E City/State/Zip: New Britain, CT 06052 Phone#: 413-798-0273 or 844-564-7283 Are ou an employer?Check the appropriate box: Type of project(required): I. a employer with 10 4. 0 lam a general contractor and 1 employees(full and/or part-time).* have hired the sub contractors 6. 0 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. El Demolition working for me in any capacity. employees and have workers' g Building addition [No workers'comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 Roof repairs insurance required.]'' c. 152,§1(4),and we have no 13.�Other insulation employees. [No workers' comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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: Associated Insurance Services Policy#or Self-ins. Lic.#: WC 9083282 _ Expiration Date: 8/24/2023 Job Site Address: 9-11 Bancroft Rd. City�Stateizip:RNorthampton, MA 01060 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 perjury that the information provided above is true and correct. d/f...Sje,nattue: Date: 4/12/2023 Phone#: 413-798-0273 or 860-620-4433 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): lDBoard of Health 20 Building Department 3rOCity/Town Clerk 4.0 Electrical Inspector 5tlumbing Inspector 6.DOther Contact Person: Phone#: DocuSign Envelope ID:80592C29-724E-4390-9024-3089F2C9E98D WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT# WORK ORDER Aaron Knapp (413) 923-1969 01/06/2023 338320 61902 SERVICE STREET BILLING STREET PROPOSED BY: 9 Bancroft Road 9 Bancroft Road# 1 Jeff Ledoux SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL ATTIC FLOOR OPEN BLOW CELLULOSE 14" 204 $497.76 $497.76 Provide labor and materials to install a 14" layer of R-49 Class I Cellulose to open attic space. INSTALL 9"FIBERGLASS BATTING IN OPEN ATTIC FLOOR 234 $582.66 $582.66 Provide labor and materials to install a 9"layer of R-30 unfaced fiberglass batts to attic space. INSTALL 6" FIBERGLASS BATTING IN OPEN ATTIC FLOOR 234 $507.78 $507.78 Provide labor and materials to install a 6"layer of R-19 unfaced fiberglass batts to attic space. ATTIC SLOPE ENCLOSED CELLULOSE DENSE PACK 6" 210 $564.90 $564.90 Provide labor and materials to install a 6"layer of R-19 Class I Cellulose to sloped ceiling area. INSTALL 2"THERMAL BARRIER POLYISO OPEN GABLE WALL 260 $1,263.60 $1,263.60 Provide labor and materials to install 2" rigid insulation board to the open gable wall in a kneewall attic region. INSTALL 6" FG BATTING IN OPEN KNEEWALL SLOPES 260 $569.40 $569.40 Provide labor and materials to install a 6.25"layer of R-19 fiberglass batts to the sloped rafter area behind a kneewall. TEMPORARY ACCESS 1 $96.36 $96.36 Provide labor and materials to make a temporary access to an attic area. The opening will be closed with materials similar to those existing. Finish sanding and painting is not included. WALLS-ALUMINUM SIDED 4" 781 $2,467.96 $2,467.96 Provide labor and materials to install blown in Class I Cellulose to aluminum-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. WALLS-3RD FL ALUMINUM SIDED 4" 200 $668.00 $668.00 Provide labor and materials to install blown in Class I Cellulose to aluminum-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. UocuSign Envelope IU:BUb92C29-/24E-4390-9u24-3U89l-2G9E9sU WEATHERIZATION CONTRACT EVERS-1URCE CUSTOMER PRONE DATE CLIENT♦. WORK ORDER Aaron Knapp❑ (413)923-1969111] 01/06/2023❑ 338320❑ 61902[I SERVICE STREET BILLING STREET PROPOSED BY: 9 Bancroft Road H 9 Bancroft Road# 1❑ Jeff Ledoux❑ SERVICE CRY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060❑ Northampton, MA 010601 I EGMA-HES❑ Page: 1 r 1 DESCRIPTION: QTY COST: INCENTIVE TOTAL, INCENTIVE: WHOLE BUILDING_ Eversource, as a Sponsor of the Mass Save program, offers a Whole Building 100% insulation incentive per unit for eligible insulation and air sealing measures. This incentive is for a non-owner occupied single-family or,all units in a 2-4 building where all eligible major !_: insulation measures in all units are being completed at the same time.: KNOB&TUBE WIRING(Northhampton)E us We have identified that your home might have Knob&Tube wiring Q (Initials):I present.The following contract is not valid unless accompanied by I.. the Weatherization Barrier Incentive form, signed by your licensed electrician.Work will not proceed with this work until we receive a copy L of the form. I. NAILED WALL PANELS: "-us Some of your home's interior wall sheathing was fastened with nails, 6- (initials): instead of screws, and would not be able to withstand the pressure ': from adding blown-in wall insulation.Once you have these walls secured with screws, contact RISE to schedule the weatherization i_ work. : Your signature acknowledges this required action. PERFORM AIR SEALING AT ESTIMATED 62.5 CFM50 PER HO: 8: $754.64: $754.64: 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.): TRANSITION AIR SEALING: 36: $233.64 .: $233.64[_: Provide labor and materials to air seal the open kneewall transitions of your home against wasteful, excess air leakage.;: EXTERIOR DOOR WEATHER STRIPPING: 1 $31.811 $31.81: Provide labor and materials to install Q-lon weatherstripping to I door(s)to restrict air leakage. DOORSWEEP;: 1 . $26.111. $26.11;.: Provide labor and materials to install a doorsweep to restrict air' leakage. DAMMING: 25 $61.25_ $61.25: Provide labor and materials to install an approved damming material in the attic: DocuSign Envelope ID:80592C29-724E-4390-9024-3089F2C9E98D WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT B WORK ORDER Aaron Knapp (413) 923-1969 01/06/2023 338320 61902 SERVICE STREET BILLING STREET PROPOSED BY: 9 Bancroft Road 9 Bancroft Road# 1 Jeff Ledoux SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 3 DESCRIPTION QTY COST INCENTIVE TOTAL VENTILATION CHUTES 54 $223.02 $223.02 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow from the soffit ventilation. REPLACE BATH FAN HOSE 1 $28.00 $28.00 Provide labor and materials to install an insulated 4"exhaust hose to existing bathroom fan(s). CUSTOM DISCLOSURE /f"' Customer agrees to remove all existing insulation in knee wall slopes A- (initials) prior to the start of weahterization work. Customer also agrees to fortify paneling on ceiling slope of 3rd floor to allow for dense packing with insulation. HOMESOTE CEILINGS BARRIER: Your ceilings are constructed of a lightweight cardboard composite material. These ceilings cannot support the additional weight of blown-in insulation or air sealing measures,the tiles could be dislodged due to movement of workers in the attic and cause damage to the ceiling tiles. Until you renovate these ceilings,we will l/gt)p tpmlate yilt4gok,flpgtiftherglass batt insulation. This is being brought to your attention to identify it as a pre-existing condition to the weatherizatiom work planned for your home. Your signature is your acknowledgement of these conditions and agreement to proceed. Total: $8,576.89 Program Incentive: $8,576.89 Client Total: $0.00 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 manner 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 Share of the Contract cost.Changes to the individual line items and/or previous BkomfairFease or decrease the size of the Program Incentive Share. P—pocusigned by: L9P 44 Fl.. iSINaNI W374AA_. Jeffery Ledoux 1/6/2023 1 2:49 PM EST Printed Name Date of Acceptance DocuSign Envelope ID:80592C29-724E-4390-9024-3089F2C9E98D mass save® Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Aaron Knapp owner of the property located at: (Owner's Name) 9 Bancroft Road Northampton (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. r —Doc/uS igned by: l/2 -B9.2CB86D87374AA Owner's Signature 1/6/2023 I 2:49 PM EST Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Client: Aaron Knapp RISE Address: 9 Bancroft Road AN EMPLOYEE OWNEDCOMPANY Northampton, MA 01060 Energy Specialist: Jeff Ledoux See Client# Phone: (413)923-1969 Program: EGMA-HES 442802 Client# 338320 Work Order# 61902 424161 -LI 338335 Work Scope For additional attic, wall and basement DESCRIPTION work Qty Notes 1 KNOB&TUBE WIRING(Northhampton) 1 2 NAILED WALL PANELS 1 3 PERFORM AIR SEALING AT ESTIMATED 62.5 CFM50 PER HO 8 4 TRANSITION AIR SEALING 36 5 EXTERIOR DOOR WEATHER STRIPPING 1 6 DOORSWEEP 1 7 DAMMING 25 8 ATTIC FLOOR OPEN BLOW CELLULOSE 14" 204 9 INSTALL 9"FIBERGLASS BATTING IN OPEN ATTIC FLOOR 234 Cross bat 10 INSTALL 6"FIBERGLASS BATTING IN OPEN ATTIC FLOOR 234 Cross bat 11 ATTIC SLOPE ENCLOSED CELLULOSE DENSE PACK 6" 210 12 INSTALL 2"THERMAL BARRIER POLYISO OPEN GABLE WALL 260 1.4aterlal added In for common wals In loneewal elopes 13 INSTALL 6"FG BATTING IN OPEN KNEEWALL SLOPES 260 14 TEMPORARY ACCESS 1 Temp accea to 3rd floor attic.Homeeote ceilings discuss with customer on best option 15 WALLS-ALUMINUM SIDED 4" 781 16 WALLS-3RD FL ALUMINUM SIDED 4" 200 17 VENTILATION CHUTES 54 18 REPLACE BATH FAN HOSE 1 19 CUSTOM DISCLOSURE 1 20 HOMESOTE CEILINGS 1 Diagram 38 c'a""'"�" Entire basement wM need ground covering.All exterior walls are aluminum 14"OBC,2nd floor sided.3rd floor spec attic added for gable ends.All exterior Knee wall slope r-19+RB doors will need Test hole WSS DSP elope 6" Homeeote Croce boa 41 DSP slope 6' Knee wall slope r-19+RB 3 8 14"OBC -- -", POTEN-1 OP ID: LF ACORO DATE(MM/DD/YYYY) �„�, CERTIFICATE OF LIABILITY INSURANCE 01/09/2023 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 860-793-9601 CONTACT Associated Insurance Services Associated Insurance Services PHONE FAX 106 West Main Street ,(A/C,No,Ext):860-793-9601 (A/C,No):860-747-3580 P.O. Box 630 E-MAIL Plainville, CT 06062-0630 ADDRESS: Associated Insurance Services _ INSURER(S)AFFORDING COVERAGE NAICM INSURER A:Selective Insurance 12572 NSUREp INSURER B:Lloyds Potential Energy,LLC. 1 Hartford Square INSURERC: New Britain,CT 06052 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSDJIVVD IMM/DD/YYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE X OCCUR S 2437655 08/24/2022 08/24/2023 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ Employee Dishones B 6055945 06/23/2022 06/23/2023 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 1 POLICY[ J Fla LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea aMccciden SINGLE LIMIT $ 1,000,000 X ANY AUTO S 2437655 08/24/2022 08/24/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY _ AUTOS BODILYBODILY INJURY(Per accident) $ AUTOS ONLY — AUTO ONLY PROPERTY DAMAGE (Per accident) $ $ A UMBRELLA LIAB ' X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE S 2437655 08/24/2022 08/24/2023 AGGREGATE $ 5,000,000 DED I RETENTION$ $ A WORKERS COMPENSATION STATUTEPER OTH- ER AND EMPLOYERS'LIABILITY WC 9083282 08/24/2022 08/24/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Professional ANE 4572139.21 08/24/2022 08/24/2023 Occurence 2,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of workers compensation insurance and liability insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 212 Main St NorthHampton, MA 01060 AUTHORIZED REPRESENTATIVE p Associated Insurance Services ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts • Division of Professional Licensure II Board of Building Regulations and Standards oonstructionSttper s°Sor" & CSFA 106184 Expires:0412712023 • NICHOLAS ALEXANDER MEISTER 344 ANDREWS ST SOUTHINGTON CT 06489 Commissioner _ i[+ r? f ✓+'�r-�� THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC POTENTIAL ENERGY LLC Registration: 192284 Expiration: 06/21/2024 1 HARTFORD SQUARE BOX 2-E NEW BRITAIN, CT 06052 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:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 192284 06/21/2024 Boston, MA 02118 POTENTIAL ENERGY LLC NICHOLAS MEISTER 1 HARTFORD SQUARE DOOR 65 SUITE „4y� 216 6C �� i NEW BRITAIN,CT 06052 Undersecretary Not valid without signature SA City of Northampton Massachusetts f a. r' P 4-1- DEPARTMENT OF BUILDING INSPECTIONS ;''its-' ` 212 Main Street • Municipal Building �f•. „ SOD "" • Northampton, MA 01060 �i ' Property Address: 9-1 I .A c i-cN 0 Contractor Name: Q6-- e,^r1-;c ems,t ,Lit_ Address: \ \Ac,,. S -6-d iULocc_ `\\0, LC' City, State: NiP 'fg.',Ac,;,.\, Cr ao D S Phone: -dl I- -7 K-0,2i3 Property Owner Name: A 04,0,\ Y.c.cv Address: Cj'.on.c\rs-o 4- L 0 City, State: iv0.,-4,n„,,R,-4sc\ , mPr I, N ;c1,„1c mit., S - 1 Q l4 4 fn --,(contractor) attest and affirm that the building I intend to 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 A.,-''-- Date