The URL can be used to link to this page

24A-050 (6) BP-2024-0220 137 BARRETT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-050-001 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-2024-0220 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est.Cost: 3727 CLEAN TECH CONSTRUCTION 106247 Const.Class: Exp.Date: 01/05/2026 Use Group: Owner: KAUFMAN MACK, PETER TIMOTHY&RHEA Lot Size (sq.ft.) Zoning: URB Applicant: CLEAN TECH CONSTRUCTION Applicant Address Phone: Insurance: 38 ELLIS AVE 508-663-7847 6hub4n60130823 WEYMOUTH, MA 02190 ISSUED ON: 03/04/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI Z ATI 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: at �otic�t Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner It `4- 1`D o hZ c d .. The Commonwealth of Massachusetts -n Fri f FOR m Board of Building Regulations and Standards MUNICIPAL; Massachusetts State Building Code, 780 CMR USE ry { ;1 . - Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar.., 1 ca One-or Two-Family Dwelling -n �o This Section For Official Use Only o IV, \con Building Permit Number: 6,0' q (PAD Date Applied: o o,, • .-1 co L,O�A� Has br,owc,K .iti--- ( i.. ,JZ 3At,29 ___..9 Building Official(Print Name) Signature SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 137 Barrett Street 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 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Peter Mack Northampton,MA,01060 Name(Print) City,State,ZIP 137 Barrett Street 978-473-3858 petertmack@agmail.com 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 1 Repairs(s) 0 I Alteration(s) 0 1 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Weatherization Brief Description of Proposed Work2: Residential weatherization and air sealing with the Mass Save Program.No structural changes. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $3727.55 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire /$ Suppression) Total All Fees:43, Check No. 9,1/ Check Amout J` Cash Amount: 6.Total Project Cost: $37 27.55 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 106247 09/26/2026 Arianna Davidson License Number Expiration Date Name of CSL Holder List CSL Type(see below) Insulation 38 Ells Ave No.and Street Type Description Weymouth,MA,02190 U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling n M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-663-7847 cleantechconstruction48@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 196071 06/27/2025 Clean Tech Construction HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 38 Ells Ave cleantechconstruction48@gmail.com No.and Street Email address Weymouth,MA,02190 508-663-7847 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 la No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf;in all matters relative to work authorized by this building permit application. 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. 44.c t2 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces_ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton `.ye I,,'irl�' - s r Massachusetts w C J + UM DEPARTMENT OF BUILDING INSPECTIONS': .., 212 Main Street • Municipal Building Northampton, MA 01060 ;.'� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 40 Messina Drive Braintree, MA, 02190 The debris will be transported by: Name of Hauler: Clean Tech Construction N/A No Debris Signature of Applicant: 41 a Date: 2/20/2024 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ze,;, WWW.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Clean Tech Construction Address:40 Messina Drive City/State/Zip:Braintree,MA 02184 Phone#:508-663-7874 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 30 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.: required.] 5. ❑ 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. 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 Insulation employees. [No workers' an Other 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.#:6HUB6R60053223 Expiration Date:9/18/2024 Job Site Address: 137 Barrett Street City/State/Zip: Northampton,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. Signature: 4tzad tt2- Z2G:t BIZ Date: 2/20/2024 Phone#: 508-663-7874 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT# WORK ORDER Peter Mack (978)473-3858 02/09/2024 560364 11802 SERVICE STREET BILLING STREET PROPOSED BY: 137 Barrett Street 137 Barrett St Cole Payne SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 01060 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. KNOB&TUBE WIRING(Northhampton) We have identified that your home might have Knob&Tube wiring P.N. (initials) present.The following contract is not valid unless accompanied by the Weatherization Barrier Incentive form,signed by your licensed electrician.Work will not proceed with this work until we receive a copy of the form. HOME AIR SEALING 2 $213.18 $213.18 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.) ATTIC FLAT- 12"OPEN R-42 CELLULOSE 100 $256.00 $192.00 $64.00 Provide labor and materials to install a 12"layer of R-42 Class I Cellulose to open attic space. ATTIC FLAT-8"FLOORED R-25 DENSE CELLULOSE 936 $3,004.56 $2,253.42 $751.14 Provide labor and materials to install an 8"layer of R-25 Class I Cellulose to floored attic space. VENTILATION CHUTES-HALF 40 $55.60 $41.70 $13.90 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow. TURBINE ROOF VENT 1 $198.21 $148.66 $49.55 Provide labor and materials to install a roof mounted turbine vent. Document Ref:RKOVA-OBAUC-G6Z6M-B48EP Page 1 of 3 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT B WORK ORDER Peter Mack (978)473-3858 02/09/2024 560364 11802 SERVICE STREET BILLING STREET PROPOSED BY: 137 Barrett Street 137 Barrett St Cole Payne 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 CONTINGENCY An attic area in your home that could benefit from weatherization work PM. (initials) haS been identified. Although your home would benefit from weatherization work in this area,we have to remember the safety of the workers who will need to enter this space. The insulation contractor may need to inspect this space prior to scheduling the work to verify their ability to accomplish the scope of work. Total: $3,727.55 Program Incentive: $2,848.96 Client Total: $878.59 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(TIC)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 incentives may increase or decrease the size of the Program Incentive Share. Cale--flalffia RISE Representative Client Signature Cole_Payne _ 02-11-2024 Printed Name Dab of Acceptance Document Ref:RKOVA-OBAUC-G6Z6M-B48EP Page 2 of 3 -4104t mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Peter Mack owner of the property located at: (Owner's Name) 137 Barrett Street 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. Owner's Signature 02-11-2024 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 Document Ref:RKOVA-OBAUC-G6Z6M-B48EP Page 1 of 1 ❖ •. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A, • .i•�•�. -_��^�..._�_�. -___.s--' y<.rt '� _ s • -.•�..' fir• ,�. s--� ~.-a' '-• .• . :•. Signature Certificate 1 - -j :�:�: Referrance number:RKOVA-OBAUC-G6Z6M-B48EP, �,+ ► .,�,"' "+"-+ 1•:;:; •••••, - - _. - -: •r r► '+ +" - �'- ;..: *ir; Signer = '*t✓`"`�* Timestamp J . , Signature _ '••4 • ,r 411.41, At Cole Payne _-_ 1 •:•%; Email:cpayne@riseengineering.com tip.;:; •ti••. CO/e P� �/' Sent: 09 Feb 202421:19:15 UTC �r, •.•i." -•••: Signed: 09 Feb 2024 21.19:16 UTC - :❖' • • ••••; IP address:71.192.28.32 ••;•�•; %% Location:Northampton,United States �••, A Vet •Q•y. Peter Mack 1 •r:•.•, �•••; Email:petertmack@gmail.com • �;�, •�•�: • Sent: 09 Feb 2024 21:19:15 UTC ;�;:• A' Viewed: 09 Feb 2024 23:48:05 UTC �L� :••�•; ii•.' Signed: 11 Feb 2024 15:36:38 UTC I '•ii :i•o. Recipient Verification: IP address:71.233.113.206 '.•::' ••••: lk /Email verified 09 Feb 2024 23:48:05 UTC Location:Northamptone. ,United States •••.:' c.�,: •..: 3 •❖.•• 1- .�,,. .J �r._,C.. „, r:-.-j..`--w 6. �. - 1*.'' }rµ'... T^1•d'•i L. ,..•.. 'P:. D��u Went comoleta i by al!parties on ••r■' .�► -,r+ .e - 'i . T ••• �i� 11 Feb 2024 15:36:38 UTC ,.'' ��► 2_'.�`? t't + • i 11well. ,Y.,, t . i1 "; 7.q�. �;., • • � Page � }` . . yam" I i.i•i•. S.� � ' •. -wow ��c .. . .iAirr . ...•.. �► +� may' 0 w.'` 1 t ,:�►. �, � � .i •••••, yam►,.Y .J /-,� '� . �..-ti•��. ,� .� ..:ill?: � r • M •��•:Q• S _ - > . ►• s 'rr' ••' . • Vtiefi :•�•�• ..'_ r•• •�'P"�•' y•r��4� 'a .� ir, '•�•,w.-_r _„ E.••._ ' !•••••. !•0:•, yam'+•.' �►'. '�'I►..2� '/► '.may.-i�.�►� `.�„ �! .•�•�S w V Signed with PandaDoc r.r El �• � •::' ;•�•, PandaDoc is a document workflow and certified eSignature ': -'r .. r, r:;k :•••• •••••. solution trusted by 50,000+companies worldwide r�,Y ••,. • +[� •0`i:i:i i*i i Pi.`d:::i i::i i-.0. _ _ _.i •*. -0*. _ .-00.•i Oi i,: .4-•-.-•- - .-�;.:::::•�•-••:O•-:i-•' ♦1•: ,i�i:l.c :��4_�•!!i!::!.::•i.:::::•• i ! :i•: : .ki.r e•ti::::::!�i !O.. ••�!• ! • :4•i :•:i.1i.1.l•.••4•0 .�0 i:!..%%%.�.0/i• RISE Client# 560364 Work Order# 11802 RISE Rep: Cole Payne Name: Peter Mack DESCRIPTION Qty Notes 1 KNOB&TUBE WIRING(Northhampton) 1 2 HOME AIR SEALING 2 3 ATTIC FLAT-12"OPEN R42 CELLULOSE 100 4 ATTIC FLAT-8"FLOORED R-25 DENSE CELLULOSE 936 5 VENTILATION CHUTES-HALF 40 6 TURBINE ROOF VENT 1 Confirm placement with homeowner 7 ATTIC CONTINGENCY 1 Access opening is tight 5 12 /--/ 4 38 12 i 4 F 4 12 B 12 E 21 ►8 A 28 1' 13 D 10 4 3C, 35C53 7 Commonwealth of Massachusetts Construction Supervisor Specialty kitt Division of Occupational Licensure Board of Builr.- qulations and Standards Restricted to Constrw 'petvylgor Specialty CSSL-IC-Insulation Contractor CSSL-106247 f fires: 09/26/2026 ARIANNA JAMLS DAVIDSON 38 ELLS AVE WEYMOUTH MA 02190 • '), ;` , 1 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner For information about this license Call(617)727-3200 or visit www.mass.govldpi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration y"* 11t —lr 7.Type: Supplement Card CLEAN TECH CONSTRUCTION LLC eE 4..ation: 0 /2 196071 38 ELLS SVE E anon: 06/2712025 4 . WEYMOUTH,MA 02190 � inn �t# I r SW e _ Inr "t M T 0 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 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 Registration Expiration 1000 Washington Street -Suite 710 196071 06127/2025 Boston,MA 02118 CLEAN TECH CONSTRUCTION LLC ARIANNA DAVIDSON 38 ELLS AVE ,ly 4.4ad A7�- Z)& A4 4- � ..� <�:�,�- WEYMOUTH,MA 02190 Undersecretary Not valid without signature ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYYY) 09/15/2023 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 CONTACT GaryHebsch NAME: TOBMAN PARTNERS INSURANCE AGENCY INC PHONE FAX o.ExO: (617)471-1123 F Not: _ E-MAIL hebsch mwins.com ADDRESS: 9 t � 21 MCGRATH HIGHWAY SUITE 303 INSURER(S)AFFORDING COVERAGE NAIC# QUINCY MA 02169 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: CLEAN TECH CONSTRUCTION LLC INSURERC: INSURER D: 40 MESSINA DRIVE INSURER E BRAINTREE MA 02184 INSURERF: COVERAGES CERTIFICATE NUMBER: 931330 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 INSD SUBR WVD POLICY NUMBER A'POLICY EFF POLICY EXP LIMITS (MMIDDlYYYY) (MM/DDYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $__ _ DAMAGE TO RENTED CLAIMS-MADE OCCUR - _ PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $I OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION PER X STATUTE OTH- ER AND EMPLOYERS'LIABILITY A OFFICER/MEMBEREXC UDANYPROPRIETOR/PARTNEEDXECUTIVE N/A N/A N/A 6HUB6R60053223 09/18/2023 09/18/2024 E.L.EACH ACCIDENT $_ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE_$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS/LOCATIONS/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.gov/Iwd/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 Clean Tech Construction, LLC ACCORDANCE WITH THE POLICY PROVISIONS. 40 Messina Drive AUTHORIZED REPRESENTATIVE Braintree MA 02184 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 'd DATE(MM/DD/YYYY) AC:T)R� CERTIFICATE OF LIABILITY INSURANCE 09/19/23 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Tobman Partners Insurance Agency Inc. (a/cC,No.Ert): 617-471-1123 jac,No): 617-773-2474 21 Mayor Thomas J McGrath Highway E-MAIL Suite 303 ADDRESS: Quincy,MA 02169 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Nautilus Insurance Company INSURED INSURER B: Safety Insurance Co Clean Tech Construction LLC INSURER C: 40 Messina Drive INSURER D: Braintree,MA 02184 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. LTRIN TYPE OF INSURANCE INSD ADDL 3UBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DDIYYYY),(MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RND CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A NN1562513 09/18/23 09/18/24 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B AWNED X SCHEDULED AUTOS ONLY AUTOS 5931459 09/16/23 09/16/24 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AN1293596 09/18/23 09/18/24 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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Clean Tech Construction,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 40 Messina Drive Braintree,MA 02184 AUTHORIZED R ENTATIVE ©1 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: 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 s.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c.111 s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department.If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR-6th Edition .cy ua4toLt2 Z7G:, rL Signature of Permit Applicant Date