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17B-015 (18) BP-2024-0349 399 BRIDGE RD UNIT A COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17B-015-001 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-2024-0349 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 4636 CLEAN TECH CONSTRUCTION 106247 Const.Class: Exp.Date: 01/05/2026 Use Group: Owner: KATIE OLMSTEAD 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: 03/28/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Airing 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: 172. Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner I -11 (go►Lr 2006 i MAR 2 7 2 j 1 The Commonwealth of Massachusetts I I oza •. I Board of Building Regulations and Standards , L FOR ^� tJ1 Massachusetts State Building Code,780 CMR USj? ��o�g ; Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011'- One-or Two Family Dwelling This Section For Official Use Only Building Permit Number:4/9-- 7,l- 3 Date Applied: K ev) — /I o55 // 3 28-2oZq Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 399 Bridge Road Suite A Road A 1.1a 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 I Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Katie Olmstead Florence,MA 01062 Name(Print) City,State,ZIP 399 Bridge Road Suite A Road A 413-585-0564 kdolmstead@aol.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building 0 I Owner-Occupied 0 1 Repairs(s) 0 I Alteration(s) 0 I Addition 0 Demolition ❑ 1 Accessory Bldg.0 1 Number of Units 1 Other ❑ Specify: Insulation 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 $4636.60 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $0.00 ElStandard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 0.00 2. Other Fees: $ 4.Mechanical (HVAC) $ 0.00 List: 5.Mechanical (Fire $ 0 Suppression) 00 Total All Fees:Sit Check No. 104 I Check Amount#616 Cash Amount: 6.Total Project Cost: $4636.60 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 106247 09/26/2026 Arians Davidson License Number Expiration Date Name of CSL Holder List CSL Type(see below) Insulation 38 Ells Ave No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Weymouth,MA 02190 R Restricted 1&2 Family Dwelling City/Town,State,ZIP 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 Ens 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 0 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 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. AriannaDavidson ,e 446Z,Utt!L ,Z7a1c.' I,t n- 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 o..,='_ - SAS •• SAC _" Massachusetts �� '<<c ;; DEPAR24ENT OF BUILDING INSPBGTIOPS y 212 Main Street • Munici BuildingJ ® Pal r,.,= Northampton, I 01060 �S1y A,OCN`� 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 02184 The debris will be transported by: Name of Hauler: Clean Tech Construction Signature of Applicant: 4& i Z7a ter- Date: 3/18/2024 _ City of Northampton 0S - S� 7„'" \ Massachusetts 4., c z :I L' DEPARTMENT OF BU I+ILDIN INSPECTIONSz. '..`'^• -r " 212 Main Street • Municipal Building ti CDC Northampton, MA 01060 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born (insert month, day,year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20 . 4 �truz.. (Signature) The Commonwealth of Massachusetts Department of Industrial Accidents 1;c- ! Office of Investigations s' =61= �'-� '', 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/Individual): Clean Tech Construction Address:40 Messina Drive City/State/Zip:Braintree,MA 02184 Phone#:508-683-7874 Are you an employer?Check the appropriate box: Type of project(required): 1.ll 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 workingfor me in anycapacity. employees and have workers' P tY 9. ❑Building addition [No workers' comp.insurance comp.insurance.1 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 11.0 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' 13.❑� 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: 399 Bridge Road Suite A Road A City/State/Zip: Florence,MA,01062 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: 4 Pawitidsoot. Date: 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Construction Supervisor Specialty 111) Division of Occupational Licensure Board of Bull julatlons and Standards Restricted to: Constrt: )er441roor Specialty CSSL-IC-Insulation Contractor CSSL-106247 Etyires: 09/26/2026 ARIANNA JAMES DAVIDSON 38 ELLS AVE- WEYMOUTH MA 02110 •- ram- ��,,` ,Of�t,a,�J * Failure to possess a current edition of the Massachusetts �/ State Building Code is cause for revocation of this license. Commissioner 1, °. �, t;7&rntiuk_ For information about this license Call(617)727-3200 or visit www.mass.govfdpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration Z ,e t'q - • Type: Supplement Card CLEAN TECH CONSTRUCTION LLC = Registration: 196071 38 ELLS SVE _ Expiration: 06/27/2025 WEYMOUTH,MA 02190 77. ti v4°‘ 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 Reuistration Expiration 1000 Washington Street -Suite 710 196071 06I27l2025 Boston,MA 02118 CLEAN TECH CONSTRUCTION LLC ARIANNA DAVIDSON 38ELLSA� Pa / 38 ELLS AVE - ,,.d z,C,.r ,(�/ if,- YVEYMOUTH.MA 02190 Undersecretary Not valid without signature WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT• WORK ORDER Katie Olmstead (413)585-0564 02/19/2024 456167 38506 SERVICE STREET BILLING STREET PROPOSED BY: 399 Bridge Road Suite A Road A 399 Bridge Road Suite A Daniel Diaz SERVICE CITY,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 10 $1,065.90 $1,065.90 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 DAMMING 60 $166.80 $125.10 $41.70 Provide labor and materials to install an approved damming material in the attic ATTIC FLAT-10"OPEN R-37 CELLULOSE 570 $1,345.20 $1,008.90 $336.30 Provide labor and materials to install a 10"layer of R-37 Class I Cellulose to open attic space. ATTIC FLAT-10"OPEN R-37 CELLULOSE 468 $1,104.48 $828.36 $276.12 Provide labor and materials to install a 10"layer of R-37 Class Cellulose to open attic space. FSK COVERING 176 $193.60 $193.60 Provide labor and materials to install a FSK Paper air barrier. RECESSED LIGHT COVERS 5 $284.45 $284.45 Install recessed light covers over existing recessed light fixtures.Up to 6 at no cost. HATCH-INSULATE RIGID BOARD 1 $53.96 $40.47 $13.49 Provide labor and materials to insulate the back of an attic hatch with 2"rigid insulation board at R-10. VENTILATION CHUTES 14 $65.52 $49.14 $16.38 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow from the soffit ventilation. VENTILATION CHUTES-HALF 17 $23.63 $17.72 $5.91 Provide labor and materials to install ventilation chutes in the rafter bays to maintain air flow. Document Ref:VIN86-PO3PA-DPU4G-KNTUS Page 1 of 5 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT K WORK ORDER Katie Olmstead (413)585-0564 02/19/2024 456167 38506 SERVICE STREET BILLING STREET PROPOSED BY: 399 Bridge Road Suite A Road A 399 Bridge Road Suite A Daniel Diaz SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL VENT BATH FAN TO ROOF OR OTHER 2 $333.06 $249.80 $83.26 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. Total: $4,636.60 Program Incentive: $3,863.44 Client Total: $773.16 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 Incentives may increase or decrease the size of the Program Incentive Share. Vaui¢t D(4? Kake o/utlw.aat RISE Representative Client Signature Dan Diaz 02-19-2024 Printed Name Date of Acceptance Document Ref:VIN86-PO3PA-DPU4G-KNTUS Page 2 of 5 mass save PERMIT AUTHORIZATION FORM I, Katie Olmstead owner of the property located at: (Owner's Name) 399 Bridge Road Suite A 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. Kalie Olusle1d Owner's Signature 02-19-2024 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 4 a f PG 0.- 3/18/2024 Participating Contractor Date Document Ref:VIN86-PO3PA-DPU4G-KNTUS Page 5 of 5 ,•••••••••t•!•••••t•t:!!•.44!•�:t ?.!::!::tet!.I.!tr tet:t!tV!e%•�ill•:. %i i%i:1.:%%!.!•tVItt• �e••ttet t•O!V!�,.:!�:!::t:::t%�!ttt. 4X �•••: .•. AN eo. Signature Certificate efi. R.fe-Pnra ni,mhr- VIN86-PO3PA-DPU4G-KNTUS :•:*. W. .••• ••• •••4•• .**. •••; Signer Timestam44: p Signature t .'••• Daniel Diaz vv. •i: Emaicddiaz@riseengineering.com •••4% ., , .•••••• �. �. Sent 19 Feb 2024 14:44:29 UTC V(I�u V14? ...., .*: Viewed: 19 Feb 2024 14:44:33 UTC ��; :A.' Signed: 19 Feb 2024 14:44:53 UTC "• %•t :+:, Recipient Verification: IP address:73.149.194.169 +' �, ♦Email verified 19 Feb 2024 14:44:37 UTC Location:Springfield,United States *%!*: ,••. ••, %. Katie Olmstead ::, :•••: Email:kdolmstead@aol.com ,•;•;e, we •t Sent 19 Feb 2024 14:44:29 UTC Kate' ] • /t �//it �/j/ad t••. i ii Viewed: 19 Feb 2024 16:47:05 UTC \a' ""'' """"'"�' "'"'"' V••: 1.•• Signed: 19 Feb 2024 16:48:27 UTC :�%•; ;•:%: Recipient Verification: IP address:73.89.160.177 •'••••: .•i•: •Email verified 19 Feb 2024 16:47:05 UTC Location:Florence,United States 'd••1 iii i••••: we Armv. ;•;;' Document completed by all parties on: "At 4.4 %i; 19 Feb 2024 16:48:27 UTC '%%:' 'OW AlliV •••••: Page 1 of 1 ••:': •• .••. 4.. •.. '•••' 411.4. 'iii' '••i:' iM Ay. ••• y•• '•�•••, • VV. i•••: 'WWII' '.•••i .•••• .•1•i. I I ':44. gi ....... :•ii�. ;.0 : Signed with PandaDoc ■ ■ ..4.4. we .;•�•; PandaDocisa document workflow and certifiedeSignature t. :1T: ;•••; t:•ii solution trusted by 50,000+companies worldwide. �t !a_ ...mv. '••••; •....:. 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R I S E Client# 456167 Work Order# 38506 RISE Rep: Daniel Diaz Name: Katie Olmstead DESCRIPTION Qty Notes 1 HOME AIR SEALING 10 FOR ATTIC AND RIM JOIST 2 ATTIC DAMMING 60 3 ATTIC FLAT-10"OPEN R-37 CELLULOSE 570 ATTIC FLAT 4 ATTIC FLAT-10"OPEN R-37 CELLULOSE 468 VAULTED CEILING 5 FSK COVERING 176 CATHEDRAL WALL AND SKY LIGHT 6 RECESSED LIGHT COVERS 5 4 RECESSED LIGHTS IN VAULTED CEILIJNG AND 1 IN ATTIC FLAT 7 VENTILATION CHUTES 14 FULLS FOR VAULTED CEILING 8 VENTILATION CHUTES-HALF 17 HALF FOR ATTIC FLAT 9 VENT BATH FAN TO ROOF OR OTHER 2 1o• VENT 2 BATH FANS TO SOFFIT.CONDO ASSOCIATION MAY HAVE AN ISSUE GOING OUT TO ROOF 10-INSULATE ATTIC HATCH NOTES:VENT CHUTES AND RECESSED LIGHT COVERS MAY BE DIFFICULT TO ADD OVER VAULTED CEILING. ASSESS THE SITUATION 8 MAKE ADJUSTMENTS IF NEEDED ACCESS TO CRAWL g 1,2,3,8 A/H El SKY LIGHT 5 A cR�® CERTIFICATE OF LIABILITY INSURANCE DATE(wrl00frrYr)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 O N.ExU (617)471-1123 FAX No): _ ADDRESS: 9hebsch@tmwins.com 21 MCGRATH HIGHWAY SUITE 303 INSURER(S)AFFORDING COVERAGE NAICs QUINCY MA 02169 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: CLEAN TECH CONSTRUCTION LLC INSURER C: INSURER D: 40 MESSINA DRIVE INSURER E: BRAINTREE MA 02184 INSURER F: 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD W M/ VD POLICY NUMBER (MDD/YYYY) (MMIDD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(My one person) i$ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY L JEQ [ I LOC PRODUCTS-COMP/OP AGG $ 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 LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYA OFFCEOR/MEMBEREXCLU EXCLUDED'? 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 es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 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.Crovday,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 `tC C)RU CERTIFICATE OF LIABILITY INSURANCE DATE(MAAlDOlYYYY) 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. PHONE No,Eat): 617-471-1123 FAX 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. INSR ADDLTYPE OF INSURANCE INSO WVDBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISESO(EaEoccurrrence) $ 300,000 MED EXP(Any one person) $ 5,000 A NN1562513 09/18/23 09/18/24 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT 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 OWNED AUTOS ONLY AUTOS x SCHEDULED 5931459 09/16/23 09/16/24 BODILY INJURY(Per accident) $ X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X 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 AND EMPLOYERS'LIABILITY Y/N STATUTE EERH 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) 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 ,Au g Z7e24. 4- Signature of Permit Applicant Date