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35-224 (11)
46 LADYSLIPPER LN BP-2019-0907 GIs#: COMMONWEALTH OF MASSACHUSETTS Map Bloc :35-224 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2019-0907 Project JS-2019-001511 Est Cost. 51325.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: AFFORDABLE BUILDING &WEATHERIZATION - TODD LEDUC 106019 Lot Size(sp.ft.): 91040.40 Owner: HORNOR JOHN W&RONALD E SKINK zonjne. Applicant. AFFORDABLE BUILDING & WEATHERIZATION - TODD LEDUC AT. 46 LADYSLIPPER LN Applicant Address: Phone: Insurance: 330 VICTOR RD (401) 965-8578 WC ATTLEBOROMA02703 ISSUED ON:212012019 0:00:00 TO PERFORM THE FOLLOWING WORK INSULATION 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 9i Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy SLnature: FeeType: Date Paid: Amount: Building 2/20/20190:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner bp, lq,qo7 a "� City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587- {^ U APPLICATION TO CONSTRUCT,ALTER,REPAI ,RE OVATE OR DEMOLISH A NE R TWO FAMILY DWELLING Q) SECTION t-SITE INFORMATION ba oaMd�M 1/iSorst,i '.. 1.1 Prooeriv Address: nr'r44;11:1 QF � '�4w.. i"IT U(p LpQL�5LLOpeA �-qn2 LDf ` w I ti I1D)intpiDYl DI(�� 2 un.ri)3G DI ) _ EIm SL Diets Omebiel SECTION 2-PROPERTY.CWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: John H-LrrDr Ln LD* )5 Name(Print /� / Current Mailing p�� i 1� 4"I Yy Telephone O `T Signature 2.2 Authorized Agent: 7h�J� 1 1�'� 1,i r� 33D �IGfbY P� oS�e Attleboro Name(Print) _ Current Mailing Address: " I- 2 Ll D I gCa5 �5 S Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed by toermit applicant 1. Building ) 3 n 5 q ,), (a)Building Permit Fee 2. Electrical d (b)Estimated Total Cost of Construction from fi 3. Plumbing Building Permit Fee 564. Mechanical(HVAC) 5. Fire Protection 6, Total=(1 +2+3+4+5) Check Number This Section Film Official Use Only Date BuildingPem1R Numb r. i. Issued: Signature. � 2-IQ 2�1� Building Canmissioner/lnepector of Buildings Date af&F)dabb7bu) c 5mar r'om EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) $eC[IOn 4. ZONING All Information(Aust Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front O ll-- �--I Side L:� R:0 L:r�—� R:L_J Rear Building Height Bldg.Square Footage Open Space Footage (Lot arw manus bldg&raved parking) N of Padding Spaces vnlnme&Lowtlon A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES Q IF YES, date issued:C----] IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book �] Page=--i an /or Document M�� B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,exc vaticn,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTIONS DESCRIPTION OF12892OSED WORK 1 heck all applicable) New House ❑ Addition ❑ Replacement Windows jAlteration�(s):E=] Rooffbirig Or Doors 0 Accessory Bldg. ❑ Demolition ❑ I New Signs [01 Decks [p Siding[D] Other R�II Brief Description of Proposed Work: j LI 1n1 I �y h r�� ^ /� rrj / - -�/ ,IC Alteration of existing bedroom Ves .! / 1.No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet a. Use of building: One Fairi Two Family Other It. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ City Sewer Private well City water Supply SECTION To-OWNER AUTHQRIZATION-Til BE COMPLETED WHEN ENT OWNERS AGlM 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. Signelure of Owner Data 1 D�] Q L �� U G ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penaltiesof perjury. -Odd LcAuC Pnnt Nam. Signature of OwnedAgent Date AE{.TIONS•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervise }Ir: p ,{I Not Applicable El Q N..../Licence Holder'. TnC� 16 L a l J Lirense Nu bar 330 �<<{� !�' S t� fl f�ttfle�x ro mfl azin� ,770 v Address Expiration Date �`l 111 �Dl /o5�5 �g Signa ure Telephone Not Applicable ❑ APPORUAXLY BUnDING& I WEATHERIZATION, _ Registration Number 10V.,, Rud, C A¢I,bmMA � 0290.3 11II /� ,,G,p n Expiration Dete Telephone�7DI-I�V�O57n SECTION 14 WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(S)) 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...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northae,ton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors perforating improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.G.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any preexisting owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: tf )SL<�Q J] nn I I Est. Cost: Address of Work vLfi L i (d77 )55 b nn f4 )4) La ) S Date of Permit Application: oL-� I L l I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _ Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): J {J G i n a f) � OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: ,21r3/1 -� 7ddd ZedUC /-795� Z Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Pugs 1 of i CONTRACT Slay' 0ep"' 0 mWleuuh J .� Mlnpbn a4aFL 11 euatomer l JC41N W"lNeppplOY h M0.0r$61 small: 4M pM4anwnonlnm hOM:41�564 Pn5We Prem1M RYOrwa:<81.atlysllgper I.n,LOT I5,NogM1xmplOn.MP OIeE2 PmW011a:3a102e9 D4a:A!dy 26.Ze16 Job DMUIPtlon Contractor will perform or cause to be performed the following work on these"Premises'in a professional manner brad in accordance with the terns of this Contract including the attached reconinmedaderls/wonk order describing the wank in detail(the'Work')which are incorporated herein by reference. _ Measure Desorlptlon Quantity Unit Totd Cost Cusbmer Cost Air Sealing at Estimated 62.5 CFMSO Per Hour 10 ty $925.80 $0.00 W hale House Fan Box-2"Tllelmal Barrier Polyiso(whh AS hrs) i each $16770 $0.00 Eleanor Door Weather Stripping(with AS hrs) 3 each $90.21 $0.00 Door Sweep(with AS hrs) 3 each $75.93 _$0.00 Pasch-T Thermal Barrier Potyiso 1 each $x6.28 $11.57 Total; 51,325.92 Program Incentive: 51,314.35 Customer Total: $11.6] Payment Customer agrees to pay Contractor for the Wolk,the Customer Share of the Contract Pace as follows:Payment#1:$5.00 as a Deposit payable to GI_EAResult upon signing the Contract(rot to exceed 1/3 of the total mtall casts). Mail check 8 co insect to CLEAPes,It 50 Washnngton Street,,Westborough.MA,01581.Pinel Payment:56.57 as me final payment for the Work shall be payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility kcantive Share of the Contract price in the amount of$1,314.35. Changes to individual line hems andior previous incentives may Increase or decrease the sire of the Uitihy,Incentive Share, Dispute Resolution The IIC end Customerhemby mutually agree In aWame that in the evera the the IIC hese dispute concerning this Contras the IIC may submA such dispute to a pnveei emigration service whkh has been sporwed by the Office of Consumer Affairs and Business Regulation and Cus[nmen shall be requksd to submit to sum arbitration as pm ked M M G.L,c 142A. You may cancel Ws agreement if rt has been signed by a party at a place other than an address of the seller,prowded you notify the seller In wraing by ordinary mail posted,by telegram sem or by dolvery,not later than midnight of the third business day lukreang the signing of this agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. ow �roq zo;a , Customer Slg"MM Date Indicate your selected IIC here,it applioahle Initla�f you want the Program to assign a Participating Contractor Shannon MCKmn SRb;IS Shanerm AlcNmn _ CLEAResultSignature Date Name of CLEAResult Representalve 1Mga 3 a(9 TERMS AND CONDITIONS ASSIGNMENT OF CONTRACT BY CLEARauR Customer ecknuwledgas that GLEAResult will,and Customer hereby requests CLEAReaull m,assign this Contract to the IIC ro undertake Me Work on the terms set forth In the Contrast.After surth assignment:(a)CLEARasoft shall no longer he a party to this Contract;and dee Customer shad have w re burse,against CLEAResull for any of the peaformenwnm-performance or deficient performance,of Me When or any obligations vnderthis Cwimcl performed by,m m bahat of.the IIC.NotMlhstanding the foregoing,Cuslorrer EM1ell pdvitle GLEAResutt watt Ri such nfpmation regerdrg the ITC's performance as CLEARaevit may reasonably,request;and(ity reasonadda saws to the Premises as CLEAResurt may roovastto wind CLEAResu, to habitat IIC's work and(c)FratliermIXe,Customer agrees that M1a+ahaRheY(f)shad notify CLFJJwsuR of any debate between Gusrom r,aid the IIC umceming the Contract:(dl shell provloa CLEARYoult wM wah information regarding the dispute as CLEARew11,mea,reaswabiy request;ars(lift consent to CUAResulls penifipaton,at its sate election,in any arbitration or other dhoute teadiUlion proceeding hdame,Customer and the IIC. LIMITED TIME OFFER The terms.prices,and arty intens,offered in this Combed are valid for only thirty(W)days Irem the date of CLEAResuit s presentation or this Gonmost adder Customer.In the shorn that Customer dos not execute ME Contract and return R to CLEAResWt within audt filmy(30)day period,be dome.ported of any incentive offered W CLEARewR m Ni antl V010. wMMENCE ANO COMPLETION The IIC wB not begin the Work o order Me materials before has sixth i6M)day after the execndon of this Contract by CLEAResull and Custaner, whichever Buns arm mrs'CO(Naa1 Execution Date-I,Sub(aot to tie aVaiEblllty of SUIXAmIraQMS'nratafidls Yd to delays,atldbutawe fe,Rhe Mather or 'acs of God",the IIC shad begin padomng fie Wok as Econ as pactwl ming,le Can usi Execuger Date,ofd beyond IIC shellC a widtally complete Me Wok no any Men sixty 160)days after unto that Contract Execution Oatp barring delay ceased l- drtumstaid t e IIC the RC's wht to advid'mg but not WniNtl f any delay resulting from Castanets derdsion to wah!a ed vast, IIC Each,W CLEMesuR end The IIC reserve the right to advise to Wealoman I changes n Me Pmlm!atl start and and Moody dates,based upon et be hart of materials eM subwntra suffrage Upon wmpbdon of Me Work,Fro IN;coat leave the Premises in a neat ontl orderly onrcd[.n but shah no be raswnsMe to cortecl mMitons Onside the Max,of i6 Work. MODffdCATION Prior to CLEMyau I's assgnmant of this Contract to to IIC set foM in Recttw IV(above).this Contract cannot oe charged except by a writing signed, by 0MARel and the Customer.After CLEAResure assignment of his Contrast to the IIC set forth in Section IV(above).this Contract farm.,be changed aircraft by a and,signed by the IIC and the Customer Met hes been aopoved in writing by CLEAReepft. KAMM In connectla,with the Were,to W perMme!at the Premises by the IIC Under Contract,the foilowirg armiN may be requirad dr' is project depending upon Mepvdgmert of Imdl inspe m:Elecidwl,Pl fting(O ,Mechanical.Budding.The IIC shell be responsible to.and shad,obtain any and ed permits resulted for pedonnerge of the Work.The IIC shahoink m to Customer of Me earth.required and any Customer so-bey or at p1 the required permit ecquisMons.If Customer chooses W ferrets Tattle awn work-reidted nermte,am'or dead AM an unregistered contractor. Customer All be todutled from the Guanerty,Fund provisions of 10,431,C.Ia2A, CUSTOMERS DUTY Customer must pnsoare the Premises her the Wei Objects which obstmcl areas of Work must W brmed before the Wom N to commence.Customer of oral that they have hadoi m.incarri(from the above named War during the Est calendar year. DISCLAIMER OF LIABILITY OF CLEAResuht AND UTILITY Customer understands and aahndatedges Mat Me IIC E hot an agent,verde or sub-vendor of the Utility o CLEARefuft ado respect to Me asselietan of any energy ediderkry measures.In the evert of the failure of any energy conservation device to perform as expected,Customer agrees Mat Gvelomeys Ede recourse is.the IIC and ml to CLEAResuR or the UMity.The Groomer, end its operating companies sM1all not maintain,remota IX Mass S any anon Energy Services on Iha anergy is voluntary measures aswre Customer understands and eroodow our Mel n oreherfaraetiw in Me Mass Sew Hone Energy RllTEesd CLEf4ifvoiurte and Met ,has wreathed forMeIIC roinstall the proposedenergy 10 par ant moawres. under egress Mat R shad not hod ori ormax.Me Utdtty,Meir affiliates Written, foro operating c among. es IEbla!se Mtr ITC's a, oe a pertam its obligation. MYs andel MIs Contract re Fai4te of the energyonnseosMcythe enema function,foranydamage roCustmers Premises caused by tie IIC afor any Md ad damages to property,or IMury M persons roused by Me energy wnservallm measures. ENERGY BEREPRS The bead Adersong URiry E Mated to 100%of the energy benefits assudat¢d AM all energy conservation measures,exdudirg me value of Money MA seWrgs by the Customerbit inetum,sit rights Well associated IS NE Energy.Capacity and Reserves Protlucis(as defnw by ISO New England).and to IIC agrees b provide the Way whet such further tlwurhwnlad a,as Me Utility may mqutst to rMilm the Ublitys bwnaneM1ip of such deneli[s and Pmducia. IIC REGISTRATION The TIC and any subcontractors must be negish ed by the director and any Inquiries about the IIC or any subwntraclo reletng to a regeshadion should W dkede d to:OMw of Conahmar Affairs and Business Regulation,Home impru loom Contactor Regh yetw,10 Pam Two,Roam 5170,Basest.. htaesachusahs 02116.617-W$670g. Pnga 4 0[d K WARRAHHES Thea IIC wWmra.follows: A. frktedaW and workmanship will meet or exceed the specttkations in CLENResulVe "toM1als am IrWeliafian Simon de. 8. Oa Work and Me mmarbea Iumished by Me IIG will sorer to the reaulreme its of thle Contract.If there be a mi workmanship ar materiels,or any damage Caused by bs aubwnaadors or emplpyeas is disoo.red within one year af*aomell.of the Work tlmluCirg deanupl,the IIC A",at as own expense,at to option,remedy,repalr,wnect.replan,ar nusa'c M remedied,repaired, onmed ar repFarad such dried or darnega. fA1BTOMER BIOH1 UNDETi M.O.L.C 142A Cuetpmer has the following rights under M G L.t.142A. A. At the Ulm of signing Mis Contract.Me Customer shell be furnished whh a copy No Work matt begin pierM to signing of this Cort act by the Caere.aro CLEARasulL 8 Any party may bring an ataon to enforce any povSoro of Mau.G .a.142A a to seek dnugas or the CosWmer may repuast that a disputa IR decried order Me Wm of a priwte mobstan probe.approved by the Secretary of the Exewrive Office of Consumer Affairs and Boalness Regulations. C. Custmwr may have the fight to be canpensetad from she Nesoonual Comractora Guaranty Ford far actual Wsses intoned as a nostril of a registered nmracbrs or saber t.Wfs vended tound by anurt to be work WO."ra d M e pea ar umvortcmangke mane,or which Noletee amain lees far the poteeban of nrwmera shrrn 6 rromhe after Ma Customer has obtained a judgment or arbitretion award aro has exhausm wstaawy reasonable efforts W cWlad the judgirat or award. Permit Authorization r*. " Form Site ID: 3407610 Customer: JOHN W HORNOR 11 ownerof the property located at: �� I � (Pvmr's Rame,Dnntedl 46 Ladyslipper Ln LOT 15 Northampton, MA 01062 wr,p tYumetn ,d w ILMI hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property, "O Owner's Signaturo: Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Le�luC- 1 ,7 Participating Contractor Date Name: CLEAResult Phone: 300-480-7472 Email: Rev,102015 n lbr 15 [1)Su 1 (ttj ori on ) � DEBRIS FORM In accordance with the provisions of MGLc40,s.54,a condition of Building Permit Number o : 0 is that the debris resuNing from this work shall be disposed of In a properly licensed solid waste disposal facility as defined by MGL c.ill,s.150A. This Debris Will be disposed of in: _ 33U Yi �-kr , f- f-Heburo W1 G'Z-lo3 (LOCATION OF FACILITY) Signature of Permit Applicant �2h3 6q Date IF DUMPSTER IS USED IN EXCESS OF SIX(6)CUBIC YARDS A PERMIT FROM THE FIRE DEPARTMENT IS REQUIRED FOR COMMERCIAL,INDUSTRIAL,INSTITUTIONAL AND MULTI-FAMILY RESIDENTIAL OVER 20 UNITS DEMO, RENOVATIONS OR ALTERATIONS OF THE EXISTING BUILDING: CIRCLE ONE HAVE YOU SUBMFr=THE AQO6 NOTIFICATION TO THE MASSACHUSETTS DEM YES NO DESCRIPTION OF WORD TO BE PERFORMED: USE GROUP: Tn'E; a.L"Dr) Commercial: Residential• Mixed Use: Accesso M w'"Ber New Strmetnre on vacant bud: ChMC of Use: Chan a of Oecu an Addition: Alteration: Renovation: Repair. Demolition: Type of Foandadou: 0 10 of Frame: Wood: Manufactured: Steel: Heat: yl C Gas: Oil: Electric: Other: .style of structure: n1a of uuits: Owner Occupied: Structure#1 Dimensieus; SquareFootage: Straeture#2 Dimension: - 5 ware Footage: Stracture#3 Dimeosions: Square Footage: Bedrooms#: Baths#: Number ofDechs: Dimensions: Squaw footage; Number of Porches: Dimensions: S ware footage: Garage: #of cars: Dimensions: Square footage: njo Under: Ground level: Pool: Depth Dimensions: Square footage: Heated: Above ground Inground: Shed: Dimensiow: Square footage: Detail Des ' tion: Estimated Value of Project: S ; 2 . 9 d Official Use Only: ReLOM015 =-- The Commonwealth of Marsachweris DepaCong Congress SlrIndushial to 100 nts I Congress Sheet Suite 700 Boston,MA 02114-2017 wwncmdss gw/dia Ulklimrs'Cmapeasation Insurance Affidavit:BoWerslContractonffikctriciaoalPlombers. TO BE FILED WITH THE PER6BTTING AUTHORITY. AmOmMlefo titan C Please Print Legibly Name(Busineworgaumni vWdmdunq: Affordnb�e'3u11�11n1u 'F �.�QQ thC'.C1711 tIDC1 ��G Address: 330 +c}cv P_oad City/State/Zip: Rttlebcro MA O'7--7o3 Phone#: 4 G 1 /of(,�5 85, 2 Are You an aployer?Cluck the apgnpriae hoc: Type of Project(required): 1.®I meempioyc wins 24 empbyees<adt aodlm vubthml.• 7. ❑New construction 2.❑Imamkptapeuor«pmmeNdp mdWwmempby«s woddgg fm me ill 8. ❑Remodeling -w-9 r+ty.0+o wgrhm'mnR.lnw.®w wagvei.l 3.Olmahammwwr doing eitwohmyxl[pJow«keta'wmp.insewoee rtquved]t 9. ❑Demolition 4.❑lmahomeawmrmdwalhehhagconpnulo wwadnn,awwtonmypmpwW twin 10 Building addition mvmetlm dl mtrxsaneoty haw waken'mmpmv6ev untrmm«m w4 11.❑Electrical repairs or additions pnptiemn with m evg10 . 12.❑Plumbing repairs or additions 5.❑1®aamaiwmacNv and l6eve h-t a-mb-mnhnckn lined oD tae ended sheet 13.❑ROofrepairs "1'hwe mbewnacmn haw employees mdlwewmkm'vgn4.iDnvmce? (4). an®other IISUI(.ttlo 6[]W. 152mfl eodwehrve m engloyew.pJo woken'wmp.maiamw tryrynhM.] •Any RPikam tlm rtieeb box Al mml dao fill mums ucembelaw awwm8 tlwc w«aaa'campem0tim Poli Y krotmation tflwwowma t anbmit Wia�dnilmdiw�gtlsym doing diwodc ft.aeaobide eanuamm�mo at mbb a or atndavitmaiming ewL. :Contracoas chit daedctlm hump rlshed maddiemal.bort aluw�e taw oma o(tlx mbcomauma ad abs wbuhu«got tlwse mean have eff,d « . Hdn wbawmsaehnemplgyew,diet map,ovide lbeh woden'comp polity Dumber. l am an engdoyer that is providing workers'eanpeasaden iron m for my engdoyees Below is thepolieYand job site information. Insurance Company Name: 11 �n( L�I� �fittilin� l !l/�Ilrl i i „ y Polley#or Self-ins.Lie.#: J't l V 1473 "2L{ Eximmum Date.1 Job Site Address: qb LaLn Lgt LS C3tyi$ateizip: 7 ��r� f)11� DIDo2 Attach a copy of the workers, peosation policy declaration page(showing the Policy oomber aad expiration date Failure to seem coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.W and/or o year impdommem,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage vert&cation. I do bweby ardJy rndert -palm andpenef�erjrry ddthe/nfommdanproridd above is trotaudeorreeg �) ff .cif_ tee. �-j �1 Phone �AI7✓R qD -525'l Of)2dof use ooIA Do nor nude in this area,to be coxWdedby city or town 01TwIol City or Tetra: PermiF/l.icense# lasing Authority(circle tae): 1.Board of Halm l Bandies Department 3.Cityfrmn Clerk 0.Electrical Impeclor 5.Ph®bias inspector 6.Other Contact Person: phone#: "� CERTIFICATE OF LIABILITY INSURANCE 1/2/201u9 vvl 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poliry(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy.Certain policies may require an endorsement. A statement on this Certificate does not confer rights to the certlllcato holder In lieu of such endorsereent(s). NTA PRODUCER OKI .CT RosalyN1 Davila Loieelle Insurance Agency PxoxE (401)923-5510 FAx ran Sze-7ezo 279 Dexter Street "RAS .rosal'n.Utloiaelleiaaurance.Com P. 0. EOX 1148 INRURER8A) <FORDINO COVERAGE NAM Pawtucket RI 02862-1148 IxsuaERA£m lover. Mutual_Casualty Co 21415 INSURED NsuREa e: SC ENERGY, INC. IMSURERC: DBA AFFORDABLE BUILDING i WEATHERIZATION INSURERD: 330 VICTOR RD-HDILDING A IxauaERE ATTLEBORO MA 02703-6294 1 INSURER COVERAGES CERTIFICATE NUMBERMas Ger 2018 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THF 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. INBR POLICYEFF PO1JCYE%P L TYPE INSURANCE POgCYNUMDER MI D MW M(YY LIMES GENE LIABIXY EACH OCCURRENCE 1 1,DOO,000 EN $00,000 X COMMERCIAL GENERAL LIABILITY PREMISESEaocc 8 A CLAIMS MADE ❑% OCCUR D9802< 2/27/20182/27/2019 MED E%P(Any me PFI $ 10,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS{QNPIDPAGO $ 2,000,000 X M CY Pfl0. LOC % AITOMMILE LIABILITY £e ac[be SNCL LC.MIMI A ANY AUTO RODrtr w.luRV IPx 20000 LOWHEO ALIX SCHEDULED B98G2a 12/27/20CR 19 z121 Ola a00 W.URYlL! zvtiknq s G0 000 X HREDAUT09 X NUTxOgWNFD ,PPoLPyEPTV DAM4GE_ $ 5 OOD �rcd m�N,�,IRI. arl�1 % 1 DOD 000 X UMBRELLALAB OCCUR EACHOCWRPENCE S 2,000,000 A EFCE$S WB CIAIMg,AApE AGGREGATE S 2,000,000 DEO X RETEMIOxS 10,00 J98024 2/27/2010 2/27/2019 y A WORKERS COMPEN54MW W $TAN. OM AND EMPLOYERS'LIABILITY ANYPROPRIETOSPARISEREERACHUNIF Y� x'A EL FArH ACDIOFHi 5_500 _000 oARA R'.. EXCLUOEGI -90029 2/27/2018 2/27/2019 E1 DISEASE-EA EMPLOYE $ 5500 000 IMc CURSH A NHI 0ewrnse under _ EI. DISCASe-POLICV OMIT 3 500 000 CESGRIPTIgV OF OPERATIONS NebW _ �� DEB MPTN)N OF OPERATIMS I LMAMIN-I VEHICLE$ IAHadr ACORD 101 AdtllMoml WmaM1e 9cM1eEUM.11 moreipxU le eequlretl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, SC Energy, Inc. DBA Affordable Building i Beatherization nuTNORI2Eo asveESENrAmE 330 Victor Road, Building A Attleboro, RT 02703-6294 y� acI..1,on Davila/ROSH ' A-F"-�+4,,I ACORD 26(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INRO2Rnnm,M.r , ".ernRn......l.nnn.w.enmmeetl,nabs nF aMon o-xcen..m.rur.l ae r+rem.uo„ HOME IMPROVEMENT CONTRACTOR Peg ation v.Itd for In Nuala only TYPE:Como . bforeteeapiraf,mtl Rfaaldnm IW g qO Exoravon M.n`^orm.Afatre and Sueinnf RpWalbn 17-gsn 0&172025 J MI W,.ngton fi n-SuAa 710 AFFOROABIE BUtLONG SWEATHFRRATION INC Bm;for. 'A 82118 TODD LEDII `+'-<< =�'--" -_ _ '• 330 VICTOR RUSkA f t '.Wid with"'Mgnatufe ATTLEBORO AMA 0+'/03 UnOersecreldry rpa x¢n of rvtassacnusetts {,� nlassional L¢e St u antl St HOn:J C, Gu ntllnp Regulations a, 11 1- misor Specie. . �sSI_go�r, ExPtres. 1.L:L TODD 1'.`11C. 6 „� Comncsr,in ner