17A-157 (8) BP-2023-1045
61 FOX FARMS RD COMMONWEALTH OF M SSACHUSETTS
Map:Block:Lot:
17A-157-001 CITY OF NORTHA PTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGIS ERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARAN FUND (MGL c.142A)
BUILDING P .RMIT
Permit# BP-2023-1045 PERMISSION S HEREBY GRANTED TO:
Project# insulation 2023 Contractor: License:
Est.Cost: 11643 CLEAN TECH CONS RUCTION 106247
Const.Class: Exp.Date: 01/05/202
Use Group: Owner: CIAMP DOSTAL ERIC D& ELENA L
Lot Size (sq.ft.)
Zoning: URA Applicant: CLEAN ECH CONSTRUCTION
Applicant Address Phone: Insurance:
40 MESSINA DR 508-576-1026 6hub4n60130822
BRAINTREE, MA 02184
ISSUED ON: 08/07/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATI ON
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Seri ice: Meter: Footings:
Rough: Rough: House# Foundation:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NO THAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
itk Een M'il
laiLT 1g5y
IL, The Commonwealth of Massachusetts ��Board of Building Regulations and Stan..rds ^ FOR
W. Massachusetts State Building Code, 7:i C ' •� ICIPALITYUSE
Building Permit Application To Construct,Repair, ' -no - Or olish a /'- 'd Mar 2011
One-or Two-Family Dwelling 'i oc ` 0
This Section For Official Use Onl 9):5‘6.65,
(%
Buildin Permit Number: 65+"^.0) 3 . iQf s Date Applied: T��>
• ro
�l� (1.Z55 ��� �'°� ,) 8-4.2a?3
Building Official(Print Name) Signature KS Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
4?\ RN. COSYYlS
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Waterte Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public tie Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'of Record:
r‘C OoSk-QJ, A)p(- osn c r , 1 \A , O\ O(n
Name(Print) City,State,ZIP
(e\ c-oY )C.‘rt(IS cZ-\ _ 4• s-ilX)-301Li
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other l 'Specify: V vls v\c OvZ
Brief Description of Proposed Work2: \; 14 CL\-\'\&'c iz( C V\ O.. Or Se 0.c):%v,
tn.t-\k-PN i'A.G5S jc,:j-e 7cOa cs_vv\ _ JVo '-Fruc_fixc=„.i. C.=\."0-vkOr.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ r\,(Q k' (.0c21. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount. �I Cash Amount:
6.Total Project Cost: $\\, CQt{3 . CoC� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
lceG qZPID
License Number Expiration DateCo
Name of CSL Holder
List CSL Type(see belowcW \55L)`o Ov\
(2)? F\\S US
No.and Street Type Description
Y <�\ w �Z,Q C� Unrestricted(Buildings up to 35,000 cu.ft.)
I�JC c
�( � V) , R Restricted 1&2 Family Dwelling
City/Towb,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
jh cac
o3-7bct'l Nsi,�)cG/NCOVIS�(orkievictlh�,Ctwt\`\ ( ) Insulation
Telephone Email address -Cbvv D Demolition
5.2 Registered Home Improvement Contractor(HIC) i4 ��,` L7 /�2
QA.LO3 A \C_Can l.GV15 oc-sciOV1 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name •
8 �l t S Avg- "#' C aVkk6ncOv,sk-r-uc ((.g i‘\CA k . C Owl
No.and Street Email address
1\)P1.1\w oVVI r M.k c ()21q() ;tom- 1Y
City/To*n,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isssu e of the building permit.
Signed Affidavit Attached? Yes g No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize ,Sc i Q.M QC z1/4
to act on my behalf,in all matters relative to work authorized by this building permit application.
See a C t�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
v,v,a " 7:5
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
ilIK
mass save
Savings through energy efficiency
PERMIT AUTHORIZATION FORM
1, Eric Dostal owner of the property located at:
(Owner's Name)
61 Fox Farms Road Florence
(Property Street Address) (City)
hereby authorize the Mass Save® Home Energy Services Program assigned Participating
Contractor to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my property.
This form is only valid with a signed contract. The permit will be secured by the
subcontractor, at no additional cost.
Owner's 'gnature
Date
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor
to the above reference proPct: _
a"----21„,-/--2. 0 ' -------/ 0 /�.5/2oz
Participating Contractor Date
Commonwealth of Massachusetts
Construction Supervisor Specially
it y Division of Occupational Licensure ---
'. Board of Buil , ' julations and Standa , Restricted to:
Construe nert$or Specialty CSSL-IC-Insulation Contractor
:y
CSSL-106247 -. L ires: 09/26/20 -
ARIANNA JAMES DAVIDSON r
38 ELLS AVE —
WEYMOUTH MA 02190
ter,- 1
407J,Yd:.1)' Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
Commissioner ./ K. ,tjea_ For information about this license
Q�t bl& Call(617)727-3200 or visit www.mass.govldpl
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer AffatP and Business Regulation
1000 Washington Street- Suite 710
Boston. Massachusetts 02118
Home Improvement Contractor Registration
„,
r" s" -l Arai t Type: Supplement Card
v =:_ _ :. r ation: 196071
CLEAN TECH CONSTRUCTION LLC "', ��L— E abon: 06127l2025
38 ELLS SVE .' 1usi
MEM
WEYMOUTH,MA 02190 uoa?i s_ sow et,VTR a moss ji
i{J1% — ,tie i
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Supplement Card Office of Consumer Affairs and Business Regulation
Renistration Expiration 1000 Washington Street .Suite 710
196071 06127/202`5 Boston.MA 02118
CLEAN TECH CONSTRUCTION LLC
`-z s "T 4.
ARIANNA DAVIDSON ` �,, *J" fj
38 ELLS AVE t �..�GG.k'
WEYMOUTH,MA 02190 .>- , ,�„,.w�.
44 Undersecretary Not valid without signature
The Commonwealth of Massachusetts
i 4 Department of Industrial Accidents
_' ► 1 t Office of Investigations
talk Lafayette City Center
� 2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organization/ndividuat): Clean Tech Construction
Address:40 Messina Drive
City/State/Zip: Braintree, MA 02184 Phone#:617-271-0768
Are you an employer?Check the appropriate box: Type of project(required):
1.❑■ I am a employer with 6+ 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance. 10.0Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13 ®fir Insulation
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Traveler's Indemnity Co of America
Policy#or Self-ins. Lic.#:6HUB4N60130822 Expiration Date:9/18/2023
Job Site Address: 6, Fo Y VA-S P\c 1, City/State/Zip:A t1( `0i 0 G Z
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjary that the information provided above is true and correct
Signature: �€:€0,lsa D.�zr.e4 P Date: g / 3 /20 23
Phone#: 617-271-0768
Official use only. Do not write in this area,to be completed by city or town ojficiaL
City or Town: Permit/License#
Issuing Authority(check one):
10Board of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#:
MIIIIDomrY)
A`CORE, DATE( MAXNY
CERTIFICATE OF LIABILITY INSURANCE lorz
6/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Gary Hebsch
TOBMAN MOLIGNANO&WEINER INSURANCE AGENCY INC _i, "4.0,y: (817)471-1123 FAX
EMAIL
ADDREss; ghebschet n vIns.com
21 MCGRATH HIGHWAY SUITE 303 INSURERS)AFFORDING COVERAGE NAIc
QUINCY MA 02189 OIIIUmA: TRAVELERS INDEMNITY CO OF AMERICA 25666
INSURED INSURERS:
CLEAN TECH CONSTRUCTION LLC INSURER C:
INSURER D:
40 MESSINA DRIVE INSURERE:
BRAINTREE MA 02184 INSURER F
COVERAGES CERTIFICATE NUMBER: 828667 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
'NW POUCY EFF POLICY EXP
TYPE OF DURANCE INSD W VD POLICY NUMBER IISTKIDIYYYYI RNIIDD/YYYY) Lis
COMO1MINALMINERAL LUla1L TY EACH OCCURRENCEDAMAGE TO RENTED -
$
CLAIMS-MADE OCCUR PREMISES Ms occurrence) $
MED EXP(Any one person) $
N/A PERSONAL&ADV MJURY $
GEL AGGREGATE UNIT APPLIES PER GEMERAL AGGREGATE $
POLICY JFERcT LOC PRODUCTS-COUPIOPAGO $
OTHER:
AUTOMOBILE LIABILITY SINGLE LIMIT $
(Es scddent)
ANY AUTO BODILY NJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS N/A BODILY INJURY(Per so:Want) $
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY _AUTOS ONLY (Per sodderU
f
UIBRE LA LIAB _ OCCUR EACH OCCURRENCE s
EXCESS LIAR CLAIMS.IItDE N/A AGGREGATE s
DED RETENTJON$ $
WORRIERS COMPENSATION x PER OTH-
STATUTE Eft
AND EMPLOYERS LIABILITY
YIN
ANYPROPRIETOR/PARTNERIEXECUTIVE El.EACH ACCIDENT $ 1,000,000
A OFFICER/MEMBEREXCLUDED? NIA NIA 6HUB8R60053222 09/18/2022 09/18/2023
(Mandatory In NH) E.L.DISEASE-EABrPLOYEE $ 1,000,000
If yes describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT f 1,000,000
i
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govflwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Boston ACCORDANCE WITH THE POLICY PROVISIONS.
1 City Hall square
AUTHORIZEDREPRESEMATNE
Boston MA 02201 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
ACOROt DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 09/09/22
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Tobman,Molignano&Weiner Ins Agency PHONE Ext): 617�71-1123 FAX No): 617-773-2474
21 McGrath Highway,Suite 303 E�AIUL
Quincy,MA 02169 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC
INSURER A: Norfolk&Dedham Mutual
INSURED
INSURER 8:
Clean Tech Construction LLC INSURER C:
40 Messina Drive
Braintree,MA 02184 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE s n BWvo POLICY NUMBER (MIDD/YYYTY) (MAEFF /DO//YYCY EXVFY) LIMBS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE 10 RENTED
CLAIMS-MADE X OCCUR I PREMISES(Ea occurrence) $ 300,000
MED EXP(Any one person) $ 5,000
A — P012011894 09/18/22 09/18/23 PERSONAL a ADv INJURY $ 1,000,000
yGEN'L AGGREGATE UNIT APPLES PER: GENERAL AGGREGATE $ 2,000,000
POLICY a JECT I I LOC PRODUCTS-COMP/OP AGO $ 2,000,000
I OTHER: $
AUTOMOBILELIABILJTY (COOMBEs IeEnD(SINGLELIMIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED accident) $
AUTOS ONLY X X UTOS 91972894A 09/16/22 09/16/23 BODILY INJURY(Per accident)
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY _ AUTOS ONLY (Per accident)
$
X UMBRE—r A UAB X OCCUR EACH OCCURRENCE $ 2,000,000
A EXCESS UAB CLAIMS-MADE U2003464A 09/18/22 09/18/23 AGGREGATE $ 2,000,000
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
The City of Boston is an additional Insured per written contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Boston ACCORDANCE WITH THE POLICY PROVISIONS.
1 City Hall Square
Boston,MA 02201 AUTHORIZED NTATIVE
®1 -2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
DEBRIS DISPOSAL AFFIDAVIT
In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit
# was issued with the condition that all debris resulting
from this work shall be disposed of in a properly licensed solid waste
disposal facility as defined by M.G.L c. 111, s. 150A.
The debris will be disposed of in:
Clean Tech Construction
Name of Waste Facility
Not Applicable - No Debris
Address of Waste Facility
111.5 Debris: As a condition of issuing a permit for the demolition, renovation,
rehabilitation or other alteration of a building or structure, M.G.L.c.40 a.54 requires
that the debris resulting therefrom shall be disposed of in a properly licensed solid waste
disposal facility as defined by M.G.L.c.111 s.150 A.Signature of the permit applicant,
date and number of the building permit to be issued shall be indicated on a form provided
by the Building Department and attached to the office copy of the building permit
retained by the Building Department.If the debris will not be disposed of as indicated,
the holder of the permit shall notify the building official,in writing,as to the location
where the debris will be disposed.
780 CMR—6th Edition
41,e.QILfZCL T7Gi 68rL
Signature of Permit Applicant
/Zo2-
Date
City of Northampton
,�o..- ff.;I.
SAS^'—S.0
'•''" Massachusetts �4?. K. •!<.
t` 1 k Y` DEPARTMENT OF BUILDING INSPECTIONS �`. j„
" 212 Main Street • Municipal Building 1- .cam
�=. Northampton, MA 01060 *54 ,.• 60.
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: k,o\_ 001ic ,47j(Q C.,_,,_ a c\AQA
)
The debris will be transported by:
Name of Hauler: /30\- cj cc-3,0 2_
Signature of Applicant: •,(-4n� .� Date: S%3/2 GZ
WEATHERIZATION CONTRACT EVERS=URCE
CUSTOMER PHONE DATE CLIENT WORK ORDER
Eric Dostal (036)500-3014 07/26/2023 450802 61604
SERVICE STREET BILLING STREET PROPOSED BY:
61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux
SERVICE CRY,STATE,ZIP BILLING CRY,STATE,ZIP Program
Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 1
DESCRIPTION QTY COST INCENTIVE TOTAL
INCENTIVE 75%
For eligible weatherization measures, Eversource is offering an
incentive of 75%for insulation measures and 100%for the air sealing
measures, both with no limit.You are eligible to apply for the 0%Heat
Loan to finance your co-pay,applications must be submitted before
the weatherization work begins.
HOME AIR SEALING 18 $1,918.62 $1,918.62
Seal areas of your home against wasteful,excessive air leakage.
Materials to be used to seal your home can include caulks,foams
and other products. Primary areas for sealing include air leakage to
attics,basements,attached garages and other unheated areas
(windows are not generally addressed.)
WEATHERSTRIP DOOR 2 $72.64 $72.64
Provide labor and materials to install Q-lon weatherstripping to
door(s)to restrict air leakage.
DOOR SWEEP 2 $59.32 $59.32
Provide labor and materials to install a doorsweep to restrict air
leakage.
ATTIC DAMMING 50 $139.00 $104.25 $34.75
Provide labor and materials to install an approved damming material
in the attic
ATTIC FLAT-5"OPEN R-19 CELLULOSE 2,072 $3,874.64 $2,905.98 $968.66
Provide labor and materials to install a 5"layer of R-19 Class I
Cellulose to open attic space.
RECESSED LIGHT COVERS 1 $56.89 $56.89
Install recessed light covers over existing recessed light fixtures. Up
to 6 at no cost.
WHOLE HOUSE FAN COVER 1 $222.03 $222.03
Provide labor and materials to fabricate and install a rigid foam
insulating cover for the whole house fan.
WALLS-CLAPBOARD SIDED 4" 1,460 $4,292.40 $3,219.30 $1,073.10
Install blown in Class I Cellulose to clapboard sided exterior walls.
Touch-up painting,if needed,will be the customer's responsibility.
Homeowner has received a copy of the EPA's Renovate Right Lead-
Safe information guide explaining the potential risk of the lead hazard
exposure from the weatherization work to be performed.Your
signature is your acknowedgement of receipt and agreement to
proceed.
WEATHERIZATION CONTRACT EVERS=URCE
CUSTOMER PHONE DATE CLIENTS WORK ORDER
Eric Dostal (036)500-3014 07/26/2023 450802 61604
SERVICE STREET BILLING STREET PROPOSED BY:
61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux
SERVICE CITY,STATE,ZIP BIWNG CITY,STATE,ZIP Program
Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 2
DESCRIPTION QTY COST INCENTIVE TOTAL
WALLS-INTERIOR DRILL AND PLUG 4" 184 $540.96 $405.72 $135.24
Provide labor and materials to install blown in Class I Cellulose to
exterior walls through an interior surface drill and plug method. Plugs
will be spackled and left with a rough finish. Finish sanding and touch-
up priming/painting will be the customer's responsibility. Homeowner
has received a copy of the EPA's Renovate Right Lead-Safe
information guide explaining the potential risk of the lead hazard
exposure from the weatherization work to be performed.Your
signature is your acknowedgement of receipt and agreement to
proceed.
BASEMENT SILLS-6"FIBERGLASS 88 $268.40 $201.30 $67.10
Provide labor and materials to install R-19 unfaced fiberglass
insulation to the perimeter of the basement ceiling at the house sill.
VENT BATH FAN TO ROOF OR OTHER 1 $166.53 $124.90 $41.63
Install an insulated exhaust hose to a flapper vent to exhaust existing
bathroom fan(s). Fan will be vented through the roof or an acceptable
alternative if contractor cannot vent through the roof.
INSULATED BATH EXHAUST HOSE 4 INCH 1 $32.23 $24.17 $8.06
Provide labor and materials to install an insulated 4"exhaust hose to
existing bathroom fan(s).
WEATHERIZATION CONTRACT EVERSWURCE
CUSTOMER PHONE DATE CLIENTS WORK ORDER
Eric Dostal (036) 500-3014 07/26/2023 450802 61604
SERVICE STREET BILLING STREET PROPOSED BY:
61 Fox Farms Road 61 Fox Farms Road Jeff Ledoux
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program
Florence, MA 01062 Florence, MA 01062 EGMA-HES Page 3
DESCRIPTION QTY COST INCENTIVE TOTAL
PREPARE YOUR HOME 1
Homeowner is responsible for the removal of any items stored in the
areas where the weatherization measures will be installed. The
workers will need the space cleared to safely bring their tools and
materials into these work areas.
If you have any questions or specific concerns, please bring them to
the attention of your subcontractor when they call to schedule your
work.
Total: $11,643.66
Program Incentive: $9,315.12
Client Total: $2,328.54
I.DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be performed the above work at the Client's Address in a professional mamer and in accordance with the terms of this Contract:
II.PAYMENT
Client agrees to pay the Contractor for the Work,the Client Share of the Contract Cost is payable to the Independent Installation Contractor(IIC)upon satisfactory completion
of the Work.Client understands that they will not be required to pay the Program Incentive Shar of the Contract cost.Changes to the individual line items and/or previous
incentives may increase or ecrease the size of the Program Incentive Share.
Representative Client Signature rj...(s)
Printed Name Date of Acceptance
Client: Eric Dostal
R I S E8 Address: 61 Fox Fauns Road
AN EMPLOYEE-OWNED COMPANY Florence, MA 01062
Energy Specialist: Jeff Ledoux Phone: (036)500-3014
Program: EGMA-HES Client# 450802 Work Order# 61604
Work Scope
DESCRIPTION Qty Notes
1 HOME AIR SEALING 18
2 WEATHERSTRIP DOOR 2
3 DOOR SWEEP 2
4 ATTIC DAMMING 50
5 ATTIC FLAT-5"OPEN R-19 CELLULOSE 2,072
6 RECESSED LIGHT COVERS 1
7 WHOLE HOUSE FAN COVER 1
8 WALLS-CLAPBOARD SIDED 4" 1,460
9 WALLS-INTERIOR DRILL AND PLUG 4" 184
Interior drill exterior wall in garage.
10 BASEMENT SILLS-6"FIBERGLASS 88
11 VENT BATH FAN TO ROOF OR OTHER 1 Preferably soffit
12 INSULATED BATH EXHAUST HOSE 4 INCH 1
13 PREPARE YOUR HOME 1
Diagram 9 12
/11//il
61
10 I
® 5 BF BF
5
Garage
5 WH 5 28
23
El
5
5
1\ 32
23
1\
2,3 2,3 Test hole