An application was received from Ricky Zeng representing Brooklyn Bagel factory, requesting permission for an awning at the premises numbered 168 Hampshire Street. Approval has been received from Inspectional Services, Department of Public Works, Community Development Department and abutters

Location Applicant Sign/Awning Permit 168 Hampshire St Д Ricky Zeng 183112 Cambridge, MA 02139 [phone removed] @[email removed] Submitted On: Jul 1, 2022 General Information What option best describes this application? Awning(s) Description of Proposed Work install new awning to the wall Estimated Cost of Awning(s) in dollars 6800 Describe any existing signs or awnings that will remain (including the size of the remaining signs/awnings). no Cambridge City Council approval may be required. Will one or more of the proposed signs extend six (6) inches You must submit a Projected Sign Application and into the public sidewalk? Abutter's Form (https://viewpointcloud.blob.core.windows.net/profile- Yes pictures/City_Clerk_Sign_Awning_Application_Wed_Jan_o 2_2019_15:28:46_GMT+0000_(Coordinated_Universal_Time ).pdff) to the City Clerk's Office. Awning Information Width of Awning (feet) Height of Awning (feet) 65 3.5 Height from the ground to bottom of the awning (feet) Height from the ground to the top of the awning (feet) 9 12.5 Weight of the awning (Ibs) Awning Material 350 Galvanized tubing, Sunbrela fabric Projection from the Building (inches) 3.7 Contractor Contractor Name RICKY Z ZENG

Address 1211 PLEASANT STREET Telephone E-mail [phone removed] [email removed] License Expiration Date License Number 07/13/2022 CS-113216 Contractor's Signature Date Signature of Licensed Contractor 07/01/2022 Ricky Zeng

OFFICE OF THE CITY CLERK CAMBRIDGE CITY HALL, 795 MASSACHUSETTS AVENUE CAMBRIDGE, MASSACHUSETTS 02139 PHONE [phone removed] FAX [phone removed] PAULA M. CRANE DEPUX CITY CLERK ANTHONY I. WILSON CITY CLERK _ 20_ Cambridge, To the Honorable, the City Council of the City of Cambridge: EACH PETITION MUST BE ACCOMPANIED BY A DRAWING OF PROPOSED SIGN, INDICATING DESIGN AND DIMENSIONS AND LOCATION ON PREMISES. The undersigned respectfully prays that Brooklyn Bagel factory (NAME OF BUSINESS) be granted permit to erect a sign of the following specifications in front of premises located at 168 Hampshire St. Cambridge, MA (ADDRESS) Type of Sign: Awning (slate whether electric or otherwise and material used in construction) Reading matter to go on Sign: blank Weight: 350LBS Size: 41"X43"X520", 41"X43"X197", 41"X43"X67.5" Public Way B. 108 inches A. Inside property line Obstruction: (Also exact distance from bottom of sign to sidewalk) (Give exact distance sign is to extend over sidewalk) Top: 149 inches Height Above Grade: Bottom: 108 inches NOTICE - REGULATIONS Section 1212.0 State Building Codc - Projecting Signs) (Section 12.08.010 Municipal Code - Encroachments onto Streets] • A projecting sign shall be constructed wholly of incombustible materials. • All signs must meet requirements of Zoning Ordinances and Building Code. • Note: Section 12.12.220 provides in part "every owner who maintains a... structure in or over a streel... shall do so only or he condition that such maintenance shall be considered as an agreement on his part to keep the same and the covers thereof i good repair and condition, at all times during his ownership, and to indemnify and save harmless the City against any and al damages, cost or expenses which it may sustain, or be required to pay by reason of such. structure" PROPERTY OWNER OR AUTHARIZED AGENT HEREBY STATES THAT INFORMATION IS TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND UNDERSTANDING UNDER PAINS AND PENALTY OF PERJURY. 15-19 Elmer St [phone removed] (Tel. No.) (Address) (Property owner or authorized agent) 85724609 168 Hampslur It. (Tel. No.) (Address) (Business owner)

110-91 110-61 NORTHEASTERN CONFERENCE CORPORATION ZTKR MANAGEMENT LLC, CAMBRIDGE ELECTRIC LIGHT CO 27 HUCKLEBERRY HILL SEVENTH DAY ADVENTISTS C/ONSTAR ELECTRIC CO LINCOLN, MA 01773 115-50 MERRICK BLVD PROPERTY TAX DEPT, P.O. BOX 270 JAMAICA, NY 11434 HARTFORD, CT 06141 87-35 84-69 84-52 258 PROSPECT LLC CASSIN LLC BREENHAP PROPERTIES CORP 228 PARK AVE S PMB 35567 C/O NCP MANAGEMENT CO 907 MASSACHUSETTS AVE NEW YORK, NY 10003 PO BOX 590179 CAMBRIDGE, MA 02139 NEWTON, MA 02459 87-40-1 87-39 87-37 WEEKS, BENJAMIN MESSOM, CHARLES H. JR. BERKMAR LLC 3 MURDOCK ST., #1 & NANCY LEE MESSOM C/O NCP MANAGEMENT CO CAMBRIDGE, MA 02139 166 HAMPSHIRE ST PO BOX 590179 CAMBRIDGE, MA 02139 NEWTON CENTER, MA 02459 87-40-4 87-40-3 87-40-2 YANGDON, RIGZIN TRUSTEE OF MOZA YENI, CYRUS DAVID & HUDSON, LINDA SY NOMINEE TRUST SUSAN XU LUO 3 MURDOCK ST 2353 MASS AVE #66 75 SCOTCH PINE RD CAMBRIDGE, MA 02139 CAMBRIDGE, MA 02140 WESTON, MA 02493 87-42 87-41 GRANGER, DAVID M. & CHRISTINE M. FOOT KOHMAN BRYNNE C & RICHARD E TRS TRUSTEES OF THE 9 MURDOCK ST NOM 7 MURDOCK ST REALTY CAMBRIDGE, MA 02139 96 BLAKELY ROAD MEDFORD, MA 02155

U.S. Postal Service™™ U.S. Postal Service™ CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT Domestic Mail Only Domestic Mail Only For delivery information, visit our website at www.usps.com For delivery information, visit our website at www.usps.com" 5964 E U 0189 Certified Mall Fee $3.75 0189 Certified Mall Fee $3.75 22 $0, 00 22 $0,00 Extra Services & Fees (check box, ad foo g faTopat) • Return Receipt (hardcopy) Extra Services & Foes (chock bax, ad too (-(file) • Return Recept (hardcopy) Postmark SU,000 •Return Receipt (electronic) 90.100 Postmark Return Recelpt (electronio) Here •Certifled Mall Restricted Dellvery 30.401 Here $0.00 • Certified Mail Restricted Dellvery •Adult Signature Required $0.00 •Adult Signature Required 0001 8461 5940 $0.00 0001 •Adult Signature Restricted Dollvery S • Adult Signature Restricted Dellvery S Postage Postage $0.58 87-42 87-3540.58 06/29/2022 Total P Total Pos 258 PROSPECT LLC 0410 GRANGER DAVID M. & CHRISTINE M?766722 TRUSTEES OF THE 9 MURDOCK ST NOM 228 PARK AVE S PMB 35567 Sent Te REALTY Sent To NEW YORK, NY 10003 122 96 BLAKELY ROAD Street i Sireet ani MEDFORD, MA 02155 Chiy, si City, Stati PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 U.S. Postal Service™* U.S. Postal Service™ CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT Domestic Mail Only Domestic Mail Only For delivery information, visit our website at www.usps.com For delivery information, visit our website at www.usps.com AL 5971 SE Comprise A 02031 Cambni duay MAN 02109 SE Certified Mail Fee 0189 $3.75 $0, 00. 22 Certilled Mail Fos $3.75 12 8461 Extra Services & Fees (check box, add foo g perpiate) •Retum Recelpt (hardcopy) EAS 8461 Exira Services & Fees (check box, add fee grip copyjiate • Return Receipt (electronic) • Return Receipt (hardcopy) 501,000 Postmark. Postmark 50.00 Here • Certilled Mall Restricted Delivery • Return Receipt (electronio) $0,00 Here • Certified Mail Restricted Delivery • Adult Signature Required $0.00 $0.00 0001 • Adult Signature Required • Adult Signature Restricted Delivery S 1001 $0.00 Postage • Adult Signature Restricted Dellvery S Postage 87-490.58 06/2922022 Total Poste 87-40-80.58 06/29/2022 CORMANBRYNNE C & RICHARD E TR 0410 Total Pi / MURDOCK ST WEEKS BENJAMIN 0410 Sent To 3 MURDOCK ST., #1 CAMBRIDGE, MA 02139 Sent To CAMBRIDGE, MA 02139 Sireet and. Sireet a [City, State, Cliy, Sti See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 U.S. Postal Service™™ U.S. Postal Service™ CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT Domestic Mail Only Domestic Mail Only For delivery information, visit our website at www.usps.com For delivery information, visit our website at www.usps.com and TOTAL USE USE Weston A 2C IAL 0189 Certilled Mall Fee $3.75 0189 Cartlied Mall Foo $3.75 $0.00 22 22 $0,00 Extra Services & Fees (check box, add tea eg profiato) 8461 •Retum Receipt (hardcopy) Extra Services & Foes (check bax, add too g iP plete • Return Receipt (hardcopy) Postmark 10.000 • Return Receipt (electronio) Postmark • Return Receipt (electronic) 50.002 •Certified Mall Restricted Delivery $ Here 50.00 Here • Certified Mall Restrioted Delvery 30,00 • Adult Signature Required $0,00 • Adult Signature Required •Adult Signature Restricted Delivery $ $0.00 0001 • Adult Signature Restricted Delivery S Postage Postage 87-40-2 06/29/2022 Total Postag 87-40-358 $ 06/29/2022 Total Posta HUDSON LINDA 0410 MOZA YENI, CYRUS DAVID & 3 MURDOCK ST Sent To SUSAN XU LUO CAMBRIDGE, MA 02139 Sent To 75 SCOTCH PINE RD Street and Ai Sireet and 7 WESTON, MA 02493 City, State, 2 Cliy, State, PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions

U.S. Postal Service™ U.S. Postal Service* CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT Domestic Mail Only Domestic Mail Only For delivery information, visit our website at www.usps.com For delivery information, visit our website at www.usps.com comp de MA 23 AL USE Cambride 21 AL Certified Mall Fee 0189 0189 Certified Mall Fee $3.75 $3.75 22 50,0 $0.00 22 8461 Extra Services & Fees check boy, add to pa • Retur Receipt (hardcopy) Extra Services & Fees (check box, nd foo of opproprate) •Rotum Recept (hardcopy) $0,00 EAS • Return Receipt (electronio) Postmark $0,000 • Return Recept (electronic) Postmark •Certilled Mall Restricted Delivery Here • Certified Mail Restricted Delivery Here 10.00 30.00 • Adult Signature Required $0,00 • Adult Signature Required 0001 $0,00 0001 • Adult Signature Restricted Dellvery S • Adult Signature Restricted Delivery $ Postage Postage $0.58 60.58 84-52 87-39 06/29/2022 06/29/2022 Total Post BREENHAR PROPERTIES CORP 0410 0410 MESSOM CHARLES H. JR. 907 MASSACHUSETTS AVE & NANCY LEE MESSOM $ Senl Sent To CAMBRIDGE, MA 02139 166 HAMPSHIRE ST Strei CAMBRIDGE, MA 02139 Sireet and 022 7022 City, Cily, State, See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000.9047 See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 U.S. Postal Service™ U.S. Postal Service™ CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT CO Domestic Mail Only Ln Domestic Mail Only For delivery information, visit our website at www.usps.com® For delivery information, visit our website at www.usps.com 5919 USE USE Certifted Mail Fee $3.75 Certified Mall Fee $3.75 0189 EAS089 EAST 22 8461 $0.00 22 $0.00 8461 Extra Services & Fees (check box, add fee ge gpagapiato) Extra Services & Fees (check box, add fee e ippPejate) •Return Recept (hardcopy) • Retum Recept (hardcopy) •Return Receipt (electronic) $0,001 Postmark $0.00 • Return Recept (electronto) ~ Postmark •Cortified Mail Restricted Delivery 10.00 L Here ~ Here 100.00 • Certifled Mall Restricted Dellvery •Adult Signature Required 0001 • Adult Signature Required $0.00 $0.00 • Adult Signature Restricted Delivery $ Adult Signature Restricted Delivery $ Postage Postage $0.58 $0.58 84-69 110-61 06/29/2022 Total F 06/29/2022 0410 Total Posti CASSINIAC CAMBRIDGE ELECTRIC LIGHT CO C/ONCP MANAGEMENT CO. C/ONSTAR ELECTRIC CO Sent 7 Sent To ru PO BOX 590179 PROPERTY TAX DEPT, P.O. BOX 270 Sireel NEWTON, MA 02459 HARTFORD, CT 06141 Sireet and. 7022T City, s City, State, PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions U.S. Postal Service™ U.S. Postal Service™ CERTIFIED MAIL® RECEIPT CERTIFIED MAIL® RECEIPT Domestic Mail Only Domestic Mail Only For delivery information, visit our website at www.usps.com LN For delivery information, visit our website at www.usps.com Newton Cartery /TA 02439 | USE 0189 Certilled Mail Fee Certified Mail Foe $3.75 0189 $3.75 22 $U.00 22 $0.00 8461 EAST ]Retum Recept (hardcopy) • Return Receipt (hardcopy) • Retum Receipt (electronle) 10.00 Postmark Postmark • Return Receipt (electronic) 30.000 01 • Certified Mail Restricted Delivery Here 8$0,00 Here • Certifled Mail Restricted Deilvery $0.00 • Adult Signature Required $$0.00 • Adult Signature Required 0001 • Adult Signature Restricted Delivery S 40,0031 •Adult Signature Restricted Delivery S Postage Postage 110-910.58 $0.58 06/29/2022 87-37 06/29/2022 Total Posi ZTKR MANAGEMENT LLC, Total i 0410 BERKMAR LEC 27 HUCKLEBERRY HILL C/O NCP MANAGEMENT CO Sent To LINCOLN, MA 01773 Sent i PO BOX 590179 Sireet and NEWTON CENTER, MA 02459 Sireet City, State City, S PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions

U.S. Postal Service™™ CERTIFIED MAIL® RECEIPT Domestic Mail Only Ln For delivery information, visit our website at www.usps.com" USE Certified Mall Fee $3.75 ST NL89 40.00 22 8461 Extra Services & Fees (check box, add foo ge protopylete) • Retum Recept (hardcopy) 10,000 • Return Receipt (electronic) Postmark Here • Certified Mail Restricted Delivery 30.00 • Adult Signature Required $0.00 0001 • Adult Signature Restricted Delivery $ Postage 84-51$0.58 Total Poi 0410 NORTHEASTERN CONFERENCE CORPORATION Sent To SEVENTH DAY ADVENTISTS 115-50 MERRICK BLVD Street an JAMAICA, NY 11434 Chiy, Siat See Reverse for Instructions PS Form 3800, April 2015 PSN 7530-02-000-9047 U.S. Postal Service™™ CERTIFIED MAIL® RECEIPT Domestic Mail Only For delivery information, visit our website at www.usps.com SE 0189 Certified Mall Fee $3.75 22 $0.00 8461 Extra Services & Fees (check box, add foe ge repriate) • Return Recept (hardcopy) 511,00 1 Postmark • Return Receipt (electronic) Here 30.00 • Certified Mail Restricted Delivery • Adult Signature Required $0.00 0001 ] Adult Signature Restricted Delivery $ Postage 87-40-40. 50 0672972022 Total P YANGDON, RIGZIN TRUSTEE OF 0410 SY NOMINEE TRUST Sent Ti 2353 MASS AVE #66 CAMBRIDGE, MA 02140 Sireeti [Cliy, si PS Form 3800, April 2015 PSN 7530-02-000-9047 See Reverse for Instructions

Stock Company * COMMERCIAL GENERAL LIABILITY COVERAGE PART * C * DECLARATIONS * Group * POLICY NUMBER:_PAV0352667 1. NAMED INSURED: DBA NEW CC SIGN INC; NEW CC SIGN INC 2. LIMITS OF INSURANCE - INSURANCE APPLIES ONLY FOR COVERAGE FOR WHICH A LIMIT OF INSURANCE IS SHOWN. 2,000,000 General Aggregate Limit (Other than Products/Completed Operations) $- 2,000,000 Products/Completed Operations Aggregate Limit + 1,000,000 Each Occurrence Limit $. 1,000,000 $. Personal & Advertising Injury Limit $. 100,000 any one premises Damage to Premises Rented to You Limit 5,000 any one person $ Medical Expense Limit LOCATIONS of all premises you Own, Rent, or Occupy 3. Zip State City Address 02169 MA Quincy 1 259 Quincy Ave No. 2 PREMIUM BASIS ADVANCE PREMIUM RATES Prod/CO All Other All Other Prod/co Code / Exposure 4. CLASS ** 153.00 109.00 11 ginations are Numbered to coverage apples to the ponding Lot o No. 2 Bldg 1 98993 Sign Erection, Installation or Repair 36.00 Included Incl 0.299 s) 120,000 No. 2 Bldg 1 58408 Printing - Other than Not-For-Profit +PRODUCTS-COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT 50.00 Included 50.000 No. 2 Bldg 1 Additional Insured- CG2011 100% FULLY EARNED No. No. * If Classifications are Numbered, the coverage applies to the corresponding Location No. TOTAL: $ 348.00 (m) admissions - per 1000 (e) each (c) total cost - per $1000 (s) gross sales - per $1000 (u) units (0) other (a) area - per 1000 sq. ft. (P) payroll - per $1000 (t) see classification notes in company or ISO Commercial Lines Manual Policy may be AUDITABLE 5. 6. SPECIFIC GENERAL LIABILITY FORMS/ENDORSEMENTS As per S1007 [12-001 This page alone does not provide coverage and must be attached to a Commercial Lines Common Policy Declarations Common Policy Conditions, Coverage Part Coverage Forms) and any other applicable forms and endorsements. Page 1 of 1 S2000 (06/01)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty Mutual. INSURANCE INFORMATION PAGE AR 175 Berkeley Street Boston, MA 02116 27243 Issued by IM INSURANCE CORPORATION Issuing Office 016C WC5-31S-389517-022 Policy Number 03-23-22 WC5-31S-389517-021 RENEWAL OF: Issue Date Sub Account 0000 Account Number 1-389517 1. Insured and Mailing Address NEW C C SIGN INC 000972540 RISK ID 259 QUINCY AVE QUINCY, MA 02169 Status 03 - CORPORATION Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 04-04-2022 to 04-04-2023 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: each accident Bodily Injury by Accident $ 1,000,000 policy limit 1,000,000 Bodily Injury by Disease $ each employee Bodily Injury by Disease 1,000,000 C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Rate per $100 Premium Basis Total Estimated Annual Code Premium of Remuneration Estimated Annual Remuneration Number Classifications See Extension of Information Page Total Estimated Annual Premium $ $ 500 (MA) Minimum Premium 3,709 Premium will be billed ANNUAL Producer 0004-024848 TAM FINANCIAL ILC 200 LINCOLN ST STE 001 BOSTON MA 02111 WC 00 00 01B (CA) © 1987 National Council on Compensation Insurance,Inc. WC 00 00 01 A Page 1 of 1 All Rights Reserved Ed. 07/01/2011 Insured Copy

06/22/2021 Ricky *Welded 1"x1" galvanized tubing frame Specifications: *Photo install as shown. *Brown Sunbrela fabric DRAWN FILED ID ORDER DATE TITLE JOB 67.5"- Brooklyn Bagel Factory Cambridge [phone removed] Paul Chief 168 Hampshire St. 520" CITY CLIENT TEL ADDRESS COMPANY DATE 197" 43" Client Must Review & Approve all Drawing BEFORE production CLIENT SIGNATURE PRINT NAME The price, specifications and are hereby accepted. CC Sign is authorized to execute the project in this agreement. 41" 41" Awnings 41"

Proposed Existing

41° Awnings 43" 197" PRINT NAME Tha pree, specticatons and are naraby accepted. CC Sign in author ted to execu Ronga. Client Must Review & Approve all Drawing BEFORE production Landlord: _ амін4 м- DATE 12/10/21E CITY 520" CLIENT ADDRESS COMPANY Berkmar LLC Paul Zack Sambucci Cambridge 67.5"- [phone removed] 168 Hampshire St. Brooklyn Bagel Factory Date: I allow New CC Sign install awnings to the building 12/15/21 Approved as noted JOB TITLE DRAWN Provide mounting method to buiding FILED ID ORDER DATE Please provide issued signange & awning permit 108" Ricky Specifications: 11/18/2021 "Brown Sunbrela fabric *Photo install as shown. "Welded 1"x1" galvanized tubing frame

Awning Mounting 1- x 1" Frame 3/9" x 3" Z Bracket 3/8" Tex.

NEW CC SIGN INC. Tel:[phone removed] SIGNAGE INVOICE [phone removed] 9 Quincy Ave. Quincy, MA 0216 mail: [email removed] 03767 Address: CLIENT: Brooklyn Bagel Factory 168 Hampshire St. Cambridge MA 02139 Telephone: Contact Person: [phone removed] Paul Chief Date: • Installation • Delivery • Pick-up 06/22/2021 Storefront Awning Supply & Installation included TOTAL $ 6800.00 Not included permit fee TAX $ DEPOSIT $ • CASH • CREDIT CARI Paul Chief DATE: 6/22/22 ] CHECK NO. SIGNATURE OF CLIENT: BALANCE $ DATE PAID IN FULL: SONATE OF ME SNESON: Lin DATE: 6/22/21 COLLECTED BY:

The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information Name (Business/Organization/Individual): New CC Sign Address: 259 Quincy Ave. Phone #: [phone removed] City/State/Zip: Quincy MA 02169 Are you an employer? Check the appropriate box: Type of project (required): 4. • I am a general contractor and I 1. • I am a employer with 2 6. • New construction have hired the sub-contractors employees (full and/or part-time).* 7. • Remodeling listed on the attached sheet. 2. L I am a sole proprietor or partner- These sub-contractors have Demolition 8. ship and have no employees employees and have workers' working for me in any capacity. Building addition oi comp. insurance.F [No workers' comp. insurance 10.• Electrical repairs or additions 5. We are a corporation and its required.] officers have exercised their 11. Plumbing repairs or additions 3. • 1 am a homeowner doing all work right of exemption per MGL 12. • Roof repairs myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] + Other Sign 13.L employees. [No workers' comp. insurance required.] I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Expiration Date: 04/04/2023 Policy # or Self-ins. Lic. #: WC5-31S-389517-022 City/State/Zip: Cambridge MA 02139 Job Site Address: 168 Hampshire St. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 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. 07/01/2022 Date: Signature: Ricky Zeng [phone removed] Phone #: Official use only. Do not write in this area, to be completed by city or town official. Permit/License # City or Town: Issuing Authority (check one): 10 Board of Health 2 Building Department 3 City/Town Clerk 4. Electrical Inspector 5Plumbing Inspector 6.Other Phone #: Contact Person:

Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) names), addresses) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in City town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the pplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out eact year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial ventur (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111 Tel. [phone removed] or 1-877-MASSAFE Fax [phone removed] Revised 7-2019 www.mass.gov/dia