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29-091 (4) BP-2022-0606 38 BRIERWOOD DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-091-001 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-2022-0606 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 2500 HOME ENERGY SOLUTIONS INC 106188 Const.Class: Exp.Date: 12/28/2023 Use Group: Owner: J. CROW-BILADEAU,ELIZABETH Lot Size (sq.ft.) Zoning: WSP Applicant: HOME ENERGY SOLUTIONS IC Applicant Address Phone: Insurance: 233 COLLEGE HWY (413)203-2454 0 HOWC 140654 SOUTHAMPTON, MA 01073 ISSUED ON:05/31/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/W E ATH ER I Z ATI ON POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I • 1 • Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner J i!l(Yy City of Northampton Building Department A � 212 Main Street _ NSULATION Room 100 MAY 2 7 Northampton, MA 060 phone 413-587-1240 Fax 13-587-1272 QI.1JL_ hcnT n I DINr INc.,. APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 SITE INFORMATION INSULATION PERMIT T This section to be completed by office 1,1 Property Address: Map Lot iJ Unit } 7one Overlay District —_-- 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ElizabelhCrow Biladea 38 Brierwood Dr Florence, MA 01062 Nar.+t'(Print) Current Mailirig Address: 413-923-2233 Attached Telephone Signature 2.2 Authorized Aaent: Shawn Mitchell 233 College Hwy Southampton MA, am_ Name(Print) Current Mailing Address: i 413-203-2454 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2500 (a)Building Permit Fee 2. Flectr ral (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee (14 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 2500 Check Number < /� b n r,This Section For Official Use Only Building Permit Number: `'1 0 � Date Issued: Signature: ✓ & 5 27 Z0z2 Building Commissionerilnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder. Shawn Mitchell 106188 License Number 6 Russellville Rd 12/28/23 Address Expiration Date 413-203-2454 Signature Telephone 9. Registered Home Improvement Contractor. Not Applicable E Home Energy Solutions Inc. 193885 Company Name Registration Number 233 College Hwy Southampton MA, 01073 12/4/22 Address Expiration Date Telephone 413-203-2454 SECTION 5-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 ' No 0 'Brief Description of Proposed Work NOTE: INSULATION ONL Y Blown in insulation and air sealing 1, Shawn Mitchell , 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 penalties of perjury. Shawn Mitchell Print Name 7s i 5/6/22 Signature of Owner/Agent Date I, Elizabeth..C.row Biladea , as Owner of the subject property hereby authorize Shawn Mitchell to act on my behalf, in all matters relative to work authorized by this building permit application. Attached 5/6/22 Signature of Owner Date City of Northampton Massachusetts l�`� , DEPARTMENT OF BUILDING INSPECTIONS err 212 Alain street • Municipal Building a r Northampton, MA 01060 A J" 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, 5 150A, The debris will be disposed of in: Location of Facility: Springfield, MA The debris will be transported by: Name of Hauler: Waste Management Signature of Applicant: I goe Date: 516122 The Commonwealth of Massachusetts =� Department of Industrial Accidents "1 = t Office of Investigations is :IN- , „ �-- Lafayette City Center ,r 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 tBusiness'orgsnization!lndividualj:Home Energy Solutions Inc Address:2 3 oll e H City/State/Zip: Southampton, MA 01073 Phone #: 413-203-2454 Are you an employer?Check the appropriate box: Type of project(required): 1.V I am a employer with 5 4, 0 1 am a general contractor and I employees (full andior part-tittle). have his: the sub-contractors 6. D New construction 2.G I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance,: required.] 5 © We are a corporation and its 10.0 Electrical repairs or additiot 3.❑ I am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additiot myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] ' c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.) , *Any applicant that checks box M 1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit tins affidavit indicating they are doing all work and then hire outside contr>lctors heeler submit a new affidavit indicating such Contractors that check this box must atta;hs l an additional sheet showing the name of the sub-contractors anti state whether or not those entities have employees, if the sub-contractors have employees,the 'mat provide their workers'comp.policy number. I um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site information. Insurance Company Name:AmGaurd Insurance Company Policy#or Self-ins. Lie. a: HOWC361807 Expiration Date; 01/04/2023 Job Site Address. 38 Brierwood Dr City/State/Zip:Florence, MA 01062 Attach a copy of the workers' compensation policy declsratlor page showtng the policy neabet 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fi: of up to S250,00 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 an ' I e pains and penaltie try that the information provided above is true and correct. i at•t _-_• .__ _✓ Date: 5l6/22. s lH4 t'hOne#: 413-203-2454 _...._.. Official use onlyy. Do not write in this area, to be completed by city or town official. City or Town: Permit/license Issuing Authority(cheek one): 1©Board of Health 20 Building Department 31:City/Town Clerk 4.0Electrical Inspector 5E'lumbing Inspector 6.DOtht'r Contact Person: Phone a: R ISE ENGINEERING" OWNER AUTHORIZATION FORM I, Elizabeth Crow Biladea (Owner's Name) owner of the property located at: 38 Brierwood Drive (Property Address) Florence, MA 01062 (Property Address) hereby authorize Subcontractor(to be filled in by office) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform 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. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. '. ' / AO I / Owner's !nature 5 • 9 • 2DZ Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com