Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
04-010 (7)
BP-2022-0686 640 KENNEDY RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 04-010-001 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-2022-0686 PERMISSIONIS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 7000 SEAN BRADSHAW 108517 Const.Class: Exp.Date: 12/10/2022 Use Group: • Owner: HUBBELL EVERHART, CARLY &MADELINE Lot Size (sq.ft.) Zoning: WSP Applicant: BRADSHAW ENTERPRISES LLC Applicant Address Phone: Insurance: 246 CONNECTICUT AVE (413)250-4746 A0158300004 SPRINGFIELD, MA 01 104 ISSUED ON:06/10/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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` , r i 3-11 •� i Fees Paid: S65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner w,_r l'773 The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR .k311 Massachusetts State Building Code,780 CMR MUNICIPALITY USE 7- Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 4011 E C E I V E[.) One-or Two-Family Dwelling This for Official Use Only Buildtng.PerrltttNumber: f i?; Date'Applied: JUN - 9 2022 pawing official(Print.Name) Signature Date , . � D[r^T.OF BUILDING INSPECTIONS . SEC'ITON I:SiT)✓INFORMATION NORTHAMPTON.MA 01060 1.1 40 Kennedy ti ,Add., A Road 1.2 Assess rs Ma &Parcel Nam e 640 Kennedy Road,Northampton Ma �' ` p 1.1a Is this an accepted street?yes x no Map Number Parcel Number 13 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 N/A N/A N/A N/A N/A N/A 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 0 On site disposal system ❑ Check if yes❑ S eTION 2 PROPERTY OWN IflP'. 2.1 Owner'of Records Madeline Hubbell Northampton Ma 01053 Name(Print) City,State,ZIP 640 Kennedy Road No.and Street Telephone Email Address SECTION 3 11ESCRIPTIQN OE PROPOSED WORK?(cheek all that apply) New Construction 0 Existing Building Ut Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Gd Specify:Insulation MassSave Brief Description of Proposed Work2:Adding blown cellulose to attic flat to achieve an aggregate R-49.Please see attached work work order. SECTION 4 EST• IMATED CQNSTRUCTION-COSTS Item Estimated Costs: ' (Labor and Materials) Official Use Only 1.Building $ 7000 .1 Building Permit Tee:$ Indicate how fee is determined: 2.Electrical $ l 0 Standard City/Town Application Fee ❑'Total:Project Cost'(Item 6)x.muttipiier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ jj ' 7000 Check No2`12' eck Amount:Le (-1‘."- Cash Amount: 6.Total Project Cost: $ b Paid-inFuli • 0 Ontstanding::Balance Due: 'SECTION 5 CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 106517 12/10/2022 Sean Matthew Bailey Bradshaw License Number Expiration Date Name of CSL Holder List CSL Type(see below) 246 Connecticut Ave No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Springfield,MA,01104 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-250-4746 Sean@BradshawEnterpisesLLC.com I Insulation Telephone Email address D Demolition 5.2 Registered Rome Improvement Contractor(HIC) 194456 02/07/2023 Bradshaw Enterprises,LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name Sean Matthew Bailey Bradhsaw Sean@BradshawEnterpisesLLC.com No.and Street Email address 246 Connecticut Ave,Springfield,MA 01104 413-250-4746 City/Townt 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 2 No ❑ OWNER;AUTHORI ATIONTO$E COMPLCOMPLETEDCOMPLETEDWHEN S)gCTT©N 7a,. OWNER'S AGENT OR CONTRACTQR:APPLIES FOR BUILDING,PERMIT • I,as Owner of the subject property,hereby authorize Bradshaw Enterprises,LLC to act on my behalf,in all matters relative to work authorized by this building permit application. Please see attached customer signature authorization form provided MassSave. Print Owner's Name(Electronic Signature) Date SECTION 7h OWNER'•ORAUTHORIZED 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 ct of my lrnnwlMar anti nntloretanrlino dodoop verified eaor,Ozadd/wei 06/06/22 1138 AM EDT Sean Bradshaw authorized Agent 6NKP-AHOE 46H7-Kf IG 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" /...O'� BRADENT-01 BROOKE A�/R� CERTIFICATE OF LIABILITY INSURANCE DATE D/1VYY) 9/1/2021 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 Brooke Barre NAME: Phillips Insurance Agency,Inc. PHONE FAx 97 Center Street (NC,No,Eat):(413)594-5984 (aC,No):(413)592-8499 Chicopee,MA 01013 EADD -MAREss:brooke@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A_Middlesex Insurance Company INSURED INSURER B:Sentry Insurance - 24988 _ Bradshaw Enterprises,LLC INSURER C: PO Box 944 INSURER D: Chicopee,MA 01021 --- 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 S HOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD WVD IMMIDD/YYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ _—__ CLAIMS-MADE i X l OCCUR A0158300 8/12/2021 8/12/2022 DAMAGE TO RENTED 500,000 PREMISES(RENTlr[dncd) S MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMITq�APPLIES PER: '� GENERAL AGGREGATE $ 3,000,000 POLICY I X JECT 11,LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ed accident) _ _. _$ X ANY AUTO A0158300003 8/12/2021 8/12/2022 BODILY INJURY(Per person) $ OWNED ISCHEDULED AUTOSIgE�ONLY AUUTNOSW�.�Ep BODILY INJURYiPer accident) $ AUTOS ONLY AUTO ONLY II PROPERTY acEcidentDAMAGE - $ A X $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE A0158300 8/12/2021 8/12/2022 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B ANDEPLYRSE COMPENSATION X SAUTE ERH WORKERS i_YINiA0158300004 8/12/2021 8/12/2022 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE -�'N/A OFFICER/MEMBER EXCLUDED? Y E.L.EACH ACCIDENT $ (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE,$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Town of East Longmeadow THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' 9 ACCORDANCE WITH THE POLICY PROVISIONS. 60 Center Square East Longmeadow,MA 01028 — AUTHORIZED REPRESENTATIVE ,ll''LyY I, , ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Suite 100 zy Boston,MA 02114-2017 ,a' www.mass.gov/dia Tt i5.+ Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/Organizational/Individual):Bradshaw Enterprises, LLC Address: 34 Front St Indian Orchard Mills Suite G60 City: Springfield State: MA Zip: 01051 Phone#: 413-250-4746 Are you an employer?Check the appropriate box: Type of project(required): ✓ 1. I am an employer with 11 employees(full and/or part time)' 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in any ri 8. Remodeling capacity.(No workers'comp.insurance required.] 719. Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required]± 10. Building addition —14. I am a homeowner and will be hiring contractors to conduct all work on my property. 11. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs sheet. These sub-contractors have employees and have workers'comp.insurance.± —^ 6, We are a corporation and its officers have exercised their right of exemption per MGL. I J 114. Other C.152,§1(4),and we have no employees.[No workers'comp.insurance required.] III `Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy information. +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 attach 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. !am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. Insurance Company Name: Sentry Insurance (Agent- Phillips Insurance 413-594-5984) Policy#or Self ins.L c.#: A0158300004 8/12/2022Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL.c.152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 !do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the field below will act as my signature. Name: Sean Bradshaw Date: 9/29/20 Phone#: 413 250 4746 Email: sean@bradshawenterprisesllc.com Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 194456 BRADSHAW ENTERPRISES, LLC Expiration: 02/07/2023 246 CONNECTICUT AVE SPRINGFIELD, MA 01104 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 194456 02/07/2023 1000 Washington Street -Suite 710 BRADSHAW ENTERPRISES,LLC Boston,MA 02118 SEAN M.BRADSHAW 34 FRONT STREET SPRINGFIELD,MA 01151 Undersecretary Not valid without signature ,le r%l�ii4/1/('rift,e(76! 1 ./f/,eleAill %4.)K,ff' Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement.Gantractor Registration •_.,,t.- r-.9:,1 TYPE: LLC Registration: 194456 BRADSHAW ENTERPRISES,LLC .'``'t'"4 4—"= �� Expiration: 02/07/2021 246 CONNECTICUT AVE Sz `= k=`. , SPRINGFIELD,MA 01104 ' tl' -` (/� { Update Address and Return Card. :CA I a 2OM+Os,7 • .J/ri 'i:iivnrnirr r4/'r/.G�q iiv.4,Wr/6 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 194456 02/07/2021 1000 Washington Street•Suite 710 BRADSHAW ENTERPRISES,LLC Boston,MA 02118 SEAM M.BRADSHAW 34 FRONT STREET SPRINGFIELD,MA 01151 Underr retary Not V-.# without 51• ature A� i't a i n ; . ,, : x fVe..F4;c a o, : r t g +tn s * . y .F b7d;+ 1 Y �� ay #i xAl': -.. .y ' { y"z�! 'fi � ° , "0 *A��' r`x,iN„ aY�n�. ar! U r r i . sA „t s , , _ 7 A � ^ � rrS ;..t h� .� °:sz ; t ns ,e.k'�r�'� t .,,.. . _k ltiksiti%, „ri +y ,p.R�rY ;. 4'1- -1 �� 1 i p� "° v to ii e u• ,, I d*}r c 42".,:. y n•1w .+.. ..2 Slay :.4 , ='lei , . :.i.,7 1 DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of MGL c.40,s.54,is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.111, s.150A. ANY AND ALL DEBRIS PROUCED AS A RESULT OF WORK PERMITTED UNDER THE ATTACHED APPLICATION WILL BE DISPOSED OF IN: USA Waste Recycling Name of Licensed Solid Waste Disposal Business/Facility 15 Mullen Rd, Enfield CT 06082 Address of Licensed Solid Waste Disposal Business/Facility USA Waste Recycling Name of Hauler Sean Bradshaw 9/20/2020 Print Applicant Name Date ❑ I,Sean Bradshaw do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the field above will act as my signature. BRADENT-01 BROOKE ,4CoRO CERTIFICATE OF LIABILITY INSURANCE DATE 9/1/2 DIYYYY) 9/1/2021 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 Brooke Barre NAME: Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (NC,No,Ext): (413)594-5984 (A/C,No):(413)592-8499 Chicopee, MA 01013 Al oRlEss:brooke@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Middlesex Insurance Company INSURED INSURER B:Sentry Insurance 24988 Bradshaw Enterprises,LLC INSURER C: PO Box 944 INSURER D: Chicopee,MA 01021 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI IMMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR A0158300 8/12/2021 8/12/2022 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY x PE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO A0158300003 8/12/2021 8/12/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNED ONLYY PROPERTY accident DAMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE A0158300 8/12/2021 8/12/2022 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N A0158300004 8/12/2021 8/12/2022 STATUTE ER 1,000,000 ANY OFFICER/MEMBER/EXCLUDED?ECUTIV E v N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 Town of East Longmeadow THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 60 Center Square East Longmeadow,MA 01028 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) O ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD dotloop signature verification:dtlp.us/StSv-3BgT-Hw3K1 The Commonwealth of Massachusetts "-mot Department of Industrial Accidents rt ( 1 Congress Street,Suite 100 t$� Boston,MA 02114-2017 4 ,, www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/organizational/Individual):Bradshaw Enterprises, LLC Address: 34 Front St Indian Orchard Mills Suite G60 City: Springfield State: MA Zip: 01051 Phone#: 413-250-4746 Are you an employer?Check the appropriate box: Type of project(required): • [y 1. 1 am an employer with 1 1 employees(full and/or part time)* ri 7. New construction •7 2. I am a sole proprietor or partnership and have no employees working for me in any 8. Remodeling capacity,[No workers'comp.insurance required.] l l 9. Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance requiredit ` 110. Building addition — 1 4. I am a homeowner and will be hiring contractors to conduct all work on my property. 11. Electrical repairs or additions 1— I will ensure that all contractors either have workers'compensation insurance or are _ sole proprietors with no employees. 12. Plumbing repairs or additions U5. I am a general contractor and I have hired the sub-contractors listed on the attached H13. Roof Repairs sheet. These sub-contractors have employees and have workers'comp.insurance.± 16. We are a corporation and its officers have exercised their right of exemption per MGL. J 14. Other c.152,§1{4),and we have no 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. tHomeowners 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 attach an additional sheet showing the name of the sub-contractors and state whether or not those entitles 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: Sentry Insurance (Agent - Phillips Insurance 413-594-5984) Policy#or Self-ins.Lic.#: A0158300004 8/12/2022Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL.c.152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the WA for insurance coverage verification. 11/ I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the field below will act as my signature. Name: Sean Bradshaw Date: 9/29/20 Phone#: 413-250-4746 Email: sean@bradshawenterpriseslIc.com CLEAResult CONTRACTOR WORK ORDER Mass Save® Home Energy Services 50 Washington St.Suite 3000 Westborough,MA 01581 Customer Name:MADELEINE HUBBELL Bradshaw Enterprises LLC Email:madeleine.hubbell@gmail.com PO Box 1276, Phone:617-417-1055 Chicopee,MA,01021 Premise Address:640 Kennedy Rd,Northampton,MA 01053 413-301-8010 Project ID:4447903 Location Measure Description Quantity Unit Unit Cost Total Cost Living Space Attic Floor- 10"Open Blow Cellulose 638 SF $1.90 $1,212.20 Living Space Kneewall Floor- 10"Open Blow Cellulose 126 SF $1.90 $239.40 Living Space Propavent 24 each $4.16 $99.84 Living Space Kneewall Wall-2"Thermal Barrier Polyiso 632 SF $4.78 $3,020.96 Living Space Hatch-2"Thermal Barrier Polyiso 3 each $46.28 $138.84 Living Space Damming 150 each $2.39 $358.50 Living Space Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $92.58 $555.48 Living Space Transition Air sealing 125 LF $6.84 $855.00 Contractor Project Adder Fee 648 each $1.00 $648.00 Installed Measures Total $7,128.22 WorkOrder Notes Utility Incentive and Customer Share Information Utility Incentive Weatherization incentive $3,802.31 Air sealing incentive $2,058.48 Total Utility Incentive $5,860.79 Customer Share Total Customer Share $1,267.43 Less Deposit Of $422.48 Customer Share Balance $844.95 Page 1 of 1 4fekPermit Authorization mass save Form Site ID: 4419625 Customer: MADELEINE HUBBELL Madeleine Hubbell I, ,owner of the property located at: (Owner's Name,printed) 640 Kennedy Rd Northampton, MA 01053 (Property Street Address) (Cty) 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. HadeleiRe //�� „ Owner's Signature: U J�,(� Date: 03/27 /2022 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only Document Ref:VASMY-PQ4SI-ADIFI-ERQOT Page 6 of Commonwealth of Ma' sachusetts D:vision of Professional Licensure Board of Building Regulations and Standards ConstruCtiOn Supervisor CS - 108517 fires : 12/ 10/ 2022 SEAM MATTHEW BAIL BRADSHAW 246 CONNECTICUT AVENUE #;5 SPRINGFIELD MA 01104/111%/41, 1 Commissioner (jai? A'. ►� ... Bradshaw Enterprises, LLC PO. Box 944 Chicopee, MA 01021 Hello Building Department We are Bradshaw Enterprises, LLC located in Indian Orchard, MA. We are an Insulation / weatherization contractor for MASS SAVE. Enclosed in this packet is our Permit application and supporting documentation as follows: -Application -HIC Registration -Insurance Certificate -Signed customer Authorization form or copy of signed contract -Construction Supervisor License -Worker's Compensation Insurance Affidavit -Pre stamped return envelope We hope you find this packet intact and convenient. If you have any questions or concerns please call or email at 413-250-4746 Sean Bradshaw 413-301-8010 Office phone Email: Sean@BradshawEnterprisesLLC.com