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Einhorn Building Permit Application The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Dwelling FOR MUNICIPALITY USE Revised Mar 2011 This Section For Official Use Only Building Permit Number: _____________________ Date Applied: ______________________________ ___________________________________ ____________________________________________ ___________ Building Official (Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: ____________________________________________ 1.1a Is this an accepted street? yes_____ no_____ 1.2 Assessors Map & Parcel Numbers _____________________ ____________________ Map Number Parcel Number 1.3 Zoning Information: _______________ ___________________ Zoning District Proposed Use 1.4 Property Dimensions: _____________________ ____________________ 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 Water Supply: (M.G.L c. 40, § 54) Public  Private  1.7 Flood Zone Information: Zone: ___ Outside Flood Zone? Check if yes 1.8 Sewage Disposal System: Municipal  On site disposal system  SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner1 of Record: ________________________________________ _________________________________________________ Name (Print) City, State, ZIP _____________________________________________ _________________ ___________________________________ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction  Existing Building  Owner-Occupied  Repairs(s)  Alteration(s)  Addition  Demolition  Accessory Bldg.  Number of Units_____ Other  Specify:________________________ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $_______ Indicate how fee is determined:  Standard City/Town Application Fee  Total Project Cost3 (Item 6) x multiplier _______ x _______ 2. Other Fees: $_________ List:_________________________________________________ ____________________________________________________ Total All Fees: $_______________ Check No. ______Check Amount: _______Cash Amount:______  Paid in Full  Outstanding Balance Due:__________ 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical (Fire Suppression) $ 6. Total Project Cost: $ 16 Ice Pond Drive, Florence, MA 01062 **no change****no change** **no change** Jennifer Einhorn 16 Ice Pond Drive Florence, MA 01062 646-872-0173 einhorn.jenn@gmail.com X 50,717.00 Brief Description of Proposed Work2:___C _o n__v _e _rt __e __xi _s _ti __n _g __b _a__s _e __m _e __nt __s __p _a _c _e __i _n _t _o _ f __a __mi _l _y _ r __o _o __m _. ___________ ___S _e __e __at _t _a _c__h _e _d___w _o _r _k _ l _i _s _t __a _n _d__d_r __a _w _i _n __g _______________________________________________________ _______________________________________________________________________________________________ . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) ________________________________________________________ Name of CSL Holder _________________________________________________________ No. and Street _________________________________________________________ City/Town, State, ZIP _________________________________________________________ __________________ ______________________________________ Telephone Email address _____________________ ______________ License Number Expiration Date List CSL Type (see below) _______________ Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation D Demolition 5.2 Registered Home Improvement Contractor (HIC) ______________________________________________________________ HIC Company Name or HIC Registrant Name ______________________________________________________________ No. and Street ________________________________________ ____________________ City/Town, State, ZIP Telephone _____________________ ______________ HIC Registration Number Expiration Date _______________________________________ Email address 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 ……….  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_____________________________________________________ to act on my behalf, in all matters relative to work authorized by this building permit application. ______________________________________________________ ______________________ Print Owner’s Name (Electronic Signature) Date SECTION 7b: OWNER1 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. _____________________________________________________________ ______________________ 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” Stephen Greenwald Stephen Greenwald PO Box 272 PO Box 272 Turners Falls, MA 01376 Turners Falls, MA 01376 413-863-8316 413-863-8316 info@renbuild.net info@renbuild.net 199409 CS-013302 8/17/2023 U 8/23/2022 X **see attached signature page** 7/11/2022 PO BOX 272, TURNERS FALLS, MA 01376, 413.863.8316 INFO@RENBUILD.NET, WWW.RENBUILD.NET February 4, 2022 Jennifer Einhorn 16 Ice Pond Drive Florence, MA 01062 Work List to Convert Existing Basement Space into Family Room, Approximately 640 Square Feet, at Above Address. Scope to include the following: • Insulate exterior concrete walls and new interior walls. • Frame and finish soffits to conceal duct work. • Finish all walls with drywall. • Install lay-in acoustic tile ceiling. • Construct closet under existing stairs. 1000 GENERAL CONDITIONS 1020 Permits A. Supply all building permits as required. 1300 Project Management A. Provide copy of current Construction Supervisor’s License. B. Provide shop drawings, samples, color choices, and/or selection charts as needed for Owner’s approval. C. Coordinate operations under different sections that are dependent on each other for proper installation and operation. D. Notify Owner as necessary when scheduled work will impact occupied portions of the premises. E. Site investigation and plan development, final scope of work, and design. 1310 Supervision A. Provide supervision at all phases of construction performed or subcontracted by Renaissance Builders. 1400 Warranty A. Supply certificate of liability (minimum $ 2 million) and Worker’s Compensation Insurance. B. All work performed or subcontracted by Renaissance Builders to be guaranteed for one year. Einhorn Work List Page 2 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #199409 4/5/2022 1530 Temporary Protection A. Protect completed work in progress to ensure protection from damage or deterioration until substantial completion of project. 1570 Winter Conditions A. Owner responsible for all snow plowing and sanding as necessary to ensure safe access to the work area. Owner will be billed for cost of snow removal and/or sanding by Contractor if it is required for safe and/or timely access. 1730 Cleanup & Trash Disposal A. Clean up all debris and leave the job site broom clean at completion of all work. B. Legally dispose of all debris. 1950 Owner Responsibilities A. Cost of electricity and water during construction. B. All other phases not specifically outlined in this Proposal. 2000 SITE WORK 2225 Demolition, Interior A. Cut openings as necessary for new electrical work. 5000 METALS 5160 Steel Studs A. Soffits to be constructed using 20 Ga x 1-5/8” steel stud framing system. B. All framing to be to be 16” o.c. 6000 WOOD & PLASTICS 6110 Floor Framing A. Install ¾” Dricore panels over existing concrete floor. 6120 Wall Framing A. Frame perimeter walls and demising wall from remainder of cellar using 2” x 4”, 16” o.c. B. Sill plates to be pressure-treated with Dow foam sill sealer. 6220 Casing & Base A. Window and door casings to be 1” x 4” S4S paint grade. B. Base moulding to be 1” x 6” S4S paint grade poplar. 6430 Wood Stairs & Railings, Finish A. Install yellow pine treads and poplar risers on existing stairs. 7000 THERMAL & MOISTURE PROTECTION 7200 Insulation, Vapor Barrier A. Concrete walls to have 3” of polyisocyanurate foam (R-21) from top of slab to top of wall. B. All demising walls to have 3-1/2” rock wool (R-14). 8000 DOORS & WINDOW 8200 Doors, Interior A. Interior hinged doors to be 1-3/8” Brosco 6-panel pine, #M1051. B. Interior bifold doors to be 1-1/8” Brosco raised panel pine. Einhorn Work List Page 3 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #199409 4/5/2022 C. Interior door sizes and quantities as follows: Quantity Size Type Jamb 2 3’-0” x 6’-8” Hinged, raised panel pine Clear pine rabbeted 1 2’-4” x 6’-8” Hinged, raised panel pine Clear pine rabbeted 1 8’-0” x 6’-8” Bifold, raised panel pine Clear pine flat 9000 FINISHES 9200 Sheetrock & Plaster A. All walls and soffits to have ½” moisture resistant drywall. B. All joint tape to be fiberglass mesh type, applied using Durabond dry mixed compound. C. Finish all drywall with three coats of joint compound, sanded smooth. 9500 Acoustic Ceiling A. Install Chicago Metallic grid system. B. Install Armstrong 2’ x 2’ lay-in ceiling tile, per allowance. 9620 Specialty Flooring A. Install LVT flooring per manufacturer’s instructions in the entire area, per allowance. 9920 Paint, Interior A. Fill all nail holes with non-shrink putty. B. All new interior walls and ceilings to receive one coat of Benjamin Moore Fresh Start® MoorWhite®, Sherwin Williams, or equivalent primer sealer. C. Interior walls to receive two coats of Benjamin Moore, Sherwin Williams , or equivalent flat acrylic paint. D. Interior ceilings to receive two coats of Benjamin Moore, Sherwin Williams , or equivalent ceiling paint. All ceilings to be the same color. E. Standing and running trim, door and window casings, millwork, and interior doors each to receive a total of three coats of Benjamin Moore, Sherwin Williams, or equivalent latex paint. 16000 ELECTRICAL 16100 Electrical Wiring A. Install a total of 12 outlets in interior to comply with Massachusetts code. B. Install ten (10) 6” LED wafers in ceiling. C. Install 8 linear feet of electric baseboard with wall mounted thermostat. END WORK LIST The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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/Individual):_________________________________________________ _ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 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 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:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ 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 perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: ___________________________________ Permit/License #_________________________________ Issuing Authority (check one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:_________________________________ Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13. Other____________________ 1. I am a employer with _________ employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] Renaissance Builders P.O. Box 272 Turners Falls, MA 01376 413-863-8316 25 AIM Mutual Insurance Co. MCC20020004972022A 08/01/2022 16 Ice Pond Drive Florence, MA 01062 7/22/2022 413-863-8316 Webber & Grinnell 8 North King Street Northampton MA 01060 Andrea Feeley, CISR (413) 586-0111 (413) 586-6481 afeeley@webberandgrinnell.com Gill Building Corporation DBA: Renaissance Builders PO Box 272 Turners Falls MA 01376 Arbella Protection 41360 MA Employers/A.I.M.12886 Exp 8/2022 A 8500066134 08/01/2021 08/01/2022 1,000,000 100,000 5,000 1,000,000 2,000,000 2,000,000 A 1020057016 08/01/2021 08/01/2022 1,000,000 Underinsured motorist BI split limit 250,000 A 10,000 4620085703 08/01/2021 08/01/2022 9,000,000 9,000,000 B N MCC20020004972022A 01/01/2022 01/01/2023 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 7/22/2022 Jennifer Einhorn & Debbie Krivoy 16 Ice Pond Drive Florence, MA 01062 AFFIDAVIT FOR DISPOSAL OF DEMOLITION DEBRIS Supplement to Permit Application As a result of the provisions of MGL c. 40, s54, I acknowledge that as a condition of the issuance of a Building Permit, all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c. 111, s150A. I certify that debris resulting from this demolition will be disposed of as listed below: Job Site Location: Name of Permit Applicant: Renaissance Builders Disposal Facility: F & G Recycling Address of Facility: 15 Mullen Rd., Enfield, Ct 06082 IF SAID FACILITY IS OTHER THAN WHAT I HAVE LISTED, I CERTIFY THAT I WILL NOTIFY THE BUILDING OFFICIAL OF THE CORRECT LOCATION OF THE SOLID WASTE DISPOSAL FACILITY WITHIN TWO MONTHS OF THE DATE OF THIS APPLICATION. Signature of Applicant Date 16 Ice Pond Drive, Florence, MA 01062 7/22/2022