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29-221 (8) BP-2023-0037 112 ACREBROOK DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-221-001 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-2023-0037 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 23 Contractor: License: Est. Cost: 4793 BRYAN HOBBS CS-083982 Const.Class: Exp.Date: 05/02/2024 Use Group: Owner: PATRICIA HATHAWAY RAYMOND L& Lot Size (sq.ft.) Zoning: WSP Applicant: BRYAN HOBBS REMODELING LLC Applicant Address Phone: Insurance: PO BOX 1535 (413)775-9006 WC9057270 GREENFIELD, MA 01301 ISSUED ON: 01/12/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI 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: 10 • f I 1 Cwp1.'ll�J( r a 1�r, .52 Y Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner r .--- I__ 0. t. n1 /StJlL 1- 1971 o The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR fj Massachusetts State Building Code, 780 CMR 1vIUNICIPALhY USE a Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building PermitWeuif-i Numbg35s r: )3 3 7 Date Applied: i /4/2 I-1Z-201 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Ila Ac - brtxN1.` ---- ' 1.1a 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 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 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 Owners of Record:` (l Name(P 'nt) City,State,ZIP \1-1 AcarebrWL -0 '-IPPr5gto -cyluq yAhco-hawc Q5rncU.0.c,.,-Y, 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 Specify: (Joef +hi epr Q,9)0i Briefn ass J Description of Proposed Work':Q �,, I�-i 9 ,, CI)q gi rl r ' 01s)-; 'Q.).3 t(io- 2'1 \'c�_ pk,0 C._om UY141ail� Z.1 (24A`1Lc, Q kta_ Z." li l io I iv i2l.�Ll�.i , diogk AJE t 11" �fl 7d e i CA,V.I% , It-riot we-1‘ \r 1 our, k OA 'l Qj LCp.lt. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ Llici 3, �+ 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fe'essp$ Check No.!f D✓ Check Amoun Cash Amount: 6. Total Project Cost: $ 19 5. 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 08 cT1 C _s�.� ,J 1-14., License Number Expiration Date Date ame o CSL Holder ?Co ," ,2)c-- List CSL Type(see below) U No.and Stre Type Description ereenVkl.Q �� a\.�„� U Unrestricted(Buildings up to 35,000 cu.$.) City/Town,State,ZIP tJJ R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding i 1 SF Solid Fuel Burning Appliances 1-I)5 7)C.- 9i 1 n�p'�. 0 1 `f•] _i S'(Y I Insulation Telephone Entail address c. n D Demolition Registered Home Impro mennt Contractor(HIC) q��— �.Q,,Expiration X4 HIC Registration Number Expiration Date NamIC egistrant Namenr — Inne anhse r ia.�J� CAys, PSl U�i s Str en. 0' t/Jy /r)1 9�e Email add es tty/Town,State,ZIP)4 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 provid this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 7 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: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 ained in this a plication is true and accurate to the best of my knowledge and understanding. rh 9\Zzz-c - wne '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" RISES ENGINEERING- OWNER AUTHORIZATION FORM l Raymond Hathaway (Owner's Name) owner of the property located at: 1 1 2 Acrebrook Drive (Properly Address) Florence, MA 01062 (Property Address) hereby authorizeb'` ��t�1 T ►l_4j IY1,UAL3 k,U (Subcontractor) (J 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. Owne s Signature - /b - Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com Office of Consumer »lid du�nw iingutation aoa0uwat-aul�rlo , . eo�on,iW� 0110 Home lmpmw nlnt Convector ILO BRYAN HOBBS MODELING,LLD, Rea P,O.BOX IWO EREEEPIELD.MA 111392 pdeMAtilNNerN1(1r1 ant efflifiellkatilairNOWMI A( i au tlon megr YtB W . CP'Wa ,MISagensA . BRYAN MBE REMODELSN%,LLD. ERYAMHDBBS I � valliltiifieIm • 6. ComnonyNealth of PAaSsachusetts ___'' Division of Occupational Licensure Board of Building Re uicaattiions and Standards NA CS-083982 .cy "" BRYAN 0 H CBS Aires:O;i/O P2024 POBOX 1s 5 GREENFIELIyA 01302 • rill .: 1r; Commissioner r.f cL / .� . L7<ss7r.�.Pa., (.l'N The Commonwealth of Massachusetts Department of Industrial Accidents 9 y .,f�l Office of Investigations I° Lafayette City Center �t;' 2Avenue de Lafayette, Boston,MA 02111-1750 `'"=6 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bryan Hobbs Remodeling, LLC Address:576 Leyden Rd Po Box 1535 City/State/Zip:Greenfield, Ma 01302 Phone #:413-775-9006 Are you an employer? Check the appropriate box: Type of project (required): 1.Q I am a employer with 7 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. 0 Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ID Building addition [No workers' comp. insurance comp. insurance. t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 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.❑■ Other Weatherization 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. tContractors 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:Selective Insurance Company Policy#or Self-ins. Lic. #:WC9057270 Expiration Date:1 0/20/2023 Job Site Address:'\a kir x u,u._ Or- City/State/Zip: c`OCC'(1C2 , � 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 hereb :fy under the ins and penalties of perjury that the information provided above is true and correct. Signature: ( C,ep Date: i \ci\D3 Phone#: 413-775-9006 I 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 5alumbing Inspector 6.0Other Contact Person: Phone#: AC€ RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/24/2022 I 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 Adina Edgett,CISR Webber&Grinnell PHONE (413)586-0111 FAX (A/C,No,Ext): (A/C,No) (413)586-6481 8 North King Street E-MAILSS: aedgett@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: Selective Ins Co of S Carolina 19259 INSURED INSURER B: Selective Ins Co of America 12572 Bryan Hobbs Remodeling,LLC INSURER C: Selective Ins Co of Southeast 39926 PO Box 1535 INSURER D: Evanston/XS Brokers INSURER E: Greenfield MA 01302-1535 INSURER F COVERAGES CERTIFICATE NUMBER: LIAB EXP 8/2023 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 ADDL SIJbR POLICY EFF LTR TYPE OF INSURANCE INSD W MMIDD/YYYYVD POLICY NUMBER POLICY EXP X COMMERCIAL GENERAL LIABILITY { ) (MMIDDIYYYY} LIMITS 1 000,000 EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A S2289042 08/04/2022 08/04/2023 PERSONAL E.ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 2,000,000 X POLICY JE o LOG 2,000,000 PRODUCTS-COMP/OP AGG_ $ — OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ B �— OWNED SCHEDULED A9105300 08/04/2022 08/04/2023 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS XHIRED 'se NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /'s AUTOS ONLY (Per accident) _ _ Underinsured motorist BI $ 20,000 X UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-NAPE S2289042 08/04/2022 08/04/2023 AGGREGATE $ 2,000,000 DED I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTNE JYY N NIA WC9057270 10/20/2022 10/20/2023 E.L.EACH ACCIDENT $ 1,000,000 C OFFICER/MEMBER EXCLUDED? I 11,000,000 (Mandatory in NH) E.L.DISEASE•EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT • $ Per Occurance $250,000 Pollution Liability D CPLMOL109637 01/19/2022 01/19/2023 Aggregate $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 501,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • • 0 0 ° o k. lieu"��r�.'��g'ia�� J1�,1`'UitU�9�t1�kQ4�Qn...t q i,„, t +� � o72,rc°o o nor 6,ttox7E7rAi,z,cA7 j\ 0-4i:A Witt • �'�`Oft ' wisik. 1 I as j .1 �. 11. ,N�N� ram II N Nil i i a �e ill/ 0 ' ''' .'— ' ' -.;,-1., flew 111111.1144 111111111111001% g '' 1 lot IA I MI e !� a