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35 Maynard Road 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:________________________ Brief Description of Proposed Work2:_________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 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: $ 35 Maynard Road 31A-152-001 **no change****no change** **no change** Steven Breslow & Caryn Brause Northampton, MA 01060 35 Maynard Road 413-320-6261 cjbrause@yahoo.com X XX interior and exterior renovations per attached plans and work list. 227,818.00 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 P.O. Box 272 Turners Falls, MA 01376 413-863-8316 info@renbuild.net CS-013302 8/17/2023 U 199409 8/23/2022Stephen Greenwald P.O. Box 272 Turners Falls, MA 01376 413-863-8316 info@renbuild.net X **see attached Owner authorization** 6/15/2022 PO BOX 272, TURNERS FALLS, MA 01376, 413.863.8316 INFO@RENBUILD.NET, WWW.RENBUILD.NET May 24, 2022 (updated 6/15/2022) Caryn Brause and Steven Breslow 35 Maynard Road Northampton, MA 01060 Proposal for Interior and Exterior Renovations to Home at Above Address Per Owner Supplied Plans and Specifications Dated April 4, 2022, and Whetstone Engineering SK 1 through SK 4. Revised from Proposal dated February 8th and additional revisions to lighting and kitchen. Scope to include the following per owner provided outline:  Renovation of kitchen and dining room.  Structural changes per Whetstone Engineering drawings.  Replacement of roofing.  Additional lighting and painting throughout the house.  Plaster and drywall repairs and replacement in work areas.  Insulation upgrades.  Limited window and door replacement.  Renovation to powder room and mudroom on first floor. 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. Brause Proposal Page 2 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #106490 6/15/2022 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 Workers Compensation Insurance. B. All work performed or subcontracted by Renaissance Builders to be guaranteed for one year. 1520 Temporary Facilities A. Provide portable toilet for workers. 1530 Temporary Protection A. Construct temporary dust-proof partition to separate work areas from surrounding areas. B. Provide floor and dust protection to work areas and provide a walkway to and from work areas. C. Provide protection against the spread of lead dust to surrounding work areas. D. Protect completed work in progress to ensure protection from damage or deterioration until substantial completion of project. 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. C. Vacuum all affected areas with vacuum equipped with HEPA (High Efficiency Particulate Air) filter at completion of repairs. D. Clean interior of house prior to move in. Includes: a. Wash interior of all windows. b. Vacuum and/or damp mop all floors. c. Wipe down all cabinet interiors, countertops, bath fixtures, woodwork, and shelving. 1950 Owner Responsibilities A. Any charges by utility companies. B. Cost of electricity and water during construction. C. Provide written specifications (available from dealer) for all appliances. D. Provide the following for installation by contractor: kitchen cabinets, windows and exterior doors, plumbing fixtures, bath accessories, and closet systems. E. All other phases not specifically outlined in this Proposal. 2000 SITE WORK 2220 Demolition, Exterior A. Remove and legally dispose of existing roof shingles on all roofs. B. Remove and legally dispose of existing double coverage roofing on office roof. Brause Proposal Page 3 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #106490 6/15/2022 C. Provide protection from adverse weather conditions, as needed, for any portions of work exposed during the course of work. D. Saw cut siding per owner’s plans for new flashing. E. Remove existing windows in the following locations: south wall primary bedroom, west wall kitchen, north wall kitchen, and mudroom. Includes removing entire frame in preparation for installation of new constructions units. 2225 Demolition, Interior A. All demolition as shown on plans. B. Remove entire existing ceiling in playroom and mudroom. C. Remove existing walls shown on demolition plan in kitchen/dining room, chimney, and wall in closet to access chimney. D. Cut openings as necessary for new plumbing and electrical work. 4000 MASONRY 4210 Brick A. Repair and replace brick on steps and sides of front entry stair. B. Remove two existing brick stairs at side entry and replace with Bluestone treads. C. Repoint steps and landing and replace all damaged brick on landing. D. Saw cut and tooth out brick at new door to pool. E. Resize kitchen window using salvaged brick. 6000 WOOD & PLASTICS 6105 Carrying Timber & Sill Plates A. Install Lally column per Whetstone Engineering plans. B. All Lally columns to have Springfield plates at tops and bottoms of columns. C. Install two new beams in ceilings per Whetstone Engineering plans. D. Sister rafters per Whetstone drawings. E. Install rafter ties per Whetstone drawings. 6110 Framing, Floors & Ceilings A. Prep all ceilings opened during the course of renovations for new finishes. B. Install CDX underlayment in kitchen in thickness required for new wood flooring to meet existing wood floors. 6120 Framing, Walls A. Frame new opening in west wall for new entry door. B. Construct all new walls and openings as shown on drawings. 6220 Casing & Base A. Window and door casings to be paint grade poplar and match existing profiles as closely as possible. B. Base moulding to be paint grade poplar and match existing profiles. C. Install picture rail to match existing on all new walls. Brause Proposal Page 4 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #106490 6/15/2022 6405 Cabinets, Premanufactured A. Owner to provide kitchen cabinets and hardware. Owner responsible for field measurements prior to ordering cabinets and for cabinet design. B. Install all cabinets and hardware. 6410 Custom Shelving & Casework A. Supply and install custom casework and shelving, per allowance. B. Shelves in kitchen and bench in entry and mudroom. 6415 Countertops A. Supply and install solid surface kitchen countertops, per allowance. 6720 Exterior Trim A. Install new trim where siding has been cut back for new roof flashing. B. All new exterior trim to be either Boral fly ash composite or Cellular PVC. C. Repair all damaged windowsills using structural epoxy. D. Install new exterior trim around new window in primary bedroom and new doors. E. Replace miscellaneous trim not connected to window door replacement or roofing work. F. All work in this section to be per allowance for labor and materials. 6800 Porch & Deck Framing A. Floor joists on deck to be 2” x 6” pressure treated, 16” o.c. B. New deck at west entry door to be 3’-6” in depth and full width between mudroom and screen porch. C. Stairs to be boxed construction and full width. 6810 Porch & Deck Finish A. Deck and treads to be 5/4” x 6” clear red cedar decking. B. All decking and treads to be installed using concealed fasteners. C. All risers to be red cedar. 7000 THERMAL & MOISTURE PROTECTION 7200 Insulation, Vapor Barrier A. Playroom ceiling and roof to have 7” of sprayed in place closed cell polyurethane foam (R-51). B. Insulate all exterior walls opened during the course of renovation with 3” of closed cell foam. C. Install spray foam insulation around perimeter of all new exterior doors and windows. D. Seal penetrations between floors with Thermafiber fire stopping or fire rated silicone. 7300 Roofing A. Install 8” aluminum drip edge along all rakes and eaves. B. Install Grace Ice & Water Shield along first 6’ of all eaves. C. Install Grace Ice & Water Shield on all roofs with a slope under 4/12 over heated areas. D. Install Palisades shingle underlayment on remainder of roof. Brause Proposal Page 5 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #106490 6/15/2022 E. Install lead counter flashing and aluminum step flashing around all chimneys. F. Install aluminum step flashing where roofing meets side wall of building. G. Install continuous ridge vent. H. Install architectural shingles, LANDMARK Pro Series, by CertainTeed. I. Install 60 Mil EPDM roofing fully adhered to office roof. 8000 DOORS & WINDOW 8100 Doors, Exterior A. Exterior door and sidelight to be as shown on plans. B. Owner to supply two (2) entry doors and one (1) screen door, including all hardware. C. Exterior door to have bituthene membrane installed at sill down to bottom of joist and 6” higher than door. D. Set exterior door in bed of acoustical sealant. E. Shim door at all hinges and all corners. All shims to be installed prior to insulation. 8500 Windows A. Install windows supplied by owner in the following locations: Kitchen, mudroom, office, and south wall of primary bedroom. 9000 FINISHES 9200 Sheetrock & Plaster A. New walls and ceilings and demoed walls and ceilings to have ½” drywall. B. Fill all voids and holes using Durabond dry mixed compound. C. All joint tape to be applied using Durabond dry mixed compound. D. Bath walls and ceilings to have ½” moisture resistant drywall. E. Finish all drywall with three coats of joint compound, sanded smooth. F. Patch all areas affected by renovation and leave ready for painting. 9300 Tile A. Install ceramic tile back splash, per allowance for labor and materials. 9640 Wood Flooring A. Install white oak hardwood floor covering, per allowance, sanded and coated with three coats of oil-based polyurethane in the kitchen. 9650 Sheet Flooring A. Install Marmoleum flooring, on top of ¼” Ultraply underlayment, in the powder room and mudroom. 9690 Floor Finish & Restoration A. Sand existing floor to the point of removing all existing finish all floors on first floor. B. Finish flooring with three (3) coats of polyurethane, semigloss/satin finish. 9910 Paint, Exterior A. All exterior trim to receive two coats Benjamin Moore, Sherwin Williams, or equivalent best quality paint. Brause Proposal Page 6 Renaissance Builders, PO Box 272, Turners Falls, MA 01376 License #013302, Registration #106490 6/15/2022 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 William, 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. All walls and ceilings in affected area to be painted corner to corner. F. 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. 15000 MECHANICAL 15400 Plumbing A. Install water line connection for ice maker in refrigerator. B. Install one (1) dishwasher hook-up. C. Remove and reset sink in powder room. D. Remove and install new toilet in powder room. E. Install Owner-supplied kitchen sink and faucet. F. All water piping to be copper or cross-linked polyethylene tubing. G. All sewer and drains to be ABS plastic. 15800 Ventilation Ducts & Fans A. Install venting for new kitchen exhaust hood supplied by owner. 16000 ELECTRICAL 16100 Install lighting per revised plan dated 4/26/22 A. New switches per plan minus the existing to remain. a. 20-amp circuits for new exhaust hood and kitchen receptacles. b. 50-amp circuit for range. c. 50-amp circuit for wall oven and microwave. d. Relocate existing switches in kitchen. e. Install one (1) new sconce in powder room. Fixtures to be provided by Owner. f. Fixture type P and CM are by Owner. g. Code required arc fault and GFI breakers for new circuits. 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 24 AIM Mutual Insurance Co. MCC20020004972022A 08/01/2022 35 Maynard Road Northampton MA 01062 6/15/2022 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-MAILADDRESS: 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 EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR 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 6/15/2022 Caryn Brause & Steven Breslow35 Maynard RoadNorthampton, MA 01060 AFFIDAVITFORDISPOSALOFDEMOLITIONDEBRIS SupplementtoPermitApplication AsaresultoftheprovisionsofMGLc.40,s54,IacknowledgethatasaconditionoftheissuanceofaBuildingPermit,alldebrisresultingfromtheconstructionactivitygovernedbythisBuildingPermitshallbedisposedofinaproperlylicensedsolidwastedisposal facility,asdefinedbyMGLc.111,s150A. Icertifythatdebrisresultingfromthisdemolitionwillbedisposedofaslistedbelow: JobSiteLocation: NameofPermitApplicant:RenaissanceBuilders DisposalFacility:F&GRecycling AddressofFacility:15MullenRd.,Enfield,Ct06082 IFSAIDFACILITYISOTHERTHANWHATIHAVELISTED,ICERTIFYTHATIWILLNOTIFYTHEBUILDINGOFFICIALOFTHECORRECTLOCATIONOFTHESOLIDWASTEDISPOSALFACILITYWITHINTWOMONTHSOFTHE DATEOFTHISAPPLICATION. SignatureofApplicant Date 35 Maynard Road, Northampton, MA 01060 6/15/2022