22B-059 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
k!F Boston,MA 02111
www mass.gov/dia
Workers,Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Bus nessfOrganizationnlu ividual): Bryan G.Hobbs Remodeling
Conway St.
Address:
Greenfield,MA 01301
City/State/Zip: Phone#:
Are you an employer?Check the appropriate boa: Type of project(required):
1.[ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or Part-time)-* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t ? ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in an capacity. workers'comp.insurance. 9.
any ty. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.[1 Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
i nwrance.required.]t employees. [No workers' 13. Other i,1' J(J)L,1
comp.insurance required.] v t
;Any*Any applicant that checks box#1 nwst also fill out the section below showing their workers'compensation policy information:
who subrait this affidavit indicating they at doing all work and then hire outside contractors must submit a new affidavit indicating such
IContzwtors Oat check this box must attached an additional sheet showing the nanx of the sub-contractors and thets workers'comp.policy information.
I am an employer that Isproviding workers'compensation insurance for my employees. Below is the policy and}ob site
information.
insurance Company Name: A i 11 �=t� r l k' � � 1 1�L 4 (� ` Wt,G O(.= ) t I `C i, ) 1..i
Policy#or Self-ins.Lic.#: [�• (� '� 1 Expiration Date: )0�-_c I
t
Job Site Address: �47— I � ) �, 21 ,t .... City/State/zip: C t ,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Faihue 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 pales and penalties of perjury that the information provided above is truce and correct.
Sienature e� .{ � � Date:
—T
Phone J° d. `a .rC
0O lcld use only. Do not write in this area,to be completed by city or town offixial.
City or Town: PermdtUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
OWNER AUTHORIZATION FORM
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(odws MMO
omw of the property located at
Address)
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hereby MMMAM � �
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an auftdied a dmonbador for RISE EngineeMV,to ad cn my behalf to obtain a binding
pmM and to perform waft on my pnoperty.
0wrWs
Date
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Bryan G. Hobbs Remodeling C J— or6?r( 5 2
346 Conway St. License Number
Greenfield,MA 01301
Address Expiration Date
/"Aiv,a � & 7,i
Signature reI Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑ }
Bryan G. Hobbs Remodeling i 7 ,C� � (b;�a`—i
Company Name 346 Conway St. Registration Number
Greenfield,MA 01301
�/2 I s c�
Address Exp�n Date
!1 l
/ � Telephone� 3 r7 -crL 17 1
SECTION 10-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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[o] Other
U
Brief Description of Proposed r, v l A\.-I) l r]2
Work: a (r. Cc t( 01c sJ_ {_�t_o r C �UL LU M; b 16 wo , 1) QAPSj
Alteration of existing bedroom Yes_ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housina; complete the following: �l
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS 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.
Signature of Owner Date
as Owner/A honzed
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my cZnbVXeedge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/ gent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L:_ R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES Q
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,a cavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO '
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
w\f
ity of Northampton
�w B 'ding Department
:.o" Main Street , N ; t ,
npliq
fie' ESQ o Room 100 a E' ,
° ortham ton MA 01060
413-587-1240 Fax 413-587-1272
GQ���Q � �fidn- jib r�`� f't��€r:ip'���t�rt,�?i+' t }•,£'tr. i ,ts'�,
A IC ION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
35f -� f� -� Map Lot Unit
T- I C4 I () CY z
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r-
VY1C�r �I i �� 355pr,n ' J . , c( azt ..
Name(Print) Current mailing Add �(``` ,
`; n p V _ �J T 2.
Telephone
Signature
2.2 Authorized Aaent:
e i o .._ 19 ��U(� �'n l u to +�= / ! : P f ci' .. / .
Name(Print) Current Mailing Address: f
Signature Telephone--7 SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building I (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) , Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1114
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD01301 (413)775-9006
PROPERTY LOCATION 35 SPRING ST
MAP 22B PARCEL 059 001 ZONE URA(100)/WP(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building-Plans Included:
Owner/Statement or License 83982
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D lay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
35 SPRING ST BP-2015-1114
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 22B-059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-1114
Proiect# JS-2015-002105
Est.Cost: $17662.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin BRYAN HOBBS 83982
Lot Size(sq ft.): 24785.64 Owner: LIZEE ELIE R&MARY E LIZEE
Zoning: URA(100)/WP(100)/WSP(100)/Applicant: BRYAN HOBBS
AT: 35 SPRING ST
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON.511812015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/18/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner