36-216 (8) 16 BIRCH LN BP-2017-0314
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-216 CITY OF NORTHAMPTON
at-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-2017-0314
Project# JS-2017-000519
Est.Cost:$2057.03
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(sq. R.): 86248.80 Owner: DRABEK ROBERT&YAN SHEN
Zoning: Applicant: BRYAN HOBBS
AT: 16 BIRCH LN
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON:9/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEALING & INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.F.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: Rouse# 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 9/8/2016 0:00:00 $65,00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
• Nt,r Department use only
ity of Northampton Status of Pelma:
ei+�(�b : ilding Department CurbcuuDriveway Perm:
Sit AI '12 Main Street Sewer/Septic Availability
ROOM 100
aternNell
ilability
Y' amu`"a�e' •'s• hampton, MA 01060 Trwo Sets of Structural aural Plans
'
'tpo`t t114 one 413-587-1240 Fax 413-587.1272 PloUBite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 property Address: This section to be completed by office
I (0 31(c h C,-.rk, Map Lot Unit
FI6r2l1 Ga , PIA O)0 63 Zone Overlay District
Elm St District Ca District-,,,,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.11 Owner of Record:
`r5a1").4i1 1- ThfAbeK .._.J'6r, 614 rr -`s�--
Name(Print) Current Mailing Add ))‘.2(,:6
gR,: Actih in?cs11,,n r"( Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address-
%� C1 L 3 -'7Z L— Y'Qh
Signs Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building (a)Building Permit Fee
2. Electilcal (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection
6. Total=(1 +2+3+4+5) 6{-7 is.T7/ OA Check Number al c,4 gal 4(06
This Section For Official Use Only
Date
Building Permit Number:
Issued. cs
Signature: O T-71C
i�
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
ibis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rea
Building Height
Bldg.Square Footage .o
Open Space Footage
(Lot area minus bldg&paved
partinfo
hof Parking Spaces _
Fin:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued forion the site?
NO Q DONT KNOW 'O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry1of Deeds?
C
NO C DON'T KNOW YES Q
IF YES: enter Book Page and/or Document A
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW e YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location:
E. YJdi the construction activity disturb(clearing,grading,excavation or fining)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES Q NO 'f�J
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑, Replacement Windows Alteration{s) — Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding[DI Other[M[
Brief Description of Proposed I) /
Work: rr �rd( s ,nr IL ( a.yL h iii,;43 -.Actor � O), ,6 kks Cede(
d(1 A NC -
Alteration of existing bedroom `yes__No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
So If New house and or addition to existing housing, complete the following:
a- Use of building :One Family Two Family _Other
b. Number of rooms in each family unit, Number of Bathrooms
a Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
a. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each____
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached,—,
II. 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
L Septic Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,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.
Si nature of Owner Date
I, r'/J/ln as Owner/Authorized
Agent hereby declebe that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury
Print Name /!
Siena wt (Agent Date
City of Northampton
+ + Massachusetts a. ec
h c
x
r+ ' r DEPARTMENT OF 'WILDING INSPECTIONS g
�:::1:1"(-'.aP' 212 Mein Street a Men tcaeal evalrnC e
- Northampton, wl 0106 37 C.
Property Address: / p I)JICTt7 -/1/16
Contractor l L r�
Name: /3¶r& on ,,tir) K F/i�"( ciejf,RC
Address: 1C'; 62jcfin /t c1
City, State: (Hill itp,n 7 / P1,4 (1 /3Q/
Phone: CV/2) - 7 7 - Win
Property Owner !- L,
Name: l t hQ/tA ,I v4hUC
Address: JiP 73l✓74 (Qn
City, State: 7-410/7(( /r'n to/6(4„:7-.
I, ' ,/L p,1 )'t 1 12 ) (contractor) attest and affirm that the building I intend to
insulate deres not have any open air(knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date k2,c l iv
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / (.� Not Applicable 0"y ('��`y
Name of License Holder _ ,9'1\ I'1 0, ic/'✓,S C'� -0 ,3 9 J
33 `� License Number
Address Expiration�L��6:�Ctl,��vJ� •
�1� A,. 1.--1/.4 Expiration Date
•
_IIIII�—yJ/ _
Signature Telephone
9.Rest tared Home Improvement Cann raptor Not Applicable 0
II )� 1`crib) ` Tic F I�nS _ 1 S�tot�
Company Name Registration Number
r /il � t 6-2),--23 196/7-
Address {lt£ t Expiration Date
�' �,v t y Y
�C .Q �Q)4\ Telepnone yGL
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(141.01.C.152,§25C(6)) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
N the denial of the issuance of the building permit
Signed Affidavit Attached Yes t#— No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended ro include Owner-occupied Dwellings of one(I) 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
us supervisor.CMR 780. Sixth Edition Section 1081,5.1.
Definition of Homeowner Person(s)who own a parcel of laud 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 Fenn
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(or 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 persons)
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,Stale and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature_
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the 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 , S 150A,
Address of the work: /(c ? 4 I D x,41 7 '
The debris will be transported by: (C, ri174(a 1 )2,'3aP Cc
The debris will be received by: CL,,0(�. � tAQICk Cil -
Building permit number:
Name of Permit Applicant 6,tJAn Tki Or& C ,7
) ) J , 1
Date Signature of Permit Applicant
•
r�r
���' eaara�rezaerr,e�rfx r/(�,�� 6
Office of Consumer Affairs and Business Regulation
! ���j
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 139554
Type: DBA
Expiration: 7/23/2017 Tp zs73sa
BRYAN G. HOBBS REMODELING
BRYAN HOBBS
346 CONWAY ST _
GREENFIELD, MA 01301
Update Address and return card.Mark reason for change.
CA I !y 2OM-Os11 Address
_, Renewal IT Employment -. Lost Card
>L, r, :,,,.-,/A,,, -,/A y—u,..,,,,Le.,u.
-. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
, +�?�ipIOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ll40914Iratian: 139564 Type: Office of Consumer Affairs and Business Regulation
" '_'Ezplration: 7/23/2017 DOA 10 Park Plaza-Suite 5170
'.RYAN G.H06SS REMODELING Boston,MA 02116
RYAN HOBBS
46 CONWAY ST
REENFIELD,MA 01301
Undersecretary • —
Not valid without signature
•
•
•
Massachusetts Department of Public Safety
tyBoard of Budding Regulations and Standards
License: CB-083982
2
BRYAN G HOBBS
346 CONWAY STREET
GREENFIELD MA/01301
N'7 r Expiration: ,
Commissioner 05102/018
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IdmrSE 60 Shawmut Road,Unh 2 I Canton,RA 02021 1339502$335
EERING www.RlSEergineedngmom
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ris
OWNER AUTHORIZATION FORM
I, % ti
(Owners Name)
owner of the properly located at
t to �‘r _ Lit- I
(Property Address)
`nC)ttC_ s✓ INA{}- OLbh
(Property Address)
is uvi iTi —,
hereby authorize i;
(Subcontractor) 01i
an authorized subcontractor for RISE Engineering,to act on my behalf tmjpl m a building 5 c�16 J
permit and to perform work on my property.This form is only valid with signed contract.
Owner's Signature /,
Date
The Commonwealth of Massachusetts
' =;= Department of Industrial Accidents
'= _ —![
,1�= Office of Investigations
— ;!; 600 Washington Street
• =� = = Boston,MA 02111
•;`'- ''� www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Buvoeawcrpulariodlndividual): Bryan G.Hobbs Remodeling
346 Conway St.
Address: Greenfield,MA 01301
City/State/Zip: Phone#: It7
Are you an employer?Check the appropriate box: Type of project(required):
l.ey I am a employer with 6 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees OM and/or part-lime).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the winched sheet t 7. ❑ Remodekog
ship and have no employees These sub-conuagmrs have 8. 0 Demoting')
working fur me in any amity. workers' comp. insurance 9. D Building addition
[No worker' corp. insurance 5. 0 We area corporation and its •
required.] officer have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowou doing all mirk right of neuwtion pm MGI. 11.0 Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]I employees. [No worker' 13.[[ Other e/15v-fo--GrA ^�
comp. insurance required.] V. Ir CCA-ie
•Any spplimof am dodo mx a1 MUM LSO fill GUI the sedoo below rowing then wmhm'compemmtkm policy iaforrpdm
t lionsowapa who men this•ffideeh indicating They me doing on work and then biro nide;cowman most tun:•new'Estoril indorsing mob.
:Crohn ann Oat cheek Ibis box mug sorbed to additioiY ohm Mowing the on of the rvbcooaenme and their workers'map.policy mIo miens
I met a employer that IT providing workers'conywnea ion insurance for my employees Below is the polity and Job rue
iaforrtllian
Mamma Company Name: tit roti-GUAe.iti 1 I n S( Arc f �ad. l oro attic c i
Policy#m Self-ms.Lie #: IiZ t810-515q e y Expiration Date: IC/[r111'15
yob Site Address: City/State/Zip:
Attach■copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to lenge rove age as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fore up to$1,500.00 and/or ono-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m$230.110 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesimationc of the DIA for insurance avenge verification.
1 do hereby cenify under the pats and penalties of perjury that the inforsamion proofdrl above Li true and correct
Stant: Date
Phone#: l +— r7 7 5- goo&
O ial use only. Do no:write in this area,to be co
!� completed by cfry or town ofJlclaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3.Clty/I'otw Clerk 4.Electrical tweeter 5.Plumbing Inspector
6.Other •
Contact Person: Phone#:
• : BERKSHIRE HATHAWAY Workers Compensation and Employer's Liability Policy
i�j INSURANCE Ail1GUARD Insurance Company A Stock Company
Pim GUARD COMPANIES Policy Number R2WC648612
Renewal of R2WC513915
NCC/ No. [21273)
Policy information Page (AR)
:(1]Named Insured and Mailing Address Agency
Bryan G Hobbs A. H. KIST INSURANCE AGENCY INC.
346 Conway Street 159 Avenue A
Greenfield, MA 01301 PO Box 391
turners Fails, MA 01376
Agency Code: MARISTI1
Federal Employer's ID C1-3523850 Insured is Individual
Risk ID Number 842909
Additional Names of Insured
(N2) Bryan G Hobbs Remodeling Contractor
Locations on Policy
(L2) 171 Wells Street , Green field, MAhr.501
(LC/20/2015 t 10120/2016)
(23 Policy Period
From October 2C, 2015 m Oco e:20, 2001, 12:01 AM, scanmard tirne as the :neureG's mailing address.
j31 Coverage
A. Workers' Compensaticn Indic anew - Part One of ISS policy applies co the Workers' Con'.pensattion
Law of the following states; Massachusetts
B, Employ rs Li binty unurarace - Part Two di and panty epplcb Lu L.nn r I:, rh 111' Ute stdtas listed
in item [3]A. The iim.Ys of our liability under Part Tiers are:
Bodily injury by Accident- each accident 5500,000
Podily Injury by Disease each employee $500,000
Bodily Injury by Disease - policy Halt 5500,000
c, Refer to Residual Market Lirniteo Other States Instance Endorsement-WC2003C6B
0. This policy induces these endorsements and schedules'.
Sep Extension of Information Pegs - Schedule of Forms
(4) Premium --
The Premium basis and, therefore, the premium Foe be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. Au requ'reb inrormatnn Is subject to verification and chance by
mutt- (Continued on another page)
Total Estimated Policy Premium S 10,916
Total Surcharges/Assessments s 599.00
Total Estimated Cost s 11,515.00
vIFR6'At USE OR Vane Inrnrchafinn Pa
Gn R2WC64a612 g�.
ate 'IOft/2&/201; V/C OOCCOIA
ANOTE
Issuing Office: P.O, Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0026 • Www,mi=..r ---