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15B-036 (4) 9 DIMOCK ST BP-2019-0721 GIS#: COMMONWEALTH OF MASSACHUSETTS Mqp:Block: 15B-036 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-2019-0721 Project# JS-2019-001180 Est.Cost: $3153.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BRYAN HOBBS 83982 Lot Size(sg.ft.): 90 169.20 Owner: GOLDSTEIN SETH Zoning:URA(100)/WP(2)/ Applicant: BRYAN HOBBS AT. 9 DiMOCK ST Applicant Address: Phone: Insurance: PO BOX 1535 (413)775-9006 WC GREENFIELDMA01301 ISSUED ON.1211812018 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC INSULATION, VENTILATION CHUTES, VENT HEATER FAN TO ROOF, AIR SEALING 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 12/18/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner s�vsv��`�oiv 13apartm+ent use only City of Northampton Staters of Permit: Building Department Curb Gut/Drl wayPe tt 212 Main Street SewedsoptkAvail t !� Room 100 Water/Well Availat Northampton, MA 01060 Two Sets of'Structtor .1 phone 413-587-1240 Fax 413-587-1272 Plot/Site 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 7 Map Lot t� Unit M A 0 1 OS j Zone_ Overlay District { Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SL81 (ries i-c,�n q :m odu�K I= do ing o i D 5 3 Name(Print) Current ailin Address: Sa ma iaorS IC.A Vl • Cli-m Telephone Signature 'V1 2 Authorized Agent: Name( rint) Current Mailing Address: 'J '-X 13 - 17.5 00 L 12 Sign a Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 5,15 b`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=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: 1Z-17-)oO Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 Q DONT KNOW YES Q IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES Q IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO (D DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained © , 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? YESQ NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO 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 E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other Brief DesqnptJon,of Propose / Work: 'I: j M fI� j lyla �(M rJA1i� - Vgyt7A1f 13cckl a to r -1 alb_ S�OJ1�,e*` aAc ft, Alteration of existing bedroom Yes__X_No Adding new bedroom Yes X No 's f �c (c- Attached Narrative Renovating unfinished basement Yes Ne- No Plans Attached Roll -Sheet 6a.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 c. Is there a garage attached? d. Proposed Square footage of new construction. Klaceds e. Number of stories? f. Method of heating? ves Number of each g. Energy Conservation Compliance. mpliance form attached? h. Type of construction i. Is construction within 100 ft.of wetland . Yesithin 100 yr. floodplain Yes No j. Depth of basement or cellar flo elow 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 1 as Owner of the subject propeYy RR hereby authorize A nJn J �0/y'') 11 L LL toacton my behalf, inff �al�ma�ttters relative two work authorized by is building permit application. �/ I? Signature of Owner Date I ' as Owner/Authorized Age t statements her by declare that the and inf r ation on the foregoing application are true and accurate,to the best of my knowledge and belief. Si ned under the pains and penalties of perjury. nn1Z i�'UJ_A� afiq t i Signa of wner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ i` Name of License Holder, 10- 1 �a l� - y PO Box 1535 License Number Mob&Greenfield,MA 01302 r5)P ,;)o 113)775 9006p6 Ex iration=ate D A ss Si ture Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 1 Company Name Ox Registration Number Greenfield,MA 01302 (413)775-9006 `l lay I Address Expiratio�e Telephone 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...... ❑ RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Seth Goldstein (Owner's Name) owner of the property located at: 9 Dimock Street (Property Address) Leeds, MA 01053 , (Property Address) hereby authorize 6C_ , (Sub ontractor) 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. Owners Signature t �f;L1 � Date RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 i Canton,MA 020211339-502-6335 www.RISEengineering.com 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: q The debris will be transported by: 61azal 7 Inc LM Plr'Z1 The debris will be received by: �/� ,� hJ(i'IL kAinU Building permit number: Name of Permit Applicant 4 i-LL Z'41QAA kfg" Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apmlicant Information Please Print Let'ibly Name (Business/Organization/Individual): Bryan Hobbs Remodeling LLC Address: 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.[Z]I am a employer with 7 employees(full and/or part-time).* 7. E]New construction 2.n I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.n I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L E]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.�✓ Other weatherization 6.❑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.] *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. $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: Selective Insurance Co. Policy#or Self-ins.Lic.#: WC9057/270 Expiration Date: 10/20/2019 } Job Site Address: `1 6 I M nC l� &. City/State/Zip: ��� C i m 0105-3 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyr ' under the and penalties of perjury that the information provided above is true and correct. Si nature: pains Date: Phone#: 413476-9006 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: A&CO CERTIFICATE OF LIABILITY INSURANCE DATE7/25/2018 Y) 07/25/2018 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(les)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 endomement(s). CONTACT Adina Edgett PRODUCER NAME: Webber&Grinnell (PA o Ext): (413)586-0111 A/C No: (413)586-6481 8 North King Street E-MAIL,,.Daedgettlr"webberandgrinnell.Com INSURERS)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina INSURED INSURER B: Selective Ins Co Of America 12572 Bryan Hobbs Remodeling,LLC INSURER C: Selective Ins Co of Southeast 39926 346 Conway Street INSURER D: INSURER E: Greenfield MA 01301-1516 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 08/19 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. INTR TYPE OF INSURANCE I WVD POLICYNUMBER MM/DDADDLISUI Y/YYYY MM/DD/ YYYY LICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA T NT 500,000 CLAIMS-MADE FX OCCUR PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 15,000 A S2289042 08/04/2016 08/04/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY L]JERCT El LOC PRODUCTS-COM P/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY EO aBlcdentSINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ BOWNED X SCHEDULED A9105300 08/04/2018 08/04/2019 BODILY INJURY(Per accident) $ AUTOS ONLY Ix HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY ONLY Per accident AUTOS Underinsured motorist BI $ 20,000 PANY UMBRELLALIAB OCCUR EACH OCCURRENCE $ 1,000,000 AEXCESS LAB HCLAIMS-MADE S2289042 08/04/2018 08/04/2019 AGGREGATE $ 2,000,000 DED RETENTION$ $ KERS COMPENSATION X PER OTH- EMPLOYERS'LIABILITY STATUTE ER Y/N 500,000 PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ C OFFICER/MEMBER EXCLUDED? NIA WC9057270 Bryan Hobbs Excl. 10/20/2018 10/20/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Building $493,004 COMMERCIAL PROPERTY A S2289042 08/04/2018 08/04/2019 BPP $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,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 lit- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Commonwealth Of IV13SS3chusetts Division of Professional Licensure Board of Building RogUlatibris and Standards Construction Supervisor EXpireS: 05,02/2020 BRYAN HOBBS POI BOX 1635 GREENFIELD MA 01302 Commissioner r7l. Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual BRYAN HOBBS Registration, 139564 D/B/A BRYAN HOBBS REMODELING Expiration; 07/22/2019 346 CONWAY ST GREENFIELD,MA 01301 Update Address and return card. Mark reason for change. 9M*yM--r—# 0 Office of Consumer Affairs&Business Regulation 7 HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only' TYPE:Individual before the expiration date, If found return to: Registration Exciratign Offlo#of Consumer Affairs and Business Regulation 139564 07/22/2019 10 Park Plaza-Suits 3170 BRYAN HOBBS Bottom,MA 02116 DIS/A BRYAN HOBBS REMODELING BRYAN G,HOBBS 346 CONWAY ST 3REENFIELD,MA 01301 Undersecretary Not valid without*19natur8