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36-412 789BURTS PITRD COMMONWEALTH OF MASSACHUSETTS BP-2021-1909 Map:Block:Lot:36-412-001 Permit: New Build CITY OF NORTHAMPTON PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-1909 PERMISSION IS HEREBY GRANTED TO: Project# NEW SINGLE HOUSE Contractor: License: PIONEER VALLEY HABITAT FOR Est. Cost: 150500 HUMANITY INC 046013 Const.Class: Exp.Date:04/14/2023 Use Group: Owner: PIONEER VALLEY HABITAT FO HUMANITY Lot Size (sq.ft.) Zoning: Applicant: MICHAEL BROAD Applicant Address Phone: Insurance: P O BOX 94 (413)636-6747() SHUTESBURY, MA 01072 • ISSUED ON:09/28/2021 TO PERFORM THE FOLLO WING WORK: NEW SINGLE FAMILY HOUSE WITH ATTACHED SHED 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. Signature: el • �!, C,1 • Fees Paid: $481.20 212Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECE i'vLzu The Commonwealth of Massachu etts F R 107 Board of Building Regulations and S nda s SEP 2 1 2021 I IPALITY Massachusetts State Building Code, 7 0 C R SE Building Permit Application To Construct,Repair, Renoya f(_IILnIN sites Rrvise Mar 2011 N One-or Two-Family Dwelling p GrdI �SPEa o,oC IONS rn This Section For Official Use Only Building Permit Number: ✓0- j .- j 901 Date Applied: yaval,0 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 789 Burts Pit Road (lot 5) 36 412-001 I.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SR residential 7053 85.84 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 30' project n/a -zero n/a -zero 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: I'ublicX Private 0 Zone: _ Outside Flood Zone? Municipal On site disposal system 0 Check if yel SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Pioneer Valley Habitat for Humanity, Inc. Florence, MA 01062 Name(Print) City,State,ZIP Po Box 60642 413-586-5430 megan c©pvhabitat.org No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Build new single family home with attached shed SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 117,400 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ 12,000 ❑Total Project Costa (Item 6)x multiplier x 3. Plumbing $ 9,100 2. Other Fees: $ 4. Mechanical (I-IVAC) $ 12,000 List: 5. Mechanical (Fire Suppression) 0 Total All Fees: $ lc'), Check No.CISv3Check Amount: Cash Amount: 6.Total Project Cost: S $150,500 (Paid in Full 0 Outstanding Balance Due: City of Northampton Massachusetts t * c LA!)[ DEPARTMENT OF BUILDING INSPECTIONS y ` 212 Main Street • Municipal Building % a Northampton, MA 01060 "J'ih, 1.0\'‘`\c PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. I. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s) and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new / replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit - public land by DPW/ private land by Building Dept. 13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CSFA-046013 4/14/2023 Michael Broad License Number Expiration Date Name of CSL Holder List CSL Type(see below) R PO Box 94 — No.and Street Type Description Shutesbury, MA 01072 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted I&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-636-6747 mfbroad@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 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 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: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 contained in this application is true and accurate to the best of my knowledge and understanding. Megan McDonough, Executive Director on behalf of Pioneer Valley Habitat for Humanity, Inc. 9/14/21 Print ner' 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.) 1056 (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) 900 Habitable room count 3 Number of fireplaces none Number of bedrooms 2 Number of bathrooms 1 Number of half/baths none Type of heating system Air source heat pump Number of decks/porches Type of cooling system Air Source heat pump Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD see attached site plan SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton " Massachusettse •�L N Y �tl ,, DEPARTMENT OF BUILDING INSPECTIONS L t • 212 Main Street • Municipal BuildingPAIO Northampton, MA 01060 'fpy TO,-' CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Valley Recycling or USA Recycling The debris will be transported by: Name of Hauler: self haul or dumpter from USA Recycling Signature of Applicant: Adi Date: 8/18/21 Home Energy Rating Certificate Rating Date: 8/19/21 Projected Report Registry ID: p Ekotrope ID: VvnX479L HERS® Index Score: Annual Savings Home: Your home's HERS score is a relative 9 Bums Pit Rd 2 performance score.The tower the lorenCe, A 01062 number;the more energy efficient the i home.To learn more, visit Builder: www,hersindex.corn 4/ 1 23 *Relative to an average U.S.home Pioneer Valley Habitat Your Home's Estimated Energy Use: This home meets or exceeds the Use[MBtul Annual Cost criteria of the following: Heating 5.0 $330 ENERGY STAR v3 Cooling 0.2 $16 ENERGY STAR v3.1 Hot Water 1.8 $117 2018 International Energy Conservation Code Lights/Appliances 10.6 $693 2015 International Energy Conservation Code Service Charges $180 2009 International Energy Conservation Code Generation(e.g.Solar) 28.7 -$1,155 Total: 17.7 $180 HERS index Home Feature Summary: Rating completed by: •ei•ror Home Type: Single family detached ISO Model NIA Energy Rater: Mark Bashista RESNET ID: 7580975 Existing r`s` Community: NIA Homes :30 Rating Company:New England Energy Raters r� Conditioned Floor Area: 934 ft2 Ito Number of Bedrooms: 2 198 Sylvester Rd Florence MA 01062 43 570 5750 Revere* Home ISO Primary Heating System: Air Source Heat Pump.Electric•133 HSPF 4n Rating Provider: Performance Systems Development Primary Cooling System: Air Source Heat Pump•Electric•30.5 SEER SG 124 Grindley Street,Ithaca NY 14850 ro Primary Water Heating: Residential Water Heater•Electric•3.05 Energy Factor tai77 277 6240 °,.+ r�.. House Tightness: 15 ACH50 d. ; so Ventilation: 36 CFM•8.4 Watts ,i l so Duct Leakage to outside: Forced Air Ductless '• ..',- �`. 25 Above Grade Wails: R-39 �, ""."`... � 12cji. f0 Ceiling: Attic,R-60 zero Energy Horne 0 -XI _. Window Type: U-Value:0.27,SHGC:0.3 Mark.Bashista,Certified Energy Rater mmtsaaiu: `otrowtoo Foundation Walls: NIA Digitally signed:9I18/21 at 6:55 AM 15.1 ro e Ekotrap RAIL II-Versinri:32_4274b .�r- p I trt_,f srirc;y Rotund Disc:iosure for this home is available front the Approved Rating Provider. This re .irt does riot constitute an warran or c uararttee. HERS Rated Home Summary Property Organization inspection Status 789 Burts Pit Rd New England Energy Raters Results are projected ei er Florence,MA01062 Mark Bashista REM 16t6 Pioneer Valley Habitat U2 789 Hurts Pit Budder Rd Pioneer Valley Habitat General l Building f Number Qf Be 991:9 lgin i t e ter ,s��r i � x , A jy�, an ` 1 -)..t wt9Y..:mLg Number Of Floors I. 1 p .� ...:-. .. ate'-'t_::2 r•3r;4444 : y'SC :.ef" .:^` 44:<. 03 °`WR r. fin.,s�Electric Vehicle Ready Space N Unc1M7W j .. �{ -'s,� YSv+`k0r '1\+ V ;,t �3.giVi a+ taig'� a ..;.g*. ,.ti`.�`n �r s: Conditioned Volume Ital.1t.1 7 A S *., Y...wk "s a t_ &. f m wka''rg 'i RR R1.�8.a �S G Y, "K-ram::. Residence Type ,_ Model - .: .... w .r.,... , -spa.:.t .. ..w-. .... ,$ ... itAtliti Model Climate Zone 5A �.. s r��. `, ire + i Foundation Wait " .� .,, k� zi Foundation Wait Library List i- 0- Y OR e f g :r�i 'jf C1st ^r'9"M1.4s�n'h� ' h d4 p^ Mt w4 S None Present [ 1. . . .. . . • .. .- .. • "Slab t:.04, Library lope Feriuseter ?O ur3tit.. t:a petA Eap,aeu St raie.ire3 1..Gi3tiOri LiiG::s,±a Masonry Area -tCi r 'urx art 121.2 Cm Grp 116B 0 934SYR° wed Exterior Conditioned ,~pare s7 z ierrt pi' d ti1t P.: i ,q4'''' " t rrII t s?,�,,, ,A , � m n rP x!c',,� 4J Type [ Perimeter �- nb Name Wall Construction :• „ Slab CompletelyUndersla6 Perimeter Perimeter Thermal Break Effective R-valite insulated. Insulation Width ft insulation Depth[ft] Insulation R Value Q-10 rt- unci an wood Fran/Edger __No " _4, __ ___ Yes 10.00 II Framed Floor >,a,�f'r 2.+C-m M,.a;?,Fe,, u,x -e..fi�.t av a..,.. _.k,:.4Sw T.:c ,,2•��. d ..m.�,_rs.., s7x*4:m , ...�3:_.., rc,P� -.., ..a r. r .eti., ,a.. _, _.. , ,_ a None Present 1 HERS Rated Home Summon .` Property Organization Inspection Status 7 9 Butts Pit Rd New England Energy Raters Results are projected (1:1111.11:1s11:4% Florence,MA 01062 Mark Basnista REM 1606 Pioneer Valley i-labitat U2 769 Burls Pit Builder Rd Pioneer Valley Habitat Framed Floor Library Lis 's .� '�� " '�� ' ! •... � f.3''£H`4» � a ...'1- k,e. t.7 .,. ',..44.4 Ga,rc,,..W _`K Ys*3., ,k14fH.T 1+0u . ^.4',F^^-,1.k A None Present Ily x.- m -.,, .�, . None Present t*1Vfl joist LtDrdry List .- ,u , �. .. �'� x None Present ,'-,, c v;t,;A e€a s;,W a'.'y+ y 1" ,€'E^ens T'* Ffi' 't s A ;* ?, ;i i- :Fs- 'x , F ,io '7 t z^r ,k,4 sr,,.._ �.s ...1 ,�m Name Library'type Suttace Color Surface Area Location 1stAmb -201SC'C 0Cott luternurr 998oi°' ExposedEXtetkx + 'f 41z 4k'S#{'�'S4, , h '6trl� L 3' Sg' i ikii ''G.. 6 7s... '14 a+d.4" i4xl aa+s- ,2.tnra',C€t? a � - 4,:3'as''�`�--rv�' ..3��' 5 �' '`�`x? t,'+„���a-4 ., at ' 4 ?' '..`�:�o �a'�'• �"";i1,f1, it�'i;t ?,€.1,t Name Effective R-value R20 16CC+R10 Cont 27 843 I I4�-lazing Name Library Type W1atl Foundation Is Operable Overhang Overhang Pt 7©Overhang Ft To Orientation Surface Area AssignmeFoundationWall Depth Top Bonom 1 ------ Assignment Front 27 Sr u lsl A+tnb 1 5 1 5 SouTt 62.0 fe Lett U 27,SHGC 1st Amb +=s 1 4 west 15.0lt su Rear li 27 SHGC 3StAmb 1 = 1 4 North 75# 3o Right '`I 27,S HGC sGj 1st Amb 5 East 20.0 r X 2 HERS Rated Home Summary t-----, .s.N.r) Property Organization Inspection Status 789 Butts Pit Rd New England Energy Raters Results are projected ss Florence MA01062 Mark 6astusta REM 1606 Pioneer Valley Habitat 02 789 Butts Pit Bulkier Rd Pioneer Valley Habitat Glazing Library List ,,,,,,..,,,,,,,,,,,,,,,,,„„-„,,, Name Shgc U-tactor 1 — - - U 27,SHGC 30 0' 0.270 • Peewit .-- r ,...... .. ._...... ... . .., _ ._ . , Skylight Lib''''';'=-Y-' :.„ None Present I. ,,'17.•,?;?:••=,-'-.Z•ii].>•,er:,3-,'„.-.•!--z-',,,e,%?4(?•Wig:14,1*:,,,, ,,,,,,..f• •-.-,,tf;•1-A,:.,;•• •.i,r-;:•,Iiir,...5•,";%7..: 3,•,.'.k, -,,ty.f;',19-.1•4„.;,-,.$-.:::.k-1,..,-',.,,l-AP-,;•••.07,,-.•*?.;.,`.i.,'4,7±',•,?•,:.t.,,ttls.,•:',..- 40,•,;,,,,••;y::.,,,-411.:::::,.i'..f.,,w,-k.,-",;,-,,j, Opaque Doci-i'.t . '-. - -.'• - . -.,..','7,'.;''.,.:,,- - . . .- - - ' :::';-:",1!'z.-- , , . . L - , - • . , .-: - . - - - . ,..,-',....''''r,'''' Name Library'Pipe Wall Assignment Foundation Wad Emittance Solar Surface Color Surface Area Location Assignment AOSOrpt3fIce I _ Rear Fiberglass R-7 lst AM 0.9 Mean'..,7•.; 20.0 r Exposed Exterior . . , Right Fiberglass R-7 1st Attila 0 9 0 75 Medium 20 0 tP Exposed Exterior -,. Opaque Door Library List4 ,..-,4„-, r N,,,,,.., Fiberglass R-7 Effectiv u.factor ',-,ta'',4ittgirt.,,a-4:410'24.'sZrk''''''''' '-2—,-...''''''':",;gaiS,,'77-s•all '.,,„4,trs-i'''' ''''Attnit''''' ,"aritg...,, i;::,,i,„-- . iiii4Uiicl."--- 0 143 Roof Insulation -1 1, Name Library Type Attic Exterior Area[It') Clay or Concrete Root Surface Color Surface Area Location Tiles Cerhog R-SO Blown Attic 1.f 1,043 . I Medium 914 01r Attic . - - 3 HERS Rated Home Summary Property Organization Inspection Status 789 Butts Pa Rd New England Energy Rate's Results are projected MM Florence.MA 01062 Mark Bastista REM i 6Q6 Pioneer Valley Habitat U2 769 Ekuts Pit Builder Rd Pioneer Valley Habitat woof ir:suiation Library List t,.,..„, ,„ , , ..,,,,,.......,r, -,, ,, .,,,,,t- -. ,.,,. h Name Has Radiant Barrier E'sett a R-.aiue R-60 Stawtt Attic tr i Cd? 60215 noie House infiltration u. :. hurl tra tf a, Measurecnsnt =ass 1.5ACH at 50 Pa rer,34r tested 4 echanicai Ventilation Venthauon'hype Ventilation Rate[it'' aperattonai Hours per aay l an Watts nuns once every three Energy Recovery Percent Minute] hours Hi;v .1:‘6 CPM 24 t 4 Watts Yes Exhaust Only 9.6E4 Cnivl 24 0 Watts Yes 0 ' _- Woks LED Llgttting Exterior fluorescent %Exterior LED Lighting %= • Fluorescent %Garage LED Lighting Lighting Lighting LIEF Frill 0 100 0 100 o i one .—, , ,,� n n skid 'nbste 3enerauon Library .gist wo,n,e Present 4 HERS Rated Home Summary Property Organization tnspection Status ow 789 Butts Pit Rd New England Energy Raters Results are projected ow Florence MA 01062 Mark Bashisla REM 1606 Pioneer Valley Habitat U2 769 Burls Pit Builder Rd Pioneer Valley Habitat -'.ISolar Clserteratiop Track Mcde Nameplate Capacqy?1,,Woo i Derate Factor .,-.=,81 ovent..,t,c.,,,deg)'4-:'''''''''''' Tilt:deg) 7.2 kW i ''''-' Dehumidifier . . .None Present , Dehumidifier Library List None Present I ,i,.,;;,t,A.,;i',,-,,,,o:.',4iv„... ,,,.:7,,:':y,I,...-;,-.,,,,,,,t'%,.f_„i;",..,,f',;.,.a4i,irS:,za -aift: ,,,,n:::k:i:?,"1,'I.4,'•'::'-r-'.'4:1':ri ...-i,i'i':„..,..-',!:;;Li::,f:-:-_'ii'',s-;:.'1,',",:,',:f:-:,(':::;,.I':,?,'f,':',:,:!ili',':? -,,-,'',7:4:';'42-4;4447;.. ..-.,::::iii4itill'.,,-. 0,010kVIVIM.,,,‘-"=i-'-,7'.-, --"7.r.A.'r- ot-,-- 7.7-17"."'-''''., ''''',,1:!::.A.:.1-F4:',.-4-1,•::.,,:i.'-='::-',I'l-t1',',:17,?1,,,. -' onditioning Equipment , ,,iii.,; .,.,. Name Library Toe Heating Percent Load Cooling Percent Load Hot Water Percent Load i. Air-source neat pump 9k 30 5S 10 9K 13 5I1 50% 50% 0% Conditioned Space 0) Air-source heat pump 9k 30 SS 10.9k 13.511 50% 50% 0% Conditioned Space tY, ----------- _ .,.',> 100% ,..,.:.r.;.;.i,vrit.-:,Si..la,, Water Heating„,;, ., --,:c T%,:,^-ex*:6-..K144,4,'',I'L',",,,;V:i,,,Z,Vi.if.C.',;,,t;', /,:V+40,10,41,-gt,.70itPeT-43,:-..,...-'2:"-'?!!'';'-55q-tv-r.61,-;,,g,..,,..,,,,, g,:--E-,--cl-ii.--i-p,-,..,me- i-t-,i.y—i;-e: 58G Hyb EF 3.05 Equipment Type Distribution TrP Hot Watr-i E-I- -'I ,'-1 Residential Water Heater Fuel Type Electric Hydronic Detivery(Radiant 3 0 5 E fl e 1'9 y r Tank Capacity(gal.} 58 . 5 HERS Rated Home Summary .., Property Organization Inspection Status 789 Burts Pit Rd New England Energy Raters Results are projected i� Florence.MA 01062 Marx Bastusta REM 1606 Pioneer Valley Habitat U2 769 Burls Pit Builder Rd Pioneer Valley Habitat Equipment Typ "O.5 s tt 9k- 13. h Equipment Type �rta* � .. Air�SoruCr ceHen+I irp liti a t �al u Fuel Type ; Distribution Type �''.�, a� #'..y X4 . . F t ss }xh.� i :.�4 at i�,+_.; c+. .P�F...;. �`k-0:,Sv 'k.Y $!i r.a^ei" 5 7 � k >r„r, mot` L�`;1L i I ;,� vt. �i,;, FCM(Variable Speed) Heating Efficiency xntl:e:^�. • 1,,5 N�F� � ;��,�� �:-�, . �ef.r. K��.� m��:�^� Heating Capacity Ik8tu/h] 10 0 Backup Fuel Type ' t jPn , i d kOM x3>i fg lMe Switchover Temperature(°F1 • `0 Backup Heating Efficiency I Atfusted Ef ncv w .,. ' tit Use default Supplemental Heat No Supplemental Heat(kW] 0 i ar e sI Cooling Efficiency 30.5 SEER Crnij i 9 "- } .,, f: Distribution System '. >...— ter. • Distribution Type Forced Air Ducttese . Heating Equipment 1"•tf sdurce hen pump(1} ._ Cooling Equipment rerlii0Saurce heat pump(1) is At Frtuipment In Conditioned Space Yes I,.d _ .letae4 HERS De€ault&i akige IDuct System Efficiency 1 r s '"4y dfl, 8 5' S r er corceft A, `".ictiP.SS i-ii rai.rcnai Csrt x v 3 Heating Equipment Arilsources iedi,u , _ E ' r.i:3. Ai,.source heat.^. , , i Is Alt Equipment in Coma t riF't S ,a._e 401.***Ptgautt HERS Default Leakage ' F . , Duct System Efficiency 1 >.H S t Inq Fan fib' . • Cfm Per Watt 140-__..._.. Water F#tttute Type '11:4.*Anw pie Default Hot Water Pipe Length !lo i L ter Pipe LetiOtttlgi 20 At Least R s Pipe Insulation'? IHot Waist Rerx= tt9 No Recirculation System Pipe Loop Length(ft] 10 Drain Water Heat Recovery'? No 6 HERS Rated Home Summary ,,..„ __,....... Property Organization Inspection Status 789 Butts Pa Rd New England Energy Raters Results are projected os Ito Florence,MA 01062 Mark Basnista REM 1666 Pioneer Valley Habitat U2 PIS Burts Pa Builder Rd Pioneer Valley Habitat CO -•• ' - - --- : - - - -- . ' -- 2,-56•-- - Fuel Type Electric Field UblitOn Moisture Sensing „,--„:.,_:_„::„,,,..:-.,,..,...:. „„.„-...:.....:-.,„-.,-...:.*... .. .. ... .......... . ... - -: )utside Condthoried Spi,:,, N. I Clottter$:::1:11YerAVOtable Yes Defautts Type Custom V::'' •:.1,40';*.* .!•..,„:7,,,, :,.,-4.40,i.,,-,i.', ,- 46. AI •114*- 17;:: itfitil*M.,.5".f..4tVW- '.. .. Label EnergY Rating-"•,'.14:11KiAtlitifORINi101-Z9V-Anft*C40#*-r--- Annual Gas Cost ' r le ctfi.r.Rite $024/1-1014frglIM;PAgiArOW;',W;:q,§0.7-V.i'MWAVfell.r,70: Gas Rate $1.22Tcheim *Scit').''Itttittlitt;Ngit-ttikllfli.V.it-E:_:,',. lIVAIIIIR§fttlfSFS.tltit2N,,SIVGI-:. Imet 2 1 Defaults Tv° - IS Outside Conditioned Space No .--. Clothes Wasner Available Yes-.143gleggintgailiN,1406-$001-2.24?-0 .,_. D iShWa S he r 3:irgg:i"-g40_ , .: . .N-r -:,--,:i-V45-,i'!.'4'4,,.A5V55',:ik'r,-*: Dishwasher Ffficiericy 270P Dishwasher Size g;-ggttiggg:g,2-kag-!,.g.gtNlgg'a-Odggiak Standard jis Outside.Cenditio*Mace...„.-..:-::6:,!:;;;:MAL: No . .-.:..::Isgf:s.,,a.:.:4,41::;r:....:.;,!'"-AV.:N.',.:!, ..':;.?..geOg.,.:'-g:Rit4-0.0';g04 .-- —.,-...,:, :.,•,,,,,,,,,,,„... . . .,,,f,,,,:.,,,,,,,,,...-:. ... _. . :.,,,,,.],:,... ., —., ,,,.,.. , : , , „ . . .. . • _ N,..,:!•,,,,,,,..-:,,,-rmr?r,-,emi.,-7#3.-rr,..,,T-7,?‘.9F.IF,,,,...„:•.,-:..1wgv.i.!..,.:955,37iTrp.. ..,r7.3.,;!rm.m, .17„ ,..,,, ...sr.,74.,,r1rFrA,.. .,.,-,,r,,,..-.71.r,4,7,,71., . . . .., Appliances and Controls . . Programmable thermostat? .,,„L--„„--, --,- -,-..-- --:---..,-- EYelos. ._..c' 1 1 11t:.11-.1I'ill lt ::in Range/Oven Fuel ....... ,—,...—.:.„,,.—...... m , .. „.,, . .....,—;.....,...,...,...„..„.,,„.."Convection Oven?Oven?-.,...44F0;:.A7.44,50-$&,: 6 "c) -.- 0A4-A.:„;,5g*,,,z,g..gii.ip.,....,-, _---;.-ii.:: :::;gEggrriS.,,i*:ArAr'm.:-.w-1;•.-4::,',. Induction Range. „ . No RangelOven Outsrd'e''''C'''o'rid.i:o'":ed'''''STOtilCO''.'.ril:::I.; •10_ -,-rigega-tegflagitgdfillitt#:'-': - ' •-- IRefrigerator Consumption 37t)kWhNea .. . _.. .... ..,, ....,......_...._. . . Refrigerator Outside Ce-dditienedE!00074A2k9..,..-,::„: ;:..,-,A,;:-.--,.-tothi,etatevolltrozAttatitijmort444-paraie-A4t4".44:4-44.4-454o,§.**T4**Aiiiwititi1 IY,-4..c:;!,..1-;,,..to.,.4; -otmfoet.ttfxwfsPottl'ttzzro,r5;teat'-vtvr.ttt.mgKt.toI#tmtt,mttt.o,lo.,t,-.Fsn.„.,r,;,z•„„,.- . 7 • • 34 " The Commonwealth of Massachusetts r J, Department of Industrial Accidents eMIMI ►lay_= 1 Congress Street,Suite 100 -ili1 4' Boston, MA 02114-2017 e�`jJ,A www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Pioneer Valley Habitat for Humanity, Inc. Address:PO Box 60642 City/State/Zip: Florence, MA 01062 Phone #:413-586-5430 x106 Are you an employer?Check the appropriate box: Type of project(required): i.❑✓ I am a employer with 7 employees(full and/or part-time).* 7. ✓❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑ Building addition 4.❑1 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 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.1=I 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. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *My 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:Lockton Affinity LLC Policy#or Self-ins.Lic.#:C5856168A Expiration Date:4/1/22 Job Site Address:781, 785 and 789 Burls Pit Rd City/State/Zip:Northampton, MA 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 hereby�c,/e�rtify under the pains and penalties of perjury that the information provided above is true and correct. Signature: !�/// Date: Phone#:413 M6-5430 x106 Official use only. Do not write in this area,to be completed by dry 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia j�Cl JL-yR r,'� DATE(MM/DD/YVVY) I e.,) CERTIFICATE OF LIABILITY INSURANCE 04DATE(M 21 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 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 NAMEACT Lockton Affinity, LLC Lockton Affinity, LLC E-MAINo,Ext):868 553 9002 (AC,No):913-652-3967 E-MAIL P. 0. Box 873401 ADDRESS: Kansas City, MO 64187-3401 INSVRER(S)AFFORDING COVERAGE _ NAIC# INSURER A:Ace American Insurance Co. 22667 INSURED INSURER B:Ace Property and Casualty 20699 Pioneer Valley Habitat for Humanity, Inc INSURER C:Bankers Standard Insurance Company 10279 PO Box 60642 INSURERD: Florence, MA 01062-0642 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL1064964-21 04/01/2021 04/01/2022 EACH OCCURRENCE $1,000,000 -- _. , DAMAGE TO RENTED CLAIMS-MADE rx l OCCUR PREMISES(Ea occurrence) $1,000,000 MED EXP(Any one person) $0 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY J PRO- I 1 LOC PRODUCTS-COMP/OP AGG $2=000,000 JECT — . OTHER: $ i AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accden1_ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ B x UMBRELLAL.IAB X OCCUR r UM1064964-21 04/01/2021 04/01/2022 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED I X I RETENTION$10,000 $ C WORKERS COMPENSATION C5856168A 04/01/2021 04/01/2022 PER OTH- AND EMPLOYERS'LIABILITY x STATUTE ER V I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED" NIA ------------- - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Builder's Risk BR1064964-21 04/01/2021 04/01/2022 Limit $10,000,000 - Special Form Deductible $5,000 I J DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurer A: Property Incl. Crime, Policy # PC1064964-21, 04/01/2021 - 04/01/2022, Limits Per Schedule on File with Lockton Affinity Insurer C: Directors & Officers Liability, Policy # D01064964-21, 04/01/2021 - 04/01/2022, Limit: $1,000,000 Insurer C: Excess Directors & Officers Liability, Policy # DOX11064964-21, 04/01/2021 - 04/01/2022, Limit: $1,000,000 Insurer A: Volunteer Accident Medical Expense, Policy # MED1064964-21, 04/01/2021 - 04/01/2022, Limit: $250,000 Insurer A: Volunteer Disability, Policy # DIS1064964-21, 04/01/2021 - 04/01/2022, Temporary Total Disability Limit: 60% Salary CERTIFICATE HOLDER CANCELLATION 1064964 Proof of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCEyg� WITH THE POLICY PROVISIONS. AUTHORIZ TI NTA�I' � / ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 37408708 1064964