22-012 (4) BP-2022-0530
75 SPRUCE HILL AVE COMMONWEALTH OF MASS CHUSETTS
Map:Block:Lot:
22-012-001 CITY OF NORTHAMPT I N
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERE) CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY F ND (MGL c.142A)
BUILDING PE ' MIT
Permit # BP-2022-0530 PERMISSION IS REBYGRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 5400 HOME ENERGY SOLUTIO1 S INC 106188
Const.Class: Exp.Date: 12/28/2023
Use Group: Owner: N BOBROW, ARC A& KIMBERLY H & SYDNEY
Lot Size (sq.ft.)
Zoning: WSP Applicant: HOME ENER/Y SOLUTIONS IC
Applicant Address Phone: Insurance:
233 COLLEGE HWY (413)203-2454 0 HOWC 140654
SOUTHAMPTON, MA 01073
ISSUED ON:05/16/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHA PTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I • • +�• )2 Ti •
I ' I
Fees Paid: $65.0(1
212 Main Street, Phone(4l3)587-1240,Fax:(413).87-1272
Office of the Building Commissioner
(Ult_T Ic ,3
D « ORCity of Northampton
Building Department /..N.
212 Main Street � ���
%.. INSULA TI N
'_.1- Room 100 � „
` Northampton, , 1060 ?
`-4° phone 413-587-1240 Fait , 87-127Z�42 ONLY
nT
a,
APPLICATION FOR INSULATION FOR A ONE OR TWf"O FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION IINS V LA T■ON PERMIT
This section to be completed by office
1.1 Property Address:
Map a� Lot A-Z. Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_Sydney Bobrow 75 Spruce Hill Ave
Name'Print) Current Mailing Address
530-8057
Atta.clied___- Telephone
vinature
2 2 Authorized Agent:
Shawn Mitchell 233 College Hwy Southampton MA, 01073
Name(Print) Current Mailing Address'
• 1�� 413-203-2454
': nature 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
5,400 ,
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) 5,400 Check Number I SO 4
This Section For Official Use Only
Date
Building Permit Number:, 4!47 Issued:
/ .
Signature: _'../2 - ZO
9
} Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: Shawn Mitchell
------------.-- 106188
License Number
i
i 63 Russellville Rd 12/28/23
Address Expiration Date
413-203 .2.44___ _
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable
Home Energy Solutions Inc.
1_3885
Company Name • Registration Number
233 College Hwy Southampton MA, 01073 12,4/22
Address Expiration Date
Telephone 413-203-2454
-- 1
SECTION 5-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 fi( No 0
Brief Description of Proposed Work NOTE: INSULATION ONL Y
Blown in insulation and air sealing
1. Shawn Mitchell , as Owner/Authorised
Agent hereby declare 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.
Shaucn Mitchell-
Print Name
5/6/22 _
Signature of Owner/Agent Date
I, Sydney Bobrow ,as Owner of the subject
property
hereby authorize Shawn Mitchell
to act on my behalf, in all matters relative to work authorized by this building permit application.
Attached 5/6/22
Signature of Owner Date
DocuSign Envelope ID:26E16A96-6F0C-4195-88E2-786E1 A85D411
RISES
ENGINEERING`
OWNER AUTHORIZATION FORM
I, Sydney Bobrow
(Owner's Name)
owner of the property located at:
75 Spruce Hill Avenue
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize
Subcontractor(to be filled in by office)
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.
The permit will be secured by the subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
i—DoCUStaned by:
Sys jetrew
O`47r3e? s fi bre
2/26/2022 1 11:54 AM EST
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
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el\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
, ,--
fil Lafayette City Center
2 Avenue de Lafayette. Boston, MA N111-1750
---r-7),- WWW.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Home Energy Solutions Inc
Address:233 College Hwy ,
City/State/Zip: Southampton, MA 01073 Phone #: 413-203-2454
...
Are you an employer?Cheek the appropriate box:
Type of project (required):
I.Qr I am a employer with 5 4, E I am a general contractor and I
6. 0 New construction
employees (full water part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attaehet, sheet. 7, 0 Remotieling
ship and have no employees These sub-contractors have 8, 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
:
[No workers' comp. insurance comp. insurance
required.] 5 0 We are a corporation and its 10.0 Electrical repairs or additioi
3 10 1 am a homeowner doing all work officers have exercised their 11,0 Plumbing repairs or additioi
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required,l ' c. 152, §1(4),and we have no
. Other
employees. [No workers' 1.30
comp. insurance required.] . .
An applIcant that checks box;41 must also fill out the 4cctiorr below showing their workers'compensation policy information.
'I iorneowners who submit this affidavit indicating they are doing all worit 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
empli%yoes 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 NameAmGaurd Insurance Company
Policy#or Self-ins. Lie #:HOWC361807 Expiration Date: 01/04/2023
Job Site Address: 75 Spruce Hill Ave CityStateizip:Northampton, MA G1062
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure lo 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 fi
of up to S250,00 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 certifj,an, 1,e pain.s'and penaltie: ., jury that the information provided above is true and correct.
i
.....0"-
Ol Vote:
.. 1 ,-;.,7 ,,,,,,..„.p.r Date: 5/6/22
4.40frrt- " "c;";-•-"'
?how*: 413-203-2454
Official use only. Do not write in this area, so be completed by city or town official.
II: City or Town: Permit/Liman#
1; Issuing Authority(check one):
P 10Board of Health 20 Building Department 3EIC1ty/Town Clerk 4f]Electrical Inspector 5E2Plumbing
11
II inspector 6.00ther
li Contact Person: Phone#: