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36-410 BP-2022-0676 *bpi BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-410-001 CITY OF NORTHAMPTON Permit: New Build PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0676 PERMISSION IS HEREBY GRANTED TO: Project# NEW HOUSE Contractor: License: Est. Cost: 417939 BACKYARD ADU'S LLC 116643 Const.Class: Exp.Date:07/13/2025 Use Group: Owner: A. SHORE, DAVID & HOLLIS Lot Size (sq.ft.) Zoning: Applicant: BACKYARD ADU'S LLC Applicant Address Phone: Insurance: 247 COMBS RD 207-252-9893 04WECAN6MGS BRUNSWICK, ME 04011 ISSUED ON:06/09/2022 TO PERFORM THE FOLLOWING WORK: FOUNDATION ONLY FOR NEW SINGLE FAMILY HOUSE WITH ATTACHED ACCESSORY DWELLING 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: Cas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: / �. • +' . Tat • I0 Fees Paid: $200.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner et 6 NS ct t cfiN The Commonwealth of Massachusett C�/ Board of Building Regulations and Stan ds Massachusetts State Building Code, 780 CM' tit/4/ • CIP ITY USE Building Permit Application To Construct,Repair,R ova - Sr Demolish gO Rev'.ed 'r 2011 One-or Two-Family Dwellin NOWT AM 70k. 1N^ This Section For Official Use Only o , pE Building Permit Number: 1 i J.4''0 70 Date Applied: �A 01060 DNS s; • 911/411( q Building Official(Print Name) Signature ' Ddte SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors3 Map&Parcel Number. 71 ,Burt's Pit Rd.,Northampton,MA Lai-10 29 ( TBD /D7 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: SR Single Family Home 25,244 sq ft 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' 15' 30' 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Hollis and Dave Shore Northampton,MA _ Name(Print) City,State,ZIP 508-331-4189 hollisplus@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 13 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units 2 Other 0 Specify: Brief Description of Proposed Work2: A single family home with an attached garage and accessory dwelling unit SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) , 1.Building $ $385,439.09 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ $7,500 ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $ $7,500 2. Other Fees: $ 4.Mechanical (HVAC) $ $17,500.00 List: 5.Mechanical (Fire Total All Fees: $ Suppression) $417,939.09 Check No. � Check Amoun Cash Amount: 6.Total Project Cost: SCl Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-116643 7/11/2025 Austin Gregory License Number Expiration Date Name of CSL Holder List CSL Type(see below) Unrestricted 47 George St. No.and Street Type Description Portland,ME 04103 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry __RC Roofing Covering WS Window and Siding _ SF Solid Fuel Burning Appliances 207-252-9893 austin.gregory@backyardadus.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) N/A New construction 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 0 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 Backyard ADUs to act on my behalf,in all matters relative to work authorized by this building permit application. Hollis Shore 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. Chris Lee 6/1/22 Print Owner's or 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.) 1625 (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms 2 Number of bathrooms 2 Number of half/baths Type of heating systemminisplit heat pump Number of decks/porches 1 Type of cooling system Enclosed Open 1 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 SIDE YARD see attached site plan SIDE YARD FRONT SETBACK FRONTAGE City of Northampton oRYHAMYTn-. y Massachusetts /# 9• �f G lf ;-E4. J DEPARTMENT OF BUILDING INSPECTIONS yr, 212 Main Street • Municipal Building y'•., .Cam Northampton, MA 01060 rsjj'••• j,�O 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, 34 Easthampton Rd, Northampton, MA 01060 The debris will be transported by: Name of Hauler: Backyard ADU's Signature of Applicant: Date: 6/1/2022 The Commonwealth of Massachusetts ►.= 'lgil=rw=e. Department of Industrial Accidents 1- 1 Congress Street,Suite 100 -€1.01111w Boston, MA 02114-2017 _ www.mass.gov/dia calkers'Compensation Insurance Affidavit:BuiklerslContractorslEketricianslPlumhers. 1'0 BE FILED WITH THE PERMITiING AUTHORITY. Applicant Information Please Print Leeiblr Name 1. us moss,Organization:1ndividual):_ Backyard ADUs _ Address: 247 Coombs Rd. City/State/Zip: Brunswick,ME Phone *: 781 999 0773 Are yea an employer?Cherk the appropriate box: Type of project(required): 1.3 lam a employer with 3 . employees(full aadiur part-tie a 7. ®New construction 20 I am a sole proprietor or partnership and have no employees working for m 8. Remodeling any capacity.No workers'comp.insurance required.] 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.]` 9. Demolition A.Q 1 am a homaowncr and will be hiring contraurs to conduct all work on my property. I will 1 a Building addition cx ensure that all c ntraciurs either have wmitets'eumperisation insurance or are sole 11.Q Electrical repairs or additions pruprictors with no employees. 12.EI Plumbing repairs or additions 50 I am a general contractor and I lone hired the subcontractors listed on the attached sheet 13❑Roof repairs These sub-contractors lame employees and have workers'comp.Insurance.. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we hose no employees.[No workers'comp.insurance required.] •Airy applicant that checks lwx a b must also fill out the section below show ing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all w ink and then hire outside contractors must submit a new affidavit indicating such. teontractors that cheek this box must attic hrcd an additional sheet shun ing the name of the sub-i:untracturs and state whether or nut thus:entities have employee,. If the sub-contractors hose employees.they must pro+ide their workers':<nnp.policy mm�ber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.Lie.#: I::.pitnttot: Bate: Job Site Address: Lot 10, Burt's Pit Rd. Cityr'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 S1.500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 certify under tin'pain.,and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 781-999-0773 Official use only. Do not write in!hi►area, to be completed by city or town ofjiciat 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#: 1 City of Northampton <M�Mpj J✓,,fi L Massachusetts ``�S' �= � t. •c ' DEPARTMENT OF BUILDING INSPECTIONS ti'` r£ `; 212 Main Street • Municipal Building b+ ' ~ " Northampton, MA 01060 P31; .. ,seDI HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born _ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of _, 20_. (Signature) T The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 am www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Backyard ADU's Address:247 Coombs Road, City/State/Zip: Brunswick, ME 04011 Phone#:2072529893 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with 3 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance.: 9. ❑Building addition comp.insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.11 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other 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. +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: The Hartford Policy#or Self-ins.Lic.#:04WECAN6MGS Expiration Date: 10/07/2022 Job Site Address:Lot 10 Burt's 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 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: y'wo�` Sow Date: 6/1/2022 Phone#:2072529893 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#: 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 numbers)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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia A/"OR DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/30/2022 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 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 endorsement(s). PRODUCER CONTACT Kristen Jenkins NAME: Paquin&Carroll, LLC PHONE (207)283-1486 FAX (207)283-4258 (A/C,No,Extl: (A/C,No): 260 Main St. E-MAIL kjenkins@insurancepc.com ADDRESS: P.O. Box 356 INSURER(S)AFFORDING COVERAGE NAIC# Biddeford ME 04005 INSURER A: Berkley Aspire 32603 INSURED INSURER B Chris Lee, DBA,Backyard ADUS,LLC INSURER C: 247 Coombs Rd INSURER D: INSURER E: Brunswick ME 04011 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 GL 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 RENTED CLAIMS-MADE X OCCUR PREMISESDAMAGE TO(Ea occurrence) $ 100,000 MED EXP(Any one person) g 5,000 A CGL 0162726 03/24/2022 03/24/2023 PERSONAL a ADV INJURY $ Excluded GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000,000 POLICY X PRO- POLICY LOC 2,000,000 PRODUCTS-COMP/OPAGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY .AUTOS BODILY INJURY(Per accident) $ HIRED • NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED'? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Proof of General Liability coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD -- Commonwealth of Massachusetts ft Division of Occupational Licensure Board of Building Re ulations and Standards 1 IT' Cons ion Sf rvisor • CS-116643 - cpires: 07/13/2025 1 AUSTIN R GLEGORY 47 GEORGE STREET =' 1 I -$ --s — PORTLAND It 04103 I i f , 1,4 : - Al 4. ra, -. , ,> w Commissioner i'. "�iricih