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36-410 (2) BP 2022-0676 771 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 GRANTE'I 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 WHOLE HOUSE PERMIT ISSUED 10/12/2022 BYJ.FLAGG 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 NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I , ' � a kk, .5 d i� Fees Paid: $200.00 / I 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner . c • / 1/� YL, The Commonwealth of Mass•, us s ‘5?p Q . Board of Building Regulations d dards 26 .OR W Massachusetts State Building Col <2USA LITY °9rti Uri Building Permit Application To Construct, Repair, Ren• . .pr, olish a Rv ised filar 2011 One-or Two-Family Dwelling °��;q"Fcr,) Thisis Section For Official Use Only 'oNS Building Permit Number: (3i - "'Ci -ICI Dat- Applied: \ , i iI' i o j Building Official(Print Name) E Signature Da e SECTION 1: SITE INFORMATION 1.1 Property Address: 77 / 1.2 Assessors Map& Parcel Numb Lot 10,Burt's Pit Rd.,Northampton,MA 36 4I Us-001 1.1 a Is this an accepted street?yes X_no_ Map Number Parcel Number 4.3 Zoeng Information: 1.4 Property Dimensions: SR Single Family Home with attached ADU 25,244 sq ft See plot plan Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) --SEE SITE PLANS-- Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public[3 Private 0 Check if yes!: Municipal Ellgtin site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Hollis and David Shore Lancaster, Ma. 01523 Name(Print) City,State,ZIP 498 Neck Rd. 508-331-4189 hollisplus@gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Q Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units 1 Other 0 Specify: Brief Description of Proposed Work': A single family home with an attached garage and home office space SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ $431,059.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ $1,480.00 0 Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ $6,750.00 2. Other Fees: $ 4. Mechanical (HVAC) $ $18,600.00 List: 5. Mechanical (Fire $ +° Suppression) Total All Fees: $ $457,889.00 Check No.3�/O Check Amount: Cash Amount: 6.Total Project Cost: $ ti(Paid in Full 0 Outstanding Balance Due: n,.,. in c,.17titi)..-,7G..,,.nna0„01Gn000.,7Gnti7„A0ngtils SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-116643 7/13/2025 Austin Gregory License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 47 George St. No.and Street Type Description Portland,ME 04103 U Unrestricted(Buildings up to 35,000 cu. Ii.) 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 pro''ide 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 Backyard ADUs to act on my behalf,in all matters relative to work authorized by this building permit application. Hollis Shore 2. '/ 09 / 16 / 2022 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,Backyard ADUs ��kl� 09 / 16 / 2022 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 plannsd, ovide the information below: Total floor area(sq. ft.) lI' iVWU alkifIPSi (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) 1 a 3 a 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 I Type of cooling system Enclosed Open 1 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton !CV ': Massachusetts Lie c'T Oti DEPARTMENT OF BUILDING INSPECTIONS r " 212 Main Street • Municipal Building yak Via~` Northampton, MA 01060 sfrJy 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 ADUs Signature of Applicant: ��1��"'�' Date: 09 / 16 / 2022 c..47L,L,')..., A,..IIAcn..4lc1100')i.7cAk7. AQAckic • ..hc,t'N...N. The Commonwealth of Alassachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017• ,.., ,:Ap ittrIVW.ntass.govidia -„IeW *4 takers'(7onipensiniun Insurance Affidavit:Buildersit7ontractorsiElectricianstPlumbers. TO RE FILED WITH iiii,..PERMUTING'AUTHORITY. Applicant Information Please Print Leniblv Name(0ustness.20rganization1ndtvdual): _ . BackyardADU.s... Address: „„2.4.7 Loomhs.B(1, _ _____ _____ „ . . . City/State/Zip: Ri.nr,„....wick. ME--..... Phone 4: 217-252-9893 .. .. . . .. . •• you an employee 4 leek the appropriate bat: , Type of project(required): ! la tam a etopkrya with, ,5_,,,,,,,,esivipyvei;(full untrue part-timel..* 7. ONcwotno 2.0 I anis sole propriette or partnership and have no empliti'yeeit working for ettoe its i 8. Remodeling my:eanseity.[No workers'comp.irismatiee mptireil.) 9. 0 Demolition i 30 I am a liortaisassiter doing all work myself[No*niters'ema .immunise reividoil t . 100 Building additio 1 4.C31ain a Inatioawrita and will he Lraring coattaidors its conthiet iall%lilt tht iny property_ I will entilitt that all contraelotS either have workieni'compensiiiii%itsuirimee or aiV sole : 11.0 Electrical rep •or additions proprietors with tto einployees: ...: i 2.1]Plumbing repai . or additions .10 I am a general contractor and I hire hired the subseutitraetnrs listed on the attached sheet. , 31:1 These sub-eurtioacipts how employees.and have workers'comp.insiaance.; l Root repairs !: I 4.tnOther 60 we me Oif4pQrstient and as officers have exercised their right of exemption per MC&e. 151,*14.4),and we have no cmployee.s.[No workers'comp.insurance required.] *Any invitem that cheeks box*I mod also fill out the section below showing their workers'compensation policy utfonnation. t Ilea/tots ran who submit this allidatit indieating they are doing all eirrk and that hire c.4.1taiiile contractors amid submit a new affidavit Wresting swell. lcontractors that check this box most attached an additional sheet show in the name Of the saNciettractors and!Mae whether or r101 those entities have ourik,:,,.,,,.. lithe st.,zb,o.itttnictin, ba'e einployites.they must prtividc their workers"comp.policy manher. I am art employer that is providing worliers compensation insurance for my employees.. Below is the policy and job site infornnotion. 'Insurance Company Name: The Hartford Policy 4 or Self-ins.Lie.4: 4WECAN6MGS Exptratton Date: 10/7/2022 Job Site Address: Lot 10,Burt's Pit Rd. City/State/Zip: Northampton,MA Attach a ropy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MG".e. 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 certify under he pains and penalties ofperjury that the information provided above is true and carrecL N7 09 / 16 / 2022 Signature: Date: Phone#: 7819990773 . , official use only. Do not write in this area,to be completed by city or town official(74 or Town: Permitticense# • Issuing Authority(circle one): I. Board of Health 2,Building Department 3,City/Town Clerk 4,Electrical inspector 5.Plumbing Inspector 6,Other Contact Person: Phone 4: m-- in. ,17kkQ„7Aao,c2ignon0-7rAk7-A0Aekic Commonwealth of Massachusetts 1 Manufactured Buildings Program -Plan Identification Number Assignment Name of Manufacturer Professional Building MC Identification Number Systems, Inc. 221 Third Party Identification Number 02 Project Title 103610 Use Group R-3 BBRS\OPSI Identification Number 0341-22 Review Required All plans are reviewed by MA and a BBRS Number assigned when approved Date: 09/06/22 Manufactured Buildings Program From: Syno Tell, CBO Manufactured Buildings Program Manager Re: Confirmation of Receipt of Building Plans &Assignment of BBRS\OPSI Identification Number (BBRS\OPSI I.D.Number) The Board of Building Regulations and Standards and Office of Public Safety (BBRS\OPSI) has received your building plans for the referenced project and has assigned the identification number noted above (in the block marked BBRS\OPSI I.D. Number). This number has been assigned for purposes of internal tracking methods. This number shall be used in reference to this project and on all future correspondences, inquiries and plan revisions. Thank you for your cooperation with this matter. Send all correspondences,inquiries and plan revisions to: Office of Public Safety&Inspections-Syno Tell 1000 Washington Street,Suite 710 yioNwEA1 T Boston,MA 02118 �o`M1 * u bo„ Syno.Tell@>mass.gov a Bbrs\forms2\manufacturedbldgplanid-06/2018 ;` e 44. A �n ta j@s 'y qe c a P� OL s �. cm 1e 6Nxa t t` 3n r, Home Energy Rating Certificate Rating Date: 2022-08-02 HIS Projected Report Registry ID: HERS P Based on Plans Ekotrope ID: VvnpP9aL , 1 -4 R. n/ ex 9-' fin4;k4?;"4.04ii0;wigi,074;wk35WAA20, ,,,,...6:- 'MO -,A, v, ,,a$&4%Florence Aitit 01062 ,41-"MniNAW*Ikiii,1 �s.,, _ 4 .s-.. :'rs'i ...s a sv�;%;/,/i ::•�"i y % %;4 ... q. y//.it. >�� 'i,; ,'! ' � /� 4.47 Your Home's Estimated Energy Use: This home meets or exceeds the Use[MBtua Annual Cost criteria of the following: Heating 6.9 $448 2018 International Energy Conservation Code Cooling 0.4 $28 Hot Water 1.6 $102 Lights/Appliances 11.1 $716 PFS _... _.. Corporation Service Charges $120 Northeast Region Generation(e.g. Solar) 0.0 $0 APPROVED H Raup-3 Total: 20.1 $1,414 9/6r 22 Approval limited to Factory Bildt Portion HERS`Index Home Feature Summary: Rating Completed by: More Energy Home Type: Single family detached Model: N/A Energy Rater: Hayden Cantoni tSo RESNET ID: 6193669 ExooHFng j u.n Community: N/A Homes ''< „0 Conditioned Floor Area: 905 ft2 Rating Company: HIS&HERS Energy Efficiency 1?n Number of Bedrooms: 1 57R Adams Rd.Williamsburg,MA 01039 Reference ., Primary Heating System: Air Source Heat Pump•Electric•12.5 HSPF 4136588784 Home i"`""100 .90 Primary Cooling System: Air Source Heat Pump•Electric•18 SEER Rating Provider: Energy Raters of Massachusetts -80 Primary Water Heating: Residential Water Heater•Electric•3.06 UEF 2 Woodlawn Street Amesbury,MA 01913 . House Tightness: 1 ACH50 978-270-3911 .F° ,, c° Ventilation: 26 CFM•15 Watts AC"'AlbDuct Leakage to Outside: Forced Air Ductless .,n This Home Above Grade Walls: R-31 10 Ceiling: Attic,R-65 Zero Energy f° Window Type: U-Value:0.27,SHGC:0.3 Home 0 Foundation Walls: R-20 Hayden Cantoni,Certified Energy Rater Fees Energy Framed Floor: N/A Digitally signed:8/2/22 at 5:32 PM ir) ekot e Ekotrope RATER-Version:4.0.1.2961 The Energy Rating Disclosure for this home is available from the Approved Rating Provider. This report does not constitute any warranty or guarantee. Energy savings calculated without modifications to the energy model.(As Modeled) IECC 2018 Performance Compliance HIS Property Organization Inspection Status HERS 10 Burts Meadow HIS & HERS Energy Effici Results are projected Florence, MA 01062 Hayden Cantoni 10 Burts Meadow Builder 10 Burts Meadow Prelim Backyard ADU This report is based on a proposed design and does not confirm field enforcement of design elements. Annual Energy Cost Design IECC 2018 Performance As Designed Heating $426 $291 Cooling $38 $36 Water Heating $92 $91 Mechanical Ventilation $22 $19 SubTotal - Used to determine compliance $578 $437 Lights &Appliances w/out Ventilation $460 $460 Onsite generation $0 $0 Total $1,038 $898 R405.3 Source Energy Exception:The proposed home uses 10.3 MBtu LESS source energy than the reference home. Requirements The proposed house meets the IECC 2018 Performance reference energy bit 405.3 Performance-based compliance passes by 24.3% requirement by$140.26(10.3 MBtu),but a post construction blower door test is required for confirmation. ;.; R402.4.1.2 Air Leakage Testing A post construction blower door test is required to verify the air leakage meets the requirement. R402.5 Area-weighted average fenestration SHGC R402.5 Area-weighted average fenestration U-Factor 4 R404.1 Lighting Equipment Efficiency R403.6.1 Mechanical Ventilation Efficacy Mandatory Checklist Mandatory code requirements that are not 2018 IECC Mandatory Checklist must be checked as complete. checked by Ekotrope must be met. IRC M1505.4.3 Mechanical Ventilation Rate R405.2 Duct Insulation Design exceeds the performance requirement for IECC 2018 Performance compliance by 24.3% but fails the mandatory requirements. As a 3rd party extension of the code jurisdiction utilizing these reports,I certify that this energy code compliance document has been created in accordance with the requirements of Chapter 4 of the adopted International Energy Conservation Code based on HAMPSHIRE County.If rating is Projected,I certify that the building design described herein is consistent with the building plans, specifications, and other calculations submitted with the permit application. If rating Is Confirmed, I ce 'fy that the address referenced above has been inspected/tested and that the mandatory provisions of the IECC have been installed to meet or exceed the intent of the IECC or wit e rifled as s by anothtypa Name: Hayden Cantoni Signature: Organization: HIS & HERS Energy Efficiency Digitally signed: 8/2/22 at 5:32 PM PFS Corporation Northeast Region APPROVED H Raup-3 9!6/22 Approval limited to Factory Built Portion Ekotrope RATER-Version 4.0.1.2961 IECC 2018 Performance compliance results calculated using Ekotrope RATER'S energy and code compliance algorithm. Ekotrope RATER is a RESNET Accredited HERS Rating Tool.All results are based on data entered by Ekotrope users. Ekotrope disclaims all liability for the information shown on this report. Building Specification Summary HIS Property Organization Inspection Status HERS 10 Burts Meadow HIS & HERS Energy Effcii Results are projected Florence, MA 01062 Hayden Cantoni 10 Burts Meadow Builder 10 Burts Meadow Prelim Backyard ADU Building Information Rating Conditioned Area[ftI 905.30 HERS Index 41 Conditioned Volume[ft3) 9,506.00 HERS Index w/o PV 41 Thermal Boundary Area [ft2] 3,282.35 Number Of Bedrooms 1 Housing Type Single family detached Building Shell Ceiling w/Attic I Windows (largest)1 U-Value: 0.27, SHGC:0.3 R65, 17.5"cell , 6-16_R63.7effcty; U-0.016 Window/Wall Ratio 10.17 Vaulted Ceiling I None Infiltration 1 1 ACH50 Above Grade Walls I Duct Lkg to Outside 1 Forced Air Ductless R31,6-16 FG G2 1.5" ISO R28.1 actual; U-0.036 Total Duct Leakage I Untested Found. Walls 1 2"XPS int, 2"XPS ext. R20; R-20 Framed Floors f None Slabs I R10 under,R20 edge_8'width;R-20 Mechanical Systems Heating Air Source Heat Pump• Electric• 12.5 HSPF Cooling Air Source Heat Pump•Electric• 18 SEER Water Heating Residential Water Heater• Electric• 3.06 UEF Programmable Thermostat No Ventilation System 26 CFM• 15 Watts Whole House Fan N/A Lights and Appliances Percent Interior LED 100% Clothes Dryer Fuel Electric Percent Exterior LED 100% Clothes Dryer CEF 3.0 Refrigerator(kWh/yr) 670.0 Clothes Washer LER(kWh/yr) 151.0 Dishwasher Efficiency 270 kWh Clothes Washer Capacity 3.3 Ceiling Fan None Range/Oven Fuel Electric PFS Corporation Northeast Region APPROVED H •aup-3 s6/22 Appr•val limited to Factor Built Portion Ekotrope RATER-Version 4.0,1.2961 All results are based on data entered by Ekotrope users.Ekotrope disclaims all liability for the information shown on this report. Component Loads -� HIS Property Organization Inspection Status HERS 10 Burts Meadow HIS & HERS Energy EfficiF Results are projected Florence, MA 01062 Hayden Cantoni 10 Burts Meadow Builder 10 Burts Meadow Prelim Backyard ADU Heating & Cooling Loads 8 H 7 PFS Corporation 6 _: Northeast Region .w APPROVED F Raup-3 5 ;;= 9/6/22 :s :: ,{ Approval limited to t cr':'.! Factory Built Portion 4 =::: :,:.. co . to s t .... ram .._._.,,_... ,1111_ -1 , l :!:.1,1!:...1„...1.1,....1„..1„..!„..;..!_i„..!...1:„.1,i,,....!.....,...1„1 -2 NEI -3 Above-Grade Infiltration & Slabs & Roofs Ducts Windows & Foundation Internal Walls Ventilation Floors Doors Walls Gains Heating Cooling In Ekotrope RATER-Version 4.0.1.2961 All results are based on date entered by Ekotrope users.Ekotrope disclaims all liability for the information shown on this report. A�E) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYVYY) 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 l PA/HONE,Exd: (207)283-1486 FAX Nb). (207)283-4258 260 Main St. E-MAIL kjenkins@insurancepc.com ADDRESS: P.O.Box 356 INSURER(S)AFFORDING COVERAGE NAIL# 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 SUER 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 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) I $ MED EXP(Any one person) $ 5,000 A CGL 0162726 03/24/2022 03/24/2023 PERSONAL&ADV INJURY $ Excluded GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1 $ 2,000,000 POLICY X jE 0. n LOC PRODUCTS-COMP/OP AG6 $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ I OWNED SCHEDULED BODILY INJURY(Per acciden) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMI $ 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 :Zk. The Commonwealth of Massachusetts Department of Industrial Accidents 3 Office of Investigations 600 Washington Street Boston, MA 02111 7-7 AY 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 i Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 3 4. ❑ I am a general contractor and I 6. ®New construction employees(full and/or part-time).* have hired the sub-contractors I 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [' Remodeling I ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P n 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repair or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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: 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 O ER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of ice of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: )'r S.,-- Date: 6/1/2022 1 Phone#:2072529893 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth Massacl u$ s * - Division of Occupational �. censUr Board fBuildingRe t. ulations an Standards is to4,1'‘UV';'r l' on � " • Cons 1 rS ; 07 ' 25 AUSTIN RqfG°RY � - 4 GEORGE • T ,� , , PC�►RT�.AND 04103 �� y ; . Comm-ssioner �� (C-::)16/YI .(-1)-4.a.'"."' 66 Commonwealth of Massachusetts AI Manufactured Buildings Program Transmittal Form for all correspondences relating to Manufactured Buildings and Building Components To: Linda Shea, Manufactured Buildings Program Phone Number: Date Transmitted linda.shea@mass.gov 617-826-5225 9-6-22 Commonwealth of Massachusetts Office of Public Safety and Inspections Atth: Manu. Bldgs. Board of Building Regulations and Standards 1000 Washington Street, Suite 710 Boston Massachusetts 02118 The person forwarding this material shall complete the following portion of this transmittal Name of Person Chris O'Brien MC Number TPIA Number Transmitting Material 221 02 The following information is being transmitted to the Board of Building Regulations Please indicate the Distinct and Standards and/or the Department of Public Safety for reasons detailed below Model and/or Serial Use (Please check the appropriate box or give a further description of the transmitted Number pertaining to Group items under the section labeled other. Be sure to identify the appropriate Use Group.) transmitted items Building Plans for Review and Approval Building Plans forwarded as a record copy for your files (Review not required) 103610 one-family Revised building plans for review. (Please clearly identify revisions on the plans.) Revised Building Plans forwarded as a record copy for your files (Review not required- Please clearly identify revisions on the plans.) Compliance Assurance Programs Original Submission Modification to: Calculations Manual Original Submission Modification to: Installation Manual Original Submission Modification to: Systems Drawings Original Submission Modification to: Other-Provide a detailed description of any other materials which are being transmitted. Identify any revisions clearly along with BBRS number. Also, identify the requested action. Site Location: BURTS PIT RD.,NORTHAMPTON,MA 01035 The office transmitting this information has reviewed the above mentioned and attached materials and has found them,to the best of our knowledge and abilities,to be in compliance with the codes and\or rules and regulations for the Commonwealth of Massachusetts' Manufactured Building Program, as applicable D gitally signed by Harold Raup ••cn=Harold Raup,o=PFS,ou, Signed BV Signed By for TPIA:a ail=harold.raup@pfsteco.co BBRS No: assigned by Mass. for MASS: m c=US D te:2022.09.06 10:33:44-04'00' Print Form