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15-006
BP-2023-0085 446 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15-006-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-0085 PERMISSION IS HEREBY GRAN ED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 6000 BRADSHAW ENTERPRISES LLC 108517 Const.Class: Exp.Date: 12/10/2024 Use Group: Owner: F BURTON DAVID L&ANNE Lot Size (sq.ft.) Zoning: WSP Applicant: BRADSHAW ENTERPRISES LLC Applicant Address Phone: Insurance: 413-310-8010 A0158300004 SPRINGFIELD, MA 01104 ISSUED ON: 01/26/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/W EAT H ERI ZATI ON 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 VI O LATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Q a y.J . T11 I ! I Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner /> \,, / `�,�`- 'gul:.r Ine) The Commonwealth of Massachusetts, \'. *rit Board of Building Regulations and St ndards J,y,�� FOR Massachusetts State Building Code,.780'CMR MUNICIPALITY `'S` US'E ' '<,, --3 Revised Mar 2011 Building Permit Application To Construct, Repair,Renovate- ,P emoliSlif a One-or Two-Family Dwelling ', �s This Section For Official Use Only 's\o'C. . Building Permit Number: igias ea a— "J,5- Date Applied: '\ o' 4-1.)143 /Ko59 / ...2 1-25-20Z3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: I 1.2 Assessors Map& Parcel Numbers _446 Chesterfield Road,Northampton Ma 01053 IA 1.1 a Is this an accepted street?yesYES no Parcel ID 1.3 Zoning Information: 1.4 Property Dimensions: NA NA NA NA Zoning District Proposed Use Lot Area(sq 11) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided NA NA NA NA NA NA 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: Anne Burton Northampton Ma 01053 Name(Print) City,State,ZIP 446 Chesterfield Road 413-548-4254 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addi ion 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:MASS SAVE:ADDING INSULATION TO THE ATTIC.AIR SEALING WALL PLATES WORK SCOPE AND PLANVIEW ATTACHED. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 6000 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Suppression) Fees:_$$ Check No,4`t'{l Check Amoun . V Cash Amount: IF 6.Total Project Cost: $ 6000 0 Paid in Full Cl Outstanding Balance Due: Treasurer's Approval: Board of Health DPW Conservation Comm Approval: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 108517 12/10/2024 SEAN MATTHEW BAILEY BRADSHAW License Number Expiration Date Name of CSL Holder List CSL Type(see below) 246 CONNECTICUT AVENUE No.and Street Type Description SPRINGFIELD, MA 01104 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering Signature WS Window and Siding SF Solid Fuel Burning Appliances 413-301-8010 SEAN@BRADSHAWENTERPRISESLLC.COM I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 194456 02/07/2023 BRADSHAW ENTERPRISES,LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 1 246 CONNECTICUT AVENUE gZ163 ,LpM*„ {ESLL No.and Street Signature Email I SPRINGFIELD,MA 01104 413-301-8010 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 Signature Date SECTION 7b:OWNER1 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. SEAN BRADSHAW .n B °' "'°'KIOC Esr Print Owner's or Authorized Agent's Name 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 arbitratior program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be fbund 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.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" dotloop signature verification:dtip.us/RpFP-6GzK-Cd8t The Commonwealth of Massachusetts • Department of industrial Accidents 1 Congress Street,Suite 100 Boston,MA 021 1 4-201 7 r' 'L www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO SE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/Organizational/Individual):Bradshaw EnterpriSes, LC. Address: 34 Front St Indian Orchard Mills Suite G60 City: Springfield State: MA Lip: 01051 Phone tt: 413-250-4746 Are you an employer?Check the appropriate box: Type of project(required): Lit__ I. I am an employer with + 1 employees(full and/or part time)' ["7. New construction n2. I am a sole proprietor or partnership and have no employees working for me In any 8. Remodeling capacity.(No workers'comp.insurance required.] —1 9. Demolition I13. I am a homeowner doing all work myself.[No workers'comp.insurance required)t 1-110. Building addition n4. I am a homeowner and will be hiring contractors to conduct all work on my property. rill. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. n12. Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs sheet. 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. 4. Other c.152,§1(4,),and we have no employees.[No workers'camp.insurance required.] iIII `Any applicant that checks box as must also fill out the section below showing their workers'compensation policy information. ±Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indlea$ing such. ±Contractors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entitles have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Sentry Insurance (Agent- Phillips Insurance 413-594-5984) Policy#or Self-ins.Lac.#: A0158300004 8/12/2023Expiration Date: lob Site Address: 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. I1 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbax and typing my name in the field below will act as my signature. Name: Sean Bradshaw Date: 9/29/20 Phone : 413 250-4746 Email: sean@bradshawenterpriseslIc.com Office nfConsumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 � Home Improvement Contractor Registration Type: LLC Registration: 194450 BRADSHAVV ENTERPRISES, LUC Expiration: 0207/2023 248CONNECT|CUTAVE 5PH|NGF)ELD. MA 01104 Update Address and Return Card. Office or Consumer Affairs& Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. |f found return to: Registration EupjrsdioD Office of Consumer Affairs and Business Regulation 184456 02807/2023 1U0U Washington Street - Suite 710 Boston,BRADSHAVV ENTERPRISES, LLC Buo ` MA 02118 SEANM. BRADSHAVV 34 FRONT STREET SPRWGFIELD MA 01151 ^=—' ' Not valid without signature dotloop signature verification:dop.,:siRpFP-n :KCr1.=i DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of MGL c.40,s.54,is that the debris resulting from this wdrk shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.i l 1, s.150A. ANY AND ALL DEBRIS PROUCED AS A RESULT OF WORK PERMI1 1ED UNDER THE ATTACHED APPLICATION WILL BE DISPOSED OF IN: USA Waste Recycling Name of Licensed Solid Waste Disposal Business/Facility 15 Mullen Rd, Enfield CT 06082 Address of Licensed Solid Waste Disposal Business/Facility USA Waste Recycling Name of Hauler Sean Bradshaw 9/20/2)20 Print Applicant Name Date ❑ I,Sean Bradshaw do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the field above will act as my signature n 0 0 0 v c a m t m 0 0 a commonwealth of Mas sachusett% 1 lry D:vision of Professional Licensure Board of Building Regulations and Standards C k, `1struction Supervisor CS-108517 * ires: / 2110/2022 SEAN MA11 W :., - •aol... 4 BRADSHAW c 246 CONNECTION ' : .4/ SPRINGFIELD VA .0 _ . _. Commissioner , n1s dotloop signature verification:dtlp.,is/PpFP-6GzK C'I: I BRADENT-01 _BROOKE AC©R :3 DATE(MM/DD:YYYY) CERTIFICATE OF LIABILITY INSURANCE 425/2022 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 Brooke Barre Phillips Insurance Agency,Inc. PHONE 413 594-5984 FAx 97 Center Street A C,No,Ext). ( ) (A/C,No):(413)592-8499 Chicopee,MA 01013 ADoaEss:brooke@philiipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Middlesex Insurance Company - INSURED INSURER B:Sentry Insurance 24988 Bradshaw Enterprises,LLC INSURER c.EVANSTON INSURANCE CO. 35378 PO Box 944 INSURER D Chicopee,MA 01021 INSURER E INSURER F •VERAG S 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 P•LICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT •WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS INSD WVD tMM1DO/YYYYI IMM/DDITYYY) A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE .. CLAIMS-MADE X OCCUR A0158300 8/12/2022 8/12/2023 pREM SESE T ER Eceortence)_. .$ 500,000 MED EXP(Any one person) $ 10,000 r PERSONAL BADV INJURY $ 1,000,000 GEMLAGGREGATE LIMIT APPLIESPER: GENERAL AGGREGATE 3,000,000 Rp� 2,000,000 POLICY X.JECT ',LOC 'PRODUCTS•COMPiOPAGG "a OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 1,000,000 X ANY AUTO A0158300003 8/12/2022 8/12/2023 BODILY INJURY(Per person) $ AUTOS ONLY AUUTNOSSyUyLED BODILY INJURYp (Per accident).,,S. A�TOS ONLY AUTOS ON � (PerO G�ulq AMAGE _$ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LIAB CLAIMS-MADE A0158300 8/12/2022 8/12/2023 AGGREGATE $ 2,000,000 DED X RETENTIONS 0 B AND EMPLOYERS'COMPENSATION Y 1 N - -- ---- X :STATUTE ERH- ANYPROPRIETOR/PARTNER/EXECUTIVE A0158300004 8/12/2022 8/12/2023 1,000,000 QF�FICER/MEMg EXCLUDED? V N/A E.L.EACH ACCIDENT 5 (Mandatory to Nj 1,000,000 E.L.DISEASE-EA EMPLOYEE $ yes describe under 1,000,000 ;DESCRIPTION DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C ''Pollution Liability CPLMOL105072 1/1/2022 1/1/2023 Aggregate 250,000 DESCRIPTION OF OPERATIONS i 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 Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE bELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All N hts reserved. The ACORD name and logo are registered marks of ACORD Massachusetts Oft „s, Contractors-Academy C e rt P� Of C d-i'np lettOi t' �~ A PDH Academy Company Sean Bradshaw CS-108517 has completed the Massachusetts Contractor Classroom Renewal Course Part 1 Approval # CS-010212 Code Review 2 hours Energy 0 hours Workplace Safety 0 hours Lead Safety 1 hour Business Practice 1 hour Elective 2 hours 11/18/2022 Coordinator: Annie Schultz, Program Manager Coordinator Number: CD-000102 If you have any comments about this course offering, please mail them to the Board of Building Regulations and Standards, CSL, Continuing Education, One Ashburn Place-Room 1301, Boston, MA 02108 CLEAResult® CONTRACTOR WORK ORDER Mass Save® Home Energy Services 50 Washington St.Suite 3000 Westborough,MA 01581 Customer Name:ANNE BURTON Bradshaw Enterprises LLC Email:ferguson.anne@yahoo.com PO Box 1276, Phone:413-548-4254 Chicopee,MA,01021 Premise Address:446 Chesterfield Rd,Northampton,MA 01053 413-301-8010 Project ID:4697334 Applicable Customer Required Actions: Notes: • Storage Removal Prior to weatherization,homeowner is responsible for crawlspace and hall closet storage removal. Prior to weatherization,homeowner is responsible for removal of shelving from hall closet to allow access to wall hatch. Location Measure Desct ption" Quantity Unit Unit Cost Total Cost Vapor Barrier-6 mil Polyethylene(with AS hrs) 1256 SF $1.02 $1,281.12 Air Sealing at Estimated 62.5 CFM50 Per Hour 14 hr $94.33 $1,320.62 Hatch-2"Thermal Barrier Polyiso 2 each $47.37 $94.74 Damming 36 each $2.45 $88.20 Propavent 52 each $4.13 $214.76 Kneewall Wall-2"Thermal Barrier Polyiso 162 SF $4.81 $779.22 Attic Floor-5"Open Blow Cellulose 1482 SF $1.63 $2,415.66 Installed Measures Total $6,194.32 WorkOrder Notes ✓% Utility Incentive and Customer Share Information Utility Incentive Weatherization incentive $2,694.44 Air sealing incentive $2,601.74 Total Utility Incentive $5,296.18 Customer Share Total Customer Share $898.14 Less Deposit Of $299.00 Customer Share Balance $599.14 Page 1 of 1 Permit Authorization mass save Form Sweep iseisueh away eructanc Site ID: 4697334 Customer: ANNE BURTON Anne Burton , owner of the property located at: (Owner's Name,printed) 446 Chesterfield Rd Northampton, MA 01053 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: 4aae 81.0-lna Date: 01 / 09 / 2023 e**•••••••••••••••••••••••••••••••••••+••••••••••••••••••••••••••••••• FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only The Official Website of the Executive Office of EOHED,the Dtvsion of Professional Licensure and the Division of Standards Public Safety Mass v ome State Agencies MUSS• Licensee Details Demographic Information Full Name: SEAN Matthew Baiey BRADSHAW Owner Name: License Address Information City: South Hadley State: MA Zipcode: 01075 Country: United States License Information License No: CS-108517 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 1/6/2023 Issue Date: 4/28/2015 Expiration Date: 12/10/2024 License Status: Active Today's Date: 1/9/2023 Secondary License Type: Doing Business As: Bradshaw Enterprises, LLC Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Close Window 2011 Commonwealth of Massachusetts Site F'oiic e I Contact Uc dotloop signature verification:dtlp.us/RpFP-6GzK-CdTr ,--"", BRADENT-01 r BROOKE AWR'D• DATE(MMIDDIYYYY) t.----- CERTIFICATE OF LIABILITY INSURANCE 8/25/2022 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 THEPOUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AU HORIZED 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 NAME: CONTACT Brooke Barre _. Phillips Insurance Agency,Inc. PHONE Eat):(413)594.5984 FAX )592-8499 97 Center Street (A c.No):(413 Chicopee,MA 01013 Mks s;brooke@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE ___ NAIC# INSURER A:Middlesex Insurance Company INSURED INSURER B:Sentry Insurance _. _ .,_ 24988 Bradshaw Enterprises,LLC INSURER c:EVANSTON INSURANCE CO. 15378 PO Box 944 INSURERD: J Chicopee,MA 01021 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(NHICH 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 TYPE OF INSURANCE 'AOOL-SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR MD WVD IMMIDD/YYYYI NAM/DD/YYYYI A ' X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR A0158300 8/12/2022 8/12/2023 DAMAGE TO RENTED 500,000 PREMISES(Ea occooence) $. MED EXP(Any one person) $ 10'000 PERSONAL&ADV INJURY -$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _$ 3,000,000 PRo- 2000,000 POLICY X JEOT LOC PRODUCTS-COMP/OP AGO $ ' OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO A0158300003 8/12/2022 8/12/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED y___AUTOSgE�ONLY „-- AUTOS yy� p BODILY INJURY(Per accident)„$ AUTOS ONLY AUTOS ONELY (PPer acrid ntDAMAGE $ A X UMBRELLALIAB X OCCUR 2,000,000 EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE A0158300 8/12/2022 8/12/2023 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B ,WORKERS COMPENSATION X PER OTH- ' AND EMPLOYERS'LIABILITY STATUTE ER ANY Aqnda PROPRIETOR/PARTNER/EXECUTIVE Y/N A0158300004 8/12/2022 8/12/2023 E.L.EACH ACCIDENT $ 1,000' Na 000 (Mn EnBER EXCLUDED?" Y NIA 1000000 E.L.DISEASE-EA EMPLOYEE $ Ups,describe under , , 1,000,000 -DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Pollution Liability CPLMOL105072 1/1/2022 1/1/2023 Aggregate 250,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I 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 Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD dotloop signature verification:dtlp.us/RpFP-6GzK-Cd8t ti The Commonwealth of Massachusetts Deportment of Industrial Accidents -'ii 1 Congress Street,Suite 100 "" T °T Boston,MA 021142017 ` ..- www.mass.govfdia Workers'Compensation Insurance Affidavit:BuildersjContractors/Elertricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/Organizational/Individual):Bradshaw Enterprises, LLC Address: 34 Front St Indian Orchard Mills Suite G60 City: Springfield State: MA zip: 01051 Phone fl: 413-250-4746 Are you an employer?Check the appropriate box: Type of prolect(required): J1. I am an employer with 1 1 employees(full and/or part time)' 7. New construction 1 —1 2. I am a sole proprietor or partnership and have no employees working for me In any 8. Remodeling capacity.)No workers'comp.insurance required.] 1�9. Demolition 3. I am a homeowner doing all work myself.[No workers'comp.insurance required)± [---110. Building addition —14. I am a homeowner and will be hiring contractors to conduct all work on my property. rill. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. D2. Plumbing repairs or additions 15. 1 am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs sheet. 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. ` 4. Other c.152,§1(4,and we have no emplo ees.(No workers'comp.insurance required.) ii 'Any applicant that checks box 3t1 must also fill out the section below showing their workers'compensation policy information. tHomeowners 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 attach 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Sentry Insurance (Agent- Phillips Insurance 413-594-5984) Policy k or Self-Ins.Lk,It: A0158300004 R112/2023Expiration Date: _____________ lob Site Address: 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 51,500.00 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. [Y1 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbax and typing my name in the field below will act as my signature. Name: Sean Bradshaw Date: 9129120 Phone#: 413-250-4746 Email: sean@bradshawenterpriseslIc.com a 0 00 0 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 194456 BRADSHAW ENTERPRISES, LLC Expiration: 02/07/2023 246 CONNECTICUT AVE SPRINGFIELD, MA 01104 Update Address and Return Card. Office of Consumer Affairs& Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 194456 02/07/2023 1000 Washington Street -Suite 710 BRADSHAW ENTERPRISES. LLC Boston. MA 02118 SEAN M. BRADSHAW 34 FRONT STREET lu 114•( 'k • SPRINGFIELD,MA 01151 Undersecretary Not valid without signature dotloop signature verification: •p.us/RpFP-6GzK-Cd8t • DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of MGL C.40,s.54,is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.11 1, s.I50A. ANY AND ALL DEBRIS PROUCED AS A RESULT OF WORK PERMITTED UNDER THE ATTACHED APPLICATION WILL BE DISPOSED OF IN: USA Waste Recycling Name of Licensed Solid Waste Disposal Business/Facility 15 Mullen Rd, Enfield CT 06082 Address of Licensed Solid Waste Disposal Business/Facility USA Waste Recycling Name of Hauler Sean Bradshaw 9/20/2020 Print Applicant Name Date 1,Sean Bradshaw do hereby certify under the pains and penalties of perjury that thens;, information provided above is true and correct,and that clicking this checkbox and typing name in the field above will act as my signature.