18D-067 (7) BP-2023-0373
'OPINE BROOK CURVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
18D-067-001 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-2023-0373 PERMISSION IS HEREBY GRANT D TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 6241 BRYAN HOBBS CS-083982
Const.Class: Exp.Date: 05/02/2024
Use Group: Owner: KATHLEEN MAIEWSKI
Lot Size (sq.ft.)
Zoning: URB Applicant: BRYAN HOBBS REMODELING LLC
Applicant Address Phone: Insurance:
PO BOX 1535 (413)775-9006 WC9057270
GREENFIELD, MA 01301
ISSUED ON: 04/03/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION
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 VIOATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
javr)
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)5871272
Office of the Building Commissioner
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The Commonwealth of Massachusetts
��'7 . Irr Board of Building Regulations and Standards FOR
"\ ;; Massachusetts State Building Code, 780 CMRMAR 2 3 MUNICIPALITY
`\ 2023 USE
Building Permit Application To Construct, Repair, Renovate_Or Demolish a R'visedMar 2011
One-or Two-Family Dwelling '' r ;�, : !!
ri n l lg,Lc r r
This Section For Official Use Only "'''n,o,,,r)�` _
/
Buildinn
JC�a,11� j�o PermittNs�Nuumber: 3i9^ 31 ?� Date Applied:
� — 3.31
`��'li Z023
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
,,t 1.1 Pro u �ddress2:� 1.2 Assessors Map&Parcel Numbers
U ling_ V('NO�. (A )( re
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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
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:
Name(Print) City,State,ZIP
12-N Prve 6r(�1._ CI)(1/4.,-c_ LII3 539 - LIV1&'
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other Specify: LA)Pa.)-here z. o-‘.
Brief Description of Proposed
r 1Work': a,„- 3,a..\ q'� �,\oer-c�\c,, be me�,,lry C,r\vn,l. `i" nor,
blot,.) (2\\,,\u4 alttl CA,...„1,, 4,, 4 \.0" iens.L- ea f1.� tn\-erI 1c,.,1-ccxecI L.,�11_
1 yt,Q a i rcn Vt Z" ��\‘_{,,o rl f 1'1 cJ cl,. 6 r.rnnnvi�, be i- y-,...,u
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ I.lv''' I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) ' Total All Fees: $ ii''
6.Total Project Cost: $ ` LD4 Check N2 c leek Amount: (, Cash Amount:
�'a l'11 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5. Construction Supervisor License(CSL)
\1,« \ License Number Expiration Date
Name of CSL Holder
o t� \�3S List CSL Type(see below) (J
Type Description
No.and Street �
, (� 1 �1��Z Unrestricted(Buildings up to 35,000 cu.8.)
been c_\l _I D 1"�� R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
(� 1 �V l I_ 1 ' SF Solid Fuel Burning Appliances
OS.- I n 10 l -)No siosma r? I Insulation
Telephone Erhail address kJ('�. D Demolition
5 Registered Home Im ovement Contractor(HIC)
cIQ I C l_L Registration DC�il fie'
HIC R Number Expiration Date
C any Name or HIC Registrant Name ^,
I53�' In1v Acyn�c>nh
` ��r�-,a
and Street Email addres
peen l�Q ()\36L yl�-11 S' tj(Y L
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
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
fined in this application is true and accurate to the best of my knowledge and understanding.
'
Print Ow er'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.) (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"
Permit Authorization
mass save Form
Simiries Leirsw*two y
Site ID: 4767370 Customer: LEVON KINNEY
l� Kathleen Maiewski , owner of the property located at:
(Owner's Name,printed)
14 Pine Brook Curve Northampton, MA 01060
(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: K N(aieivikc
Date: 03 / 06 / 2023
•••/ir•tw••••••••••••••w••••••••••/•••••••w•i•••i•lfw••••••i••••••if
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
tqii\ VQ
IA - bbI
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only
Document Ref:3SJPX-POHCE-IXP3V-CKH8A Page 6 of 6
Permit Authorization
mass save Form
Site ID: 4767486 Customer: GEORGE MENOUSEK
Kathleen Maiewski , owner of the property located at:
(Owner's Name,printed)
12 Pine Brook Curve Northampton, MA 01060
(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.
K
Owner's Signature: / (ems llateiuskC
Date: 03 /06 /2023
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
S9CIA VSAV1A-NA.A.imzr
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Orly
Document Ref:KNUQD-MAWNH-5FKJU-3TYMU Page 7 of 7
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a'; The Commonwealth of Massachusetts
Department of Industrial Accidents
9 'ti° Office of Investigations
(s\ �' Lafayette City Center
�,ryY
l 2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Bryan Hobbs Remodeling, LLC
Address:576 Leyden Rd Po Box 1535
City/State/Zip:Greenfield, Ma 01302 Phone#:413-775-9006
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 7 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. El Demolition
working for me in any capacity. employees and have workers'
insurance. 9. ❑ Building addition
[No workers' comp. insurancecomp,
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.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] •r c. 152,§1(4),and we have noWeatherization
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: Selective Insurance Company
Policy#or Self-ins. Lic.#:WC9057270 Expiration Date:10/20/2023
Job Site Address: \2 -N R(l,2 hr L (,v< City/State/Zip: �
�b<�'1Gti�m " ''
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.
I do hereby cer ' under the pains and penalties of perjury that the information provided above is true and correct.
Signature: V`-1c� t-1,4 Date: - 7,< ) 7 3
Phone#: 413-775-9006
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
1OBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector Slumbing
Inspector 6.0Other
Contact Person: Phone#!
®
A`cRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
06/24/2022
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 Adina Edgett,CISR
Webber&Grinnell PHONE (413)586-0111 FAX
(A/C,No): 413 586-6481
8 North King Street E.MA(Lss: aedgett@webberandgrinnell.com
INSURER(S)AFFORDING COVERAGE NAIC#
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259
INSURED INSURER B: Selective Ins Co of America 12572
Bryan Hobbs Remodeling,LLC INSURER C: Selective Ins Co of Southeast 39926
PO Box 1535 INSURER D: Evanston/XS Brokers
INSURER E:
Greenfield MA 01302-1535 INSURER F:
COVERAGES CERTIFICATE NUMBER: LIAB EXP 8/2023 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 ADUL bUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD wVD POLICY NUMBER MM/DD/YYYY
X COMMERCIAL GENERAL LIABILITY .( )_ (MM/DDIYYYY) LIMITS 1 ODD,000
EACH OCCURRENCE $
DAMAGE TO REN I EU 500,000
CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $ 15,000
A S2289042 08/04/2022 08/04/2023 PERSONAL&ADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY PRO 2,000,000
JECT LOC PRODUCTS-COMP/OPAGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OWNED X AUTOS SCHEDULED A9105300 08/04/2022 08/04/2023 BODILY INJURY(Per accident) $
AUTOS ONLY
HIRED NON-OWNED PROPERTY DAMAGE
X AUTOS ONLY X AUTOS ONLY (Per accident) $ I'
Underinsured motorist BI $ 20,000
UMBRELLA LIAR EACH OCCURRENCE 2,000,
_ 000
X OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE S2289042 08/04/2022 08/04/2023 AGGREGATE $ 2,000,000
DED RETENTION$ _ _ $
WORKERS COMPENSATION X PER O STATUTE ERH
AND EMPLOYERS'LIABILITY Y I N
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA WC9057270 10/20/2022 10I20/2023 1,000,000
OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ _
Pollution Liability Per Occurance $250,000
D TBD 01/19/2023 01/19/2024 Aggregate $500,000
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
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
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