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10B-104 ne Cormn©mv"M ofmwswknseft 1 . OfIndW&M A a Offwe ofI gatirons I CongrM Streg Suite 100 BOU014 MA 02114-2017 WWW.Mamg0ulAff Workers'Compensation bmruee Affidavit:BnfldersiCmbwtorWEhetricians/Plumbers Annlicant Information Please PARt Leribiv Name Bryan G. Hobbs Remo"na 346 Conway St A : Greenfield,MA 013()1 City/Stgte/Zi Phone k LJ/ 3 - 9/7�"qt o ojCD V3 on an empk/yer?Check the appropriate boa: Type of project(regain d); II am a employer with 4_ ❑ I am a general contractor and T employees(full and/or - me).s have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attar sheet- 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity- employees behave workers' 9. ❑Building addition [No workers'comp insurance mP• required.] 5. ❑ We are a corporation and its 10.[:]Electrical repairs or additions 3.❑ 1 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. Other comp.insurance re#quire&] J , Ck I f VCL !1` "Any applicant that chadm box#1 must also fill out the merlon below shaving tbairy adwre co 6m poficy boa t Homwwnm who m bmk this affidavit it&asm' g they are doing all workand then hue of m mramm mm saA I anew affidavit Wicning such. tC.ontramtors that check this box mast anadod as adid= sheet shaving the name of the s*.w�and staff whir or not thorn eaffm have employees. If the svb-amtractars have agopyem dwy mmt pmvids&*vo&oW camp polity number: lam an enj*y r&r ispr worker'coaramadin Jwwwvwjbr AV expApymm Retow is 9kepoM y and,/nb site Insurance Company Nam: L 1 ! `•.•� 1'v 3 ' Policy#or Self-ins.Lic.#: f 1 Az---MS—3'rJ 0 9 d - 03/3 Expiration Date: ��/�� i`'f' Job Site Address: � C) C1 t1 P ( I r (,rt1 l C City/StmteJZip _,Q _ , Attach a cW of the workers't un policy dedW=twu page(showing the policy number and expiration date). Failure to secure covaage as required under Section 25A of MGL c.152 can lead to ttte 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 5250.00 a day against the violator: Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /tint g2a rarda•tllre ® Me So te2M6w prodded above Is&ue and corny S' ) hA law O,,ficM we on&. Do not write in A&aree,to be connglexied by city or town offidd City or Town• Permf/Lk*Bse# Iming Aut>tw*(circle one}: 1.Board of Heap 2.Bnilffing Department 3.City/Town Clerk 4.E ktrieal Ispeebor S.Plumbing Inspector 6 Other Contact Person: Phone#: OWNER AUTHORIZATION FORM I, 1aQ (Owner's Name) ' owner of the property located at L C� rt've (Property Address) "J A l S3 (Property Address) hereby authorize �� (Subcon or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Rry an G Hobbs Remodeling 0.s — , I �. 346 Conway St License Number Greenfield,MA 01301 a ka.. ) Address Expiration bate Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Bryan G.Hobbs Remodeling. 1 Y St Company Name 346 Co Registration Number � Greenfield,MA 01.301 71--7 ?, 1 j Address Expiration Date Telephone SECTION 10-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...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own 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 homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding[p) Other[I Brief Description of Proposed Work: .-At y :;P Ea 1 t P��� � 1/1�1,����`�Via.. V l n�I�-S l _C� �.t 6-�,.,. -b r_.a...'1�bicy )I� E 11 0(t4,0� Alteration of existing bedroom Yes 'x, No Adding new bedroom Yes ' No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. I k .'C �. Signature of Owner Date 1, CL:I as Owner/Authorized Agent hereby declard that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Ex Li rl .� _`, Print Name C � ci /Z' Signature of Owner/Age Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW � YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW () YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO eN IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only (� ity of Northampton Status of Permit: V SEp U 20x4 ilding Department Curb Cut/Driveway Permit 12 Main Street Sewer/Septic Availability , tens Room 100 Water/Well Availability E1e�rtc,plumbing&Ga Q106Y0 ton, ampton, MA 01060 Two Sets of Structural Plans NOnhama phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit °A � Zone Overlay Di trict Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: .. qi ?2 - S �4 Q ,Q�� � Telephone Signature v 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building C" , 1�~" (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5.Fire Protection 6. Total= (1 +2+3+4+5) r 2� 5c) :> Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File# BP-2015-0368 APPLICANT/CONTACT PERSON BRYAN HOBBS ADDRESS/PHONE 346 CONWAY ST GREENFIELD (413)775-9006 PROPERTY LOCATION 4 FLORENCE ST MAP lOB PARCEL 104 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Typeof Construction: INSTALL WALL INSULATION&AIR SEAL New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 83982 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received& Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management m tion Delay Signature of B-ui1_din'gCffficiaf Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 4 FLORENCE ST BP-2015-0368 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 1013 - 104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0368 Project 4 JS-2015-000676 Est. Cost: $2530.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BRYAN HOBBS 83982 Lot Size(sq. ft.): 23914.44 Owner: VERSON ALAN &PAULA zoning: URA 100/ Applicant: BRYAN HOBBS AT. 4 FLORENCE ST Applicant Address: Phone: Insurance: 346 CONWAY ST (413) 775-9006 WC GREEN FIELDMA01301 ISSUED ON:101212014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WALL INSULATION &AIR SEAL 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Buildin« 10/2/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner