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29-355 (8) 6 AUSTIN CIR BP-2021-0100 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-355 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-2021-0100 Project# JS-2021-000153 Est.Cost: $3482.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BRYAN HOBBS 83982 Lot Size(sa. ft.): 11282.04 Owner: BLAIS CHRISTOPHER zonine: Applicant: BRYAN HOBBS AT. 6 AUSTIN CIR Applicant Address: Phone: Insurance: PO BOX 1535 (413) 775-9006 WC GREEN FIELDMA01301 ISSUED ON.7/24/2020 0.00:00 TO PERFORM THE FOLLOWING WORK.WEATHERIZATION/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: 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: Building 7/24/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner --- -- T�p 9momp"W041A Af mummy om r Pp#vd of Ali dins 9#040om Ind*PIords A !. 1v1aSs;r �}s� S SOW��llit o CAd9,989 C MUNICIPA.14TY U USE Bui1d ng Penh App ontiou T� Conssttuctl,XopakRonowto Qr DompUgh I� Rovisad�a�#}B-Ar.4,',o— �1113i j0- �RRtiAA l oI fjMO t}l� 0 t:�i14*9r: Date Appkad:r Ev l� /- --Building Official(];Tint Name) SECTION It SIT t INFORMATIONII _pro rty d dro t � 112 As es rs Map&Parcel Nu arri_ L�11�., 1 l -- p O Ii}Is this an accepted street?yes ilei MR ber Parcet)l W JJ AppipS l-itformation; 1,4 -FrAppM Dimensions: Zoning F Frapased[Ise tot AMR(sq ft) Frootago(fit) 1.5 Building Setbacks(#t) Front Yard Side Yards Rear Yard Jp4 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❑ Private❑ . Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2; PROPERTY OWNERSHIP' 2.1 Owner'of Record: �\n ^ _�(1��11(J1M C iL��I CL'7-\ f Name(P j"� City,suitr,W' No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 'Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Oth" Q/Specify: Brief Description of Proposed Work=: QJ t� s SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Materials) Official Use Only I.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee - 13 Total Project Cost''(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:S Check No.",' Check Amount: U Cash Amount: 6.Total Project Cost: S 6Z 5 ❑Paid in Full I7 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r Yllu`C,0 License Number Expiration Date game of(SL Holder PList CSL Type(see below) " t� No.and Street Type Description hh ` U Unrestricted(Buildings up to 35,000 cu.ft.) C� Ste R Restricted 1&2 Family Dwelling CRY-7-Tow-n,State,ZIP M Masonry RC Roofinj Covering WS Window and Siding SF Solid Fuel Burning Appliances den,-LL." L2 I Insulation Telephone Email address _r. D Demolition 5.2 Registered Rome Improvement Contractor C) 9 1/0^ 4 S- 1 11IC Registration Number Ex iration MR- CoepAny Name or HIC RegistrantNarne and Street , 1ri.11r�r l ere ry.�.,J�,l1AI '� ti'Y1Cut. Go QA l) -�� ��� Email address Jr` City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NLG.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 .......... Q, No...........❑ SECTION 7a:ONI,INER AUTHORIZATION TO BE COMPLETED WREN 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 _ contained in this application is true and accurate to the best of my knowledge and understanding. 0,11\ :Za Prin wnees 6r 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.=ov/oca Information on the Construction Supervisor License can be found at w-nv.mass.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.fr.) (including garage,finished basement/attics,decks or poreb) 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"maybe substituted for"Total Project Cost" I ffie C'ommonwea/Ni of Massachusetts Department of Industria!Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber Applicant Information Please Print Leeib Natrie (Business/Organization/Individual): Bryan Hobbs Remodeling, LLC Address: P.O. Box 1535 City/State/'Lip: Greenfield, Ma 01302 Phone #:413-775-9006 Are you an employer? Check the appropriate box: Type of project(required): I.® I am a employer with 7 4. ❑ I am a general contractor and 1 6 ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g ❑ Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.¢ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or adc 3.❑ I am a homeowner doing all work officers have exercised their i 1.❑ Plumbing repairs or adc myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no Weatherizatior employees. [No workers' 13,[Z Other -__ comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below sho%k,ing their workers'compensation policy information. I lomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new arI idavit indicating suc `Conu•actons 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. Ii'the sub-contractors have employees.they must provide their workers'comp,policy number. lam an employer that is providing workers'compensation insurance fir my emplgyees. Below is the policy and jobs, information. Selective Insurance Co Insurance Company Name:_____ Policy #or Self-ins. Lic. #: WC9057270 Expiration Date: 10/20/2020 .lob Site Address: (� )SY ,/ City/State/Zip:. ��� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER an( Of ttp 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. 1 do liereh y cerci y under the pains and penalties o f perjury tl:at the information provided above is true and correct. Si Tnature: Date: Phone#: 413-775-9006 Of use only. Do not write in this area,to be completed kv 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#: 4� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/10/2019 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(les)must 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). ONTACT PRODUCER N E; Adina Edgett Webber & Grinnell PHONE (413)886-0111 AJC NO:FAX (413)586-6481 AJC. Extl-8 North King Street ADDRESS: aedgett@webberandgrinnell.com INSURERS AFFORDING COVERAGE NAIC 9 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: INSURER E Greenfield MA 01302 1 INSURER F: COVERAGES CERTIFICATE NUMBER:Exp 08/20 REVISION NUMBER: THIS48 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 LIMITS LTR TYPE OF INSURANCE POLICY NUMBER YYY YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE ExI OCCUR PREMISES (Ea occurrence) $ 500,000 52289042 8/4/2019 8/4/2020 MED EXP(Any oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO 2,000,000 POLICY ❑JECT ❑ LOC - OTHER: AUTOMOBILE LIABILITY COMBINEDnII SINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS A9105300 8/4/2019 8/4/2020 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS accident) Underinsured motorist Bl split limit $ 20,000 X UMBRELLALIABX OCCUR 52289042 8/4/2019 8/4/2020 EACH OCCURRENCE $ 1,000,000 A EXCESS LAB IN AGGREGATE $ 1,000,000 DED RETENTION $ WORKERS COMPENSATION X I PER STATUTE 1 OTH- AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 500 000 ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? � WC9057270 10/20/2019 10/20/2020 E.L.DISEASE-FA EMPLOYEE 1$ 500,000 C (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below Bryan Hobbs is ExcludedE.L.DISEASE-POLICY LIMIT I$ 500,000 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /J W Grinnell, CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) The G"ammanwealth o aisamusett$ �egr�za�tor�s and Stand' 'assa� usetts stateu�la��n aids g Code) �8 p CMA section 10,x, , , a7g0 CMn, Masaachuaetts Stare 8uildln C a l�et't�it for the derrnolition,ronovatio.,rehabilitatio Rollie saiCh.d 40§ �4, regtt(res thet the debris r � oro her Cter cion lioezreed eatq wast® dte�oaal 4011iry as da too b ©ldlhl exulting there�cm al�all bo d ca buird�hg or a� d bYM,�,z,, 150 A,�+ Aooed of in a prt Job Looation;� � permit Number��� r Zoae,t ono ao!lfty or este D(eAos` Com AanY a Noma and $ri�►�uro a e APO cant