35-043 (2) 971 RYAN RD BP-2014-0724
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -043 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-2014-0724
Project# JS-2014-001227
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 19994.04 Owner: SMITH HARRIET K
Zoning: Applicant: PAUL SCHMIDT
AT: 971 RYAN RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:12/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 12/16/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2014-0724
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 971 RYAN RD
MAP 35 PARCEL 043 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out IN
Fee Paid J
Typeof Construction: INSTALL WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103635
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO RESENTED:
Approved 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
Signature of :uilding Official 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.
. Department use only
IICity of Northampton Status of Permit:
,
11 Building Department Curb Cut/Driveway Permit
! DEC 203 U 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
ctric,Plumbing&Gas Inspections Northam ton, MA 01060 Two Sets of Structural Plans
Ncrlumbi ion,MA C1:,_0 p
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
( Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Harriet Smith 971 Ryan Rd Florence MA 01062
Name(Print) Current Mailing Address:
413'-247-5739
Telephone
Signature
2.2 Authorized Agent:
4� f 4 t'/ „L i4 '1 ) 41 39 ' t'7 C1/7 Sj114 ci 1-1,41174V
Name(Print) v Current Mailing Address: J
413-247-5739
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2,500 (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) 2,500 Check Number ,/69(
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other M A.)
Brief Description of Proposed N /A� 837 NAh� l�/�i Aow,Ai L-� c}�fl v AS
Work: � l/( '�.r�.e��
Alteration of existing bedroom Yes ›a No Adding new bedroom Yes .�- No
Ncia-ft)
Attached Narrative Renovating unfinished basement Yes ,,k 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
I, )-1A f >rEr Spar
as Owner of the subject
property r 1 1
hereby authorize f(na U ft rim][ OL 174 V I E ,�✓�I Y 6111 IfAir-
to act on my behalf, in all tters relative to work authoriz d by this building permit application.
j ,J11-Ac)4vp" r ) i "1 13
Signature of Owner Date
Pi/ (11 , �' /411/f ) , as Owner/Authorized
Agent hereby declare 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.
P40/744 JD-I--
Print Name
Signature Owner Age Date r2, /24 )3
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �`►� Not Applicable ❑
/7
Name of License Holder: / Li/ LfC/4 / )/ ,j(� 3 6j3
�t License Number
t /05f J )-.10F1 Ai0 1,.
Address . Expiration Date
�..� >3`'
--1-117-s-7
3�
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
LL- olrov mi tf 17 I/ (./1
Company Name Registration Num r
7f 6)4 J 'rA, 7 1-1ATFi'$ B 12?✓4 zl 7 J s
Address ) 1))3 - ° Expiration Date
/ 3 > 5 7✓3,`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
letworprN
1441
PAMICIPZING
mass save :�
S lY0140 thrnush~eV a ncicrxY
PERMIT AUTHORIZATION FORM
�,,����
� Q. , owner of the property located at
(Owner's Name, printed)
l l \ � -i avretn U 0t6Coa-
(Pro rty Street Address) (City/Town)
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.
QgaMe
tee 1 / 3
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
Imminelowommimilmommoi
The Commonwealth of Massachusetts
t:\.. of Industrial Accidents
'_=- ' Office of Investigations
` t, 600 Washington Street
e,'-)i1° Boston,MA 02111
-4 . www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(B usiness/Organization/Individual): L —4 j',-' -7—,ki/, +s"- ,.,,, , r
Address: Z 4 ciZS1/+/, ,,/
City/State/Zip: /qr.)/ Y1 V Phone#: j— I/75- 247-57 3I
Are you an employer?Check,ttle appropriate box:
. I am a general contractor and I Type of project(required):
4
1Z I am a employer with ❑ g
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
listed on the attached sheet. 7. ❑Remodeling
2.❑ 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' Building addition
[No workers'comp.insurance comp.insurance.: Building
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 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.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
i-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: r f
•
, I ' L JA , , '0
I I
Policy#or Self-ins.Lic.#: 5 /u` l7 67 V� Expiration Date: 7/J Z�/ zy
Job Site Address: ` / 7 / /?l1 ki 1-2,1..) City/State/Zip: FJ)r ,L/ ce jAy A.
Attach a copy of the workers'compensatio 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 a)i —
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 certify tin the p ss nod,penalties of perjury that the information provided above is true and correct.
Signature: Vii' z •��✓ Date: `" :PI 13
Phone#: l— (/)? 1Y7 -c 3/1
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#:
Ar OR°� CERTIFICATE OF LIABILITY INSURANCE AT EIND i
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 POUCIES
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 be endorsed. H 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().
PRODUCER r Cynthia Squires
Goss & McLain Insurance Agency "ONE (413)534-7335
„a�, _I la/c ita,(413)S36-9286 -
1767 Northampton Street =as&csquires8gossmclain.com
P 0 Boa 1128 INSURERS)AFFORDING COVERAGE J NAIC ._Holyoke MA 01041-1128 INmURERA:Safety Insurance Company 39454
INSURED INSURERa:Travelers Property Casualty Co
SDL Home Improvement Inc INSURER C:
24 Chestnut Street INSURER D:
INSURER E;
Hatfield MA 01038 _INSURER P:
COVERAGES CERTIFICATE NUMBER:CL133400156 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.
R TYPE OF INSURANCE A.T. r �ppq�C/�Y EF' or—MCP
LTR yg42aT POLICY NUMBER ,JMM/OOIYWYI IMMODJYYYY) UNITS
GENERAL LIABILITY
_ EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PRMAGE SO RENTED
PREMISES(Ea occur ence) r$ 100,000
A 4 CLAIMS-MADE [OCCUR CP00002464 2/1/2013 2/1/2014 MEDEXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGO $ 2,000,000
X POLICY[JFCaT I 1 LOG $
AUTOMOBILE LIABILITY COMBII4E0 SINGLE LIMIT
(Ea accident) $ 1000000
A ^� ANY AUTO BODILY INJURY(Per person) $
ALL OWNED y SCHEDULED 6222056 2/26/2013 2/26/2014 BODILY INJURY(Peroccidsnt) S
��
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per accident) —$ included
. Optional BI ICSLZ(Mg_GA] , S 1.000,000
X UMBRELLA(JAB —7C, occuR EACH OCCURRENCE $ 1,000,000
A EXCESS L.IAO CLABIAS-MADE
AGGREGATE q $ 1,000,OQQ
DED I X 1 RETENTION 10,000 MD 2/1/2013 2/1/2014
B WORKERS COMPENSATION $
WC LIMIT (( f OTH•
AND EMPLOYERS'LIABILITY Y/N TORYIIMITS t x l FR,
ANY PROPRIETOR/PARTNER/EXECUTIVE EACHACCIOENJ $ 500,000
OFFICER/MEMBER EXCLUDED? U E.L.NIA
I(4yMeenssdate�ry In NHS 50844090 2/23/2013 2/23/2014
E.1-DISEASE•EA EMPLOYEE S 500,000
DESCRIPTION OF OPERATIONS beWw - E.L DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES(Attach ACORD 101,AddItIonsl Remarks Schedule,II more specs to required)
Insulation Contractor
Paul. Schmidt, Kendrick Dempsey & Douglas Schmidt are exempt from coverage on the Workers Comp policy.
Conservation Services Group, National Grid, NSTAA, Boston Gas Co., Colonial Gas Co and Essex Gas Co. are
named as additional insureds per written contract in regard to general liability only - for work
performed on behalf of the named insured subject to policy forms, conditions and exclusions
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Conservation Services Group ACCORDANCE WITH THE POLICY PROVISIONS.
50 Washington Street
Suite 300 AUTHORIZED REPRESENTATIVE
Westborough, MA 01581
-
Cynthia Squires o,
ACORD 25(2010/05) 019e$-2010 D CORPORATI . All rights reserved.
INS02S(2o100s}D1 The ACORD name and logo are registered marks of ACORD
Massachusetts -Department of Public Safety •
Board of Building Regulations and Standards
Construction Super- isor
!_icens : CS-103635
PAUL SCHMIDT
24 CHESTNUT STREET
HATFIELD MA.01038
J..`...•JJ� . „ i: Exoiration
Commissioner 05/20/2015
Office of Consumer Affairs&Business Regulation
-HOME IMPROVEMENT CONTRACTOR
•
t� --#, Registration: 174415 Type:
1: -'-7:txpiration: 2/7/2015 Corporation
SDL HOME IMPROVEMENT CONTRACTORS, INC. `\
PAUL SCHMIDT
24 CHESTNUT STREET _
HATFIELD,MA 01038 Undersecretary
oatµ- City of Northampton 5
f hr.µ_ 5� ,. f
f Massachusetts 4`� ��
II l DEPARTMENT OF BUILDING INSPECTIONS y •
. , 212 Main Street • Municipal Building J,ts ",c,
"" '"." " Northampton, MA 01060 SNV 30>1
Property Address: q -7 ( o,ti pp
Contractor
Name LO2 Z PQM I4- i _ •1 t'vV
Address: .. -4 6/4
City, State: f N► 41 pY 0 ,/-
Phone: 1, t'/8 17 31
Property Owner
Name: 111Arc)r4_. to,21l f�
Address: Z l4 %,,4004- a 97 / R/1,24.4' RD
City, State: i )O I A/ej p '
I, i! cz11 ) (contractor) attest and affirm that the building I intend to
ins atli t does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
1 / )-v ) )