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22-021 (4) 239 RYAN RD BP-2017-0931 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22-021 CITY OF NORTHAMPTON Loc-00t PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2017-0931 Project 4 JS-2017-001591 Est.Cost: $3000.00 Fee:S65,00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sg. ft.): 10585.08 Owner: Shonna M. Hatoum Zo Ino: Applicant: PAUL SCHMIDT AT: 239 RYAN RD Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATF I E L D MA01038 I cSLTED ON:2/7/201 7 0:00:00 TO PERFORM THE FOLLOWING WORK:1000SQ FT, 10" LAYER, R-32 ADDED TO FLOORED ATTIC SPACE(DRILL & PLUG) AIR SEALING AS NEEDED 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 2/7/2017 0:00:00 $65.00 212 Main Street,Phone(413)537-1240,Fax: (41 3)587-1272 Louis Hasbrouck—Building Commissioner File# BP-2017-0931 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 239 RYAN RD MAP 22 PARCEL 021 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERM • ••LICAT(ON CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled mit Fee Paid TypeofConstruction: I000SO FT I)" LAY ' '-32 ADDED TO FLOORED ATTIC SPACE(DRIL(,&PLUG) AIR SEALING AS NEEDED 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 INFORMATION PRESENTED: ovedAdditional 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 Pennit from Elm Street Commission Permit DPW Storm Water Management D if. Delay P- 9-77 Sigof":uih ing 0 'dal 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. City of Northarripton 1 BMW% C 4.> 212 Main Street Room 100 Northampton, MA 01060 phone 413-567-1240 Fax 413-567-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DC$OUSN A ONE OR MO FAIRLY TJIIEIJ4NG ftEESEASSEINE 0237 'elan ouhexY1�} 0Iota, : 1OnICL ; y. ) r9C39 ecgQn n.tm�u.. /I Nana(Prim) Cunene Mating AtlAda.(o )^" g"o t0 {e -.t " Sp 9.. a l�X�-C � - Taione �J Sloan "Rita I Onr�� i t a2-J C P51n, .\ .—��t„etdt Name(Pnnt) Current hieing Atlmew: -,t41:2 4/ tR47-N 73� Telephone hem Estimated Cost(nes)to to be 1. Budding 2 Eieeetca 4 Mechanical 04VAC) 5.Fire Prion r�``//�- 6. Total ,C4-)=(1 +2+3+4+5) a� OOD , + ';', • 07/,F1 •// H- Section 4. ZONING AR Information knot Be Completed.Permit Can Be Denied Due To Incomplete Information Eidstmg Proposed Required by Zoning This column to be®led in by Building Department Lot Size Frontage Setbacks From Side L — R:— _. L:._. R._____ Rear Building Height Bldg Square Footage Open Space Footage (Lot aaaminus bids&paved paddve) S of Parking Spaces Fill: (wimne&Location) �___..___ _ ___..___..__ �,. •._—_..,_..�_.._____—. A. Has a Special Permit/Variance/Findi been issued for/on the site? NO 0 DONT KNOW YES O IF YES, date issued:; IF YES: Was the permit recorded at theRegi try of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page. and/or Document N B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 1.2 YES 0 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 ®� IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Y!/ IF YES, describe size,type and location: E. Will the construction activity disturb(clearing,grading,/�v,��i�v�,n�� or filrag)over 1 acre or is it part of a common pian That will disturb over 1 sae? YES 0 NO V IF YES,then a Northampton Stone Water Management Permit from the DPW is required. SECTIONS-DESt`IFROII OFPRSROS®WORIOItlssclaag aDsgwbks) New Nouse ❑ AdNio.i ❑ uwtA tla(s) Roofing ❑ R� � Accessory Bldg. 0 Demolition ❑ New Signs [[D1 Decks [O Skiing Other um/ Brief Degairphon of Proposed y00° 6q -F+ /o" l e ,e as • Aran ¢Tcor(Q_1 Work: f�-M'1G 6,�4 c-c-(r�✓'i 11 v Pin I� nir o..i/n tzd-.. na..P �q-c- Alteration of e,dsbrp bedroom_Ys v No Adding new bedroom Yes ✓No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Rog -Sheet a. Use of busting:One Family Two Family Other b. Number of rooms in each family whit Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Di e. Number of stoles? f. Method of heating? F = or Waodstoves Number of each g. Energy Conservation Compliance. Masschecr Energy Compliance farm attached? h. Type of cor»ucion i. Is construction%Morin 100 R of wands? Yes No. Is construction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor. finished grade le Will building conform to the - • • and Zoning regulations? Yes No. Septic Tank_ Sewer_ Private well City water Supply SECTION7e-E11MIMA THCNm1'ROOM-.108€COUPLEIED WHEN MIM*OBIT OR OO 4 R&CTOR APR:l FOR musserr rr as Owner of the subject Probeny hereby authorize S>L T4cryti-w�✓7N/Z/'Y1e✓l+ �acnkru=does, IC°�• to ac on my behalf,in all matters relative to by this building permit application. 'Je,G ct44-ticks-A ----• a2 - co- " '7 a Date I. d[A-! S'hm l d-fr as OvmedAuthorized Agent hereby declare that the statements and information on the foregoing application are toe and urate,to the best of my knowledge and belief. Signed under the pains and penaDes of perjury. NW Wane • - - 1 Date Not Applicable 0 ,,� • te cense Number 010 S oZo �9 Address / Expiration Date 1/l - aAr -5 ' re Telephone __ - � � Not Applicable ❑ 5 4-- V,�.fyBJe .r .[ e.Ar-> ' A • Canmaw Nave Registration Number ?�( Pike 41-nut Irl re — E)orationo2 /9 Address /4a-=gel d 1 YY1R DI 03S' Telephoneyo?ag7573' 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 buildi permit Signed Affidavit Attached Yes @' No ❑ The current exemption for"homeowners"was extended to include Owner-camied Dwd4ao 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 savervisor.CMR 780. Sixth Edition Section 1883.5.1. 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-vear period shah net be moldered a homeowner. Such"homeowner shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be resposu'ble for all such work Performed sander 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,von 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 end Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ✓ .._ (- RISE60 Shawmut Road, Unit 21 Canton, MA 02021 1339-502-6335 ENGINEERING" www.RlSEengineering.com OWNER AUTHORIZATION FORM Shonna Hatoum 1. (Owner's Name) owner of the property located at. 239 Ryan Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize _ (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. E-SIGNED by Shonna Hatoum Owner's Signature January 28, 2017 Date I, -IrlyananuEls Japeauoo ISPCI a la Adan a giro AlaCiald aW Pate wa4IPLR Pis P44ri4aQwtad.ail 4WM(MRPa*Wen 4slw.�tanew+_saw of PSI I Sultry INaaC nor Plat SIP Gal ado,+) 41,i 1.z FAMia, —e. 0-) Q Q (Au 7"d "nr-14 / amRS'Aso o� ,rvh - 'appy L.A.ArQ} n nvLout( ,man wszi 6tiiLs'-I_ti*r .gtfy Vitro &w ' piNS- a as 'Apo azo -f1'u-j1/2---dit J fits say -FirAit Pved- �'�©� U� 6c° :sappyAp.+aid • o - . The Commonwealth of Massachusetts Department of Industrial Accidents _ I 1 Congress Street, Suite 100 Boston. 114 02114-2017 www.mass,gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED KITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name Business orvannlrudnn Indiv'dual SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street Cltvrv'State Zip: Hatfield MA 01038 Phone 7: 473-247-5739 Are,ou an emplmer'.Check the appropriate has: Type of project(required): I e enTei>c,weh 8 __ :nye, —. Nev. construction peeneectep andd Ieo,kree Io n _ 8- ❑ Remodeling C1 uc =Ivo 1 flDemolition - .a 0 Q Building addition re en h ,; en. I eneure n.. ,her ke r v..,01 lie I7.0 Electrical repairs or additions t -cs;., lowe.2.. 17.❑Plumbing repairs or additions T .. .ha,ee ap and ha.e.,r _nee IiRoof repairs w. - JIare. n:r I a l ee per Aince. 14.❑✓ Other Insulation ., h nq.l No ken 1 ,.reeLered.. 'Nee. eppeeert,ke ehee4s boa-I mug,.also fill n.the,ect I ,. _c'hem 031,:r. couneresemon polo-in ,nation. Hor:cox:kr. he eube : tial mdeenuig.he.ern eumg Jr or,eedl SUOMI a newaffidavit indicating n I, taue cheek I ,. et attachedn ml lee .itoe.iree.Inc nelne othe.ein-e and sae whether or not hose entitles have ernplo•ec.. 1]theub envie he%e employees lob.gingy deh.- .mr npole.::.imba. 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 Co Polk' nr soft-in, Lie (r. WC9024456 Expiration Date: 2/23/201% Job Site Address: et. A _. 0 ' .I/ • City State zip: / (,(U n .--_ Attach a copy of the workers' comp nsation policy declaration page(showing the policy number and expiration date)p)p[o a- Failure to secure coverage as required under A4GL e. I52. 425A is a criminal ,iolalion punishable by a fine up to 51.500 00 and or one-year imprisonment.as u ell as Civil penalties in the four,of a STOP V.ORK ORDER and a fine of up to 5250 00 a ca, again the violator-.A copy of this situenen may be ford diCedto the 0Inec of investigation of the DIA for insurance coy erage cerilication. I do hereby certify yadbr the p z s and penalties of perjury that the information provided above is true and correct. Signature: ob �✓�� /��___ Date: c) -J0'f 7 ('hone=. 413-247-5739 - - — Official use only. Do not write in this area.to he completed by city or town official City or Town: Permit/License a Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City(Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone Accw o® CERTIFICATE OF LIABILITY INSURANCE DAi29no""Y 17 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 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 LONTn6T C thiHenderson, CISR .NAME. yn a Webber 6 Grinnell PHONE o,Enf1i. (413)586-0111 ( )SSS-6481 8 North Icing Street EMAIL ADDRESS: weerandgri n chenderson@bbell.com n INSURER(SI AFFORDING COVERAGE NAIC Northampton MA 01060 INSURERA:SeleCtiVe Ins CO Of S Carolina INSURED INSURERB:SelOCtive Ins Co of Southeast _ 39926 SDL Home Improvement Contractors Inc. INSURER 24 Chestnut Street INSURER 0: INSURER F: Hatfield MA 01038 INSURER F: COVERAGES CERTIFICATE NUMBERMaster 2017 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. NSA TYPE OFINSURANCE AOOL SUER POLICY EFF POLICY EXP --- - - - - LTRN5n wvD POLICY NUMBER IMM/DDIYYYYI IMMIDD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR PREMISES( aoccEDRENTED e) 100,000 DAMAETO S 52204065 2/1/2017 2/1/2018 MED EXP(Any one person) S 10,000 PERSONAL NADV INJURY § 1,000,000 GENLAGGREGATE uO. APPLIES PER GENERAL AGGREGATE $ 3,000,000 X POLICYjE�7 LOC PRODUCTS-COMP/OP AGG § 3,000,000 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Eaent) A ANY AUTO BODILY INJURY(Per permit) $ ALL ALTOS OWNED AUT05VLE0 A9100328 2/1/2017 2/1/2018 BODILY INJURY)Per accident) 8 NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Jper aedden0 _ $ Undennsured motors SI split $ 100,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A ExLE88 LIAB._.- _ CLAIMS-MADE AGGREGATE § 10000000 DED X RETENTION$ 10,000 52204065 2/1/2017 2/1/2018 WORKERS COMPENSATION X SPER TATUTE X OTH- ER q- AND EMPLOYERS LIASILITV YIN — —ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT S 500,000 OFFICERIMEMBER EXCLUDED? B Y .NIA Mandatory In NH) W09024456 2/23/2017 2/23/2018 E=05EASE-EA EMPLOYEE$ 500,000 n yes.describe under -DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101.Additional Remark•chedule,may be attached if more apace is required) The workers Compensation policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas Schmidt. Columbia Gas of Massachusetts is hereby named as Additional Insured per written contract with respects to General Liability & Auto Liaiblity, for work performed, and per the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Columbia Gas of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4 Technology Drive Ste 250 ACCORDANCE WITH THE POLICY PROVISIONS. Westborough, MA 01581 AUTHORIZED REPRESENTATIVE '` E�CCe1501r rG53/�6 9 - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INSO251po41111