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29-521 (7) 29 MATTHEW DR BP-2017-1115 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-521 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory: INSULATION BUILDING PERMIT Permit# BP-2017-1115 Project# JS-2017-001898 Est.Cost: $2000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot size(sd. ft.): 6359.76 Owner: CHAPMAN TIFFANY ZonZ? Applicant: PAUL SCHMIDT AT: 29 MATTHEW DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413)247-5739 WC HATFIELDMA01038 ISSUED ON:4/6/2077 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION ADDED TO ATTIC FLOOR, OPEN BLOW CELLULOSE 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 ft Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: OI: 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 4/6/2017 0:00:00 565.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 • Louis Hasbrouck—Building Commissioner File#BP-2017-1115 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 29 MATTHEW DR MAP 29 PARCEL 521 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST NCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSULATION ADD'.• TC:6RS' ' C FLOOR,OPEN BLOW CELLULOSE 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 INFO ATION PRESENTED: 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 I• .1iti r, Dela �/� Y /7 Sign e of Buil. ng "lcia ll 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 ofNorthampton \ Belem Department \ 212 Main Street \. Room 100 Northampton, MA 01060 '✓ phone413-587-1240 Fax 413-687-1272 a*j1-- I.M. • • r• -,F" -- -c-'i.- • +- a, • F: ' • e • _ -f■"' . ' . 9 7)9a-3441f") l r y brert , MA o oCo a- 3 5 • fp X. i Y _ fry — 9 6� �. . z1 afaseraRaamg: r � � fn,�, ,. ) q /rlaiIlLu. rName Train "mg AIM (-)-7a-0 Telephone Signature gadatigartS z� n er�pry e 1 mof/ern ac� a�7 -5�rSI —tefi�e c4 MP- Current Mallet, great Name(Sint Oaf <%� Teatime nitt .. . ItemEstanated Cost(DoNes)to be meanxpemucwc cont 1. &aiding r2 OOOO 04- 2. Statical .. . &� 3. Plumbing 4. Medi(HVAC) 5 Fire Prtaedon Toter0 +2+3+4+5) cQ Q. OC7 cJJ41O-0144* rv7(! / . ig/I6 tTr! Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This cola to be Died in by Building Department Lot Size Frontage Setbacks Front Side _ . REK Building Height Bldg.Square Footage Open Space Footage (Lotawamimisbldg&pavtd -. parking) of Parking Spaces Fill: (volume&La:atm) A. Has a Special Permit/Variance/Finding,ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:: IF IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 07 YES 0 IF YES: enter BOckI Page • and/or Document it, B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (2) YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO (9- IF YES,YES, describe size,type and location: E. will the construction activity disturb(clearing,grading, Øation,or fitting)over 1 acre or is it part of a common plan that will disturb over 1 aae'? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. $EC770N 5-DESCRIPTIONOFMOPOSEDWORKtdvackallmalleable) New Howe 0 Addition 0 P-pbxsmneWindage Atteetion(s) 0 Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ Nsw BgFw I09 Oscine IQ cviiadn . _ DerscrAPrned-Lf (-i) " o s k-‘9,3 f}ddd�� #41c_Mcce_. rpn / c-, ) Air Sea,-=1- h o a «y , c.e.iu{w of -- Yes No Adding new bedroom Yes AlterationNo Attached Na adve Renovating unfinished basement _Yes No Plans Attedted Roll -Sheet a. Use of bilking:One Family Two Fenly Omer b. Number of moms in each family unit Number of Bathrooms .,--- „- a o Is there a garage attached? d. Proposed Square otage of new construction. �/ footage Dimensions e. Number of stories? f Method of heating? Fseplaces or Waacemves Number of each_ g. Energy Conservation Compliance. /, Masscheck Energy Compliance tam attached? h. Type of construction i. Is cornhuction 4th in 100 ft.of wearpes?_Yes No. Is construction within 100 yr. floodplain_Yes No I. Depth of basement or cellar floc_ /7 finished grade k. Wal building conform to the and Zoning regulations? Yes No I. Septic Tank City Sewer Private well_ City water Supply SECTION?” IERTiO .-TOCOSE Lfl YtSI OWNERS*eENr OR'OOIRt MILA'Fflfl FORBOILDINGpear I, as Owner of the subject PmPeilY hereby authorize J}C. ,nerd MC/1-f" �"C-S, V' to at on my behalf,in al matters relative to by this building permit application. 5"- c�{-s.A___ 5/ A /7 I, "Paul .Lim id-f' as Owner&Authorized Agent hereby declare that the statements and information on the foregoing appfcadon ere true and acwrate,to the best of my knowledge and belief. Signed under the pens and penalties of perjury. �� /9 Not Applicable 0 Naw.ettifJrer.Helder: _ — J IL' • e.. _ , - 4a-1---Cctd fig 010 : 5/ /! e.2e '9 Address/ - Expiration Dale �.l ,.., -, es 41 - a / -5 ''.•naaae _ Telephone _. Not Applicable ❑ _..,..t �6_Ja e g- , 7yyrS Comoanv Name Registration Number reed- a0 rExpiration 'A;1=Acl d I rn,4 Dl 038f Telephone / ow7 573' e _ 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 67permit Signed Affidavit Attached Yes No 0 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 suoerviser,SMR 786. Sixth Edition Section 188.35.1. Dem of Homeowner Person(s)who own a prod 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 menu who eeruacts more than one home in a two-vear period shall net be considered a homeowner. Such`homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that heishhe shall be responsible for all suds work nem oder the buikha¢permit As acting Cgmtradiea Soervieor 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature b / -h -ft elea --fitly ansufigt- apeatios -fit qg p Moo B a MIND,Wedesd exp papwd eta 1 PIA Pus Pe 148904 goads ma0!8w(o4ntPls4P 'QX14u0e+ineangWitt 02 Punts!1&I Wall SRA LIMP Ple WWI U ) -1-171W1.71/4; f „ I Jfl-rfl f 0(A/ 6 e`-' =espy( v v n "hu-)0i--iii--F 3 6(eLv-taffy -cot amid e '4b1C t'W ' pnitp3N 'Avo +Cfisc'u-. ___Aj fte misippy ✓✓ -Prli d' 1 '1 9 :eta 'tee' }c( r yrf77ai 622 suPrif*Odom Onto a seine ainattele s atos:ff . _r., ,t. , a cy, UCCIdeinniTON Z° 1443 • • "nr Permit Authorization '°t4"°_ mase save Form et4.0s Safrd:wpl�.ergq,..eldddiiq,. UNITItACION Site ID: S00050299441 Customer: TIFFANY CHAPMAN 1, TIFFANY CHAPMAN ,owner of the property located at: (Owners Name,printed) 29 Matthew Dr FLORENCE (Properly 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: rhi9CM4-gr Date: ,7g3/1--7 f'7 • FOR CLEAResult OFFICE USE ONLY CLEAResutt has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor • Date • •• • • aCcel CLFARmult • 50 Washington Street.Suite 3000 • Westborough,MA 01581 • 1800<80-7/12 ror OMce useOny Rev. 102015 The Commonwealth of Massachusetts " Department of Industrial Accidents n4t —x Office of Investigations 7411'�• r J 600 Washington Street _ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business Drgaiii,atimi lain'dual 11 SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street City/State/Zip: Hatfield, MA 01038 Phone #: 413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): L© I am a employer With 8 7. ❑ I ani a general contractor and 1 employees(full and or pan-tins L' hase hired the sub-contractors 6. 111 New construction listed on the attached sheet. ❑ Remodeling _.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition Working for me in any capacity_ employees and have Workers 9. ❑ Building addition [No Workers' comp. insurance comp. insurance.- required.] 5_ ❑ We area corporation and its 10.0 Electrical repairs or additions officers have exercised their 1 I.❑ Plumbing repairs or additions i El 1 am a homeowner doing all work myself [No Workers comp. right of exemption per MGL 1' ❑ Roof repairs insurance required.)* c. I52. $I(4L and we have no employees. [No Workers 13.E Other comp. insurance required. `Ant applicant that checks hos<Imutt also liltnut the.eoum helot. show mg their worker, ,unpcnailon poke} information. Inineowner,t.ho m,hmn this amdas it indieaeng the are doing all work and then hire outs W:contractors must submit a new atildat It indicating sod, I bmrv:tors that check this hos must attached an additional sheet show mg the nae of the suh—c niraaors and state s nether or riot those entities hase empinsces If suh-amuactort hate unplusecs.then must pro'ide their workvn comppolio number. /am an employer that is providing workers'compensation insurancefin my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Co Policy a or Self-ins Lic. =: WC9024456 Expiration Date 2/23/2018 7 �C`f- Jab Site Address: e o � -� C it State'Zip: / (ZZ.1 ry,.,E m 4 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 tine up to S1.500.00 and'or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to S250.00 a da.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 cot' nder t pains and penalties of perjury Mal the information provided y above is true and correct. Signature .9' -f _._._ Date: � Phone=: Official use ooh'. Do not write in this area,to be completed hr eitr or town official City or Town: Permit/License# 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 It: A`O CERTIFICATE OF LIABILITY INSURANCE DATEDD1T 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 INSURERS), 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 CONTACT C thl Hen Berson, CI$R HAMS _-_yn Webber & Grinnell ,PHONE (413)586-0111 FAX IAM No Etll' We No):(433)586-6463 B North King Street "AftS:chenderson@webberandgrinnell.com INSURE13LAFFORMNG COVERAGE NAIL# Northampton MA 01060 IxSueERA:Selective Ins Co of S Carolina INSURED INSURER a:Selective Ins Co of Southeast : 39926 SDL Home Improvement Contractors Inc. INSURER C: 24 Chestnut Street INSURERD: INSURER E: • 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. INSR ADDL SUER. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IgSD WVD POLICY NUMBER (MWDDIVYYY) IMWDD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence/ $ 100,000 32204065 2/1/2017 2/1/1018 MED EXPµD one Person/ 5 10,000 PERSONAL a ADV INJURY s 1,000,000 _GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 3,000,000 X POLICY JEC LOC PRODUCTS COMP/0P AGG 5 3,000,000 OTHER AUTOMOBILE LIABILITY IEa CO MBIBINdEDISINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY,Per persn 5 ALL OWNED SCHEDULEDmi -- - AUTOS X AUTOS A9100328 2/1/20172/1/20172/1/2018 BODILY INJURY{Per adent) s X_n RED AUTOS .X_- NAuNoOswNEG PROPERTY DAMAGE (Persn9 -- — 5 -- - Underinsured motorist BI split 5 100,000 X UMBRELLA LIAS X OCCUR EACH OCCURRENCE s 1,000,000 EXCESS LEAH CLAIMS-MADE AGGREGATE 3 1,000,000 A _. _. DED X RETENTION 10,000 S2204065 2/1/2017 2/1/2018WO3 AND EMPLSOYERS' COMPENSATION X STATUTE X ER OTx- AND EMPLOYERS'LIABILITY YIN TAR _. ANY PRDMEIMBEREXCLUDwExecurlvE y- EL EACH ACCIDENT 5 500,000 OFFICER/MEMBER EXCLUDED' A - - B It RIPTI (Mandatory in aNH)nd wc9024456 2/23/2017 2/23/2018 - EL.DISEASE_EA EMPLOYEES 500,000_ DESCON OF OPERATIONS below E L DISEASE-POLICY LIMIT 5 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS'VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) The Workers Compensation policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas Schmidt. CLEAResult, Eversource and National Grid, NSTAR, Boston Gas Co. , Colonial Gas Co. , Essex Gas Co. , and Western MA Eelectric are named as Additional Insured per written contract with respects to General Liability 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 CLEAResult THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Contractor Services ACCORDANCE WITH THE POLICY PROVISIONS. 50 Washington Street, Ste 300 Westborough, MA 01581 AUTHORIZEDREPRESENTAIVE U Henderson, _ISR/C-N rap^^- se- ©1988-2014 e- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IN5025201401