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42 CERTIFICATE OF LIABILITY INSURANCE DATE{MMfD0.;YYYYJ 1/15/2016 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 13Y 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 I i 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 endorsemen s. PRODUCER z Cynthia► Henderson, CI3R NAME: Webber & Grinnell ' aExt1 (413)586-0111 IAC,No):(417)SY6-6481 8 North King Street ?ADDRESS:chenderson@webberandgrinnall.com INSURER(e)AFFORDING COVERAGE MAIC k (Northampton MA 01060 INSURERA:SalaCtiVO Ins Co of S Carolina IINSURED INSURERB:SalectiVe Ins Co of Southeast 39926 f SDL Home Improvement Contractors Tnc. INSURERC 24 Chestnut Street INSURER D. INSURER E lHatf field MA 01038 INSURER F COVERAGES CERTIFICATE NUMBEWHaster Exp 2019 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE I ISTED 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 AFFORDE(J BY THE POLICIES DESCRIBED HEREIN IS SUBJECT :O ALL THE TERMS, EXCI USIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 1N$R TYPE OAF INSURANCE ASL SU8I2 POLICY N MBER POLICY EF Y POLICY EY LIMITS 'LTR ,X COMMERCIAL GENERAL LIABILITY ;.AG'-JCCURRENCz S 1,000,000 'DAMAGE TO RENTED A C.AN$VA:)f X L?GCUR PREMISCSrE,a100,000 S220406S ;1:,.'2018 1/1/2019 x,;,tA,,v:X)De;W', 10,000 PS.RSONA:.a AoV INJURY 1,000,000 N, A116RI-GA 7;,MIT APPLIES PER GPNI RAi AGGRPGAU .S 3,000,000 PRO, S�HCC?t;^.FS C(MPA)f AG{� 1 3,000,000 X at3.' Y ACT fit` I ETHER C=WO%057 AUTOMOBILE L (Fa ABILITY : acoadatl; f 1 ff 1,000,000 ANY A.;70 N(?)i,.Y JNJtiRY tPe^00(SC'; S A Ali,OWNt[) SCrd%-Dkw I( J y aC71,, f!'dJUflt P :rA.a�cr, S AU16S X AUTOS A9:.00328 I;.;2C18 /1/2019 - =NWOWNFU P Rr 'iSR'Y DAMAGE S X Ir:RCDAi,TL)S `- X ACTO°. lPn a,.c�idia; ..n,can e$r onrit U.s :, 3 100,000 X UMBRELLA LIAO X Ctt,Gt)tx EACH ) CURRENCt 5 1,000,000 A EXCESS UAB r;LANS MADE, .AW;RE.':,=ATE S 1,000,000 OEt) X RFrENOONS :0 000 52204065 2./1/2018 1/1/2019 PTH 5 WORKERS COMPENSATION X g*A7,1'IL X I R AND EMPLOYERS'LIABILITY Y t N ANY Pao-R.f" R PAR*NFRi1-'X ',J"err _ CR ACCtDtN1 4 500,000 Occ+fiER1MEMB°R Yf:1iR) !N f A .. - Y WC9024456 1/2310We 1/23/209 E;. ISEAU. EAl.NIP1.OYE..1, $ 500,000 B iMsndabary in NH) I`,baa osac-,ba Jt9kASr POLICY order OWSC Pt,ON VUPE ;IONS txevw L 61N:Jt $00000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES tACORD 101,Ad4ttlonal Remarks Schedule,may be matted 0 more space is requited) The Workers Compensation policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas ISchmidt. i CLEAResult, Eversource and National Grid, NSTAR, Boston Gas Co. , Colonial Gas Co. , Essex Gas Co. , and :Western MA Selactric are named as Additional Insured per written contract with respects to General iLiability for work performed and per the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CLEAResult THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Contractor Services' ACCORDANCE WITH THE POLICY PROVISIONS, 50 Washington Street, Ste 300 I Westborough, MA 01581 AUTHORItEOREPRESENTATIVE ,v. Q 19$&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 f20-40' The C:ammon wveafth rr f.L�assac!t trsetls Department of Industrial Accidents E Office crf,it[Vesligatn,*ts 600 Washington Street Boston, :114A 02111 wwi,v mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/('ontractors/Electricians/Plumbers, Applicant Information Please Print Lgyjb1v Name lat:,mt itfttatf t'. SDI.Home Improvement Contractors Inc Address: 24 Chestnut Street Hatfield MA 3-247-5739 (i[N Staze�l,i �; 01038 f'huttc 4 Are you an employer?Check the appropriate box: Type of project(mq uiredy t �t. � ! ,.arts t t�c�nrrai ,.�unn•artt�r �trtd l 1,� 1 ain a emplo-er kith f). U "'ttk Construct itll einplokee's(full and.or part-tire).* hat%c htred thti pub-cotttractt,rs listed rsn the attached sheet 7. 7 Remodeling '.❑ I ant a sa�tie proprietor or partner- y, , 3 f hc,h Iib-contractors hati C """ p hipand have:no emploN ees h 7. 0entolition vNorking for re in any ca sacro nplcnees anti h;tvc a ocher r r; y F ��. Building addition o work,ers comp, tnsuran,Ce itlt�tl SttatranC4'. i reyu?rrd.j �-1 A%: Irc,a I.onloration and ltti f+). J 1:lei:trical repairs or additiow, jraftWur,hio c everciwd their !f. Plumbing repairs or additions I am a hoincov;ner doing all work p m}sch'. (No evorkers' comp, right of c<ernpiion p+.r 'tifi;l , t­❑ Rool'repairs j insurance required.) " C and\,%e have On comp, rl Nonce sI ork reqred.l I j.[ t her Insulation +it IpplIc:xn[that dteck,tx3v"''i must Whu tilt oto the,:euor.h06,„ ,,,nkcr� . ,mpen,ation poltet intorntauoll iorrtc;,k,cur,%A Ili Noboru this anida%it mdreatmu the art:d+mz al .tti,i then fwc-t :,,atraetore must,tibmtt a noA atlidavit rndteattni,nch o+rtraoor',that 4hca ths,to=ti must atvactcd an adc2illonot.hers Aw%u the:nanw ai the and state tefiether w not thr'w emiltes hm, ;:ntptt,tee> it the vtth- r+niz ctc,r,hate emplo ee .the% most pram I&thea t,,.€ko, :ofnp nualbe: /am an enWloyer that is providing workers'compensation insurance for n!v enrlaa ees. Below is thepolict and jab site information. Insurance C'ontpan,, Nare: Selective Insurance Co Polic\ ..or Self.ins. f.ic. ": WC9024456 1 \piration Date: 02123/2019 �j .lob Site Address: ....��`�} �����'}�!kx 1�� � _ _ t aN State Zip: Attach a copy of the workers' compeasatim policy declaration page(showing the policy number and expiration dote). Failure to secure coverage as required under Section 2,;A of\461 c 15' can lead to the imposition oferitninal penalties of a titre tip to S1.500.o(l andror ane-,year iniprisonntent,as well,as Civi€penalties its the form of a STOP WORK ORDflt and a fine of up toS''+(f OO at day against the violator_ Be advised that at cop\ of this stsatement inay be forwarded to the Office of Investigations of the DIA for insurance coverage verificatic,n I do hereht'cert' »der t pants and penalties ej'perjun,that the information provided above A true and correct. Si. r,>�t re: �_...._._ _ _ 4)ate: .. �.�r.�' l ------ Pilo Official use only. Do not wrh'e in this area,to he conWleted by city car town official. Citv or Town: Permit/L.iceust# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.CitrfTtmo Clerk 4. Flectricat Inspector i. Plumbing Inspector b. niher Contact Person: Phone#: City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street * municipal Building Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units...,or to structures which are adjacent to such residence or building"be done by reg6tered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered gi d a TJ Type of Work: k A-A Est. Cost: Address of Work.-— Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain):___ Job under$1,000.00 Owner obtaining own permit (explain):__ Building not owner-occupied —Other(specify):___ OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building pe .t as the agent ofthe' Date Contractor Nime ;WY�-HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARMWT OF BUILDING INSPECTIONS 212 Main Street eMunicipal Building Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, i acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: &Z? bLI�1021=Ql� P—A J-i4+)ame+CK/ (Please print house number and street name) Is to be disposed of at: L + (Please c2q cJv,�Jr,4,� orint n�)cation of facility) name and Ic Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 15ignature- of Pe?rnit Applicd-nT or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. J E Z 4 Flaunt Aumorization nia-ss saw Form Site 1M.34602/3 Customer: E fF R E.: . N1 NAS E K owner of the property located at: (0wrter's Name,printed) 0, a rr,nwon MA 01,062 (Property Street Address) (cdy) 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 weather tion work on my property. DocuSigned by. OwneesSign ature: D*ft: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Alk 1 P; o 00, 4 r) For offica Use Only Rev. 102015 SECTION$-CONSTRUCTION SERVICES 8.1 Licensed Construction Sup=isor: Not Applicable 0 Name of License Holder: C 10/1 _/__ License Number. 64 '.:§_/P6 1,2 0 Add!!;re;�s� Expiration Dite '0 4 0 SvIture Telephone 9.R60111166001kMaift I 1 11 Not Applicable El ComDany Name Registration N�mber , Address Expiration flate Ooze 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 bui'id7'1g permit. Signed Affidavit Attached Yes....... No...... 11 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aop#icable) New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding Other[ r' ,ca Brief Description of Proposed F g `s � � Work U /- Alteration of existing bedroom Yes V No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet 6a. 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? n. Type of construction Is construction within 100 ft. of wetl ds? Yes No. Is construction within 100 yr. floodplain Yes No �. Depth of basement or cedar flo below finished grade k. Will building conform to th uilding and Zoning regulations? Yes No . L Septic Tank ity Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COtAPLETED WHEN OWNERS AGENT OR COINTRACTOR APPLIES FOR BUILDING PERFAIT ! as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aut orized by this building permit application. (� Signature of Owner Date 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. Sign under the pains and penalties of perjury. rn L14- Print Name ry Date Sig u !re of Own nt 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 Setbacks From Side L R: - .. L: R: Rear Building Height _.... . _.. - Bldg.Square Footage - % --- Open Space Footage __- (Lot area minus bldg&paved — aricin #of Parking Spaces Fill: volume&Location) __-- A. Has a Special Permit/Variance/Findi ver been issued for/on the site? NO 0 DONT KNOW YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW (D' 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 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 activity disturb(clearing,grading, tion,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. - City of Nort amr tone` Building Dwartryient 212 Main Street OCT 3 1 2018 Room 100 Northampton. MA �b t BUILDING INSPEC ` > phone 413-587-1240 x 4118�7afifi2 MA010 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i SECTION 1 -SITE INFORMATION '✓ ®"'` r✓ L 1.1 Property Address: This sem to be r:now 1*1541111111w C� a g e h Q,n pin Lot /V o L1 a ml040n ""n o I U Q- zee" Elm St District Ce Disbict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J.P Ljfie�� a�2 OJ�k' Name(Print) Current Mailin Address: Telepho e Signature 5� 2.2 Authorized Anent: Sb� - �rJ✓1=�r�n'L-Q�1 L �- �5, /�/G AM)A+ Sf mar ! I-, m4 Name P' Curr ailing Address: y13-dy2=S?'3� gnature Telephone SECTION 3-ESTIMATED COUSTRU,CTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit a licant 1. Building (a) Building Permit Fee 2 Electrical (b) Estimated Total Cost of Construction from S 3 Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 411 6. Total= (1 +2+3+4+5) (fid Check Number Tt S1eelill For 011111ctal Use Ordy Building Permit Number: Date I Issued: ' Signature: 1 Building Commieskxm9inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 628 WESTHAMPTON RD BP-2019-0540 cls#: . COMMONWEALTH OF MASSACHUSETTS Map:Block:42- 149 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Bui,ldinp DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2019-0540 Proiect# JS-2019-000876 Est.Cost: $4000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: use Group: PAUL SCHMIDT 103635 Lot Size(sa. ft.),: 51400.80 Owner: GNATEK JEFFREY Zoning: Applicant: PAUL SCHMIDT AT. 628 WESTHAMPTON RD Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.111712018 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD INSULATION 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# 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: FeeTyne: Date Paid: Amount: Building 11/7/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner