32A-196 (6) 22 PHILLIPS PL BP-2019-1067
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Ma❑:Block: 32A- 196 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-2019-1067
Proiem# JS-2019-001734
Est.Cost:$2000.00
Fee: $65 00 PERMISSION IS HEREBY GRANTED TO.
Const Class Contractor: License:
Use Groun, PAUL SCHMIDT 103635
Lot Size(so. @.): 7666.56 Owner. STODDARD MICHAEL&PATRICIA
zoning URCrtool/ Applicant: PAUL SCHMIDT
AT. 22 PHILLIPS PL
ApplicantAddress: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:3/27/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:R-30 ADDED TO ATTIC FLOOR, AIR SEALI NG 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 Sienature:
FeeType: Date Paid: Amount:
Building 3x27/2019 0:00:00 565.00
212 Main Street, Phone (413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i� /'�C
Cfty ofN rtha'f'tYEVLI ���
Building paiLy'9
212 M in S eet ,
Roo 10 MAR 2 7 9019 7
Northampt n, 01060o
phare 413-587-12 F '*
.ars 11471N,ar^ r io
�^roa •:� r .
APPLICATION FOR INSULATION FOR A ONE OR TWO FAWLY DWELLING ONLY � Cr. tQ
SECTRTN,-slrm i;ORaIATIOw INSULATION PERMIT
1.1 ProoerN Addreu TBMF
nit_No?� Ph rUpS P1 QeA Wsv —n6)74- Let Unit—
NJ)4-hary
J)4-hary , mf, L.. 000%VM MR -
I" �jloLo U
EM at Nwk% _____ CB DMkt
SECTION t-PROPERTY OWNERSHWAUTHORIZED AOENT
2A Oa r of Record:
m .rchit
Name(Prinn Cunem Maarg Address.
.� ✓"or....-""^-� TalNrpne
Signature
GLu! SCS m ) �1
Name ) I Cuient Mailing Address.
760`7
Sgnature Tekplane
tyfr"^O"3-ESn MTW ODNMrLn^_T M CM3
Item Estimated Cost(Dollars)to be Official Use Drily
connpletadmlftapplioart
I. Building (a)Building Peart Fee
2. Electrical (b)EstimaEsd Total Cost of
Cdetruc4on ham
3. Plumbing Bul""PwRdt Fee
4. Mechanical(HVAC) T7 1 1�✓
5. Fire Protection llllll
6. Total=(1 +2+3+4+5) 00c)— Check Number
TNs Seslbe
FaOfll
W
suaO 1n
a
BuildingPeritNumber N
signature:
3- Z7-ZO r9
aWwraCoWionwdrrprswala Dais
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION a.CONSTRUCTION SWIVICES
8
LISM24 2No/t�Applicable ❑
Noma ofLieemaNrarNr. � � CS- jD�(,35
ticerue Nu r
sI
ems.as� EAdaidio Date
gee TebpMna
-. Not Applicable ❑
C 1� IyA, .)yl 7�v� t/'L�/t egistration Number
rT 'l � .�'i-Y1t A'I' S� ate pGv of
Address— E ratio
0103� Telepho'A a47-593
t
SECTION 6-WORKERS'COMPENSATION WKWANCE AFFIDAVR NO.G.L.a 162,§29gS))
Workers Compensabon Insurance affida must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the build' permit.
Signed Affidavit Attached Yes....... No...... ❑
Brief Deabriptlon of Proposed Work NOTE: INSULATION ONLY
aqo
A r L Ad-(- 8-1
I. �nU cX.A-wy as OwnsdAuthitiumd
Agent hereby dedare that 6te statements and information on the foregoing applicagon are hue and accurateto the best of my knowledge
and belief.
Signed under the pains and penalties of penury.
Fnnt Name
1
Slgnaba t Agent Date
I ,as Owner of the Subject
property
hereby authorize
to act on my behalf,In all matters relative to wo&authorized by this bustling cannot application.
Sgnawre of Owner Date
Permit Authorization
Fem
SI`M IID::3t"366476 Cust[Hoer: Michael Stoddard
6 'Ml�r yA�.Q Ji-C ,c-c\ ,owner of the pro0erty located at:
(owiwYxa�e,pkadi
22 PHILLIPS PL NORTHAMPTON, MA 01060
p�apegSaeu�) (rxd
hwebyautlww the A4W Saw!Nome Erwrgy Services Program as W"Plartiquat"Contractor Ind
below to act on my behalf and obtain a building permit to perm bau allon WNWw weatheriawtion
work on my property.
owmessiaamre
Data.
FOR O11Aa UR oar
we have assgred the fogewt Apes save Home Bann services Parbopwm con racaor to the
above referenced project:
Particwft Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
ry arrce use a^h
Rev.102015
City of Northampton
1lassachvsstts -L
V""211bm or sortvise zeaysczzoas
212 win 9t .t •Nunicv"I a—l"i
Dorcnampwn, 1P 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 property licensed solid waste disposal facility, as defined by MGL c 111. S 150A.
The debris from construction work being performed at:
a s P�Vi l S a
(Please pont house numbernd street name)
Is to be disposed of at:
�- - go C94C
( lease pnnt n me and iota 11 n of facility)
Or will be disposed of in a d-u�m(p'gjgr onsite rented or leased tr
SrhL—+ �'�f�- -YT'I-_•,��tb.l-z-�r�.tte1'�' l,_.C�C"`
(Company Name and Address)
Sig a unY of Permit Applicant 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.
City of Northampton
Haasachuaatts L
Ox:PAx2NWT OF BtrrLOZeO ZaRaLTZORS
212 IYie rer • Mtl suvltllnq
NorCheR<on, io,Nx 01 01060
AFFIDAVIT
Home Improvement Contractor Law
Supptement 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 most he registered as a Home Improvement Contractor CHIC"),
I.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-erisbng avner-accupled building containing
at least are but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
A'ote:If the homeowner bas contracted with a corporation or LLC,that entity mast be registered
oC�
I ype of Work:_ Est. Cost._-ZPO _
.Address of WorL
Date of Permit Application:_.
I hereby certify that:
Registration is rtes required for the following reason(s)'.
Work excluded by law(explami:___
_Job under$1,000.00
_Owner obtaining own pernit(explain).__,___
Building not owneroccupied
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.GJ_Chapter 142A.SUCH OWNERS ALSO ASSUME THE RFSPONSIB111TES 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 putt as the enc of the o
�rl>��.�n+-
Date Contractor`Jame 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
r.
DraseachuaetGs ' '- cPti
212
tos evsaosrrc zaseurzoes I.\�
Yl] Win etiNt 1Wnacapel Bulldiny ,�
NoiNYp[en, W 8106 �
MANDATORYFORHOU�7J'cI'ES BUILT BEFORE 1945
Property Address: d a !`ntU'' lei ,5 Contractor
Name:
Name: 1,T'
Address-. -
City. State: ' ��\ c���q" (D1 L)
Phone:
Properly Owner
Name: Crl""j
Address: -�Cjt->L1.Lu�u- L!
a � Qh:l�ups `Y�lac�
City, State.
IZ. CI'� (contractor) attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
Zi
provided the property owner with a copy of this affidavit.
Contractor
Date
--` "" The Commonwealth of Massachusetts
01-t > Department of Industrial Accidents
' I Congress Street,Suite t00
yt_` ic
Boston, .MA 02114-2017
a;=rrs www massgovldia
Workers'Compensation Insurance Afftdarin HuiWers/('ontrectors/EleeWdxns/Plum bets.
TO nE FILED A'FI'II'I'HR PERP11117](;AF1}IORI I%.
Applicant Inioroution Pt<au Print Le ib
'dame nna.;,ws.+rctrgmi.urf.eeIDd{aaradlt SDI.Hone knprowerm ant Contractors, Inc
Address:24 Cheslrwt Street
CI}iStatvi/ip�,Hatfield,MIA 01030 Phone §.413-247-5739
arr,un xnrmyb r"(bM tae aPP o ubr+ . )
f
9 � 'fvpe of protest(rcyuired),
[]+ 1 pl h p1 :tt r- w na „�I
- - 1 � 7, Q 'vrw construction
0 >1 r n l i n' m 111 J w pl _ k rnr+�,.m 8. Remodeling
I -
('''�i ........... M rn•alt god rdl tin++rcA ❑t}�rradittPn f
6.1 { t -"w'd
10[3 nudd'rg,addltinn
3f�ll J 'II L.I E 1 .y 1 III A p' � , II
LLJJ ! t n ix i 4 i x :d I i.01 feemcal teras no addition,
pl _
12 []Pluntbint repot s lir additiolu
C31 gea* i...... i It enc@dil.vt
1 n + i ! yt Jry 4 - p r � Ii.�Rnoi r.paia
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14.QOIl er lnsulatmn 11 : coir a R 1 -- 111 1 1Pi 1>LI rv'I(il.. - - - -
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+ n:xunrh,acae.Aal,d�. n auveib.fun uilJirwt lxc tint+vrM1:n ouh.x tx �+.lulanF.a nn11Yx...m1 Iw+.
cn+plo+ecs If itis sutwonv:xaare iwee ertaJmms.iMc mu.xl pre,iJc tMn uorkari comp anafv numbni
ionto emlthreerdtat isproviding wnrken'cOmPensmimt lnvuranrefor my rnyrloyees. Rehm,is thepotig andjoh sae
tmfiamrtian,
tnsuranec Corp mly Name:Selective insurance Co
Policy a orf oif--ins Lie,I, VVC�9024456 _ f vpiration[),Is,0212312020 �.
Joh ti{re.Address: �t I5_._� C=Q_ .,__{ lit state;7ip9,:g
Attarb a copy of the workers'eompenxxtiox Policy declaration page(showing the policy number and espt atiot ).
Paibnc m vegan:cxrscrxgc as regal red wsdcr!.Alit,c_ ig_,fi25A is a criminal viniation ponishxbiv tR a line up in 31�iNl.iMl
load III one-rear imprisonment.as ,vit as civil Penalties in the form of a SOP Nk ORA ORDS K and a fine ofup to S]`•t).00 a
day against the sinhnor.A copy of this sImcmam mac be forwarded to the Offrec ot"Investi¢ations ofdw U14 9rr insurance
coverage venfica6al,.
I do herebl?7'-57 er f e to ondp<nntaes tJ'perjun,that Information provided above is true and correct.
.ice C�
4'lunaturc: fat' a(,P`/ /
Official live only, Da mat arim in this area.to be completed hr vie, orMwn ttfeial.
City or'i"own: —..� Permit/LicvnseH_.,_
Issuing Authority(circle one):
I. Word of Health 2. Raitding Department 3.City/1'Asia Clerk 4. Electrical Inspector 9. Planning inspector
6,(fiber
('names Persaa: _ phone a: __,
ACCI d CERTIFICATE OF LIABILITY INSURANCE 01X2L201d`"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATNELY 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(NSUREPAS),AUTHORItED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER
IMPORTANT. N N 1 WARMD,subjeat at NAL INSURED,tl the
must haw ADDITIONAL a an ono nnerhan't s el ar nt anA.
R SUBROGATION IS VANED,sugatl to the burro and condition,of the Policy,cesens Policies mry require an en00nemmL A abbnrnl on
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PPoducER xAYE CyMw Nendermn CISR CPIA
WHbber&Groner @131585-0111 Opo. (4t3)5838101
8 North Ih+g StreetUeM.rsM�.wCbOerandgnnnelfWm
wwRERIsI AEPORaxc covERAaE xAlc•
Nodham , MA 01080 WSUxFp". BeleWve ins Cb olSCambne '9259
IxwPN — wwPEp B- SHe bve ins Co of S°ulbea9l 38926
SOL Home lmproMmentOWt2Llprs.Inc Mso.
34 Chestnut Street
wwPBR E _.
Hwilleb MA 01038 IxwetR F —_
COVERAGES CERTIFICATE NUMBER: Master ERP 2020 REWSION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HOVE BEEN ISSUED TO THE INSURED NA MEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTYWTHSTANDING AN'V REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH 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,
E%CLU51t,W5PND CONOTIONS OF SUCH PCLGIES LIMITS SHOWN MAY HAVE BEEN REDUCED OY PAIDClNNS _ _
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ttPE OF M54gAMCE P0.1CY NVMBFR MMICpY MYgp W LIMITS _
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CLEAResult.EverePorce and National Gml NSTAR,Boston Gas Co.,Gwar l Gas Co.Essex Gas Co. am VMslem MA Ee lana are named!as
ArTmOnal Insured per Ymllm contract 1MIh resdI to Gmatal Liability for work nedomNd and Per pre terms and cesshIdne of the DOIicY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION SATE THEREOF,HOME WILL BE OEtNERED IN
CLEARewA CoreasTO'Services ACCORDANCE WITH THE POLICY PROVISIONS,
50 WashrTglon Sbeel.Ste 300 AUTHORIaM Reensnah ATNF
Noesis ou9n !Ah 01581 �� lam. -�Y
91988-2015 ACORO CORPORATION. A9 IgM1b maarvetl.
ACORD 25(2015103) The ACORD name and land are regislere0 marks W ADDED