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31A-266
55 DRYADS GREEN ST BP-2021-0008 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-266 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-2021-0008 Project# JS-2021-000014 Est.Cost: $1500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.- Const. O.Const.Class: Contractor: License: Use Group: PAUL SC H M I DT 103635 Lot Size(sg.ft.): 85377.60 Owner: VENTOLA DAVID Zoning: 121)/WP(54)/RR(43)/URA(41)/URC(37)/Applicant: PAUL SCHMIDT AT. 55 DRYADS GREEN ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413)247-5739 W(' HATFIELDMA01038 ISSUED ON.7/2/2020 0:00:00 TO PERFORM THE FOLLOWING:WORK:insulation/weatherization 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 7/2/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Ell ' dell City of Nor thaM on �Gl �� Building ©epartrrp t �<r 212 Main Sire c ' � ww►a "' Room 100 ti9�'% �P�, j 772011w Northampton, MA phone 413-5$7-1240 Fax 413- ni T, NI L' i °5o Qr APPLICATION FOR INSULATION FOR A ONE OR TWO FA ILY WELLING ONLY I SECTION 1 -SITE INFORMATION L INSULATION PERMIT 1.11 Prooertv Address This section to be completed by office Map i 1< Lot XUnit rn ! � Zone O, ft'It / Elm St District ... _ CB"trict I SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 1 1,2.1 Owner of Record. I Name(Print) Current Mail in d _ _ l Telephone �O i signature I i 2.2 Authorised Agent: jName P t) Current Mailing Address: l l l sigrature Telephone SECTION IT ON 3N 3 ESTIMATED CONSTRUCTION COSTS ltern Estimated Cost(Dollars)to be Official Use Only completed by permit applicant t. Building 00 (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=(,, + 2+ 3+4 + 5) D U Check Number This Section For Official Use Ont gate I Building Perini(Num' r i Issued: i signature. 7 2-Z zo f Building Commissionerlinspector of Buildings Date EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) s SECTION 4-CONSTRUCTION SERVICES 6.1 Licensed Construction-Supervisor: Not Applicable 0 Name of License Homer . :_;cense Nu bar 4 A dressatpiratiti Date I q .ems i gnature Telephone > i 3 9. isteted Nome Not Applicable D 3 -omo—n L. e . t 1W .d P1 Jr'2e_f1 egistration Number Address Expiration/Date f ./�' � Telep honk 7 ' i.. 1 SECTION S.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) I Workers Compensation insurance affidayit must be completed and submitted with this application, Failure to provide this affidavit will result in the denial of the issuance of the build g permit. Signed Affidavit Attached Yes.. ... No...... [I Brief Description of Proposed Work � EINS ULA TION O L 3 I 3 7 7 as t:7wnerlAuthonzed 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 lender the pains and penalties of perjury. Print Narne � Signaturec6f Own rlAgent Date i _ as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 2112 Ma-,,n Street *Munjcjpa1 SU-Idjng Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40. 554, 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� {Please print house n#ber and street name) is to be disposed of at: AL� (Please �nnt n4meand lacy n of facility) Or will be disposed of in a dumps r onsite rented or leased fr n. C) Ix (Company Name and Address) �ign&6re'--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 Massachusetts DEPARTWNT of BUILDING XNSPECTI)NS �- 212 Meir. street r Municjpa1. Bua djng Northampton, tea 01063 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OC ABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family horses.Prior to performing work on such horses;a contractor must be registered as a:biome Improvement Contractor CHIC"), M.G.L.Chapter 142A require; 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".hey clone by registered contractors. Yate.If`the homeowner has contracted r iIh a corporation er i",LC� that entity must be registerett Li Type of�,Vork: i� n _ _ Est.Cost Address of Work;,,., S ! 5 Date of Permit Application:�.__ I hereby certify that: Registration is not rewired for the following reason(s) Cityof Northampton Massachusetts J�r �- �" DART)WNT OF BUILDING INSPECTIONS 212 'Heirs Straat • Municipal Hui lcii,:ag Northampton, MA 0106r � MA NDA TORY TFR H0LUES B 1-1-1-L r BEFORE 1945 Property Address: �.-w-- Contractor „ Name: } Address: L, Cityf State; 'hone .. r' : Property Owner Ze� ZD Lel--) Name: Address: Cry--� �' City: State: Cl? m , D Cv c) ,^ i (contractor) attest and affirm that the building ( intend to insulate 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 W -40 The Commonwealth of Massachusetts 41 Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov1dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. i'O BE FiLED WITH THE PERMITTING AU'l HORITI'. Applicant Information Please Print Lep-ibis Name(Business/Organization/individual): 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): I [a I am a employer with_8_„___employees(full and/or part-time)' 7. New construction F1 am a sole proprietor or partnership and have no employees working fear me in 8. Remodeling any capacity.[No workers'comp insurance required.[ 9. ❑ Demolition 3.[]1 am a homeowner doing all work myself[No workers'comp insurance required I 1O EJ Building addition 4❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions proprietors with no employees. ., 1<.❑Plumbing repairs or additions 5.a I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp insurance: 6.[:]we are a corporation and its officers have exercised their right of exemption per MGL c 14.❑Other _�_ 152,§1(4),and we have no employees [No workers'comp.insurance required I Any applicant that checks box k I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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.the. must provide their workers'comp policy number I am an employer that is providing workers'compensation insurance for my empletwes. Below is the pr,lic,r tine]joh vite information. Insurance Company Name:_____ Selective Insurance Co Policy#or Self-ins. Lic.#: VYP9024456 _ Expiration Date: 02/23/2021 _. —Y ---S----.City State'7i L Job Site Address: l . Attach a copy of the workers'con sation policy declaration page(showing the policy number and expif ation date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a 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$50.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c•er ' nder t sins and penalties of perjury that Nie infiwmation provided above is true and eorrelct. Date: Phone 4: 413-24 - 739 Oficial use onl},. Do not write in this area,to he completed hl•cit),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#: DocuSign Envelope ID:A168855D-2E23-4113-9373-9A301DD73F15 R IS E ENGINEERING' OWNER AUTHORIZATION FORM I, David Ventola (Owner's Name) owner of the property located at: 55 Dryads Green Street (Property Address) Northampton, MA 01060 (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. ��DocuSigned by: `t ;ra��ature 2/26/2020 1 11:33 AM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com * I Ate'" CERTIFICATE OF LIABILITY INSURANCE DATE I WDD4Y)1.N)O1iIW2020 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 poficy(ies)must have ADDITIONAL INSURED provisions or be endorsed. ff SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cerfificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER i CMAME:ONTACT Cyndie Henderson CISR,CPIA Webber&Grinned PHONE No, b: (413)586-0111 no). (413T586-6481 (AJCEx 8 North King Street E4"L chendersonQwebbwandgrit)rteil.com M®RFS4L--- INSURER(S)AFFORDING COVERAGE N=# Northampton 10A 010,60 INSURER A Selective Ins Co of S Carolina 19269 INSURED INSURER 8 Selective Ins Co of Southeast 39926 SOL Home Wiprovement Contractors,IncINSURER C: 24 Chestnut Street INSURER 0: INSURER E Hatfield MA 01038 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 0112021 REVISION NUMBER: I-HIS 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,I HE 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 CLAIM& ffm ADDL SUBR POLICY EFF POLICY r" LTR TYPE Of INSURANCE IN SD wvD POLICY NUMISER MR2Lnn Liam X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 5X=l!10RENnzff-- CLAS-MADE 1 IN�N OCCUR PREMISES Ea qccwrw� $ 500,W0 MED EXP(Aa y one Person) $ 15,000 A 52291 W9 01101I2020 0110112021 PERSONAL&ADV INJURY $ I'00,000 GEW-AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 3,000,000 POLICY �pnoT M LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER $ AUTOMOBILE LIABILITY COMBIN40010011ED SINGLE EiVff— $ 1'000,000 (Ea 0 ANY AUTO BOIALY INJURY tPerpomon) $ A — OWNED NA SCHEDULED A9105420 01101t2020 01/0112021 awLY iNjuRy(per accident) _ AUTOS ONLY AUTOS 'I AMAGF HIRED NM "-OWNE0 PROPEIR T" AUTOS ONLY AUTOS ONLY Per ad.-I Underinsured motorist 81 $ 100,000 m UMBRELLA Lim EACH OCCURRENCE $ 1,000.0 A EXCESS LIAR S22915M 01101/2020 01/0112021 AGGREGATE $ I'M0,000 DED RETENTION$ OTH- WORKERS COMPENSATION STATUTE ON FR AND EMPLOYERS'LIABILITY YIN 500,000 A14Y PROPRIETMPARTNER,EXECUTIVF NIA WC9024456 0212312020 0212312021 E.L.EACH ACCIDENT II OFFICERJUEMBER EXCLUDED? 5W'000 (mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,dew,dm unaw sw'000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sch*&Io,may be attached ff more space is required) The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt, T hielsch Engineering is hereby named as Additional Insured per written contract,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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Thisisch Engineering ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Avenue AUTHORIZED REPRESENTATIVE Cranston 02910 I ,Oc 1988-2015 ACORD CORPORATM. All rights resorved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD