23A-293 I I LANDY AVE BP-2021-0073
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-293 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING P E RM I T
Permit# BP-2021-0073
Proiect# JS-2021-000113
Est.Cost: $3000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg.ft.): 10628.64 Owner: SMITH KATHERINE
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT. 11 LAN DY AVE
Applicant Address: Phone: Insitrance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.7/21/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC INSULATION AND 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:
FeeTyipe: Date Paid: Amount:
Building 7/21/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
m —
..... ,_ ._ _ ... r �_
City of NorthamptonZP
s
Building Department
mow212 Main Street INSULA iv Roorr� 100 Northampton, MA 01060 a i
N phone 413-587-1240 Fax 413-567-1272
� L
_�_._ -_
a TIO FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
IN SI It A TION PERMIT
1.1 ProEertV Address This section to be comple ed by awe
Map R314 Lot �23 Unit
1
M Zone Overlay District
Elm St District, � _ CS District �
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
l
2.1 town r of Record:
Name(Print) Current Mailing Address:
elephone
} Sig:ature
2.2 Authorized Aden
Name(Print) Current Mailing Address:
Si :(tore Telephone
ECTION 3-ESTIMATED CO STR CTION COSTS
Item Estimated Cosi(Dollars,to be Official Use Only
completed b ermit a licant
?. d {a) Building Permit Fee
Building oDo
2. Electrical I (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Pwn*Fee
4. Mechanical(HVAC)
5. Fire Protection
5. Total=(" +2 + 3+d+5) 000 . _._...__ Check Number /
nn This rection For Official Use Only
Building Permit Number. b�l_ � 1 Date
1 issued
Signature:
Building Commissionerllnspettor of Buildings Date
EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR)
r-
SECTION 4-CONSTRUCTION SERVICES
Licensed Construction-So
,vrvisor: Not Applicable 0
N-4
i
Name of Lir Holder /
older I
License Nu ber
)21
A8_dreiss�,� I! JEWiratiodDate
Knaiure' Telephone
-—- --- -------------------
9.Rectistered Home,knpr Not Applicable 0
Comoariv Name ' j ration Number
AddressExpiratiorvtate
Tel,epl.,A
1 SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
..............
Workers Compensation Insurance afficlaylt must be completed and submitteo with this application. Failure to provide this affidavit will resul*u
1 in the denial of the issuance of the build"ohg permit.
LSigned Affidavit Attacheo Yes.. .... ty, No... .. 0
Brief Description of Proposed Work NO TE.- INSULATION ONLY
as Owner/Authorized
Agent hereby declare that the statements and informabon or the foregoing application, are true and accurate. to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Nam
SignatureVbf OwndiAgeritt bate
a as Owner of the subject
P,;Der+y
hereby authorize
to act on m behalf in all matters relative to wo authorized by this building permit application.
)
Signature of Owner 0afe
City of Northampton
DEPARTMST OF BUILDING INSPECTIONS
21 Mia Stroot •Municipal buil.rii:;xq
Northampton. MA 01060 0. '
..,
+eo-k br1SO 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 1500,
The debris from construction work being performed at:
1 (
;Please print house nurn er and street name)
is to be disposed of at;
0,A-4 /Y fir.✓}i" .
(Please print n rrm and local I n of facility)
Or will be disposed of in a dumps r onsite rented or leased fr
7
` r
(company Name and Address)
Signature of Permit Applicant or towner 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
DEF ARTI&N " OF Si?`ILDING XNSPECTrONS
212 Mair. Sliest • Maniaipal suiiding
Northampton, MA 010611
AFFIDA TT
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("H1C"),
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 resiitetryd contractors.
Vote;If the homeowner contracted with a corporation or LLC,that entity mast be registered.
,.hype of Work:_...__._.. __. LI•L�'lOn _ .. � ,._ Est. goat:
Address of Work: ..,,_ 1In __ /
Date of Permit Application-
_----
I hereby certify that:
Registration is not required for the following reason(s):
__._. Work excluded by lava(explain):__________._
Job under 51,000, l
()oner obtaining own permit(explain):
-Building Building not owner-occupied
Other
OWNERS OBTAINING THEIR:OWN PEP-MIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND
UNDER M.G.L.CWipter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBIL.IT°ES 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 petit as the:agent,of the owner:
rt,1 Lp- aziL "A�_
: .�� "
Date ' ?.tr cz.,r Name 141C 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 Northarap' o
Massachusetts
DEPART NT OF BUILDING INSPECTIONS �, b
212 Main street * Ymnzcipal suilding
Northazptor, 0106'
1 ANDA'I" "RY FOR HOUSES Buil r BEFORE 1945
Property Address: kCZr_k4
Contractor
"d
Name: , '' " ,z
~t .
Address: Ll
f
City, State:
'hone: ..,... L .
Property Owner
Name:
Address: f
City: State: 1n,3 D
(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
provided the property owner with a copy of this affidavit,
Contractor signature ;
Date
DocuSign Envelope ID:3A39OE6C-AC5D-48FI-AB53-7D23529A52CA
Permit Authorization
mass save Form
Site ID: 3972656 Customer: KATHY SMITH
1, KATHY SMITH owner of the property located at:
(Owner's Name,printed)
11 Landy Ave Northampton, MA 01062
(Property 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,
Do�uSigned by:
Owner's Signature: F�T-Rq shltl�
--'��87CCF4DO772D402
Date: 4/24/2020 13:45 PM EDT
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page I of 1 For Offic e Use Gr i
Rev.102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING Al,"fHORITV.
Applicant Information Please Print Legib1F
Name(Business/Organization/Individual): SDL Home Improvement Contractors, Inc
Address: 24 Ctwlstnut Street
City/State/Zip: Hartfield, MA 01038 Phone #: 413-247-5739
Are you an employer?Check the appropriate box: Type of project(required):
1 O 1 am a employer with 8 employees(full and/or part-time) 7. [] New construction
2.01 am a sole proprietor or partnership and have no employees working for me in S. E] Remodeling
any capacity.lNo workers"comp.insurance required.]
9. ❑Demolition
3.)1 am a homeowner doing all work myself.[No workers'comp.insurance requited.]'
l i) E] Building addition
4.01 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.Q 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
Thew sub-contractors have employees and have workers'comp.insurance.*
6.0 We are a corporation and its officers have exercised their right of exemption per MGI.c 14.[]Other
152,§1(4),and we have no employees.(No workers'camp.insurance required.]
'Aapplicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
m
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tC:omractors 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,they must provide their workers'comp.policy number
I am an emple�rer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ Selective Insurance Co
Policy#or Self-ins.Lic.#: VI1C9024456 _ Expiration Date: 02/23/2021
Job Site Address: n City/State/zip: ,/
Attach a copy of the workers'compens tion policy declaration page(showing the policy number and expi tion 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$250.00 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.
!do hereby cpole► ainv and penalties of pedu►_h that they ittforniation pro id c d above is tate and correct.
Si atu
Phone#: 413-2Z7--1S739
Official use only. Do not write in this arra,to he completed by city or town offic•ia1.
City or Town: Permit/License# _—.____
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cit.,'I own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
F-1171 E I M,MAX)fYYYY)
ACC->Ri CERTIFICATE OF LIABILITY INSURANCE
1 :9;;O:2,;2 i
THIS CERTIFICATE IS ISSUED ASA 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 cerffcala hoWer Is an ADDITIONAL INSURED,the policy les)must have A55MMONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED,subject to the tamlis and conditions of the policy,certain policies may require an ondomement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such ondorsament(s).
PRO