29-582 (2) 131 WOODS RD BP-2021-0074
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-582 CITY OF NORTHAMPTON
Lot:-601 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2021-0074
Project# JS-2021-000115
Est.Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg. ft.): 22738.32 Owner: LIZA M PIERRO-PULSIFER
Zoning: Applicant. PAUL SC H M I DT
AT: 131 WOODS RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 _. WC
HATFIELDMA01038 ISSUED ON.7/21/2020 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSULATION ADD TO ATTIC FLOOR, 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:
FeeType: Uate 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
City of Northampton
Building Department
212 Main Street TON
Room 100 INSULA I
Northampton, MAS 31 060
hone 413-587-1240 Fax 413-587-1272
0AI
N FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATIONINS ULA TION PERMIT
1A Property Address. � � This section to be completed ce�
Ids "C Lot 5 —Unit ?
d
1
e f u U, - Zoe te
Elm St Nstrict C Y31 riWt
SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.4 Owner f Record:
C�- CSI _ rte
If f i
Flt Ems.
Current Marling)Address: j
1
i r 'eieptZrins
Sign Yore j
C
lsig7'
mPr' current Ahiling sddress:Lure - /"'ettprione
3-ESTIMATE CC3 STRUCTION C TS
3 stern Estimated Cost(Dollars)to be Official Use Only
i
completed by permit applicant
". Building <-� (a)Building PermitFee J
2. Electrical (b)Estimated'Total Cost of {
Construction from,l6'
3. Plumbing BuOd ng Pennit Fee
4. Mechanical(HVAC; 3
5, Fire Protection; �
6. Ttatal=(! + 2 + +4+ )
This S"Ition For Official Use tint
��
i
�. Date
1 Building Permit Nuns r '� [ lssuec3.
Signature, / Z/ ZIZO
Building Oommissionerlinspector of Builoings pate
EMAIL.ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
7...,
SECTION 4-CONSTRUCTION SERVICES
1 Licensed Constructio rvi pr: Not Applicable 0
I $Nanw,of License Hollig,
License
}
r
Expl
ratio Cate
gnature " Telephone
3 �
Not Applicable Ci
s
Comoanv Name Iatration Number
' a
Address 5" Eiratio ate .__
3
SECTION 5-WORKERS'COMPEN ATION INSURANCE AFFIDAVIT(M.G.L c.152, 25C{ }} ,
1 'Workers Compensation Insurance affidaytt must be completed and submitted with this application Failure to provide This affidavit will result I
i in the denial of the issuance of the build)69 permit.
L.jc�Lgned Affidavit Attached Yes....... No--, r-,
;Brief Description of proposed ii#7oric `E: INSUL
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing applicati
City of Northampton
y
Massachusetts moi, a w
DEPAR"ENT OF BUILDING INSPECTIONS
11,E Main strcrot *Municipal Suisziirsg
xorthamptonr MX 01060 ..
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:
!Please print house number and strut name]
Is to be disposed of at:
(Please print n4 rrfe and lova r, of facility)
Or will be disposed of in a dumps r onsite rented or leased fr m: '
i
(Company Marne and Address)
Signature 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 ill be disposed.
City of Northampton
Massachusatts
DEPARTMWT OF BUILDZNG XNSPEECTZONS
212 Main Street * 2ftnic3.pal Building
Northwapton, MA 01060
AFFIDAVIT
Rome 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("HTC").
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 registered contractors.
.Vote:If the homeowner has contra ted with a corporation or LLC,that entity must he registered.
'type of Work: r'� 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 S 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.ChaWr 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBLUTE'S 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 pelt as the dent cif thewrt r:
1-MID 2'712�
Contractor Naime HTC Registration'No.
OR:
Notwithstanding the above notice, I hereby apply for a building,permit as the owner of the above property
Owner Name and Signature
E
/
Massachusetts %
a'EPART2?NT OF BUILDING LDING ZNSPECTIONS
211 :Main Strclet re ,Municipal Buildingw=
'. North,=p -a.., KA 0106,.
MANDATORY FOR HOUSES 8 UWL r BEFORE 1945
Property Address" n
Contractor
Name. „
�
, f q-
Address: 3
-
City: State;
Phone
Property Owner �
Name.
Address: _.
City; State: CS 0A, C
c rntractorj attest and affirm that the building I intend to
insulate""does not Dave any open air (knots and tune)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature `°`
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 104
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/ContractomfEtectricians/Plumbers.
TO BE FILED WiTH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name 113usiness/Organiration/IndividuW): SDL Home Improvement Contractors, Inc
,address: 24 Chestnut Stmet
City/State/Zip: Hatfield, MA 01038 Phone#: 413-247-5739
Are you art employer?Cbeck the appropriate box: Type of project(r quire ft
1.Q I am a employer with$employees(full arid/or part-time).' 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8, E] Remodeling
any capacity.[No workers'Comp.insurance required.]
3.D I am a homeowner doing all work myself.(Ido workers'comp.insurance required.]t 9. El Demolition
14[] 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 I l.❑Electrical repairs or additions
o
proprietors with nemployees. 12,E]Plumbing repairs or additions
5,01 am a general contractor and d have hired the sub-contractors listed on the attached sheet l3.❑Roof repairs
'these sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MG1,c. 14.0 Other _
153,11(4).and we have no employees,INo workers"comp.insurance required.]
•Any applicant that checks bot!#t must also fill out the section below showing their workers'compensation policy information.
°Homeowners who submit this af)cidavit indicating they are doing all work and thea hire outside contractors must submit anew affidavit indicating such.
+Contractors that check this box mud attached an additional sheet showing the name of the suh-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 employer that is providing workers'compensation insurance for my emplgvees. Below is the policy and job site
information.
Insurance Company Name:_ Selective Insurance Co
Policy t#or Self-ins.Lic.# __I VVC9024456 _ Expiration Date: 02123/2021
P J
Job Site Address: 17J i ,( L�� /" Citylstate/Zip: :-[j3ctAnej-A_
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 farm of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do berebv cer ' trtder t ' Win and penalties pf perjury that the infornrution provided above is true and correcx
5i natu . Date:
Phone 4: 413-247 739
Ojjicial use only. Do not write in this area,to be completed by city or town official.
City or Town: ___ _ � Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE
0 i 11 W2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER IM"IFICT Cyndie Henderson CISR,CPIA
Webber&Grinnell PHONE FAX
�AJC,No,Ext): Nai: (413)586-6481
8 North King Street E-"L ctx)nderson@webberandgrinr%41.corn
ADDRESS;
)N$URER(S)AFFORDING COVERAGE MAIC 0
Northampton MA 01060 INSUPFRA: Selective Ins COOfS CarOlina 19259
INSURED MuRER 9 z Selective Ins Co of Southeast 39926
SDL Home Improvement Contractors,Inc,
24 Chestnut Street
1 INSURER 0:
INSURER E
Hatheld MA 01038 INSURER F;
COVERAGES CERTIFICATE NUMBER. Master Exp 0112021 REVISION NUMBER:
;'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 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 AOMWBR
LTR TYPE Of INSURANCE POLICY NUMBER POLICY EFF POIUCY EXP
W MWDDrYYYYI MWOOMM LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
CLAWS,-MADE i eN OCCUR PREMISES(Es 0Q4WrWkoeJ S
MED EXP(Any I
A S2291509 011011= 01101/2021 PERSOtOl&ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY �7T. F I LOC PRODUCTS-COMPIOPAGG $ 3,000,000
OTHEP., $
AUTOMOBILE LIABILITY =NE SINGLE 1'000,000
ANY AUTO SOOILY INJURY(Per person) is
A OWNED r-%:;i SCHEDULED A9105420 0110112020 01/0112021 BODILY iNjuRy(pera�ocwerm) $
AUTOS ONLY AUTOS 1
HIRED NON-CW NED PROPERTY DAMAGE
Avros ONLY IN AUTOS ONLY t accidem) S
Underinsured motorist B111 $ 100,000
UMBRELLA LIAR
XEACH MCURRENCE 1.000.1300
A EXCESS LtAB CLA AM 52291509 0110112020 0110112021 AGGREGATE 1,000,000
--�DELL RETENTION
WORKERS COMPENSATION PER OTH-
AND EMPLOTERS'LIABIL11Y YIN STATUTE 1R
X14Y PROPRIETORIPARTNEWEXECUTIVE _71 owmno =23t2o2i E.L.EACH ACCIDENT 500,000
B CWFlCEP,MEhff3ER EXCLUDED? ry NIA WC9024456 $
(Mandan"in NH)
E,L,DISEASE-EA EMPLOYEE S 500,000
If yes,describe under
PTIMI OF OPERATIONS below F.I.,DISEASE-POLICY LIMIT- S
DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORO 101,Addibo"Remarks Schodulo,may be*itched if mars space is requited)
T
I he Workers Compensation policy does not include caverage for Paul Schmidt,Kendrick Dempsey and Douglas SchryAdt,
Thietsch 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
Thie4sch Engineering ACCORDANCE WITH THE POLICY PROVISIONS,
195 Francis Avenue
AUTHORIZED REPRESENTATIVE
Cranston Ri CD291u
0 1988-2015 ACORD CORPORATION. All rights reserved.
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