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24C-123 BP-2022-1283 122FRANKLIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-123-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1283 PERMISSIONISHEREBYGRANTE TO: Project# INSULATION Contractor: License: Est. Cost: 4000 SDL HOME IMPROVEMENT 103635 Const.Class: Exp.Date:05/20/2023 Use Group: Owner: S SIROTA, MIRIAM Lot Size (sq.ft.) Zoning: URB Applicant: SDL HOME IMPROVEMENT Applicant Address Phone: Insurance: 24 CHESTNUT ST (413)247-57;9 WC9024456 HATFIELD, MA 01p38 ISSUED ON:10/06/2022 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL• TION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1.2010M YU Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax:(41 3)587-1272 Office of the Building Commissioner as i s City of Northamptory_-- = .) - Building-DePC l".�-� 1 212 Main r =�* Room 1 0 _ ND. Northampton, M 0 `� �` phone 413-587-1240 Fa 413-587-1272 �P cIC ustrms�ssgs9,-oF6 HA .:__._. APPLICATION FOR INSULATION FOii A ONES 1'ENO' FAMILY DWELLING ONLY , SECTION 1 --SITE INFORMATION INSULATION PERMIT 1.1 Property Address This section to be completed by office , /a d 2-rl k.L C'/-7 5-+ map .(tG Lot f 64'3 / a k1 K.L.f,rN s 4 Zone Overlay District Elm St,District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 1 2,1 Owner of Record; m i riQki SiN.-D-3---c_A_) /a a -r_--)k b 71- Name(Print) Current Mailing Address: /_ Telephone Si a e 3;Authorized A ent; G'ti o__/-rr>z,( cL S� )p �� 6r-s c. a4 eiu.suet- s Name(Prin + Current Mailing Address Al}21/1 I-45i Signet e Telephone SECTION 3-ESTIMATED CONSTRUCTION COST*, Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building '1—/‘ 66)6) (a)Building Permit Fee 2. Electrical l (b)Estimated i otai Cost of Construction from (I c 3. Plumbing Building Permit Fee 46 4. Mechanical(HVAC) �bY-, 5. Fire Protection r/ 6. Total=(1 +2+3+4+5) - l�UO b Check Number - 3001 This Section For Official Use Only Building Permit Number ''el ' /-3 Date Issued; Signature: ,.." /� _ /D- 6-202.2 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONS/RUCTION, ES 8.1 Licensed Construct* leer: Not Applicable 0 641 d C - 1 0 License Nu ber Ada 024 Chi a31- £ -T�l+ .+4 Id, i qq 0. A--- D a dress 11 F_xpirati Date nature ,3-Q '2- � ?3 g Telephone Not Applicable 0 COt1iD>Ae +-\-CD!(Y 1.t . egistration Number ci_;Ip .ski `4- .-v- . k Address ((��''� �r Expir�atio ate k ‘e.t v-g-( l t __ Ol C�7 O TelephonA 1 W�zl`7 S r7. 3 i SECTION 5 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O L c.1b2,125C(6)) Workers Compensation Insurance affida must be'compieted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bud permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: INSULATION' ONLY /097 Y £e,c,u n oA— r . i, �U t � v-v -:‘ . 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. Signed under the pains and penalties of perjury. C" Pr (,,, dk `-, 4-_,Trii„, ..-Vicyeaw-e„.,ry- 4- riZt CAS, _.r, Print Name Signatur f Own Agent Date 1, ! 1Jr1 a eii cS 1 co 'Fi , as Owner of the subject properly hereby authorize TI----to act on my behalf, in all matters relative to worized by this building permit application. Signature of Owner Date City of Northampton Massachusetts ? , ...... ta, % i le,rzegfr ' ., DEPARTMENT OF BUILDING INSPECTIONS 4 1 212 Maz.r, Street •Munlelpal Su41di.ng Northampton MA 01060 4 „ 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 r 111, S 150A, The debris from construction work being performed at / t --f /,)- -1-1-- Please print house number and street name) p--,- () I---cY"---) is to be disposed of at: uk -i:-A- -17v c..A.4 Q., IA dki , cti (Please print n4me and loca n of facility) Or will be disposed of in a dumps r onsite rented or leased frgpi, < '-. i-- L-1 c:At-V Sk- fv).--k- 5\- -.\.\-03-C-1- --kCi fY\ l' A. C)t c) (Company Name and Address) , "Z?/47171 --------- / a— 3 .„).. c.),_Signature of 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 DocuSign Envelope ID:14F793D9-10B7-4B86-B1 F9-84670C3E0BFD RISE ENGINEERING OWNER AUTHORIZATION FORM l Miriam Sirota (Owner's Name) n owner of the property located at: i 2-2" 120 Franklin 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. The permit will be secured by the subcontractor, at no additional cost. c—DocuSigned by: OSvrVen td7-e 9/7/2022 I 5:19 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com City of Northampton t a MassachusettsA, .�. g DEPARTMENT OF BUILDING INSPECTIONS 212 Mair. Street • Municipal Building Northampton, Ma 01060 y �' 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 am adjacent to such residence or building" he done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered \\ N c Cl Type of Est. Cost: CD() Address of Work: 1 a R./1k, ,-N S� 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.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 pewit as the agent of the o ,��1 —�— ��-, ern()r �.N �'m k...��1 _ 7 Date Contractor Name \ HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above pr Date Owner Name and Signature City. of Northampton e� fit,. .,L y % ,a Sjr,. Massachusetts 1'�'�, :ar. ��' =PARTI�NT OF WILDING INSPECTIONS $ f ,0r 212 Main Strodet s Municipal Suilding , � ..., ti? Northampton, MA 01 Obi' 4 _, 1 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 6 ' /a a Fr-kfli<C �-I- ___µ_ Contractor Name: L' *�1 -, w P ri-vt„...c\cf— Address: r- Li ( /Pk6`S \A....4., '&- City, State: ' ct V&A,. ‘4".C''\A- Cal u e Phone: t , c q 1 - `j 1 1 Property OwnerS Name: 11) i r i a. e----- Address: 1a 0 ri---)---ki k C4 ,s--1-- City, State: 2C/n 447a C}-(- v, 4Y1 i c3) OU- i, Paí. i . ri dt (contractor) attest and affirm that the I inters to building 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 The Commonwealth of Massachusetts Department of Industrial Accidents - C;\ l Congress Street, Suite 100 yMK Boston, MA 02114-2017 www.mass,gov/dia Workers'Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organirationhlndividual):SDL Home Improvement Contractors, inc Address:24 Chestnust Street City/State/Zip:Hatfield, MA 01038 phone#:413-247-5739 Are you an employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with 7 employees(full and/or part-time).* 7. ❑New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.0 I 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 arc sole 11 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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.: 14.E Other Insulation 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4).and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box WI must also fill out the section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indi ting such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entiti^s have employees. If the sub-contractors have employees.they must provide their workers'comp.policy number. 1 l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Selective Insurance Company Policy#or Self-ins.Lic.#:WC9024451i Expiration Date:02123/2023 Job Site Address: 6 !tea r►i'tf'1 k-C City/State/Zip: flh^g& 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,unde the ains and penalties of perju ,that the information provided above is true and car•ect. Signature j ,. Date: /U— 3— Phone#:413-247 739 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACn IA DATE(MM/DD/YYYY) �...� CERTIFICATE OF LIABILITY INSURANCE 02/08/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT' If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Cyndie Henderson CISR,CPIA ' NAME Webber&Grinnell , PHONE (413)586-0111 'FAX (413)586-6481 ,A/C,No.Ext): (A/C,No): 8 North King Street ! E AIIL chenderson@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE 1 NAIC$ Northampton MA 01060 i INSURER Selective Ins Co of S Carolina 1 19259 INSURED I INSURER B: Selective Ins Co of Southeast I 39926 SDL Home Improvement Contractors, Inc. INSURER C 24 Chestnut Street ! INSURER 0: INSURER E: Hatfield MA 01038 i INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 2023 REVISION NUMBER: THIS 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 WHQH 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 ADDL SUER POLICY EFF POLICY EXP LT TYPE OF INSURANCE POLICY NUMBER M/ LIMITS LTR INSD WYD. (MDD/YYYY),{MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TRENTED .CLAIMS-MADE X OCCUR PREMISESO(Ea occurtenq), S 500,000 MED EXP(Any one person)' $ 15,000 _- A Y S2291509 01/01/2022 01/01/2023 PERSONAL 8ADV INJURY $ 1.000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3.000,000 PRO- 3,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER $ AUTOMOBILE UABItJTY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED Y A9105420 01/01/2022 01/01/2023 BODILY INJURY IPer accident) $ AUTOS ONLY AUTOS HIRED �/ NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) Underinsured motorist BI $ 100,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS UAB CLAWS-MADE AGGREGATE 01/01/2022 01/01/2023 AGGREGATE $ 2,000,000 DED I I RETENTION $ $ WORKERS COMPENSATION XI STATUTE 1 PER I�ERH AND EMPLOYERS'LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WC9024456 02/23/2022 02/23/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ _ ' Per Occurrence $500,000 Pollution Liability A S2291509 01/01/2022 01/01/2023 General Aggregate $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space is required) The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt. Thielsch Engineering s hereby named as Additional Insured per written contract with respects to General Liability,Pollution Liability&Auto Liaiblity,for work performed.and per the terms and conditions of the policy on a primary and non-contributory basis. Umbrella is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN Thielsch Engineering ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Avenue AUTHORIZED REPRESENTATIVE Cranston RI 02910 -.I // , • (- ; r ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD