29-454 (5) u
1 Massachuse;*is - Department of ?uc!ic Sa e;.,
Board of Building Reguiaiiors and 5`ancards
L'unstrurtinn Supen isor
_icense: CS403635
PAUL SCHMIDT
24 CHESTNUT STREET
AAMELD MA.01038 =
Comm;ss nne:: 05/20 12015
_`. Office of Consumer Affairs&Business Regulation
1172 ME IMPROVEMENT CONTRACTOR
Registration: 174415 Type:
R
expiration: 2/7/2015 Corporation
SDL HOME IMPROVEMENT CONTRACTORS,INC.
PAUL SCHMIDT
24 CHESTNUT STREET � Qc
HATFIELD,MA 01038 Undersecretary
A� CERTIFICATE OF LIABILITY INSURANCE 3�4,`0
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), AUTHORMO
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy{ies)must be endorsed. H SUBROGATION IS WANED,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).
Cynthia Squires
PRODUCER
Goss & McLain Insurance Agency PHONE . (413)534-7355 FAX (413)536-9286 400 U.
1767 Northampton Street csquiresS assmclain-com
Q 0 Boa 1128 INSIUMOV AFFOROWG COVERAGE IMC A
Holyoke MA 01041-1128 INSURIERA;Safet3E Insurance Company 9454
INSURED INSURERB:Travelers Pro party Casualty Co
SDL Home improvement Inc C:
24 Chestnut Street INSURER D:
INSURER E:
Hatfield MA 01038 I Su P_
COVERAGES CERTIFICATE NUMBER:CL13340OLS6 REVISION NUMBER:
THI$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.
i SR I TYPE OF INSURANCE L LIMITS
LTC OENERAL LIABILITY EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY LgEg S 100,000
A CLAIMS-MADE MK OCCUR P00002464 /112013 7/112014 MEDEXP one pemm S 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 21000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPMP AGG s 2,000,000
X POUCY F7 PRO LOC C 5
AUTOMOBILE UABIUTY a a sl c0 E 1000004
BODILY INJURY(Per PeMan) S
A ANY AUTO
�OSN@ & SCHEDULED 222DSS /26/2013 /26/2014 BODILY INJURY(Per aaident) S
X HIRED AUTOS % AUTOS NED S included
OoWW 91 $ 11000,000
X UMBRELLA LIAS X I OCCUR EACH OCCURRENCE S 1,000,000
A EXCESS UAB CLAIMS-MADE, AGGREGATE S 1,000,000
DED $ RET ON 10,00 !1/2D13 J]l2014 S
$ WORKERS COMPENSATION WCSTATU $ 0TH•
AND EMPLOYERS'UAINU1Y
ANY PROPRIETORPARTNEWEXECUTIVE YN MIA E.LEACHACCiQENT S 500 000
OFFIC�EXCLUOur ❑ 9844090 /23/2D33 !Z3/2014 EL DISEASE-EAEMPLO f 500,000
(Mandatory lh NH)
II yes desame V_0 E-L DISEASE-*POLICY UMIT S S00,00
DESCRIPTION OF OPERATIONS oeWw
DESCRIPTION OFOPERAT IONS/LOCATIONS(VEHICLES(Aftwh ACORDtGt,AddlQandRamerlm8dw",Rm01 paceteragutre4Q
Insulation Contractor
Paul. Schmidt, Kendrick Dempsey & Douglas Schmidt are exempt from coverage on the Workers Comp policy.
Conservation Services Group, National Grid, NSTAA, Boston Gas Co., Colonial Gas Co and Essex Gas Co. are
named as additional insureds per written contract in regard to general liability only - for work
performed on behalf of the named insured subject to policy forms, conditions and exclusions
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
conservation Services Group
50 Washington Street AMORREDREPRESMATNE
Suite 300
Westborough, MA 01581
Cynthia Squires
ACORD 26(2010105} @11888-^0t0 D 05RIPORATION. All rights reserved.
INS026 potoos).ot The ACORD name and logo are registered rnaft of ACORD
City of Northampton
Massachusetts F'
r
-A
DEPARTMENT OF BUILDING INSPECTIONS Z
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: ��l Vd joff,
Contractor
Name: ^Iq�'?j'I�' 'J.ir�
Address: 7, '�1 �/ P/7✓U/ Jo)-
City, State:
Phone: _ 1/7
Property Owner r-�� a ' ' r*
Name: _�) .,�J- V
Address: ]
City, State: 1) /�/� '7� / 2,A
(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 !
PANnOrRUN
mass save aw
SAL'M9 CN+YUPP C!n:nilY MfiCt9ncY
PERMIT AUTHORIZATION FORM
_, owner of the property located at.
(Owner's Name, printed)
2 AJCC- A Q 0G 5
(Property Street Address) (City/Town)
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.
Owner's Signature
I3
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
The Commonwealth of Massachusetts
Department of IndustriatAccidentr
Office of Investigations
600 Washington Street
Boston,MA 02111
www.m=s;gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Eiectricians/Plumbers
AyLhcant Information Please Print L-eaibly
Name(Business/Orgmization/Individual):
Address: C,)-q &P /'II�
City/State/Zip: Phone#:
Are you an employer?Check 6e appropriate box: Type of project(required):
1j4 I am a employer with 1 4. [] I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed tm the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers 9. ❑Building addition
[No workers'comp.insurance comp.insurance.*-
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
❑Plumb h
d i
h
officers have exercised their I L 3.Q I am a homeowner doing all work �repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.j]Roof repairs
insurance required.]T c. 152,§1(4),and we have no
employees.[No workers' 13.E]Other
comp.insurance required.)
*Any applicant that checks box#I must also fill out the section below sbowingtheirl workers'compensation policy information.
t Homeowners who submit this af$dant indicating they are doing all work and then hire outside contractors must submit anew 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,they must provide their workers'comp.policy nurnber.
I am an employer that is providing workers'compensation insurance for my employees: Below is thepolley and}ob site
information. - J
Insurance Company Name: ' ��i�'�)�/ 136' 0-r-4J
Policy#or Self-ins.Lie.#: �t57 r�ZL7 Expiration Date: 7/ ?✓
Job Site Address:-44 t1.C� L / 1b, City/state/Zip:
AAttimh a copy of the workers'compensation policy declaration page(showing the policy number and expiry on date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fate up to S 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u� the p ' nd penalties of perjury that the information pro7ed above it true and correct
Sim Date: ,
Phone# l 2 74--V � 7
Official use only. Do not write in this area,to be completed by city or town offleial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTarwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable
Name of License Holder: �/-1 yI J G L� V 3
License Number
Address Expiration(Date
V)3- �V7 S'7
Si ature Telephone
9.Registered Home Improvement Contractor: Not Appli)ca�blte�❑)
Company Name Tom_ Registration umber
Address ) Expira ion D to
Telephone/'
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[F-3] Other
Brief Description of Proposed
Work: Insulate 1000 sqaft if atuc with 7 inch of cellulose,air seal as needed,install propa vents and damming
Alteration of existing bedroom Yes xx No Adding new bedroom Yes xx No
Attached Narrative Renovating unfinished basement Yes xx No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing, complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, J �'� I r� 61 VAI-c� as Owner of the subject
property ,�`/
hereby authorize ) �� ��/� l� /x�- �N�"rA��a�J� � oP�� `�r ii�
to act on'my behalf, in all matters relativ to work thorized by this building permi application.
- G$4' /
Signatu Owner Date
I, �I'hl of 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 an ypenies of perjury. rr
If
Print Name
Signature of O er/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO e
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
E - Department use only
�� City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
I i
AN I 0 2014 !� 212 Main Street Sevier/SepticAvailability
Room 100 Water/Well Availability
Ele tnc P,,n-;r r -- --.� Northampton, MA 01060 Two Sets of Structural Plans
Nor r,,l I, 1 _ 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
I r Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Shakira Alvarez
Na a(Print) Current Mailing Address:
�° 56 Crestview Dr,Florence Ma
f g,'�, ►�y �� Telephone �/ 7 �j
Signature LI) L/7v 7,�O
2.2 Authorized Agent:
141 Z
Name(Pri Current Mailing Address:
/-I/)?- 7_1015:X30_1`
Sign, re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building 2,358 (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=0 +2+3+4+5)
2,358 Check Number �Q
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0794
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 56 CRESTVIEW DR
MAP 29 PARCEL 454 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 103635
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§_
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
De io Delay
na re of Bui in Off1 1 Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
56 CRESTVIEW DR BP-2014-0794
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma-.Block: 29-454 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0794
Project# JS-2014-001350
Est. Cost: $2358.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 10018.80 Owner: ALVAREZ-FERRER SHAKIRA&TIMOTHY D ARMSTRONG
Zoning: Applicant: PAUL SCHMIDT
AT: 56 CRESTVIEW DR
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:111312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 1/13/2014 0:00:00 $55.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner