05-038 (9) CERTIFICATE OF LIABILITY INSURANCE 2/25/2015
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 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 Cynthia Squires
Goss & McLain Insurance Agency PHONE (413)534-7355 FAX (613)536-9286
1767 Northampton Street JAL ,csquiresRgossmclain.com
P O BOX 1128 INSURERS AFFORDING COVERAGE NAIC B
Holyoke MA 01041-1128 MSURERA:Safety Insurance Company 39454
INSURED INSURER 6:Travelers
SDL Home Improvement Contractors Inc INSURER C:
24 Chestnut Street INSURER D:
INSURER E:
Hatfield MA 0103$ 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1522501527 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 WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADM SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE WPM POLICY NUMBER Il1MiIMQJYYYY1 IMMIDDffYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO R E
PREMISE r rr n $ 100,000
A CLAIMS MADE a OCCUR P00002464 /1/2015 /1/2016 MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
x POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Me accident)
A Ix ANY AUTO BODILY INJURY(Per person) $
ALL OWNED x SCHEDULED 222056 /26/2015 /26/2016 BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS x NON•OWNED PROPERTY DAMAGE
AUTOS $
Opfional BI(CSL)(M&GA $ 11000,000
X UMBRELLA L1/La x OCCUR
EACH OCCURRENCE $ 1,000,000
A EXCESS LLAB CLAIMS-MADE AGGREGATE $
DED I x I RETENTION 8 10, 0001584 /1/2015 /1/2016 $
B WORKERS COMPENSATION WC STATU- x OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L-EACH ACCIDENT $ 500 000
OFFICEIWEMSEREXCWDEO? NIA _
(Mandatory 1n N11) 884409-0-15 123/2015 /23/2016
EL DISEASE-EA EMPLOYE $ 500,000
N yes,deecrlbe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AddHinnal Remarks Schedule,N awn apace Is required)
Insulation Contractor /
Paul Schmidt, Kendrick Dempsey & Douglas Schmidt are exempt from coverage on the Workers Comp policy.
Conservation Services Group, National Grid, NSTAR, Boston Gas Co., Colonial Gas Co., Essex Gas Co., and
Western MA Electric 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
Conservation Services Group ACCORDANCE WITH THE POLICY PROVISIONS.
50 Washington Street
Suite 300 AUTHORIZED REPRESENTATIVE
Westborough, MA 01581
Cynthia Squires
ACORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2otoos).oh The ACORD name and logo are registered marks of ACORD
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS403635
PAUL SCEMM
24 CHNS NU Ir E s
HATREID MA 41 s3l� .� `
Y \
Expiration
Conwassioner 05/2Qf2017
'Xe (r'amriaowetc:alt.4 of C-&t,i:xrclu3ea
Office of Consumer Affairs&Business Regulation
MNPROVEMENT CONTRACTOR
ratif4415 Type:
ration: 2 Corporation
SDL HOME IMPROVt 6CTORS,INC.
PAUL SCHMIDT '
24 CHESTNUT STREET,L
HATFIELD,MA 01038 Undersecretary
The Comamonwealth ofMassachaseas °lint corm
r . Department of Industrial Accidents
Office oflnvestigations
7
I Congress Street,Suite 100
Boston,MA 02114-2017
pJ www mass govli is
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Organiration/Individual):
Address: �L4AMU t::
City/State/Zip: n+ ja ()i hone#: q?' 7
Are oa an employer?Check the appropriate bog: Type of project(required):
4. I a general contractor and I
1. I am a employer with ❑ am 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on 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.M—Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repajrs
insurance required.]t c. 152,§1(4),and we have no ,,__..,,// ,j
employees.[No workers' 13.Ly�Other
comp.insurance required]
*Any applicant that checks box#1 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 hive 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,they must provide their workers'comp.policy number.
I am an employer that is providing workers'conrpensatio insurance for my employees. Below is thepo/icy andlob site
infornurtion. _�
Insurance Company Name: �Q v$ (� —41A r, rl 'SA
Policy#or Self-ins.Lie.#: r Expiration Date:_ Q
Job Site Address: l eat City/State/Zip: _/� ��U� 3- Leeds,-
Attach a copy of the workers'co pensation po' declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. 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 hereb i,certi under the d alti�s o that the in ormation provided above is true and correct.
Si ature: Date ;1 7 / S
Phone#• -
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
mass save PCONTRACMR
Ofsienes —MINENror-
PERMIT AUTHORIZATION FORM
I, Jackie Urbanovic ,owner of the property located at:
(Owner's Name,printed)
591 Kennedy Rd Leeds
(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.
Q� C✓
Owner's Signature
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor pate
affo
ForO'frcr_e Us_Only
Rev. 12132011
f City of Northampton
�5 S�
Massachusetts
or 9UXZL FG zPS W=CjFS
212 lain street a M icipal Raildim `�b•. =pa
Northa wton, M 01060
Property Address: K_nr)-'P-A.,j
Contractor Pao I rrucl,-f-
Name: �-• i � .
Address:
City, State:
Phone: �.�'
Property Owner
Name:
Address: ,
City, state: � S: ry-) C)J U s CP
(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
Section 4. ZONING Alt 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/Findin ver been issued for/on the site?
NO 0 DONT KNOW YES Q
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW (a YES Q
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,e on,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Swe is r: f Not Applicable ❑
Name of License Holder: t�C E t Se (�1� 1 y /3 (P,35—
P 3 5—
License Number
44a4-,q-C-LJ,M#q 01
Address Expiration Date
ignature Telephone
9.Registered) ome Improvement Contractor: Not Applicable ❑
S "=
Company Name Registration Number
i --e e,�- -7'
Address Expiration Date
mA CA b a)! Telephohe�q 3'r1�q/- 139
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAV.T(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and su i,Omitted 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...... —0
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 51
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
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail'aaplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doom
Accessory Bldg. ❑ Demolition ❑ New Signs [CC Decks [Q Siding)M] Other[
Brief Descri lion Of Posed 500 �� Cx�✓� t 1C �U c 1r
Work:—,= t �' �` tX i ` "� Ki i oaA -
Alteration of existing bedroom Yes _No Adding new bedroom s No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. 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, ✓' C`� t L- as Owner of the subject
property
hereby authorize )S k,
to act on my behalf,in all matters relative to worVa0thotized by this building permit application.
Signature of Owner Date
�rrt 1 d4- 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.
` A,/ &_km,i d': ---
Print Name
Signatdre of OwnedAgen Date -
a ate
> City of Northampton
�,. Building Department
212 Main Street
Room 100 A
�z
Northampton, MA 01060 °
phone 413-587-1240 Fax 413-587-1272
� n,n f
A (CATION 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 competed by of ice
Map Lot unit
Zone Overlay District
Elm&.District _ Ci6 Distract.
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner ecord:
a an V i"
Name(Print) Current Mailing Add re
/vL C Telephone
Signature
2.2 Authorized A ent:
Lwrnv
Name(Print) Current Mailing Address:
3~a L/7- 5 X3 Y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �51 (a)Building Permit Fee
2. Electrical c / (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) $ 0 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2015-1047
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038 (413)247-5739
PROPERTY LOCATION 567 KENNEDY RD
MAP 05 PARCEL 038 001 ZONE RR(100)/WSP(100,)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid `
Typeof 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
pproved 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
D m elay
Si ure�6fBtulding Official 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.
567 KENNEDY RD BP-2015-1047
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05-038 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-2015-1047
Project# JS-2015-001995
Est. Cost: $5969.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. 1): 80019.72 Owner: URBANOVIC JACKIE
zoning: RR(100 /x(100)/ Applicant: PAUL SCHMIDT
AT. 567 KENNEDY RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:51512015 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 5/5/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner