17A-097 (7) .4`oRV' CERTIFICATE OF LIABILITY INSURANCE 2/25/2""0f"'
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., H the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certifcate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER Cynthia Squires
Goss & McLain Insurance Agency PNONe . (413)534-7355 FAX -(413)536-9286
1767 Northampton Street csquiresFgossmclain.com
P O Box 1128 OMROM AFFORDe K:
10iOVERAGE NAr
Holyoke MA 01041-1128 INSURERA:Safet Insurance Company 9454
INSURED WAXIER S:Travelers
SDL Home Improvement Contractors Inc INWRERC:
24 Chestnut Street INSURER 0:
WSUREA E
Hatfield MA 01038 INSURER F-
COVERAGES CERTIFICATE NUMBER:CL1522501527 REVIS ON NUMSER:
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,TERRA 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.
Im Ja TYPE OF 87NRtANCE POLICY ERIC POL CY EXP LN41T5
GENERAL LAeBJTY EACH OCCURRENCE $ 1,000,000
% COMMERCIAL GENERAL LOSILMY $ 100,000
A 7 CLAIMS-MADE ®OCCUR % CF00002464 /1/2015 /1/2016 -
MED EXP M one peramf $ 10,000
PERSONAL 6 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEKL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AM S 2,000,000
% I POLICY PRO. 7 LOD $
AUTOMOBILE LABILITY SMGLE LIMIT
A ANY AUTO BODILY INJURY(Per p=w) $
ALL OWNED Z SCHEDULED 6222056 /26/2015 /26/2016
AUTOS AUTOS Z BODILY INJURY(Per eaidwM $
Z
NON-OWNED MIRED AUTOS $ A PROPERTY DAMAGE
UT $
IIN L)(MA,GA $ 11000,000
% UMBRELLA UAS Z OCCUR
EACH OCCURRENCE $ 1,000,000
A EXCESS LAB CLAIMS-MADE AGGREGATE $
Z I RETENTM S .10,000 1 0001584 /1/2015 /1/2016 $
B WORKERS COMPENSATION WC STATU. Z OTH-
AND EMPLOYERS'LIABILITY _
ANY PROPRIETORIPARTNEWIXECUTNE FY-1 E.L.EACH ACCIDENT $ - 500,000
purmiam in M�EXCLUDED? N/A 384409-0-15 /23/2015 /23/2016
It dss�under E.L.DISEASE-EA EMPLOYE S 500,000
DESCRIPTION OF OPERATIONS Oelow E.L.DISEASE-POLICY LIMIT $ S001000
DESCRIPTION OF OPERATIONS/LOCATIONe/VEMCLES lABssll ACORD tot,AddNImW Remvks Schedule,K mom spwA Is nqu(md)
Insulation Contractor
Paul Schmidt, Kendrick Dempsey & Douglas Schmidt are exempt from coverage on the Workers Comp policy.
Columbia Gas of Massachusetts is additional insured on the General Liability & Auto Liability for work
performed on behalf of SDL Now Improvement Contractors Inc. subject to policy forms, conditions &
exclusions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Columbia Gas of Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS.
4 Technology Drive
Suite 250 AUTHORMW REPRESENTATIVE
Westborough, MA 01581
Cynthia Squires
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025(2otoos).ot The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name Business/Organization/Individual)
Address:
City/State/Zip: )__ ,244L<-Ld, ,� ne#:
Are y an employer?Check the appropriate box: Type of project(required):
1.( I am an employer with r 4.0 I am a general contractor and 1 6.0 New construction
employees(full and/or me).* have hired the sub-contractors 7 [1 Remodeling
2.01 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers' 9.0 Building addition
[No workers'comp.insurance comp. insurance.t
reed] 5.0We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required]t c. 152,§ 1(4),and we have no 12.00 iC,!Roof re
employees. [no workers' 13. Other
comp.insurance required.]
*Any applicant that decks box#I mast also an out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afiidavt indicating such.
;Contactors that check this box mast attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If
the sub contractors have eeailoyces,they must their workers'comp.policy number.
I ant an employer that is protn&ng wo rs'compensado ' rance for my empl *ees.Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 0 0 Expiration Date: - of��' �O
Job Site Address: r City/StatelZi�&/c I'1�� �111( �-
Attach a copy of the w rkers' ompensation policy declaration page(showing the policy number and expiration(date).
Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine
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
$250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify r the pains d penalties of perjury that the information provided above is true and correct
Si lure: Date: a
Print 'Vame� l SC AM.!I"� Phone-4: �i,3 - a 7" ���/
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):
1.8oard of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
� .+�
OWNER AUTHORIZATION FORM
%k
(Owner's N
owner of the property located at
(Pronarty Address)
(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.
Ow*s Signature
- t � D
Date
City of Northampton
Massachusetts
X
ZMARllfi M OP BUZZOM ZMMIR ZCKS s�
212 Nsin Street • Ummicipal Amid;ng
Nort m ptM, DL 01060 �. 0
Property Address: ,3,
Contractor a(I I
Name: J't,�
Address: �,h i'1'1 CA ' ire r�-�-
City, state: MA C t.Q.L&
Property Owner
Name:
Address: V I
City, State: rntq D C) -0 a--
1,-TAj ..[r�1 ct-� (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 dopy of this affidavit.
Contractor signature
Date
SECTION 8-CONSTRUCTION SERVICES 7
81 Licensed Construction Supervisor: Not Applicable ❑
�� d;4— `
Name of License Holder: � �' e i v � " 3
I� liLicense Number
L.14- 2 �'-�i Li c� ,Vyl t�1 C�1 y a-° / --
Address Expiration Date
ignature Telephone
9.ttestiistered `' 1ar;• , Not Applicable ❑
Company Name Registration Number
Address /L Expiration Date
J ,M14 010�C)Q" Telephone4/3-,aq.1y.5739
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...... ❑
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.
Defmition 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 buildine 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 Aiteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [EM Decks [M Siding ) Other[
,o
Brief DOscri flop of Proposed 4 _ _ ! S� pf S'
Work..
-ate
Alteration of eAsting bedroom Yes No Adding new bed Yes No / No knkt'.� Lt -C'
Attached Narrative ,�,^ Renovating unfinished basement Yes ,/
Plans Attached Roil -Sheet T (
sa.If New house and or add3tlon to existing:hoes na.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 wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or ar 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 Q( as Owner of the subject
property
hereby authorize TV�S
to act on my behalf,in all matters relative to wo o'zed by this building permit application.
J4-41
Signature of Owner Date
' ad j 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.
Print Name
Date
Sign of Owned
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-Aver been issued for/on the site?
0--/
NO 0 DON7 KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW I� YES 0
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 11,,::9 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location*
E. Will the construction activity disturb(clearing,grading,e e ation,or filling)over 1 acre or is it part of a common plan
that YAII disturb over 1 acre? YES 0 1,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
City of Northampton
Building Department
f1' 212 Main Street
Room 100
E- l Northampton, MA 01060
w phone 413-587-1240 Fax 413-587-1272
AME�ATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWELLING
SECTWKA
1.1 Property Address:
RAN- WIN,
CoF
SECTfE; 2-'�li .., AST
2.1 Owner of Record:
Name(Prim) Cu W9 Add
Telephone
Sign
2.2 Authodzed Anent: — �� P
Name(Print) Current Mailing Address:
Sign a�7-573
Telephone ^�
Item Estimated Cost(Dollars)to be C3 Us br*
.completed it applicant
1. Building ®(� (8)
2. Electrical (b);ledwwedta af
3. Plumbing gp :
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Chedc--wwv6er,
Bt Dafe
iced:
SAS:
File#BP-2016-0330
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 37 GRANDVIEW ST
MAP 17A PARCEL 097 001 ZONE RI(100)/URA(100)/WSP(42)
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
INFOR ATION 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
iti
Sign of Building icia 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.
37 GRANDVIEW ST BP-2016-0330
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-097 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-2016-0330
Project# JS-2016-000529
Est. Cost: $3848.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GrojML PAUL SCHMIDT 103635
Lot Size(sq. ft.): 9365.40 Owner: DREYER BARBARA J&SHIRLEY I SICURELLO
Zoning: RI(100)/URA(100)/WSP(42)/ Applicant: PAUL SCHMIDT
AT. 37 GRANDVIEW ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.911612015 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 9/16/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner