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17D-050 Aco CERTIFICATE OF LIABILITY INSURANCE F2/25/2015 DATE(MM/DD/YYYY) `..� 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 NAME: Cynthia Squires Goss & McLain Insurance Agency PHONE (413)534-7355 FAC No:(413)536-9286 1767 Northampton Street ADDRESS:csquires @gossmclain.com P 0 Box 1128 INSURERS AFFORDING COVERAGE NAIC# Holyoke MA 01041-1128 INSURERA:Safety Insurance Company 39454 INSURED INSURER B:Travelers SDL Home Improvement Contractors Inc INSURERC: 24 Chestnut Street INSURER D: INSURER E: Hatfield MA 01038 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 WTH 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 TYPE OF INSURANCE A L U POLICY EFF POLICY EXP L7R POLICY NUMBER MMIDD MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,000 A CLAIMS-MADE FX_1 OCCUR CP00002464 /1/2015 /1/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED S INGLE LIMIT Ea accident $ _ A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 6222056 /26/2015 /26/2016 BODILY INJURY Per accident $ AUTOS AUTOS ( ) X 1:� NO N-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident $ I0 Options BI(CSL)(MA GA $ 11000,000 X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LAB CLAIMS-MADE AGGREGATE $ DIED I X I RETENTION$ 10,OOC =4UO001584 /1/2015 /1/2016 1 $ B WORKERS COMPENSATION I WC STATU- I X OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) BB4409-0-15 /23/2015 /23/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insulation Contractor / Paul Schmidt, Kendrick Dempsey & Douglas Schmidt are exempt from coverage on the Workers Comp policy. CLEAResult, Eversource and 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 CLEAResult ACCORDANCE WITH THE POLICY PROVISIONS. Contractor Services 50 Washington Street AUTHORIZED REPRESENTATIVE Suite 300 Westborough, MA 01581 Cynthia Squires ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025nrnnnFi ni Thn Arf)Pr1 name nnri Innn nro ronielarnri mnrlre of 0r:OPr) 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/o oanization/Individual): Address: U ►� City/State/Zip: Are ygu an employer?Check the appropriate box: Type of project(required): I.Ul am an employer with 4.01 am a general contractor and I 6.❑New construction employees(full and/or p Ime).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet_ 2•❑Remodeling ship and have no employees These sub-contractors have 8.❑Demolition working for me in any capacity. employees and have workers' 9.❑Building addition [No workers'comp.insurance comp.insurance.+ required] 5.0We are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.❑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.❑Roof repa' s employees. [no workers' 13. Other aW comp.insurance required.] *Any applicant that checks box 41 must also fill 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 it new affidavit indicating such. 'Contactors that check this box must 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 employees,they must provide their workers'comp.policy number. I am an employer that is providing wo kers'compensatio 'nsurance for my emplo ees.Below is the policy and job site information. ' � Insurance Company Name: 14 V7,CA �- Policy#or Self-ins.Lic.#: dt ( ___ _ _ Expiration Date: Job Site Address: ���'�'� �� �'�/�_ ------ City/State/Zip: Attach a copy of the workers' compensation 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$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 cert� der the pains nd penalties of perjury that the information provided above is true and correct. Si nature: tt Date: Print Name �lL �lY� tGL" 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: i,�o,M�tea►py tom!r 4 'ITT Mrr a2 Q mass save CONTRACTOR spMsp slvo Qmrsn,eMdcncy *qomllmppl PERMIT AUTHORIZATION FORM I, JAMES D. ROBERTS owner of the property located at: (Owner's Name,printed) 96 Straw Ave FLORENCE (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. x , Owner's Si na ure 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 Date Of�O Di ForORce Use only Rev. 12132011 City of Northampton Masaachusetta x 28:'PBRMM=4 OF BO MMW ZVMM=C= 212 thin stra.t • Mnaicipal BuildU* M0Ith=q*-0n, Ma 01060 Property Address: / /P Contractor 'Pao I -hrritc�-f' Name: J� Address: City, State: rAA Phone: .�.,¢13• `7 ��` Property Owner Name: Address: L, �-� City, State: 1,�f t L� .�(' 1 M- t ct-- (contractor)attest and affirm that the building I intend to insulate does not have any open air pmob 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 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ 2 Name of License Holder: r1'L� 1 0 � `/ 3- 1 n License Number C L 0 1 oak Address Expiration Date 103 a _5 ignature Telephone R k Not Applicable ❑ Company Name Registration Number Address .y Expiration Date mf} 01 Telephone�/�3 gay I'J�739 SECTION 10-WORKERS'COMPENSATION 1NSt1RANCE 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. 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 Aiteration(s) ❑ Roofing ❑ or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [C3] Decks [Q Siding ] Other[ Brief Description of Pr iI Work: Q 5 ne2d+ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll -Sheet ea. If Newhouse and or addi#ion to existing howslnt Compiete'the followincl: 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 L 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 as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to worrabithotized by this building permit application. Signature of Owner Date 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 Signat&e of Owned Age 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:1 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.&er been issued for/on the site? NO 0 DON7 KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON7 KNOW YES IF YES: enter Book Page and/or Document e-kl B. Does the site contain a brook, body of water orwettands? NO 0 DON7KNOW k:::? 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 Q 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, ex vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 l' e� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. sP °! City of Northampton BuDding Department 212 Main Street Room 100 �C;` �'` Northampton, MA 01060 9 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAWY DWELLING SEECTMI F„ 1.1 Properly Adde+ess: � r 2-1 Owner of Re�• ''"' Name(Print) Current Mailing ressAdd : u CL rk Telephone Signature 2.2 Audwdzed Aaent: 5��- �-� PrL-0 Name(Print) Gunn Mailing Address: Signa Telephone ' = Item F.stmated Cost(Dollars)to be - # comoWed by oermft applicant 1. Building Ob (0) Fee _ 2. Electrical (ts 03 3. Plumbing 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) C)0-� Bttik Die Signabure File#BP-2016-0440 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739 PROPERTY LOCATION 96 STRAW AVE MAP 17D PARCEL 050 001 ZONE URB(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 Tyneof 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 INFOJtMATION 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 Dem ' i y L '�'�� Si re of Bui mg Of is 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. 96 STRAW AVE BP-2016-0440 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-050 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0440 Proiect# JS-2016-000729 Est.Cost: $3400.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. 1): 7971.48 Owner: ROBERTS JAMES D Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT. 96 STRAW AVE Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.10/2/2015 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 10/2/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 96 STRAW AVE BP-2016-0440 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-050 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-2016-0440 Project# JS-2016-000729 Est.Cost: $3400.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 7971.48 Owner: ROBERTS JAMES D Zoning URB(100) Applicant. PAUL SCHMIDT AT. 96 STRAW AVE Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.101212015 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 Siznature: FeeType: Date Paid: Amount: Building 10/2/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner