32C-224 79 HAWLEY ST BP-2016-1441
GIS COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-224 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-2016-1441
Protect# JS-2016-002483
Est.Cost:$5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq.ft.): 2395.80 Owner: ST HILAIRE ALAN
zoning: URC(l00)/ Applicant: PAUL SCHMIDT
AT: 79 HAWLEY ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:6/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:BLOWN IN CELLULOSE, AIR SEALING AS
NEEDED
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 6/8/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File H BP-2016-1441
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 79 HAWLEY ST
MAP 32C PARCEL 224 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT /
Fee Paid CCA 1P9% 6.5-
Building Permit Filled out
Fee Paid
Typeof Construction: BLOWN IN CELLULOSE.AIR SEALING AS NEEDED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103635
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$MATION 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
Demoliti
Signature of Bu: dinffim(7 al 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.
J City of Northampton o-
a+ Budding
ddi Male Deparfeitment
et etz`� Room 100
il Northampton, MA 01060 r _ a- �� '
der phone 413-587-1240 Fax 413-587-1272 * ;�.;> &',
r I'ATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1•SITE INFORMATION
1.1 frocefHAdddress: .section tobeeoc eted NV tete
79 _.74 LLJLL-z) 5"f La Una
/ Zone OwrtayD6bkt
/�f17->t7GUrtefCw,/ P1'9 0! OCoO
E'pn St DIN** Ce Motet
SECTION 2-PROPERTY OSVNERSHIP/AUTHORIZED AGENT
$,1 Owner et Record:
Name(Print) Cunen ailing A,�d
St_t_ Tele
Signature
y,2 Authorized Agent:
Name(Print) GunMa
ging Mng Address:
Signature Telephone
SECTION 3-ESTIMATED COQ COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1, Building S DOD oL) (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(8)
3, Plumbing Building Penna Fee
4. Mechanical(HVAC)
5, Fire Protection
8, Total=(1 +2+3+4+5) <� r �?C>�� Cttedc Number
,f996
This Section For Official Use Ony
BuMs>g Permit Number I
iaeued:
Signature:
SfAdegCommissioneranspectcf of&Wigs Date
SECTION 6 DESCRIPTION OF PROPOSED WORK(cheek all a Uc*I.)
Naw Nouse ❑ Addition ❑ OrReplacement Window AImvtiortls) ❑ Roofing ❑
Dew 0
Accessory Bldg. C Demolition 0 New Signs [OJ Decks lD Siding 1 Other[
Brief Description of Proposed L .Inw ry n
Wont 1 I RD 5g -H{" ALarrun[ g,dQ.cJ-. ay_-1--0ki o! 1004/S _ t- Sacwe- AS
/(✓1 ,% i ;v a do
Alteration of edging bedroom Yes �/ No Adding new bedroom Yes No /
Plans eAttached Narrative rO Roll - Renovating unfinished basement _Yes ✓ No
Sheet
a. Use of budding:One Family . Two Featly Other
b. Number of rooms in each family unit Number of Bath .. ,.-
C. Is there a garage attached?
d. Proposed Square footage of new construction Dimensions
e. Number of stories?
f. Method of heeling? Fireplaces or Woodetoves Number of each
g. Energy Conservation Compliance. Mlasschedc Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 i of wetlaruds? Yes _No. Is construction within 100 yr. floodplain_Yes_No
j. Depth of basement or.-..:. floor below finished grade
k. Will building co form to the Building and Zoning regulations? Yes No.
I. Septic Tams_ City Sewer Private well City water Supply_
SECTION 7a-01NIERA TTIORIEMION TOBE••GONFLETW WEN
OWNERS AGENT OR OONIRACTOR-PPMES POR WADING moan
it '771Qn c"1 --1t i r-c-- es Owner of thesubject
properly
here
authorizew✓bvemeni- L�+cS,
to ad on my behalf,hkkii�se matters by this building permit application.
�w llcrh eacka 2_ - (e ' -l C 0
ea
on
t"---PaCt-I Sintrtickfr as ownedAutmorized
Agent hereby declare that tha 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.
'Tau &ivni a-1—
PNe None
Date
SECTION S-CONSTRUCTION SERVICES
S3 - -,,t Com= - nit•n Not Applicable ❑
ANmaofLfuneHilder .•_
License Number
A� t F 14JTItLIf Z �3{�FGIc��tel pio Date
/
i�c„r/{�. awl 67.E Expiration
f.nature Telephone
._ �_ Not Applicable ❑
SjJ4 u14 u _J
star n
n _Pkg. . / zy171
Company Name , Registration Number
Address n � Expiration Date
i . 4,47 -t d ryr\A. 01 °�JOl TelephonegOn;4"/#5739
SECTIONS WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L o,152.S SWISS
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 bu,st permit
Signed Affidavit Attached Yes No...... ❑
The current exemption for"homeowners"wits 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 1483.1.t.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,oris 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 thus 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 tinder the bufdtne perwdt.
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,von 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 Sigtwture
City of Northampton
Sssa isaaatta
meteor a acme STI' in
212 lain Meet • Mmp
mll r ..g aC .
v.._. t^ , la 010 110
Property Address: 791 lip. /4 ,�_// _5-1-
Contractor baa( sc},mGd+ /1
Name: Soh w ' ORrJ?M{ n� l ,nn do bcs :tele- •
Address: a CS- t 4-naf SI lase t
City, State a� Fiend , rna o LD
phone: '413- a).1:-1-5739
Progeny Owner I
Address: tri �-Ia u )( S-}-
City, State: Nfi 1421 m(Ana l v\ el ocQ Ci
I, -' (mdiactor)attest and affirm that the building I inS d to
instate does not have any open Sr(km*and tuba)veep in the spaces to be Insulated and that t have
provided the property owner with/a copy of this affidavit
Conhactor signature4 /
Date la' a_ 1 Ln
RISE !0 31wmMa Road,URN Wants*MA 02021 I S39-6028377
ENGINEERING www.RISEengtnaadng.com
OWNER AUTHORIZATION FORM
c
I, A1943 51- 4- t lAlr_e
(Owners Name)
owner of the properly located at
-7 ? 4,A(,0 lc ,/ S- ) .
(properly Address) ,�/
i' � 1
1 it ikl A o cO&'yr) ,
(Properly Address)
hereby authorize cin (-
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.Thls form is only valid with a signed contract.
7
(A
ra Signature Foe_ ?6 P-oder-Pet «f
Date
m�, \ The Commonwealth of Massachusetts
",". I= Department of Industrial Accidents
4 -+t=v, t Congress Street Suite 700
";`.'tt1=
%,77,+, of Boston, MA 02174-2077
�. www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Annticant information Please Print Legibly
Name(BusinessOrganizatioralndividuap: SDL Home Improvement Contractors, Inc
Address: 24 Chestnut Street
City/State/Zip: Hatfield, MA 01038 Phone#: 413-247-5739
Are you an employer?Check the appropriate box:
Type of project(required):
1.01 am a employer with 8 employees/full and or panrirce)' 7. Q New construction
sole pmpnetor or partnership handave no crnplk
n)ees working :or the in
2.0t am a
S. 0Remodeling
any capacity.[No workers'comp insurance required]
3.07 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. 0Dem011[I00
4- I.am a homeowner and wilt he hien contractors to conduct all work on m pro
LH Building addition
> 3 property ;will
ensure that all ccetuacaors eitherha'e workers'compensation insurance or are cote 11.0 Electrical repairs or additions
propnetor with no employees
❑ 12.❑Numbing repairs or additions
5 I am a general contractor and I have hired the subcontractors listed on the attached sheet
13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
- 14.Clothe, Insulation
&Owe are a corporation and as officers have exercised their right of exemption per MGT c.
i92 a{4t and we have no employees.(No workers'compinsurance required
that .
*Any erwho summit box of must i b cal na the asectioneirm all sock and their workers'compensation mu policy informanon
ew
Homeowner,' who submit this must att is ednatdeynae sheer allworkand then oiftousucacmoamustte hehnew nothoieniveeh.
:Contractors that check this tax must ae an hmt pro showing the name of clomp,
sub-contractors and state whether or not those entities have
employees. If atm=vbmrttrucwrs have employees,they must provide thele wwke:n'comp pi¢y kumber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: Selective Insurance Co
Policy A or Self-ins.Lie.#: W£9024456 Expiration Date: 2123/2017
]
lob Site Address: :leyj C d ,�'I` - 4ity.'State/2" i. n(C�ty't
Attach a copy of the worker 'compennatio policy declaration page(showing the policy number and expira and expinaion date l.plt`Lod
Failure to secure coverage as required under MCII.c. I2.. 2`-A is a criminal violation puashable by a fine up to 51.500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the 014 for insurance
coverage verification.
I do hereby cenbidi l er t pains and penshies of perjury that the information provided above// is true and correct.
Signa /��L,i1l Date: l,v- a'l CG _
Phone 9: 413-247-5739
Official use only. Do not write in this area,to he completed by city or town officialW
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
S.Other
Contact Person: Phone#:
ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE` ponyys
bin.--- 1/15/2016
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 candle-ate holder is an ADDITIONAL INSURED,the potltyfMs)must he endorsed. If SUBROGATION IS WANED, subject to
the terms and condition of the policy,certain policies may require an endorsement A statement on this carts Irate doe*not confer rights to the
cerebrate hander in Neu of such endornmenNa),
PRODUCER I NNC AterCynthia Henderson, CISR
Webber 6 Grinnell IRWIRE i (413)586 0111FAX
impsas-tires
8 North Sing Street j£AM4 ChendersonPwebberandgranneil.cow
,NsuRE 4 I AFFURLRNG Level/AGE MAIC*
Northampton MA 01060 --. I INSURER A Selective -._ _-. .19259
INSURED I INSURER a
SOL Home Improvement Contractors Inc. 1Nm1RERC
24 Chestnut Street 1.INSuRERo
NSUnERE.. .
Hatfield MA 01038 IIMSURERs:
COVERAGES CERTIFICATE NUMBERMaater 2016 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEROD
INDICATED NOPMTHSTANDING 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 REDUCEDPPpOIUUCGBY PAID CLAIMS
Li�fl. .- ..TOE Of INWMNCE --. ANR -_-. MOUGY NUMBER IWbS4'Y6M 10§001__--. 4M3t --.- -.-.--
X COMMERCIAL GENERAL LIABILITY ', EACH OCCURRENCE S 1,000,000
:DAMAGE O-REPTED 100,000
A C,AMSlMCE X OCCUR FREMMS Ea^'^F'1 ,t
.82209965 2/1/2016 1/1/2017 NED ENP INy one parson” 3 10,000
PERSONAL Nv,n,tlRY s 1,000.000
_..
GEN.n0O4EG+fELIMIi APPLIES PER GENERA/AGGREGATE 5 2,000,000
..
X PJiiCv 78. �Loc PRODUCTS fAMarov ACG S 2.000,000
4,
GER S
AUTOMOBILE LIABILITY COMBINED AMOsMD SINGLE LIMB 3 -- 1,000,.000
A r AUTO a'oe, a
INJURY s
At E ONNEv SG,EW.FD
TIL 05 Y AOTOS A9300938 2/1/2016 2/1/2C17 BODIIY INJURY,PorpY,pm 8
PX H!PEO AU-35 R AT�-0V,M
UED (P1/60E40.610 L{—aCE S
1666,M6,001 MRARR a 606 3 100,000
-- X UMBRELLA We X OCCUR EAU+OCCURIENCE 5 1,000,00.0
A EXCEaa WB Cyt,MSPAARE AGGREGATE 3 -.... -.
DED 'T RSTENTIONS (tl,000' 52204065 211/2016 2/1/2019 g
WOAND EMPL YE S,1 Eum W R ST AT?_E Z XR
AND EMPLOYERS, ARTIER --
ANY;nCE IFI5R EXCLU O'£CUT.p Y+*:.NIA EL EACHALCIUEM 5 $OO,000
a.¢ERM6nNM ENDL00E0 y 2/23/2017
A ngryMgy-Nm RC902M56 2/23/2016 E:- JISEIS£ EA EMPIOYEeS 500.000
y bPIDNOF
.E6CR,a!IORGKYPERRTIpN6pekr. ' '. EL;NSEASE MUGS OAT 3 500,00Q
DESCRIPTION OF OPERATIONS I1OCA1INS t VESICLES IACORO 101,Atlpona RMm W&Mmak owy M antfsd N mea spsu IS,pJlaCi
The Workers Compensation policy does not include coverage for Paul Schmidt, Hendrick DeMpsey and Douglas
Schmidt.
Columbia Gas of vatsachuseetts is hereby named as Additional Insured per written contract with respects to
General Liability a Auto liaiblity, for work performed, and per the terms and conditions of the policy.
CERTIFICATE HOLDER CANCELLATION
ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Columbia Gas of Massachusetts THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
4 technology Drive Ste 250 ACCORDANCE WITH THE POLICY PRONSONL.
Westborough, MA 01581 ,
AUTHORIZED REPRESENTATWE
C H€i;dei9Un, CCR/CIF. Jett, • A - -�-
861Se8-2014ACORD CORPORATION. All right reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INSO26 211 AC