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25C-252 (5)
37 FAIR ST BP-2017-0328 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-252 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categry: INSULATION BUILDING PERMIT Permit# BP-2017-0328 Project# JS-2017-000261 Est.Cost$2600.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.QLass: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 21170.16 Owner: TOUHEY .fl_ANNE &SUZANNE Zoning:SC(100y Applicant: PAUL SCHMIDT AT: 37 FAIR ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413)247-5739 WC HATFIELDMA01038 ISSUED ON:9/16/2016 0:00:00 TO PERFORM THE FOLLOWING WORK 616 SO FT 8" LAYER, R-28 FLOORED ATTIC SPACE, AIR SEALING AS NEEDED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.F.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 031: 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 9/16120160:00:00 $65,00 212 Main Street,Phone(413)587-1240,Fax:(413)537-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0328 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 37 FAIR ST MAP 25C PARCEL 252 001 ZONE SC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid rat # "71/2 Building Permit Filled out Fee Paid Tvpeof Construction: 616 SO FT 8"LAYER,R-28 FLOORED ATTIC SPACE, AIR SEALING AS NEEDED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine 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: .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 Demolition Delay Signature of Bui ding (ficial 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. O4IIN>, °6 Q .2` City of Northampton f Striding Department / 212 Mein Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413367-1272 APPUCATION TO CONSTRICT,ALTER,mean,RENOVATE OR DENOLIMN A ONE OR TWO FAINLY IMELUNG 1.1P y - k Ls? . ,x `54" /bra-'-{-harry') P34 )O&() Na.!e LLditc.l'..ar. trt. / TTS Mien Mei%Adams: jC ? (l �a- ( 7't l Spew 3bL-*TtY t-- -v-)pa i e° me rd- { --, Tl ou r eyeing t -f- Q L1 Chwc5k),H ' --i - S4 , -c to E c 8 r^$-}` Name(Piing Current MacyAddms: /AY dd4° d- - eQ47-573 q Li T3 cas Mem Estimated Cost(Dofters)to be 1 Building 4s caTq$ .d bT owStaeaxcarrt c-31r13 3.00 49 2. Ekdtical .. 3. Plumbing 4. Mechanical(MVAC) S.Fhe PralsaAOn , s.. . J.. .. ... 6 Tom=(1 +2+3+4+g1 cQ(f0C) • CX.3 :.. . .e.._r. Section 4. ZONING Aft iniernation Must Be Completed.Permtt Can Be Denied Due To Incomplete lnformatfon Existing Proposed Rested by Zoning Lek cater to xrand is by BtaldingDeparbrent Lot Stu Frontage Setbacks Front �..~ RIS __ ..J Solidity Height — . -- Bldg Square Footage Open Space Footage — #ofPattang Spaces —.: __ lvdume&Location) A. Has a Special Permit/Variance/Find been issued for/on the site? NO 0 DONT KNOW YES O IF YES, date issued:- IF YES: Was the permit recorded at the Regi try of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book i Page.. ` and/or Document# B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0/ YES 0 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? rtS Q NO (a ^ IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the progetty? YES © NO 9' IF YES, describe size,type and location: E. Wdl the construction activity disturb( ng,grading6(vation, or inning)over 1 acre or is it part of a common plan that vitt disturb over l ane? YES NO IF YES,then a Northampton Stone Water Management Permit from the DPW is required. SECTIONS-OSCRIPTIONOPTROR08110.11311tTfolietaraitaile0e0bill New Nouse 0 Addition p �� Atwr (s) ❑ Roofing ❑ 0 y SMS. ❑ DenWtlon 0 New Ss Sza Daae {ri Slang I-j otlmrlis Brief Denafption of Proposed /v7l �7 , b"" Ia r' R—a8s' - hurl 441-70. C L r a N�a"P Yese`d No t Aitad'red NanatihC 'J Adding newnW ed bm Yes �No / Plans Need Rog -Sheet Renovating unfinished basement Yes ✓ No a. Use of building:One Facey _ Two Fawley Other b. Number a mans in each fannyunit Number of Bathrooms c. Is thane a garage attached? d. Proposed Square footage or new constucton. Dimensions e. Number of Nodes? f. Method of heating? Fireplaces or Woodstoves Hunter of eats____ g. Energy Cansenatlm CompRance. imsec edr Energy Compliance form attached? h. Type of cons:uction i. is construction wWten 1.. of wetands?_YesNo. Is construction within 100 yr. Noon Yes No i. Depth of•=-:. ._ . .. mew f oar below finished Bade IC MI building .. • to the Budding and Zoning regulations? Yes No. I Septic Tank City Sewer Private wee City waterCuRAy� SECTIOtt i..01 .M RCRESl1`NeMs..TO COM PtET?gJ end areas keit OR'totatmesettavittsfateutoitasysturr t, as Owner ofthe subject property hheraebraWraize 5L�•., -i-1 erne..+ -{' ear of kne-s, 1ry�e to act on my behalf,in ed m aws redeye to by this Witting permit septic/Jen Sze a�+Act a 9-1-I cc, Date Read Fgent hereby declare thatstateme ts aid h.fermabon on the foregoing appficatlat are true and accurate,to the best of myknowledge and belief. Signed infer the pais and palates of perjury. ePtckil S Anti Pre Name 9 _ /7- l co SA LlcMmad Corot cionStanNot Applicable 0 Nene of License Nobler: a I �}Aehrn(.i"'d,-�- I v S Cs35- ale ii.s4-/7L.4�r s+, -G- .'�'.l'(uc,�T1 o;o LicenseNu 510-0// Address - aAr -5 - - Telephone . Not Appliceble ❑ Sb I- - , rn-4rm&Cogs / 74"i/ 5 ` Registration Number 2 the - 3--kr-eek- Lip7 d , Met Ci D38f Teiephone1/43 014/'7.5739 Workers Compensation Insurance affidavit mutt be completed and submitted with this application. Failure to provide this affidavit will result in the denial tithe issuance of the f permit Signed AlfidavitAtladhed Yes No 0 The current exemption for"homeowners"was extended to include Owner-monied Dwaine,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 snoervN9r.CMR 788. Hta Edition Section 19&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 sbtcuses.A Person who constructs more tai one home in a two-veer period than not be eaSdered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that hdehe ah.B be iraoori4Eor an suck work performed seder the building oermrt As acting Cowtraction 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 Signature City of Northampton epee s awe a_ a•_ s , as rr. MS • , 010 saum.e , :, ger 60 Property Address: c 7 'lo-1 r- (S* Fag/ 5.^_.Funid t Cordsecter Name: S`b 4-kmaa�inp ,retai 4 C .n *raeAtcs :rine- • Addressa C. e 1-nwk SA-ret+ city, Stabs i4aakhri , rnAo� Monsl3. a41-677)9 Property Orrther Address: +o-+ r o+- cay,Slats AIOrt44lamp-oJ , rn ft o Occ 0 t. —ad S-1 nn iclk (ootmaasr)attest and sauna that the bulling I Intend to i claim riothwearthopen i'mobaadtube)wiring itthe spaces tobeinsulated andin1have prodded the property oats a copyetthteaandart Cara rdgnateredia,..- Date 9-7 r (49 AISIN n OWNER AUTHORIZATION FORM 90 me l c v in�( painets Name) war of thepoprq� el / eS1 2S)12 5i. hen*eadhorte anaWarlatelsubcontractor tar REE Bement tononnybelabablainaI primend to prt==It on my poly. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, .MA 02174-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business:OraanizadonAndividuan: 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): 1.0 ant a employer with 8 employees Tull and ar part-time l' 7. New - zw construction 2.0 am olc.prop p rmersM1p mdh o employees king_ ror .n 8. ❑ Remodeling an:.capacity.[No k . comp. required ❑I am a homeowner doingall work myself.[No orker comp.insurance required 9. ❑Demolition s❑l am a homeowner and will he hiringcontractors to conduct all work on my 10 Building addition propene. I will ensureare that all contractors either ha,e workers'compensation insurance or .ole 1L❑Electrical repairs or additions poprietors with no employees_ 12.0 Plumbing repairs or additions s�l am a general contractor and l have hired the subcontractors listed on the attached sheet. 13 Rfairs These sub-contractors have employees and have worked'comp.issuance.' '❑ OOrepairs ❑ 14 e❑Other Insulation F Weare a corporation and its of vers nave exercised their right of exemption per MGL o 52.e 1141.and we haw e no employees.[No workers compinsurance required.: 4vny applicant that checks box d must also fill out the section helmi showing their workers compensation policy information. }Hon who submit this affidavit indicating they are doing all work and rhea Sire 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 then workers comp.policy number. Lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Co Policy?or Self-ins. Lic.g: WC9024456 _. Expiration Date: 2/23/2017 ]oh Site Address: �31 City/State'Zip: AZ.‘ ramp{ t mA Attach a copy of the workers'compensation policy declaration page(showing the policy number and eapiratihn date). Failure to secure coverage as required under MGL c. I52 :25.A is a criminal violation punishable by a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a floe of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ty rpthe p s and penalties of perjury that the information provided above is true and correct Signature:v.rri / / Date: 9-7'/ C Phone=: 413-247-5739 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License k Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ACO® CERTIFICATE OF LIABILITY INSURANCE DATE iMWDWYYYY' `----- 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 certificate holder is an ADDITIONAL INSURED,the policy(les)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 Nmug,GT Cynthia Henderson, CISR Webber & Grinnell PHONE . (913)586-0111 lac NPI:(413,586-6481 _INC8 North sing Street DREss chendera n9webberandgr>.nnell.nom INSURER(S1 AFFORNNG COVERAGE NAIL• Northampton fA 01060 . iiSuRERA Selective 19259 INSURED INSURER e. SDL Home Improvement Contractors Inc. ,INSURER C.. 24 Chestnut Street I INSURERD: INSURERS: Hatfield HA 01038 ,INSURER El COVERAGES CERTIFICATE NUMBERMaster 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 PERIOD INDICATED NOTWTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT HATH 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 NSA - TYPEOFIXSURFNLE --ADDI_ :Aka -_ .. -_ POUCY EFF POUCY EXP JTRIHSD AND POLICY NUMBER IMAYCMIYYI (MWOD'YTYYI UMI15 X COMMERCNL GENERAL w&LITY _. _. EACH OCCURRENCE 5 1,000,000 DAMAGE fO PENTEO A CLAIMS-MADE X OCCUR PREMISES accuse-rte.) 5 100,000 _ _.. 92204065 2/1/2016 2/1/2017 MED E%P lAny ore person; S 10,000 PERSONAL BADV INJURY 5 1,000,000 GErv'L AGGREGATE LIMIT APPLES PEq. GENERAL AGGREGATE . 2,000,000 X POLICYECT LOL PRODUCTS-COMPIOP AGO S 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMO $ 1,000,000 LERLYOwR AN BODILY A ANY INJURYperson/(Par person/ s AOWNEDX OUT- SCHEDULED AUTOS AUTOSA9100328 2/1/2016 2/1/2017 --BODILY INJURY,Per aco e,t c PROPERTY $X BIPED AUTOS X ;NAWNEDjPsacuOaiIL _ Undennsurs1=tent EI ipH 5 100,000 X UMBRELLA UAB X OCCUR _EACH OCCURRENCE 5 1,000,000 A EXCESS UAB CLAIMSMAOE AGGREGATE 5 .. _.. _. DED X RETENTIONS 10,000 82204065 2/1/2016 2/1/2017 5 ANDWORKERSCOMPENSATIDN PER O7B- ANDEMPLOYERS'wMLITY YIN _EL EACHOTE y` ER ANY PROPEMTOR EXCL)O€D'>_CUTVE NIA EL ACODENT S 500,000 A 03SICEtMEMeER EXCwceD= s Byes dean M NH) NC9024456 2/23/2016 2/23/2013 EL DISEASE-EA EMPLOYEE 5 500,000 DESCRIPTION OFOPERATIONSbelow EI DISEASE-POLICY LIMIT 5 500,000 DESLePIION OF OPERATIONS I LOCATIONS'VEHICLES(ACORD 101,AdintIonal Remarks SCMaule,may be maces N more pace le required) The Workers Compensation policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas Schmidt, Columbia Gas of Massachusetts is hereby named as Additional Insured per written contract with respects to General Liability & Auto Liaiblity, for work performed, and per the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Columbia Gas of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE W)LL BE DELIVERED IN 4 Technology Drive Ste 250 : ACCORDANCE WITH THE POLICY PROVISIONS. Westborough, MA 01581 AUTHORIZED REPRESENTATIVE IC iie.derson, c.LR/Cl:: _ __ _ 31988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IN5025"mem,