25C-043 (6) 28 WOODBINE AVE BP-2017-0924
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C -043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0924
Project# JS-2017-001574
Est. Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use croup:
PAUL SCHMIDT 103635
Lot Size(sq. ft.): 3920.40 Owner: MCKONLY JEFFERY
Zoning: URB Applicant: PAUL SCHMIDT
AT: 28 WOODBINE AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATF I ELD MA01038 ISSUED ON:2/6/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:120 SQ FT, 14"LAYER R-49 ADDED TO OPEN
ATTIC SPACE, 150 SQ FT, 2"THERMAX & FOAMBOARD TO CRAWL SPACE, 80 LINEAR
FEET,R-19 TO BASEMENT CEILING, 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:
Drieeway 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:
FeeTvpe: Date Paid: Amount:
Building 2/6/2017 0:00:00 S65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2017-0924
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 28 WOODBINE AVE
MAP 25C PARCEL 043 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT /s
Fee Paid ✓
Building.Permit Filled out
Fee Paid
Typeof Construction: 120 SQ FT, 14"LAYER R-49 ADDED TO OPEN ATTIC SPACE, 150 SO FT
2"THERMAX& FOAMBOARD TO CRAWL SPACE,80 LINEAR FEETR-I9 TO BASEMENT CEILING,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
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
en:% 'c• Del.
dor
l ; -3
Signature of Buildir(Official Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
City of Northampton
Sulam Depattnent
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,NATE OR =_ ,. ....: .. OR 7111DM lY8RBJJNG
Seliejtigli—SWW11#0.: '. . „ FEB - 3 2017
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Name(Piet) Menne Mews:
'� Gwenttn,- (717-
71
y, Tas�7-573 j
eeptenef
Cern Esdneted
by a )to be Wirt4SSE
1. 3uBobg �,� CL)
2. Electrical
3. Plumbing
4. Meds (HVAC)
5.Fre Protection 7. T
6. Total=(1 +2+3+4+5) u7�l(X7- � -;. d11 5
�-_
4
Section 4. ZONING All Information Mist 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 _
_..
&eU - ---
Building Height ,_____ 111—I
Bldg.Square Footage
Open Space Footage
parking)
I*of Parking Spaces
Fill: '
jvolume&Localion)
A. Has a Special Permit/Variance/Findi r been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES,date issued:.___
IF YES: Was the permit recorded at the05)gi try of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ( 3( YE 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? 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 Cy
IF YES, describe size, type and location:
E. WII the construction activity disturb(dearing,grading, gaton,or filling)over 1 acre or is it part of a=mon plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS-DESCRIPTION 4F PROROSEDWORK[Grda+p aeeiclWe)
New Nouse ❑ AdlBfion ❑ mReplaceme t WWki&...s ARwatlon(s) 0 Roofing 0
Doom 01
Accessary Bldg. ❑ Demolition D New signs fol Dela OMT
' kti
SKH j ,Otllayr -
Brief DesmPdan d Proposed "deo s1 14, t/' later ie- c/9 CLd cd 7C C}0'e,1 4-2C 6./fet�
Werk: aarma
- m board 13 Caw) Spae,e- 4:uar-Ft c, q
fhi aj&u i �
Y ,/No Adding new bedroom Yes No -M hrtsenwrr
ccs 4 v.--
Atbached
Rill -Sheet Nanative
Renovating unfinished basemen _Yes
Plans
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 abodes?
1. 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 11.ft of wetlands?_Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of . cellar floor below finished grade
k. WN building -. to the Budding and Zoning regulations? Yes_No.
I. Septic Tads_ City Sewer_ Private well City water Supply
SECTiaNTa-OYUIHFAUifiORHARON-TOSESDOPMED Wei
ORNERSAGERT:OR'QOMitlicgoRAPPLilisFOixatmu OpeRwr
lJigaviC,, TAC Ktiel as Owner of the subject
property ( 1 �� �� " � � ��
hereby authorize f,/�1... -}-lt7ni-- ✓m'emer1+ e.001124€404-S) 1e--."
to act on my behalf,in all matters relative to by this building permit atmlicatIon.
a- - j7
downer �- Date
I S-I/M,&F as ovmer/AuGrorized
Agent hereby declare that the statandhb and in f mwtkaon the foregoing apptcadon are true and accurate to the best of my knowledge
and belief.
Signed under Me pains and penalties of perjury.
el)/ &i-v ti Gt-'1..-
Print Name �J •
i ../s.41
w
def. Dan
Not Applicable El
NaMotLlan..Marls:
License .. _
11 ow G-40
somess
xpiratco Date
/ c Alt t/t - ail -5 E
-.nalure Telephone
_�,. - Not Applinae �
1... 11I.IT��q�Tl�ii WA a P,409. 4 ' ______
Registration Number
02
; _
• ree--�-' 1 .7 I
Expiration
ka,.k�i cl 8 MA 01 D 3$'' TelephaS
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
In the denial of The issuande of the bw7®tr rpermit
da
Signed Affidavit Attached Yes t4'/ No
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)£amities
and to allow such homeowner to engage an individual for hire who does not possess a license.provided that the owner acts
as sanmvisar.CMR Mt SUlk €dition *Mien 14S.3.5.1•
Pelialtice of Heieowner: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 aPreveory to such use and/or term
siructmts.A cs.' r: he .
Such"homeowner"shall submit to theBuiding Official,on a form acceptable to the Building Official.that he/she shell be
♦ ' I RL 3-3 •.,._ the a. p t4 i
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(Walks's'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 Sr you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Stare and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Slgmature
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RISE60 Shawmut Road, Unit 2 I Canton,MA 02021 i 339-502-6335
ENGINEERING' www.RlSEengineering.com
OWNER AUTHORIZATION FORM
I,
6_,;oFF2.tY P'icroA) tL;
(Owner's Name)
owner of the property located at:
is WOo /Furr Ij
(Property Address) H
N o ru#(6,107303 , MTh Did 60
U
(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. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permitrby contacting their municipality at the completion of this work.
Own tur
&,
III2-IOD
Date
5.2015
The Commonwealth of Maesachusens
tDepartment of Industrial Accidents
i1I Congress Street, Suite 100
'�'{_,Boston, MA 02114-2017
W• -.
- www.mass.gov/dia
Workers Compensation Insurance Affidavit:BuilderstContractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information Please Print Lo2ibh'
Marne(Business Organization indi�iauau: SOL Home Improvement Contractors, Inc
Address: 24 Chestnut Street
City/StateZip: Hatfield MA 01038 Phone on 413-247-5739
FAH you an employer?Cheek the appropriate ho' I .._ ...__Type of project (required_..
8
I ).
❑- p e c '_ O New construction
01 am a soleipropriarar or Inman-alit hain no einnitiaee,wor ¢, El Remodeling
:sp:spun. N comp p nce 'commit.
9. ❑Demolition
E1 homenwrint doing ail work t If iso - inicaird
s Eli cc a homeowner d will tr a I0❑ Bunting addirion
cure thin nil .r.m ,.rrsth x ser, xo r l .a i _ 11.0 Electrical repairs or additions
tors v ate,no oapfokeer. 12,❑Plumbing,repairs or additions
5 El I.int a general eontraiwor and t J in u-. ._xx.
Mas .no- ,w.have em „have
,a, I:i.�Aoofrepays
!s.[]Other Insulation
ii 0)) ae m no a noha n ,ur a, -:xct.,
a
e t1i and he hoe ,ay.h ec Co orke comp J
out p
V i9ewr: rs thatchecks the idic; moire at. x, ieoJne m on ntLt Shinn new
v
u .Y x n chec ti n .soda' 1 „�decn J r_a wt , 0t nmJeo Icer a n,in dao'. :d-n:moueh.
f Nf the n tab boa np]oceniwd an odd x. . del :' `' oar .' and m: : - .r _ n Yho.:.=.YiYsa k,.
mPto. h H.hc. E~ ,acts hand a,nux...;_thev mu -,duty. xo a4 Vx. amber.
I am an employer that is providing workers'compensation incurance for my employees. Below is the polity and job site
information.
1n,urance Company None. Selective Insurance Co
2{2312
0 ........
Isom,:a or Self-ins. Lie._- WC9024455 Lsp nation Dale: 01�y
Job Site Address:44 l •I ' s l 11).
City State Zip. /V A r +Co.,,-�
Attach a copy of the workers'compensation policy declaration page(showing the policy nu her and a pi ation date).
Falun: to _car coven _as required under MCI_ .. i S2 S2SA 0 s frInlin.d viela on punishable by a tine up to 51.500.00
and one-)ear imprisonment.as 0 ell a.eivil psnaluss in the i a S I OP AA ORK ORDER and a tine of up to 5250.00 a
day against the viaiator.A copy of this statement toy he fors a d 10 the Office of Inv estigmt ions of the DIA for insurance
cos era ie certficatioa
I do hereby errata gnddr the pvm s and penalties x fperjury that the information provided above is true and correct
Signature. ./ r ,Sr — 1
pi-
Phone r: 413-247-5739
Official use only Do?I or write in this area-to he completed kr cUr or town official
Citor Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cho proton Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone is
ACQ KS CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDOrryyr
1/24/2019
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: It 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 endorsements).
PRODUCER cONEACT Cynthia Henderson, CISH
Webber & Grinnell pdesp.ppPRONE (413)586 0131 FAx (4131566-64e2
8 North 'King Street ApOendersonewebberandgr±nneli com
INSURERIS)AFFORDING COVERAGE NAICp
Northampton MA 01060 -- _- - ---
INSURER A:S91®Ct1Ve Ins CO O£ S Carolina
INSURED INSURERB:Se160tiVe Ins CO Of Southeast 39926
SDL Home Improvement Contractors Inc. MSURERC.
24 Chestnut Street INSURER D:
SU
INSURER E'
Hatfield MA 01038 INSURER F:
COVERAGES CERTIFICATE NUMBERidaster 2017 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN i55050 TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VM IH 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 L$UBR POLICdYFF POLICY PO - - - --
LTR TYPE OF INSURANCE WSO WVD POLICY NUMBER IMM/DOMYYI IMMNDYYYYILIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED SOC,000
A CLAVJ9MADE X OCCUR PREMISES(EEsonnuvmwj 3
S2204065 2/1/201Y 2/1/2010 MED EXP(Any Dr*person) $ 10,000
PERSONAL&AOV INJURY $ 1,000,000
GENL AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 3,000,000
P _............_..
X pouev - LOC PRODUCTS..COMP/OP AGG $ 3,000,000
OTHER...__ _ _
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(kaacaUey
ANY:AIM BODILY INJURY(Per person} S
A - ALL OWNED SCHEDULED
AUTON R AUTOS A9100320 2/1/2017 2/1/201e BODILY INJ R ,Per accident)
ED PROPERTY DAMAGE
AUTOS
X HIRED AUTOS 8 lPb astlen0 .. 5
Untlenwleo moiUllm 6t split $ 100,000
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE E 1,000,000_
A EXCESS LIAR pLAIMS•MADE AGGREGATE 8 1,000 090
DEC X RETENTION$ 10,000 52204060 2/1/1017 2/1/2010
WQR%ERSCompeRaAnoNPER OTET
AND EMPLOYERS'LIABILITYxtN X STATUTE 'X
ANY PROPRIETOR/PARTNER/LECUIIVEN/A
B EL EACH ACCIDENT E 500,000
OFFICER/MEMBER EXCLUDED, Y "-- "
(Mandatory In NH) WC9024456 2/23/2017 2/23/2010 EL DISEASE.EA EMPLOYEES 500,000
r yes.aesalhe under ___. .
DESCRIPTION OF OPERATIONS below EL DISEASE.POLICY LIMIT S 500,000
•
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAGORD 101,AddIlonal Remarks Schedule.may be attached it more space is 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 WILL BE DELIVERED IN
4 Technology Drive Ste 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough, 14A 01581
AUTHO(BZED REPRESENTATIVE
C Henderson., CISH/GTN ee
Q)1988-2014 ACORD CORPORATION. All rights reserved,
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INSO25nn, n.