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17C-055 (5) 168 CHESTNUT ST BP-2017-1019 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I 7C-055 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-2017-1019 Project# JS-2017-001759 Est.Cost: $2700.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grouo: PAUL SCHMIDT 103635 Lot Size(sq.f ): 16509.24 Owner: GILLETTE DANA Zoning: URA('001/ Applicant: PAUL SCHMIDT AT: 168 CHESTNUT ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFI ELDMA01038 ISSUED ON:3/13/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD INSULATION TO ATTIC, KNEEWALL FLOOR, 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 3/13/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File# BP-2017-1019 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 168 CHESTNUT ST MAP 17C PARCEL 055 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT /_ Fee Paid (L,I V) Building Permit Filled out �(�.f` Fee Paid Typeof Construction: ADD INSULATION TO ATTIC. KNEEWALL FLOOR,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: proved 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 molitioa eta art 'ign, . e of ' .ildine 0 ftcia 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. ucYtoeiaad aka"g {3VAS tecamaPafri $utamnai 1e04Psl3 Z .00Z ? � 0 BJD'� !M &Wp!ne 'l aqal(8NyoO)NDOP3 — IRAinISSO- aWtlapl 1'i ?"-rte \ }� 41� s a he 1 i' `ft,+LJ Int 4U2l-noafc2-0 naliffirre //y eoveai F-1-1/ 'W`77 err; L )6 - c2a-- ..�$Cd BumI J a._.a.... > . . , 52019 frW 0/7 / 1'L arroyo x viCKt 1io3 c Ywneeao 32Y/Otelei Wfeteti'[ t-n'13( 10.at N011VOinddv ZLZI:La4£14 4 OnVain t9Ouoyd 08610 VW • N \ 1 ow, woo8 WM WeW Z1Z ci tiftk Section 4. ZONING AU Informatim,Mat Be Completed.Permit Can Be Denied Due To hrmnptete Information Existing Proposed Required by Zoning This coniine to be coned in by Building DepeWe a Lot Size _Frontage Setbacks From _ ._... _-. _._._ .._._.._ Building Height Open Space Footage ¢nt eea mina,Nd &pami '.. #of Parking Spaces Fill: . . .. .. {voi=B Location) A. Has a Special PermitIVariaricetFindi been issued forton the site? NO 0 DONT KNOW YES 0 - IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW (3/ YES 0 __ . .._ IF YES: inter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES O 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 Gr- 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 C' IF YES, describe size,type and location: E. YWII the construction activity disturb(owing,grading.���,�^�-t_a'a�,� or filling)overt ase or is it pan of a common pian that 01 disturb otter t acre? YES NO V IF YES,then a Northampton Storm Water Management Permit from the DPW rs required. aaO ,p- �, � 2It0 oil"laid —f-12114441 P19(1 'Mad P eaBaad pa—ap AWn Pau65 MK Pa a6PaWool Aw P Nag ayl 0l'aeircge Pun enP as uopa7,pde Qup6agl ap L1ou""=^- !Pun ellameaaPe aaN0•P Ara Pia PaamaArhaa!I•O ea �)wUY` 'yl�J 'I as _(7 vP L /. -of-1' 1 �p+i-f-V -"etc up Pe al 19 now.knit Apaduel Palgl+e aPPaIw0 /MEW 01037111B b10:1 SaridelV 1110e1.2VaiDKO BO SSBI0 adll ISPA m131 7938 01-010tt E14111vtctM '-it.mums Mt's JOISOAM7 was apuld uaaaS Ac *iii ogdaS I 44 eaA La+OPWee+&+POZ P1.&W1 nP M wx4 .=B+P!V IMM 'H OMB PageaiP aza Poe spa w aawaaegp 410e0 'I oN mA Weletecti IA 00/ e!4Pe uoPtaU 4 'ON saA 4S XSI e%P L COI IM1Pe WPMAam SI minimum P edAi '4 c.PapWW um'azandluo'j Aqua eaIPasaW 'aaa!pwo•J uopeesato A6alud '6 wee p agwnN eiwappooM io napeldnlLi aural P MOM 'I LaaP045 P as na 'a vuotsuee+!0 "uogonupno eau P a6ePq worths Paeodold 'P tDatpape a6ea6 e 111918 o =OMAR 0PaWnN Mian A61uy LAS 94 •P SWAIN 'q x410 19a94 DM1 *ad sup 6o9P+V P IMAM- MPd Pearce aald ON / ODA— alumna waPWn BNenollea aWaN Papally 7 ON BOA Iuoo4%q&a& MI aN SA upopaq 6uPePa �rnti S-IA ( �J +-+� S, I at P-^ 4.eo ,P ai °5X'7f v,i >n> (�n �/•7W� Il t+I�a ave ot. bi, ...e .s �Pmeaolds o PPSM ay�y c, 01 P-'- riv cf ' a' f,1 •� „£'/ -sJ �s SES P / vayapti 9.1 trnalcw �I mala ta agswl 0013110maa ❑ trio knegiOn poop ap ❑ 64/0021 0 ONIMPIINNV QaewalammaldaN ❑ '- a.-v ❑ mmm maw Owen lla'1P P1 13310ael90-BOUS33110- lausas a • :..t _.:_::<•_�-:..,. -_�,. Not Applicable C License Number s .... , - 1aA 010 1/." Oil Address` Expiation Date - is �i � ill - aAr -5 Taaohone ��� -,- _ `. Not ApplksWe ❑ "7�+i'+ *Ja[ CAUK.::: /74/"1 / Registration Number Add244 ejlt....4n44± `�fresF 02 7 , pia Expiration a: -a4,4"et d 1 flnA 01 038' Teter, wlL3 dN S73' Workers Compensation haurance affidavit must be completed and submitted with this apptiranon. Failure to provide this affidavit will result in the denial of the issuance of the'permit. Signed Affidavit Attached Yes No 0 The amort exemption for"homeowners"was extended to include Owaar-oomaied Dwdgnm 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 fig supervisor.CMR 78& Sintkirfition Section Petition of Hpaxeowaer: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 struchaes.A Duma was esistruels more than one bone in a two- Period shag not be cnaid red a homeowner. Such"homeowner shall submit to the Building Official,on a form acceptable to the Building Officislr that betake shall be As acting Combatant Severvisor 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 ay 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 Genetal Laws Annotated. Homeowner Signature 0.0 oaf*Jugumito0 wpm al9pMoo a tam••at 44adn.d*9pop AA wag inPUB; - 4 es,C4 nal ul BMA SIP Wu r'?4* issaainiestoPeoul C4 Plati 1 earn(08 SR use Po Wee papaw) .i-'t'7i r' —e 7Q /0 b r& vn9 ) :SS AO --r t-h; 9, ) s9/7 :snow vim " xitaN ..mow iskud 6ti'L5'-U1YC fly _rams 4erU y (-7essaAPPv r _ ' . t,.loTt4. . 4•4:Mer7Z SINOZOIWIN 111E4=14 JO SINNIa Sn mess-n UOSZSZOIT JO art RISEf 60 Shawmut Road,Unit 2 I Canton,MA 02021 j 339-502-6335 ENGINEERING www.RlSEenglneering.com OWNER AUTHORIZATION FORM (Owners Name) L' p, owner of the property located at: I I 11--" (Property Address) -NW' LD (Property Address) hereby authorize S �-- (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 permit by contacting their municipality at the completion of this work. /A jP _- Owner's Signature Date 1_ 1-10r I `z 6.2016 �"". The Commonwealth of Massachusetts Department of industrial Accidents --,t_:4,.... rOffice of Investigations c� 600 Washington Street Boston, MA 02111 °'a?n,: www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name IBcsiness urgaldtation !nth ttdual,: SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street Cin/State/Zip: Hatfield, MA 01038 Phone #: 413-247-5739 Are you an employer?Check the appropriate box: I am a general contractor and I Type of project(required): I. I am a employ env ith38 ' ❑ hate hired the sub-contractors 6. ❑ New construction employees(full andor part-time).* 3.❑ 1 am a sole proprietor or partner- These on the attached sheet. 7. ❑ Remodeling hi and have no employees These sub-contractors hake g shipp ❑ Demolition .corking for in am capacity. employees and hake workers 0. ❑ Building addition ]No workers' comp. insurance comp. insurance? required.] `- IDWe are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their I OE Plumbing repairs or additions 3.El I am a homeowner doine all work m)self. [No workers comp. right of exemption per MGI' 12.0 Roof repairs insurance required.' c. 152. $1(4).and we hake no employees. [No workers 13.[E Other comp. insurance required. `km apnLcant that dick,No tt I must also Dillow the section hdmr.honing their norkerf compensation mdir' Information. l lomcouncrs shonubmil ihr anlda'it indicating thin are doing all xork and then hire outside mnoannr.must mhmit a nen affidavit indicating such -t bmracturs that check this hos must attached an additional sheet dwo mg the name of the rah-contractors and Stale nhether or not those entities haw empin.eesour sub-contractors have empinems.the, must pro'ide their under'comp.polis'number. 1 am an emplorer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance C'ompank Name: Selective Insurance Co Policy.'or Self-ins. Lic. s. WC9024456 Expiration Date: 2/23/2018 Job Site Address: /,LP() O, L,Li-- c---sf' LIN/State/Zip: fr i c k'1 1_t tr i Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).OI"D a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to 81.500.00 andor one-year imprisonment.as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$2250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ten' nder t pains and penalties of perjure'that the information provided above is nue and correct. Signature: Date: 3 /0 - /7 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): I.Board of Health 2. Building Department 3.Citvrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: AcoRoo CERTIFICATE OF LIABILITY INSURANCE D�E24no YTI 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). cON PRODUCER NAMEdT Cynthia Henderson, CISR Webber & Grinnell fNC No Eyif: (413)$86-0111 FAX No].(4131.586-6481 S North Hing Streetn-oDAreess:chenderson@webberandgrinnell.com —_ . INSURERIS)AFFORDING COVERAGE NAIC Northampton MA 01060 INSURER Selective Ins Co of S Carolina INSURED INSURER B Selective Ins Co of Southeast 39926 SDL Home Improvement Contractors Inc. INSURER C: 24 Chestnut Street INSURER D: INSURER E: Hatfield NA 01038 INSURER F: COVERAGES CERTIFICATE NUMBERMaster 2017 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 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. INSR --- DDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE met WVD POLICY NUMBER IMM'DOIYYYY) (MMmDNYYYI UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED-.. _.. __. .lOO,DDO A CLAIMS-MADE X OCCUR PREM Ea one Mersa_.-$ S2204065 2/1/2017 2/1/2DI8 MED EXP lAny one parson) $ 10,000 _ _......._ .000 .0 ... PERSONAL BADV INJURY 5 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 X POLICY JE T me PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 IF enn A ANY AUTO BODILY INJURY(Per person, AUTOSALL V+NEE _X AUi05ULED A9100328 2/1/2017 2/1/2018 BODILY INJURY(Per acd0en0 5 X HIRED AUTOS X ng tED PROPERTY DAMAGE AUTOS IPer accident). Undermsurea momrst BI split S 100,000 X UMBRELLA JAB X OCCUR EACH OCCURRENCE $ 1.000,000 A EXCESS LIAfi CLAIMS-MADE AGGREGATE $ 1,000,0.00 DED RETENTIONS 10,000 52204065 2/1/2017 2/1/2018 $ WORKERSCOMPENSATION X PER X OETH- AND EMPLOYERS'LIABIUTY YIN ANY OFFICER/ME BEER PEXCLUDECT ECU9VE y N/A EL EACH ACCIDENT • S 500,000 B /mandatory in NRI WC9024456 2/23/2017 2/23/2018 E L DISEASE-EA EMPLOYEES 500,000 DESCRIPTION OF DPERATANS below E L DISEASE•POLICY LIMIT 5 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Adddionel Remarks Schedule,may be attached Ir more space Ia required, The Workers Compensation policy does not include coverage for Paul Schmidt, Hendrick 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, MA 01581 AUTHORIZEDREPRESENTATIVE COS ., 7..N 5Ph A _ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS02SI fll4on