30C-046 (5) 368 BURTS PIT RD BP-2017-1271
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:30C-046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-1271
Project# JS-2017-002121
Est. Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group:
PAUL SCHMIDT 103635
Lot Size(sq.ft.): 221720.40 Owner: MONAHON CYNTHIA& EDWARD WARD
zoning: SR(100)/WP(I5)/ Applicant: PAUL SCHMIDT
AT: 368 BURTS PIT RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:5/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORIG455 SQ FT &LAYER R-30 ADDED TO OPEN
ATTIC SPACE, AIR SELAING 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 Occu.anc si!nature:
FeeType: Date Paid: Amount:
Building 5/5/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File It BP-2017-1271 -.
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 368 BURTS PIT RD
MAP 30C PARCEL 046 001 ZONE SRO 00)(,,WP(15)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM PILLED OUT
Fee Paid N,
uG
Buddina Permit Filled out
Fee Paid
T of Co strut/on: 455 SO FT 8"LAYE' '- 0 ADDED TO OPEN ATTIC SPACE,AIR SELAING 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;
(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
D-• • iti, b1,v
Sign. . of uildinn+0Date
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 40k Contact Office of
Planning&Development for more information.
\ok , A titti omfigNorthamplon
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
1.1
C o%
g rA
-14-1:u /Y1onahm R e jr.y-13 A Rd
Telephone
Scrotum
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Name o, / C,�m t c-n, 5—
rY .—ie,-\--7, nc-
Currant Meiling Mines:
� Tom- aY7-513 j
elephone
Item Estimated Coet(Dollars)o be
1. br h> epi
6wale g r.2,cY� c
2. EleWinl as
3. Plumbing
4 Dteohail(HVAC) <.
5.Fire Protection
6. Tom:(1 +2+3+4+5)
}
.- .
Section 4. ZONING Alt kRannatten Must Be Completed.Permit Can Be Denied Due To inrumpiete Informetlon
Existing Proposed Requited by Zoning
Me wham to be Med in by
BAU M Depttmeet
Lot Size
Frontage
Setbacks Frog
IBS
Building Height _.__ _—
Bldg.Squme Footage
Open Space Footage
gut arta mmusbide A paved _...__. ..____
parMal
II of Parking Spaces
Fol:
(volume Lyceum)
A. Has a Special Permit/Variance/FI been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date Issued:':
IF YES: Was the permit recorded at theRegis ry of Deeds?
NO 0 DON'T KNOW YES
if YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 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? 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 Q NO e
IF YES, describe size,type and illation:
E. MM the construction activity distrb(ring,gradingp���aaort or Ming)over/acre or is it ped of a common plan
that will df�urb over 1 acre? YES V NO V
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,4ECHON 5-DEBCRPN®ROFPROPOSiIMONfMeta asstiseble)
New Norse 0 Addition ❑ Or Replacement Windows A oMs) ❑ Roofing ❑
Doors l:3
Accessory Bldg. ❑ Demolition ❑ New Signs LOl Decks L &fig � 52f
�./Qa
Brief Deacrrobon of Proposed i/SS S f # g" [.aYa r' R- -en [j �D
ea �Q
eddJ I0 S.irq-•Jt > f'/!�eR,C,n ,q0.....t.-- /1,2fLda_c .
Atierattan of existing bedroom Yes J No Adding gnewbedoom Yes 17No
Attached lenitive Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. Use of building:One Family Two Family Other
b. Number of roans in each family unit Number of Bathrooms
c Is there a garage attached? /
d. Proposed Square Wage of new construction. //Dimensions
e. Number of stories?
-
f. Method of healing? % Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. / Messchedc Energy Compliance form attached?
'
h. Type of construction /
i. Is construction within 100 ft of wed? Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basemen or cellar , below finished grade
k. Will building conform to Burling and Zoning regulations? Yes No.
I. Septic Tads Gla'Sewer_ Private well City water Supply
SECTION3a-OWNEEtAUIHOI i'RON-TOSEECIIPtEiSD MR31
ales nett ORECNiltAt WRAPPUES POR BOgDRaC'PERRR
I, as Owner of the subject
proPeltY
ruby authorize 5}S
Lw�i'DVtn O'1+ eon- /ue:y 044,• Ie._,.,.
to act on my behalf, in all matters relative to by this building permit appiicedon.SWS [fi447 .t. L2 —' ti"-,-3— i "-7
a Das
I. �aa-/ ...L'J,mit as Omer/Authorized
Agent hereby declare that the statements and ink.imdiun on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the painand ni penalties of perjury.
iA1/ &fi lye
Pried None
y, On
7 Not Applicable 0
fMaaatkauwa Naiaar _ A OL'}'
, -J1{�',- rr Geeme Number D 'Q
-i 47 1J 19 070 : 02.0 r 1
Attres: 0.
/or : 4, - aA/ -5 Expiration Date
'arpNre - Telephone
Not Applicable ❑
rn1ro.eAoH s, / 'V/ S
Cwa.afv Horne Registration Number
02
epiratlon
j-la-1--414.4. 8 , mf} Cl 0 38' Teleptionai//A aq/7 573'
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 bt,tpermit
Signed Affidavit Attached Yes No 0
The current exemption for"homeowners"was extended to include Owner-eaaeied Awelao of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,grevded Oat the owner acts
as sucervtsor.ChM 799. Stith Edition Section 1943.5.1.
Dem of Uoeeowaer: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 semen vibe cs acts more that sae hose in a two-veer period shall S be considered a honeownec.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all sack work performed seder the belt permit
As acting Constrectiea 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
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RISES0 Shewmut Road, Unit 2 I Canon, MA 02021 1339.502.6335
ENGINEERING www.RISEenglneerIng.com
OWNER AUTHORIZATION FORM
Cynthia Monahon
(Owner's Name)
owner of the property located at:
368 Burts pit Rd
(Property Address)
Florence MA 01062
(Property Address)
hereby authorize t—
(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 forrm� is only valid with a signed contract.
op
Owner's Signature
Date
"'- The Commonwealth of tfassackusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, WA 02111
'tAaoe'v www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders!Contractors!Electricians/Plumhers
Applicant Information Please Print Leeibty
Name{flakiness(kgaiimatiort lndn duals SOL Home Improvement Contractors, Inc
Address: 24 Chestnut Street
Chi-State/tip: Hatfield MA 01038 Phone : 413-247-5739
Are you as employer?Cheek the appropriate box: Type of project(required):'
.. an mai contractor Udd
'.. I tat a zmpi tk a ah 86 ❑ New construction
employ test Pill and or panumel h ur Ilh tb mtravtor
'_.� l ata a sok.proprietor or par n t- tel of Meeattached sheet , n Remodeling
ship and have no employees Th . -subcontractors have 8, ❑ Demolition
rl c eot he workers'
(irking for enc ea uq
Ej Building,addition
Noworkers cbntp. insurance t m hura1 -
5 71 We arca moth rat a and irk ( 1q. Electrical repairs m additions
quired.j - t i
{am a homeowner doing all murk officers has exercised their 11.0 Plumbing repairs or additions r
right of exemption per MCiI.
myself_[No erequirkers comp_ 12.0 Roof repairs
c i]_XIN) and we hake no
insurance required_' i
cniniusees No workers' 13.07 Ocher .
tomb tosurance required.;
' appiabite that:hoist h..s•n must`r tot am the a:ethic`c s r et ken >inpenuaion poliei information
%Alm tabula ht.Midair it indiebniitithe, beJoint(all erst ariaChitutadn.uvacters must submit a nen athdaiit indmanno such
• anbucmn(hal check this len must attached an additional sleet sla)u my the name.i!the mob-cJOUe dors and sola uhcth r or not dune unities time
cmato>cies. It die suMmrar>'mn have cnpigcesaa; muni twat be their w,m6an comp pima, number
t am an employer mat is providing markers'compensation insurance for tar employees. Below is the policy and job site
infernation.
nSuranett ompans. Name'. .-_ _ Selective Insurance Co
Pokes - or Self-ins. Lie 4. WC9024456 Expiration Date 2123t2018
job Site Addres4 r,�q. "mid r:} }' vad l m:Statc7ip: / C.LR,pne-E f A
Attach a copy of the workers'compensation policy declaration page(showing the policy cumber and expiration dale).
Failure to secure coverage as required under Section 25A of Wit. c- 1522 can lead to the imposition of criminal penalties of a
nne up to$1,500.00 and or one-sear imprisonmenta.sell as cias!pe=.:att(es in the form of a STOP WORK ORDER and a fine
of up 10 S2250.00 a day against the violator_ Be advised that a cap) et this statement may be forwarded to the Office of
Ink esstigations of the DIA for insurance coverage verification.
I do hereto ten' adv.t pains and penalties of perjury Mat the information provided above u tour and correct
Sienaturr % _ ..._Date. ) �
_ ....._ 2222 . . _ .
OJJwiut use only. Do not write in this area.to he completed hr citr or town official
Cin or Town: PermiuLieensen
Issuing Authority(cir<k one):
F.Board of Health 2.Building Department 3. ('ity::Town Clerk 4. Electrical Inspector S.Plumbing inspector
I6.Other
I Contact Person: __ Phone it:
ACCIRE) CERTIFICATE OF LIABILITY INSURANCE D;EZgi ai
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 ICOAMNTACTECynthiaHenderson, CISH
N .
Webber 6 Grinnell NC Ho PAL (413)586-0111 FAX
N ) "13)586-6481
3) 86 6481
B North King Street EnlitoAaiss chenderson@webberandgrinnell.com
INSURERSAFFORDING COVERAGE NAIC
�
Northampton MA 01060 INSURER-Selective Ins Co of S Carolina
INSURED
INSURER e,Select've Ins Co of Southeast 39926
SDL Home Improvement Contractors Inc. INSURER C
24 Chestnut Street INSURERD:
INSURER E: - -
Hatfield MA 01038 INSURER F:
COVERAGES CERTIFICATE NUMBERYlaster 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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMDOTTYY1 IMWDOIYYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _5 1,000,000
DAMAGE
A CLAIMS-MADE X OCCUR PREMISES(Ea occuueUm_ 5 100,000
62204065 2/1/2017 2/1/2018 MED EXP/Any onepersonl S 10,000
_ . .
PERSONAL aADV INJURY s 1,000,000
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE s 3,000,000
X POLICY
PRO.
LOC PRODUCTS•COMP/OPAGG 5 3,000,000
OTHER -_.5..
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 1,000,000
LINJUR
A
ANY AUTO BODILYINJURY 5
ALLONNECx SOHEOUOED
AUTOS AUTO$ A9100328 2/1/2017 2/1/2018 BODILY INJURY/Per accident) 5
X HIRED AUTOS
rvLf 0 D PROPERTY DAMAGE
X Amoss LPerepgdept) . _ •
underinsured molonsl Rl spin 5 100,000
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000
AEXCESS LIAR CLAIMS-MADE AGGREGATE 5 1,000,000
DED X RETENTIONS 10,000 82204065 2/1/2017 2/1/2018
WORKERS COMPENSATION X PER STAT•TE X O
ERH
AND EMPLOYERS'LIABILITY V I N
_—.
ANY
PEOMWE7OR,PARTNEP/ExECUTVE E.L.EAG/ACCIDENT5 500,000
OFFICER/MEMBER EXCLUDED? Y NIA - -. -
B (Mandatory In NH) Wc9024456 2/23/2017 2/23/2018 EL DISEASE-EA EMPLOYEE 500,000
byes descnbunder - -
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UMI? 5 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If TOM spare 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 6 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
AUTHORIZED REPRESENTAPVE
C 5ecder,ur., C SR C:11 .5 e. - �/
C)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS02512Cmenn