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29-045 (2)
23 PIONEER KNLS BP-2017-1291 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block:29-045 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-2017-1291 Project# JS-2017-002144 Est.Cost: $1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const,Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 11979.00 Owner: ELLERBROOK RAY A&W ENDY.1 Zoning: Applicant: PAUL SCHMIDT AT: 23 PIONEER KNLS Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFI ELDMA01038 ISSUED ON:5/9/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:140 SQ FT EXTERIOR WALLS, VINYL SIDED AIR SEALINNG 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 5/9/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1291 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 23 PIONEER KNLS MAP 29 PARCEL 045 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST .OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid M. /� Building Permit Filled out /l Fee Paid Typeof Construction: 140 SQ FT EXTERIOR WALLS,VINYL SIDED AIR SEALINNG 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: fr 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 doeD= ,clition Delay / /� 777 a r Signe of Building Officia 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. '.1%.'-4K4.-- x c ..-(" r jjtr. s Co 000' /ms As,>+s+Z+ t).�wt s uogriw,+d yd'S (0V/ 93DSAaW 'b &u?4UJMd £ 199Wee 't .. 00000' 9s9:998 'l ' 7 k b4 P4Wlsubo '� . eq W(smo0)iPo3 PelealOs3 WON anydMYi a v ✓ 6?4s-u& _cyf7 ewliN meafat 64114.1 law* t')?VA-01-- -1�S` -F4'u-bet-(,.) � � � nV. asmaurns 9uputlipi aisProV*PM Asa* Wild)aUWN ?Ennio' '2" �� Sty arrow AllfrJpkL NDm4 Y H%9065 to 31VA0143II7 IMAMS Ili tlV`SflL$li00 OS*W1/VOr ddV ZLZ LY93£L4 xtd 0M-ilit£L4 atia4d 09OLO VW '�1 �\ 001, woos N -Page uPit Zit 0� ucidtueapod P.fcra yu \ \\// Section 4. ZONING All Idol Inti,,At Be Completed.Permit Can Be Dented Due To Incomplete information Existing Proposed Req®ed by Zoning This coloam to be Med inby E3kliegtki»ent Lot Sim Frontage Setbacks Ftom Sit Budding Height Bldg.Square Footage Open Space Footage *dog) #ofParhng Spaces Fill: Pelmet et Lactate) A. Has a Special Permit/Variance/F' tx��pver been issued for/on the site? NO 0 DONT KNOW 4l YES IF YES, date issued:. IF YES: Was the permit recorded at theRegi of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page and/or Document#r B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW CY YES Q 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 er-- IF YES, describe size,type and location: D. Are there any proposed changes too additions of signs intended for the property? YES © NO (,Y IF YES, describe size,type and location: E. Will the construction activity disturb i ,grading. .... ion,orfang)over I acre or is it partof a carom oar nm WOWS disturb over l acre? YES NO IF YES,theft a Northampton Storm Water Management Permit from the DPW Is required. SEM:045-OSE TGI SPROPMEDWORKIds-Ss�YcVir) Mae Hour 0 Adam 0 aRopcK�- Window Ml mini 0 Ir�pp��pR��m1Yp ❑ Doom CI Ac�ary swig. ❑ Dwroiabm ❑ Msw Sipa fly Dela fO 1T131•1 Oder lQ��l� wax: / 0 � rx+ oeio �, " II i�/ Sago l 41.-- 21, h/ 4�J1 �d /Ver_ Atardfon er g beeroorn_Yes /No Adding nee badman YeeMashed Nersalive Tb Pere Maths RDs -Sheet Raeaawp unfinished teierert _Yea %./Pic: —1111011111111111110101 a Use of bldg:One Fenny Teo Fawley Other b. Hunter of MOUS m each folly omit Number of Bathrooms C. la thin a gas¢atdded? d. Proposed Square footage of new mrstruglan. Darrsraiory a Number of stones? I. Metal of heeling? R eplsces or Woodfi es Mater of each 9. Energy Canievabon Ocnplince. Mmsdadt Energy Compee ser form attacked? h. Type of corwtrurAon i. Is construction renin 100 ft of t eeeMs? Yes _No. la construction wean 100 yr. floodpialn_Yes_No j. Depth of basement or cella flow below finished grade k Ws blldg conform b the Building aid Zoning rsgrttw s? Yea No. I. Se1tc Tank_ Firf Seser_ Private reg Gay water Supply Mann 7a-MIER AISSIai®►REN-TO aaSEEM Mai SEM Amy OR c90Mmacr tfreetes Fafkaa.wIEP6iR as Ower of the sabred property hereby authorize C) +67)V vi edne/lf eoni z14' f.cs,It ' to a4 on cry behalf,in aaSS matters redeye to by ihb b Wdq permit eppxcatm. I, 7 zA-I moi:!-wrz l 4.* as DwedMmtorreed Agan hereby declare the the ealarna.5 and infarrnnon on the foregoing rppaa6m are the atl accurst.,to the best of my knowledge are beSaf. Signed under the pens p��en��s and peradee d perjury. Pre Nene II ice J - /,/ of• Date LISand tte tor4 . NotA ❑ Nwtror U¢wwXatlw: 1 ..hnU CJ - 1 D S Cg35 ENaaleo ] P11 cqCingsr ~ a+- ru4, ` 4 aio3 ' l4�^ Add rior SIR �i s� sll a J -5 ' Tekphmre 56 I .I van Comma Nam Registration dentsa ieS4 t,• Rey�so-ca,7'Num / '7 Ad si4 l,he cs-nca .55-Free a / 71 /41 Expiration deoa a + �et d 0! 03$' TelephoneV /: e/7573? Workers Compensation Menance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result M the denial of Me issuance of the txremat Signed Affidavit Attached Yes It No 0 The current exemption kr"homeowners"was extended to include Owner-oceaekd Dwelling of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner am gp sanervien CUR at Sixth Edition Sarin 19835E EmEnition of Uemeoweer:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or two family dwelling,attached or detached strucnaes accessory to such use and/or farm stmcanes.A nenaan who emigrants mom than one has it a two-veer naiad dad net be amaiskred a beatowner. Such"aomeowcer"shall submit to the Building Official,on a farm acceptable to the Building Official that balsas stall be As acting Constructive Sa terrbor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,von may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature LI - S-m Ewa C__ / - S - -9 ---nryealtasxacaboo name moos tmaSUMo Ian a4 PaPMod email POPus P +1 eq a wads apy&rNevaPaline.Sat l c OS.argil wPIStfr gaiioW*CP Pim 7MIRQo a .o$ -tr'A.rriga. ' c 07 n'n -€/ UJ 6rTurn_- Muss'ko + �, S ( 1C't))f ' 46-7-ory i cc. 6 -) :SIOAPPV°mac Jiail p Y) .Mwo 6icliS1-1-4C -C fly swot gt-ADI � &W7 pasts-rvi-f 'AID ireMi-� 1.p'ru ' _" �•J f vmarairipv 4 S S/10 �o.' ,. ' :�..i1P�r du1a .... ..... •nom vi a.ws�Ra t2/v ssem� emsrar r ass�eer s ns as .w lipalORInZON mTO RISE60 Shawmut Road, Unit 2 I Canton, MA 02021 1339-502-6335 ENGINEERING' www.RISEengineering.com OWNER AUTHORIZATION FORM I. G)LN ) LL(Owners Name) Name) owner of the property located at: 23 /9/ o/l. z -,C Kx2oLLSs7Xf.— (Property Address) rif C6. (Property Address) 'rr-. jS F hereby authorize (Subcontractor) �u 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. G(i(/ 1 �- Owner's Sig ..ture //3 //7 Date 52016 The Commonwealth of:llaxsachusetts _. .._ Department of Industrial Accidents _9' Office of Investigations ', --'t' `' 600 Washington Street "t3 = Boston. M4 02111 s- moi-rm� www.mass.gov/dia Workers' Compensation Insurance Affidas it: Huilders'Contractors/Electriciaus/Plumbers Applicant Information Please Print Lezabls Name(Business Organizat ion,Inditiduau: SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street Cit}"StateiZip: Hatfield. MA 01038 _ _ Phone -r_ 413-247-5739 are you an employer?Check the appropriate box: Type of project(required): 4 am a cnera contractor and I 1. I am a employer nd, _8 i h_ Q Ness construction " employees(full and or pastime).+ hired Thetl umrartorc : � u nm a tole plopne[or or partner le 1 n. Ole ar ached cheer - J Remodeling ship and have no employees rn °°-e.no ¢n msec I 8. 5 Demolition working for me in an' capacit\. mo s sat h' crLer` q 5 Building addition [No workers comp_insurance comp_ mslran required.I ` Ti A e a Lorporathon and it. 10 Electrical repairs or additions 3.5 am a homeowner doing all work u ollicers h.i e exercised their I I.5 Numbing repairs or additions int still [No workers comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.]° I(11 and we hate no —, non'smlA workers t3.�1 Other_ compinsurance required_1 ' 'n 'ppicant that checks x 41 must WIPP lid out the seetton Ile Ittat ItPu in;::I k.,. sorneensation policy inlirrmuu.m item:caner.d htt submiuM1 s aR tae it indicatain the' de aietite r. .d. v r .. euntr tw .ubms mustI s\ attidas a indrearina such that Junk this hoe anon attached an additio ra sheet 1 .the a h-cua-mtors and stale at helher'r MPI IMMC entities hale eranleactas It 0c cult-cnntracturs have empl.necsthe. nim mw rdc their t.ttrap. anrp Btlant number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. insurance Compant Name: Selective Insurance Co Loh Site Addressor 1 r '. WC9024456 Expiration Nate 2/23/2018 �7 "/J�) .__._c rn N'. 1 ' - J! jjL - .__L�f" e,Zip: *LE( ll ems. ii)4 Attach a copy of the workers'compensation policy declaration page(showing the policy number sad expiration date). Failure to se ure coverage as required under Section 25\of MCA, c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500,00 and'or one-year imprisonment,as well as sir it penalties in the form of a STOP WORK ORDER and a fine ,rt op in5250.00 a des againa the s iolator_ Re ad :kit :t:op hot statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. L do hereby sen' oder t pains and penalties of perjun.that the information provided above is nue and correct. s / 7 $i,ri taturt. .__ __ _ Date. _ _ _..__ Phone s. Official use only. Do not write in this area,to be completed by ri(r or town official I Citor Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City low n Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ACORE) CERTIFICATE OF LIABILITY INSURANCE DATE/ Al/za/2G1 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 CONTACTCOCynthia Henderson, CISR Webber & Grinnell (ATONE C No Fal (413)5B6-0111 INC No):1<33)586-6401 8 North King Street nonrtlEss chende son@webberandgrinnell. con INSURER(S)AFFORDING COVERAGE NAIC p Northampton bA 01060 INSURER A:Selective Ins Co of S Carolina INSURED INSURERe Selective Ins Co of Southeast 39926 __. _.. SDL Home Impzovement Contractors Inc. INSURERC, 24 Chestnut Street INSURER D' INSURERC: Hatfield MA 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 TYPE OFINSUPANCE A DLSUSR POLICY EFF POLICY EXP LIMITS LIRD WVD POLICY NUMBER I MWDDIYYYY)'IMWOO/VYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED A CLAMS-MADE X OCCUR PREMISESLEaoccurrenJ_-_5 _-. 100,000 S2204065 2/1/2017 2/1/2018 MED EXP(Any one erson) $ 10,000 PERSONAL a ADV INJURY 5 3,000,000 6ENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 3,000,000 X POLICY jEo- LOC PRODUCTS-COMP/OPAGG S 3,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 A ANY AU-0 BODILY INJURY(Per person)• s ALL OWNED SCHEDULED e _— AUTOS ' A9100328 2/1/2017 2/1/201B BODILY INJURY(Pe accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS • K NON-OAUTOS .lit@(emtlent _.. . 5 Undennsured motorist el split .s 100,000 x UMBRELLA LIAB -x OCCUR EACH OCCURRENCE 5 1,000,000_ A EXCESS LIAB CLAMS-MADE AGGREGATE s 1,000,000 DED X RETENTIONS 10,000 52204065 2/1/2017 2/1/2018 WORKERS PER OTH- ANDEMPLOYERS'LIABIl1TY y/N EL EACHAC _'tE R_ ANY PROPRiETORIPEXECUTNE EL ACCIDENT 5 500,000 OFFICER/MEMBER EXCLUDED? y NIA — ---- - B (Mandatory In NH) -- - WC9024456 2/23/2017 2/23/2018 EL.DISEASE-EA EMPLOYEES 500,000 If res.0eambe under - DESCRIPTIONOFOPERATIONSbelow EL DISEASE-POLICY LIMIT s 50 D,000 DESCRIPTOR OF OPERATIONS I LOCATIONS]VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if 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, MA 01581 AUTHORIZED REPRESENTATIVE C JenlersuL, _ISR/C16 AS • —YSz.0.0m ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nm4nn