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25C-162 (3) 12 ORCHARD ST BP-2018-0979 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 162 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catc¢ory: INSULATION BUILDING PERMIT Perm¢ro BP-2018-0979 Proiect# JS-2018-001783 Est. Cost: $1000.00 Fee: 565.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor. License: Use Group: PAUL SCHMIDT 103635 Lot Size(sg. firT 9496.08 Owner. KOCHAPSKI STANLEY I& KATHLEEN zoning: URB(100)/ Applicant. PAUL SCHMIDT AT. 12 ORCHARD ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.4/3/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.INSULATE STAIRWELL, DRILL & PLUG METHOD, BLOWN IN CELLULOSE 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: D,h,ewav 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 4/3/20180:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner �nsu,ta�-Pv-r, City of Nort am ton (� Building Rw rao 2r roe _�_: 212 MainSM Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION S-9 79 i.t ProoeMAddreeM: TirM:as�flaGiss �a D,chQ,-d s f +•��C� �� f= Eon et elwla Castanet- SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Regard: )44,71s-aL4 c 5K4 1,2 Name(Print) r—� CurterR Maingress' �� /' J/ 9 Telephone Signatur 2,2 Auds .dAgisat. Sb� mz P � rernemr Coafi�c �s,T�c /Y74 Cunem Nartre Mailing Address: �Ip3si _y%;�—a</7-,6- nature Telephone SECTION 3-ESTIMATED C-O�aTPia` L-fTS Item Estimated Cost(Dollars)to be Official Use Only corn leted by oemnit applicant 1. Building nDO. c, (a)Building Permit Fes, 2. Electrical IJ (b)Estimated Total Cost of COTAMMOM from 06) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection fi. Total=(1 +2+3-4+5) Ctretlr Number /67 laal Building Pemit Number. (late Issued. Signature: Lit y BuiMg CommmiooegrepedprafBuidogs Dale EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Itxfmmation Mat Be Cmnpieted.Pemdt Can cue Denied Due To lrcnmplete kdoa avon Existing Proposed Required by Zoning Thisc tunnmf moilinby Belding DV m Lot Sim Frontage Setbacks Fmn[ Side L�R:.— L- R: _._. RM Building Heigh __.._. Bldg.Square Footage ____.. _.. .._ % Open Space Footage __ % #ofParking S eul: A Has a Special Permit/Variance/Find been issued for/on the site? NO O DONT KNOW 0 YES O IF YES, date issued:'. IF YES: Was the permit recorded at the PPgfs ry of Deeds? NO O DONT KNOW YES IF YES: enter Book Page and/or Document#'. B. Does the site contain a brook, body of water or wetlands? NOL O DONT KNOW 0' YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO Q-- IF /IF YES, describe sire, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO e' IF YES, describe size,type and location: E. NNI the construction actively disturb(67 ,Waditl or Mling)over i aae a is it pint of a connan plan Chet wd1 dsanb over l ace? YES NO IF YES,then a Nwthampfm Ston Water Marugemexu Pend from the DPW is required. SECTION b DESCRIPTION OF PROPOSEB•WORK IcMecic aN aoPkahksl New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing E]Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q SidingOfher[ Brief De - 'on of ProPase o�0--1 /'n 1 0-.� au-ZILp- Wo5--�- Alteration of existing bedroom_Ves No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes ✓ No Plans Attached Roll -Sheet SL# a. Use of building OneFanI 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 stories? f Method of heating? Fireplaces or Woodstovee Number of each_ g. Energy Conservation Compliance. Messcheck Energy Compliance form attached? In. Type of construction Is construction within 100 ft. of web S? Yes No. Is construction within 100 yr. floodplain_Yes_No I. Depth of basement or cellar flo below finished grade k. Will building conform to th wilding and Zoning regulations? Yes No I. Septic Tank ity Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED M1EN OWNERS AGENT OR CONTRACTOR APPLIES FOR BiIN.ONM PEiMT I. as Owner of the subject property 1 ' -�1/ - hereby authorize ���1.. Mo/Y12.. 1'{'V1�1�1�E=/"1-)ClY�" l J»"ITYAG'tCal'.S� :Z—n - tc act on my behalf, in all matters r 21tve to work out onzed by this building Permit application. Signature of Owner Date I, I S M 1 � as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sign under the pains and penalties of perjury. ctu I .`3 '. f�1— PnntName 8igjVureofOwnefyA§I Dale SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constru 'on Su or: // Not Applicable ❑ Name of License Holder �T Ab3[p 3 J Lcenee Numbe sLiutf Sof "c/ /�! via38' Sao ezo � Adtlres Expiration D to S ature P, Telephone 9: '//�__ Not Applicable'/❑ 5}�L 4-1oi ✓!l rn f rrLa of zlck Acta[.. Z � /`2'4 fS Co / Registration mbar 7 Address Eryiration Date l-�'p+�ieidl MF1' D/G3� Telephon�a ���� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, Workers Compensabon Insurance affidavit must be completed and submted with this application.Failure to provide this affidavit will result in the denial of the issuance of the buildi pennK. Signed Affidavit Attached Yes..... No...... ❑ City of Northampton Massachusetts s _. ....... DEPANTl�N4 OF SDILDING INSPECTIONS ]12 Hain scree[ aHueicipal Building eiorthampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: se �1�12�er Str (Please pont house number and street name) Istobel disposed of at: T I I j'r'i1Q h ./Z. 0,40J.i �t (Please pnm name and locatio of facility) Or will be disposed of in a dumpster onsite rented or leased from: I�e rr16L-fl! lrl�' �2 C A1C L/ (Company Name and Address) Signature of�'e�riit ApplicaWor Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. City of Northampton — _ Massachusetts lan'ln2THBNT OF B=WZNG INSPECTIONS 212 Hein ii [e t a ei-icipal Building Noxpa ton, a. 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractor and subcontractors perforating improvements or renovations on detached one to four family homes.Prior to performing work on such homes, a contractor most be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the`reconstruction, alteration,renovation,repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any preexisting ownaroecopiod buttolft containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or bolting"be done by re Mertd contractor. Note:Ijthe homeowner has contracted with a corporation or LLC, that entity mast be registered Type of Work:- 12h�/y _ Est. Cost: -fl'oLo Address of Work: /"Q - Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building t as thea ent f the o r Date ContractorN e Ct1t - xS� HIC Registration No. OR: `notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature RISE60 Shawmut Road Unit 2 Canton, MA 02021 ENGINEERING OWNER AUTHORIZATION FORM I, Stanley Kochapski (Owners Name) owner of the property located at. 12 Orchard Street (Street) Northampton, MA 01060 (Town, State. Zio) hereby authorize 0000 (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 costit is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. /K/ 1)76- L" -Customer Signature -Sign Date 2/26/2018 ]be (imrmntoceafth of lfassachasetrs Department of Industrial 4erident OJfee of7nvestigations 600 W'ashingrmt Street � Briton,SLI 02111 `` wwtr.mass.govldia Norkers' Compensation Insurance Affidavit: Builders( antractors/Electricians/Plumbers Applicant Information Please Print Legibly \amt I hwi Is"alr. SDL Home Improvement Contractors Inc :Addrees: 24 Chestnut Street Cin State'Zip:_ Hatfield. MA 01038 Photiv 413-247-5739 Are you an emploI Check the appropriate lms —� 11 Tips,of protect(required) am lame llh I' Itlucer u8 r ^ V wnsuvcGon nq : ui �r pall-Wnei * I I'll III,pl ❑en?or partner- P.a r.� Fie, �!teralcl ing hip and i,a,e ro etnployces Ih Ih c, lvn lot.na.r F II><nu)titan. +rkioc §,r r roam capacifi n me _ Rulmn_ dnuon �l rl.cr ..amp ul+uran.c 5 U I � _. 1 "All'al tepuin of adduua. ' ❑ I r n�<' ::.n r. II h II I ,❑I Plunhtng wpam n addlon. - 1IIIIII! I'll' 11011,LL11 LoIEI' h . n pf Ix Mod I ❑ Rr I repo r. t.0 gree ray J L : i l a w Uhei Insulation :mliP +rouranu r"J'I"eJ 1It, 1:I nITE"En L" 1 L,.I'L I '­r"IILI �ll tilt.h.4.fE . lit"'I'd 11 ntI Ill. " ..,.. . .h. i . ire".,Eur .—ti t,,,Ii . Ln. ya: :.W M1a I .. I t en.lai 1 am an emplm'er that is providing worket ompensation imuranee for artemptalYe.s. Below A the polier and/a6 sift Informs non. inwrancc Comparr. ',ams,. Selective Insurance Co -OI \elf-la. l i. WC9024456 Lcpirauon Dale. 02/23/2019 i.�b Sim Addrec.. - -s� A /� -L�rzLzl�d �+ , rt, ylatcZip.X7/ u1 }'lv-E hl Attach a copy of the corkers' compensation policy declaration page titillating the police number and expiration date). Failure to szcure cot arage as required under Section '_5A ul Wit "7 tan (cad to the Imposition of criminal penahies of a tine up to S 1.5((((,60 and or one-year impnsonniI m iced as avli penalties in the form of a STOP WORK ORDER and a fine .nor ro$-Flt it,e day against IlEw t ioixor. Be ad,iscd ihm ,r :ap. Inti),slamtnan Ina, he,firnvarded Io the(Itiiee of m ev ivauom of the DI A lett insurance coverage .cif I ica(um 1 do herebi ,ert'__sr'# leder I pains and penahie,nj perji rhatth the mJormalian provided abrme is true a(nnd conn�t. Pllune ✓ Official pie only. l)a nor write in this area,lir hr completed hr tilt or town official. SII Citi or Tax n: _ PermA,l,icense9 issuing Authoress (circle one): I. Board of Health 2. Building Department De 3. (-i(A loan ( lerk J. Electrical Inspector pecmr 3. Plumbing Inspector h.Other_ Contact Person: Phone<: A`"Rbr CERTIFICATE OF LIABILITY INSURANCE 1/15/2018 THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE ODES 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 pDlicy(iea) must he endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain pChOun,may require an endorsement A statement on Ihls certiflcale dose net confer rights:o the certificate holder in lieu of such endorsement(s). PRODUCER Cynthia Rendazeon CLSR .Webber 6 Grinnell PRONE (413)586-0111 .11 8 North King Street E. chendereon8wabberand9=innel-cort NBURERFSI AFFORDING COVEMGE .AICA Northampton t4A 01060 NSURERA.Selective Ins Cc of 5 Carolina nelEte .NRUAL.Ir Selective :Be Co of Southeast 39926 SOL Home Improvement Contractors Inc. NSURERC 34 Chestnut Street .,onerO VSURERE Hatfield DfA OIC38 COVERAGES CERTIFICATE NCE , S 1E E BE,OV exp 2019 _ REVISIONNUMBER: _ INJIC iIS 5 TO R 1'c n1TANDIN °OUOIIE UI INSURANCE-E M 9 BE,E]VI)"FON BEL ON L -T OR I'HEREC CAVED/BONE E SPEC'TOL ICV ut AID -HE I-FnTI- EO NO I MAI BES$11 ED ANY ' -OIREMEN' TERM pR CF .J ON OE All I ,OT I? OR OTHER JOCJMENT WITH NFSYECT TO HE 'f MS CEC,I S NS MAV BE'S50_S OR -- -OR CSAIN -,IF N9CRANCE A'%O VFEC B 'E 401 -IF ID ELAIBE0 HEREN 6 SJBJEC"C 1- THE !F 9M5 EXCr JS DNS A'.D CONC'ION50=4:.Cn TO E LMITS Si� A. I�.A`h 9F-Y RFCUCE':P'RAIO CiAIM9 ♦DSL SUBP npOCV FR nuLMV EI vq CV X COMMEPL LOGENERA xLUBIe TY 5 00, (1 A xlOe.O-0 .:..OED - i acc.0-10, 3.OUL.000 z = , ., LOL.G001 X X x . N L r... ,A%AZ _ ac,ac01 X MMeRELuiae x ,.� . . E.c.60A. a _ GI . JI 0 X n TJ[. 62aCC 65 AI M E 5 M 5 x 5 > VyASOC.100 B ebry ♦ I WK2445E 201- 2 13/?tll I A Y 3 5 50'.000 -1 1,0111 l- - sE S 500"000 OESCSvi Oi N OFOPERA➢ONS LOCATIONS.VE nICLFSIACOR0.01n rYv Scrye lauem ^ •ep:vRUl The Workers Compensation policy doe. not R:RnCludc c.ovevage for PaolSchmidt, Kendrick Dempsey and Doug-as Schmidt. _o:urria Gas of Nassachusetts ce hereby named as Additicna: Insured per written. contract rith respect. to General Llablilty 6 Auto Llaihi ly, for ..Ck p.rf0_Tnuad and per ohe terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SXOULO ANY OF THE ABOVE OFSCRIBFO POLICIES BE CANCELLED BEFORE Colusibia Gas Of Mab Ba Chusetts THE EMPIRATON DATE THEREOF. NOTICE WILL BE DELIVERED IN 4 Technolocry Drive Ste 250 ACCORDANCE WITH THE POLICY PROVISIONS. Westborough, MA 01581 AUTBomaaD REPRaSENTAmE 1gSS-2014 ALORO CORPORATION. All rights rosarv4d. ACCORD 35(3014101) The ADDED,name and logo are registered marks of ACORD 'NS035 n._,