25C-037 (6) 17 NORTHERN AVE BP-2019-0192
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Btock:25C-037 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-2019-0192
Proiect# JS-2019-000316
Est Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq.ft.): 5009.40 Owner: WEISE MARISSA
Zonin2,URB(100)/ Applicant. PAUL SCHMIDT
AT. 17 NORTHERN AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.8/15/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.2360 EXTERIOR WALLS -ALUMINUM SIDED,
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 Shmature:
FeeTvoe: Date Paid: Amount:
Building 8/15/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
y,v au[,r4n&U
City of Northa npto
t Building Depa tme t ,
212 Main S eet AUG d 20 '
Room 1
Northampton, N N0 on cuu
phone 413-587-1240 F 1,11,2721^
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING `
SECTION 1-SITE INFORMATION O 'M1 I L
1.1 Property Address: This section to be compialad:Dy n
/� Ifni-m
4r-e- a�C Lot 0 „nt_
0' 64-PO zeas Gwd f
Olatfict—
El.SL District CB Distrkt
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2jMrr of R ord:
/1/155 Q� / \.b$.Q.. �,�Q � � �i7✓� /'/�. T11�''�-
Name( IM) � CumpHalling res � . ^
C-p—t � -t1� Telephone
Sign ture
2 gent- Sbt. nie Pr/cJe
.�en nt ConH�tc <s,T,✓c
N.mefjkV CuveM Mailing Addresa:tigT QIV3si
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollare)to be Official Lee Only
completed by Wmnit a licant
1. Building 96'\^ (a)Building Permit Fee
2. Electrical LX-� (b)Estimated Total Cost of
Construction from.S
3. Plumbing Building Parmlt Fee
4. Mechanical(HVAC)
5. Fire Protection /
6. Total=(1 +2+3+4+5) ` J (7(�. Check Number
This Section For Official Una Only
Date
Building Permit Num Issued:
Signa re:
BWHI m"weimnspector M Buildings Dete
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Alt Inksmation Must Be Completed.Permit Can Be WnW DW To Incomplete Information
Blasting Proposed Required by Zoning
1 cokane W be fital in by
B,dWiM Deparbnent
-----------
L.ot Size i ----------
Frontage
Setbacks Front
Side L-�PU — L: R--_
Building Height
Bldg,Square Footage %
Open Space Footage
----- - %
(W..i., b,s&P.,
Para 1-9)
#of Parking Spaces
Fill:
A. Has a Special Pemnit/VarianiceffindlL"er been issued for/on the site?
No 0 Dowr KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 DONT KNOW YES
IF YES: MW Book Page and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0' YES 0
If YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtaftserl 0 Date Issued:
C. Do any signs eNO e---
east on the property? YES 0 W
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the prop"? YES 0 NO (gK
IF YES, describe size, type and location:
E Nil the oonstrs1lon actively disturb( ering.grading, �,or filing)over 1 acre or is it part of a Common plan
Mat will dsbgb over 1 acre? YES NO
IF YES,than a Northampton Storm Water ManaWnent Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all.aeoliceble)
New House ❑ Addition ❑ Replacement Windows Aftemtion(s) ❑ Roofing ❑
Or Doom D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks IC3 Siding-CZ
Brief Description of Pro
Work 02. �L/Q Sr—
_J yUL�C(IL
Alteration ofexisting bedroom_Vas No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Ves ✓ No
Plans Attached Roll -Sheet
SO. f.New-houaaandlwaA .tss> a
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 stories?
f Method of heating? 7uiidingand
Fireplaces or Woodstoves Number of each
g. Energy Conservation Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within s?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
j. Depth of basement orw finished grade
k. Will building conform nd Zoning regulations? Yes_No .
I. Septic Tank_ _ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize ��I. -YK7/Y12. 4'Y1�rDJ'2�YtE/T�' l h✓tfYQc.^�T�/'S/ 1n C._
to act on my behalf, in all matters relative to work authorized!by this building permit application.
5z4— a-H-zycl,a c-
nature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing appficabon are true and accurate,to the best of my knowledge
and belief.
Si
uner the pains and penalties of perjury.
mi
Print Name
Name
SiofOm / ntl�({l Date
SECTION 8-CONSTRUCTIONSERVICES
A Lloensed Constructs n 3 or. // Not Applicable El
Name of Licence Holder: 4T
License Number
Addres Eplratlonruns
S store Telephone
9.Reaidend Honrfinerowmnd pnbact:lc Not Applicable ❑
Sbt- 44prye �r»amf2mr.rF �inl,acfocs,Tn� /�`i'�/is
&Cqggglay N me Registration Nmbar
Aa�aress �- Eoyirenon ale
li/p+�eJd YV�F} D/b38 Tee[hnne
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Woroars Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide Nis affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
Massachusetts
i
1\ DNPARTMQtT Or NNIIDINO ZNSPNCTZONS ? �T
212 Nein street . Wnicipel aoi141ne 'ai rCs
Northampton, Na 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing 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 anypr xisting owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note.If the homeowner has contracted nuth a corporation or LLC,that entity must be registered
G
Type of Work: ..t, or1 '✓ Est.Cost:_
Address of Work: / �'d'f a ry l •+ri/�-'
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reeson(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 RESPONSIBHdTES 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[lipp.t�u`e agentpfthe Ml lvger. �J /
�S`dLTIIJVVfYLL��SGGn
Date Contractor Nime 4 ?LC(oK-5, 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
City of Northampton
Massachusetts
lOF BDILDZNG INSPECTIONS
DEPARTs
( MENT 2
212 Main Street Municipal Building
NorGampton, 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:
I i lV"Au ✓ n 40'V--9—
(Please print ho se number and street name)
Is to be disposed of at:
W
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
� s-� - �
Signature of Pe 'mit Applica—nf or 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.
The Commonwealth efMassaehusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-20177
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADolicant Information Please Print Le tibly
Business/Organization Name:
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or Part-time).* 6. ❑Restaurant/Bav Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 1Q❑Manufacturing
no employees. [No workers' comp. insurance required]*
4.ElWe are a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees. [Ne workers' comp. insurance req.] 12.0 Other
*Any applicant that thee"bus#1 must also fill out the section below showing their workers'compensation policy ammonium,
"IfNe corpumte officcn M1ave exempted thevuelves,but the corporation bas otheremplovees,a workers'compensation poliev is required and such an
organization should check his#1.
I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. 0 Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fore up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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 certify,under the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date
Phone#:
Offleial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License 4
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone is:
www m ss.gov/dm
RISE60 Slunvmul Road,Sullc 2 Cnnlml,MA 02021
ENGINEERING
OWNER AUTHORIZATION FORM
Marissa Weiss
(Owner's N:mu)
annar nfdw Prul'<0Y lawcd M:
17 Northern Avenue
(Sueel) _.---
Northampton, MA 01060
---. (Town,Side."/_Ip)
hentyemhodm
(Suheommdor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a budding
permit and to perform work on my property.This form is only valid with a signed contract.
Ther Permit will by seared 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.
�� C
TOMER IGNA
h'w.lscr Ir 201 � _ _ ..
SIGN DATE
]2S201]
�•
The Commonwealth of Massachusetts
- _-� -
Department uj[ndusdia{Accidents
Office of Investigations
600 Washington Street
e Boston, MA 01111
wweemass-gov/dia
Workers' Compensation Insurance Affidavit: Builders/( ontractors/Electricians/Plumbers
Annheant Information Please Print Legibly
Name !nL,l➢e,.tt eaN[ali0o Indn idaal l: SDL Home Improvement Contractors Inc
Address: 24 Chestnut Street
Cin Stater Lip: Hatfield, MA 01038 Phone 413-247-5739
Are sou an employer?Check the appropriate bits T)pt of project(required)
! (� I muelnpioNet aith 4. ❑ 11n Il nerd <nuaUuAndi _
'yQ It O
elo losees(tull slid:or part-love) ha+ hired [h, II noauors _j Nes, C n INCL IJII
7.❑ I am a sole proprietor or partner- I .t d on the :ntaehrd.heel I ❑ Remodeling
ship and have no employees I he, ,th ,oatractor,hat, g. n. Demolition
tit . ha e
orking for me in ane aaPaclb- P and oork", v Building addition II
e t ss trkss comp insurance ml 1 nn
rqud.�'r- ? ❑ is v r' n rnl n and t 11) LJ nneal repairs or tddnmm I
- II Into cs r I. I Th'a 11 Plumbing re air>or additions
+.❑ I 'In- homer w ruolnp all work ❑ b P
nrc.JLutw No light t tempt nper MUI
I comp 13.❑ Roof repairs
nsumncc agn,,ed_l ' �IWI.a i hat,nn
mpIo ,,, slyke,, 13.[20ihel Insulation
' comp insurance reyuircd i
'Am ury,l¢an lltn,hrok.lx. -1n Inlw,fillon Ill, 111,11, 1' _ .niers , nrpc�, rn[+Ae, ml.✓muunn
r • alo,Ya,rl tlr,uIfdu,a"id - I elht„u.J n Ila vied t �1111Wbnntn LLm Uranyl A,[
un
(....r]tlA.,CLtrk lho Ml nl,bl NIIaJlba net lVJannTOl,M1y'�ehn„inY the rreilK..l lh,,ub-:nelluenMrtl,ltllC xlK'llrir ul Out llM,v`[1111¢,hrv,c
orel-is, 11 cob-umow'um lraw cmplotcu.llk) n tl pro,Wnhe k,r, - mit qA11,AnIvi,
1 am an rnlp/oyer that n provMnsp wonFrrs'rnmpensotion imuram'r Jnr my empiayres. Be{ow Ls rhe po{iqand job sae
anfnrntmbn.
Insurance Company Name-. _ _._Selective Insurance Co
oss f m Self-ins/. I.ie R 1WC9024466(� �� ��-eI:vpuauon Date 02/23/2019 "�
anres,e Add ,7 1'✓lP�r'1 4 , _ _ pity state'Lip'.�(}-(44,Aryy f+00
Attach a copy of the workers'compensation policy declaration page(showing the pokey number and expiration dale).
Failure to secure coverage as required under Section 35A of MGL e 15'_can lead to the imposition ol'criminal penalties of a
fine up to$1,5A)M andmr one-year imprisonment-as st eil a,cit I! penalties in the form of STOP WORK ORD[ R and a title
of up to$357 W a day against the eiolalor. Be adsised Ihnl a cop, of tlm>statement Ina. be forwarded m the Offiee of
Investigations of the DIA for insurance coverage verilicalioo
1 do hereby cert" oder paint and peno/nn of perjum that the information provited above is true and
(�correct.
h� e 3 7-5739
flffkiol ase only. Do not wine in this area,to he completed Ar tin•in,town off{eial
Cit,or Town: _Permit/License a
Issuing Authority(circk one):
1. Board of Health 2, Boadbi Department 3.(:it.,Jown Clerk 4, Electrical Inspector e, Plumbing Inspector
6.ether
Contact Person: Phone a:
,acoedX CERTIFICATE OF LIABILITY INSURANCE D• IMNmnnYYn
�- 1/15/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I
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 certif Ca a holder Is an ADDITIONAL INSURED.the polic,i..at he endorsed. If SUBROGATION IS WAIVED, mbjed,1
the terms and conditions oft"policy,retain policies may require an endorsement A statx ent on thle cmtiflcata dma not confer riphn to t
mrti caps holder in Ile.Df such andammyEwM(s). _ J
PRODUCER IEyMai=EP Cynthia Henderson, CISR
'Webber 6 Grinnell ria Em. (113)586-0111 AAMC MI,Iu"Eeo-E°x.
e North Kin, StreetIAoMEse chender...simbbarendgrinnell.com
' IMUREMe afFORpHO COVEMpE NXILF
Northampton tM 01060 INWRERA3411ectiw Inc Co of S Carolina
INSURED I165URM a Selective Ins Cc of Southeast 39926
SOL Home Improvement Contractors Inc. NFUNI
24 Chestnut Str9at IINSURER
NSURENE
Hatfield HA 01038 wwREaF
-COVERAGES CERTIFICATE NUMSER3laeter Exp 2019 REVISION NUMBER:
THISIB TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TC THE INSURED NAMED ABOVE FOR THE POLICY PFHI00
INDICATFD. NOIWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY Pi RETAIN, THE INSURANCE AFFORDED 8" IIIE. POE CIES DESCRIBED HEREIN IS SUBJEC' TO ALL THE IF HMS
EXCI USIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS
rya, MOL SVM POV11" .29=1
9 F.XP MITA
iYR OE IxsUMxCE POLICv
L1A xuR X COMNERrIR DENEML LwBILItt 15.NRRENO a 1.000.000
oaue['O RCxrzO 100,000
A J4r.6-IA,' X V[Gdn "Li,Ea arvrnrcei
94204065 1/1/291E x . z 10,000
I w,.NA euv.v�¢ f 1,000,000
I ( pp 11 IEP=A R ...,. 3.000.000
xN-I IMII4� � `
OlfOp� 4H. DMogo Tr'C a 3_000,0001
AmmomLEUAMUry ^III' S 1.000,000
M
� A Ily U 1011 NI
P YE D X51 q
_ , 06A9100326 <. ] 1 J _ 1
-I S
NONA—'-
K RECO W 09 X OS N
100.000
IT UsaRULA LINE X b.... E, C"SREhCE 5 :_000.000
A RDEft wa q.eBMACF A<...11, 111 a S,OCp.000
D[J X +ct to npNS 10 000 52204065 I"2L 1/:/2019
LVg ERS COMPENMTION X SrgpTE X
MUEMPLOYMSLIRaIL11Y
:1a -IT.11'.11A N RUL or vyx NIA. .1IL A 5 500,000
H I'Mmm YroN.) EX902ai56 2/b/20:6 2/23/2%9 b_ cr[{ 5 500.000
yy oe.iXx
OFSf.R.➢TION OF OPENA"9FS Cbav: 015CASE PDUCY,IM1' f 500 000
OFNWi OFOrtMVMSfLOCATONSIVEHICLESIALORDIDI,b11XIPVI RPmtltSCMeWt.mry GLXatXtY✓mon Py[rNnplrrMl
The Worker. Cos,aammt... policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas
Schmidt.
'Columbia Gae of research u..tts ie hereby named as Additional Insured per written contract with respects to
General Liability L Auto Lisihlity, for work performed, and per the terms and conditions of the policy.
I
CERTIFICATE HOLDER CANCELLATION
SHOULDAN OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
Columbia Gam, o£ Meeeachusett. THE EXENEXI N DATE THEREOF, NOTICE WILL BE DELIVERED IN
4 Technology Drive Ste 250 ACCORDANCE WITH THE POLICY PROVISIONS,
Westborough, REAL 01581
r41lt1oeg0 RPAESENTAINE
C 13862014 ACORD CORPORATION. All rights reserved.
ACORD 25(2011/01) The ACORD name and logo aro regWered marks M ACORD
IN502Y20 a0-'