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35-117 (3) 30 DREWSEN DR BP-2019-0354 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 117 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-2019-0354 Proiect# JS-2019-000580 Est.Cost: $3000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use rou PAUL SCHMIDT 1Q363 Lot Size(sg. ft.): 6490.44 Owner: KOCOT SHAUNFEN zoning Applicant. PAUL SCHMIDT AT: 30 DREWSEN DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413)247-5739 WC HATFIELDMA01038 ISSUED ON:9/24/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-875 SQ FT, 11", R-40 ADDED TO OPEN ATTIC SPACE 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: FeeTyRe: Date Paid: Amount: Building 9/24/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner y. rn sula , o 0 Department use only `.. City of Northampton =° rn S f Permit Building Department � -° C Driveway Permit 212 Main Street oo eptic Availability Room 100 5 ell Availability ` Northampton, MA 0106 o m oT �o-�'� is of Structural Plans phone 413-587-1240 Fax 413- 72 O° P TZPlans — $pecify APPLICATION TO CONSTRUCT,ALTER, REPAIR,EENOVATE OR DEMO ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ���/� �7 1.1 Property ddress. This section to be completed by office 1 1 ��� Ma Lot Unit o/ v - Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ` Name(Print) Current Mailing A dress: Telephone Signature 2.2 A&Ahorized Agent: Sb� " � �►'����rL���f � '�S. 1V G ;�nma""ee P ' Current ailing Address: 'e4 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee #06 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 0(� �- Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: _� Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) ` w F R4� ^...... _........_.w �, Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department LotSize ..�"�`"„""_____.� _�__ �___.__ _ ______ �.,•. Frontage Setbacks Front - --' Side L:= - ' R: - L• _ R:s.. _ Rear Building Height - -Bldg.Square Square Footage - - ay, Open Space Footage �. _ °Yo (Lot area minus bldg&paved aritin #of Parking Spaces Fill: _ i`• (volume&Location) 1 A. Has a Special PermitlVariance/Finding ver been issued for/on the site? NO Q DONT KNOW 0 YES Q IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Gi/ YES 0 IF YES: enter Book Pagey� -- - T ! and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW (2y/ YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: _.._ C. Do any signs exist on the property? YES © NO 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 IF YES, describe size, type and location: ; E. Will the construction activity disturb(ring, grading,ex vaton,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[ Other[C9! L Brief Desch 'on of Proposed n Work: �, f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes V/ No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: 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? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i i. Is construction within 100 ft. of wetla/ds? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar flo (below finished grade k. Will building conform to thuilding and Zoning regulations? Yes No . I. Septic Tank ity Sewer 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 y��!.� I'YLC�. Y)�f����' ►'1�YGc c,-f7���5 , -L n G'_ to act on my behalf,in all matters relative to work aut orized by this building permit application. Signature of Owner Date 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. Sigra'an under the pains and penalties of perjury. I m i'14- Print Name �✓ 9 - i Sig&fure of Own / nt Date r SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Su isor: Not Applicable El Name of License Holder. C ! o,3 &,3 5— License Number" 1,2 Addres Expiration D to Si ature 1 Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Comr)anv Name )) Registration Npmber Address Expiration 15ate Tel�hone 7 �� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) 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 builclin2 permit. Signed Affidavit Attached Yes....... No...... ❑ 9 City of Northampton Massachusetts ha DEPAR2WNT OF BUIbDING INSPECTIONS 1 212 Main Street •Municipal Building \ Northampton, 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: J� !��� P '12 -t7Sol�� �d t s—� (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: *�A\ J`e- t lel (Company Name and Address) ignature of Pe it 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. I I i� City of Northampton Massachusetts DEPARTMENT OF BUIZDING INSPECTIONS 212 Main Street • Municipal Building Jyb Northampton, MA 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 must 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 pre-existing 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 with a corporation or LLC,that entity must be registered Type of Work: � Est. Cost: 3 Address of Work: c�jC ii -S-� `t"( ID Q c 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 RESPONSIBILITES 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 pegniit as thea ent�pof the oVme r: Date Contractor N e C1t;rA+.C{-a,-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 i i (DIUmbia Gas of, MassachLlSetts 60 Shawmut Road. Unit 2 Canton MA 02021 A NiSource Company OWNER AUTHORIZATION FORM Shauneen Kocot (Owner's Name) owner of the property located at: 30 Drewsen Drive (Street) Florence, MA 01062 (Town, State, Zip) hereby authorize f� �__ (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 mu ipality at the completion of this work. 'Ir -Customer Signature ,-Sign Date 5/8/2018 _ The C'ontmonsvealth of Massachusetts Department of Industrial Ac•ridents -. DJftce of Investigations T 600 If ashington Street - Boston. 41A 02111 www.mass.gov/dia '11 orker,' ('ontpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber, Ant)iicant Information Please Print Le0bly Name(liusiiic.-�s"ur za6ouittdiridua)):— SDL Home Improvement Contractors Inc Address: 24 Chestnut Street Citi/State/Zip Hatfield. MA 01038 Phone r.: 413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor <tnd I /' __. g + have hired the sub-contractors . ❑ eH construction employi:es(full aftd`or part-time). 2.El am a sole proprietor or partner- listed on the attached sheet. 7, ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' q. ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing,all work officers have exercised their I V0 Plumbing repairs or additions myself. No workers' conp right ot'exemption per MGL c. 152. 01(4).and we have tit, I ❑ Rtxtf repairs insurance required.] Insul tIo� 133 Other _ employees. [No workers' - _ -- -_._..... comp. insurance required.) ',1n%applicau that c'heta6 twrx#I must alai till exit the station hdow showing,their worker compo mkin fx)lic% initw tuuitin. 'ljoate %riets wixs submit this affidavit indicating the),are doing all work and then here twtsidc wntructon must wbri i a new affidavit utdi,ai ng such Ut-witractom that check thts box must attached an additional sheet vhnwing the name t4 the sub•.xtntractiieti and;tate whether or rust thoic entities have emplo)eo. tf'die Duh-.csnuacu*rs have employee~ they+trust provi&their world, ,„mp polio mmnK-r I am an emplgver that A pmvidin,q worker'compensation insurance fnr no,emplgvees. Below is the polit:Y and job site• information. insurance Company Name: Selective Insurance Co Policy#.or Self-ins. Lic., : WC9024456 Expiration Date. 02/23/2019 Job Site Address: 11 U f' Q 7Sr�� f' - _.... .-.__ t. ity State 'Lip 4- C-i- t m� Attach a copy of the workers' cumpensation pofic. declaration page(showing the policy number and expiration date).CA`�a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 5250.00 a day against the violator. Be advised that a cop} of this statement may be forwarded to the Office of investigations cif the DIA for insurance coverage verification I do hereby cert' nage t 'p�ai,ns/and penalties of perjure That the information provided uhure is true are,!s nen c t. �i�natws: _.-.... _ --Bate. .__ -%7- 1 Phone Oficial use ontr. Do not write in this area, n,he completed br.itr err town official. CitN or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.CityfTown Clerk a. Electrical Inspector 5. Plumbing Inspector 6. ther (ontact Person: Phone#: ��"'� DATE(MM/OD(YYYY) 4C CERTIFICATE OF LIABILITY INSURANCE F1/15/2018 THIS CERTIFICATE 15 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(iss)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). PRODUCERCONYACI NAME Cynthia Henderson, CZSR Webber & Grinnell PHONE (413)586-0111 FA)( 413)3!6-6181 LNC.Na.Ent!: (AJC,NO). 8 North King Street IE,MA)L ADDRESS chenderson@asbberandgrinnell.com i I NSURERIS)AFFORDING COVERAGE NAIC a Northampton NIA 01060 INSURERA:SelQCt1VQ Ins Co of S Carolina INSURED INSURER 9.Se1QCtiVe Ins Co Of Southeast 39926 SDL Home Improvement Contractors Inc. II`INSURER 24 Chestnut Street INSURER0 NSURER E ;Hatfield MA 01038 NSURERF COVERAGES CERTIFICATE NUMBER:Master Exp 2019 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 DOCUMENI 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 ADOL'SUOR POLICY EFF SXP LTR TYPE OF INSURANCE POLICY Num4mR V UNITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE 3 1,000,000 A GLAMS YA7F 0--('JR 0--('JR�R i DAMAGE TO soowD 100,000 {PREMISES(Eaonarronce; � S220406S 1/1/2015 1/1/2019 MEDEXP(Anyo"Parsom $ 10,000 PERSONAL d ADV INJURY 3 1,000,000 GFNY AGGREGATE I IMIT APPLIES PER !GENERAi.AGGREGATE 5 3,000,000 X POl ICY /ECT :.00 PRODUCTS-COMPIOP AGG S 3,000,000 OTHER s AUTOMOBILE LIABILITY CO BINIED SINGLE LIMIT S 1,000,000 [EsA ANY AUTO BODiI Y INJURY{Per person S Ail ONMF.0 X AUTOS U'ED AilTO$ A9100328 1/1/2015 1/1/2019 BOOILYINJURY(Per a:c,cm); $ _AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X :AUTOS (Per WCXleni; 5 Undrrretrxlmcla,s BI •, $ 100,000 X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR C'LAIMS•MAUE. AGGREGATE 3 1,000,000 MCI , X i k I-Nt10N 11 10,00052204065 1/1/2015 1/1/2019 5 WORKERS COMPENSATION _ PER Or AND EMPLOYERS'LIABILITY Y J N X .STATUTE X ER ANY PROPRiETO"ARTNERIEXECUTIVF E 1. EACH ACCIDENT $ 500,000 OFFiCERM4EMBER EXCLUDED'1 y N:A i a IManda"in NMI WC9024456 2/23/2018 2/23/2019 E L DISEASE-EA EMPLOYEE!S 500,000 H as,019WAbe infer DESCRIPTION OF OPERATIONS be. E L DISEASE-POLICY LWI1 S 500,000 (DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES (ACORD 101,AddRioMi Romsrks Schedule,may be anached it mom space m 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 ilGeneral Liability & Auto Liaiblity, for work performed. and per the terms and conditions of the policy. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Columbia Gds of Massachusetts i THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4 Technology Drive Ste 250 ACCORDANCE WITH THE POLICY PROVISIONS. Westborough, MA 01581 AUTHORIZED REPRESENTATIVE /) N Gr rn"1 PC;' CLC C 19W2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025,.101401: i