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17A-225 (3) 121 LAKE ST BP-2019-0363 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 17A-225 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2019-0363 Proiect# JS-2019-000590 Est.Cost: $4000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 174415 Lot Size(sq.ft.): 21344.40 Owner: WERLE GRETCLIEN&FELIX HARVEY Zoning URB(100)/ Applicant: PAUL SCHMIDT AT: 121 LAKE ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST 413 247-5739 HATFIELDMA01038 ISSUED ON.9/24/201$0:00:00 TO PERFORM THE FOLLOWING WORK-660 SQ FT 5" LAYER OF R-19 ADDED TO ATTIC, OPEN BLOW CELLULOSE 374 SQ FT' 14" LAYER R-49 KNEEWALL FLOOR; AIR SEALING 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: Brive»ay Final: Final: Final: Rough Frame: Gas: Fire DepartmeUt Fireplace/Chimney: Rough: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. PIrtifigpte of Occupancy-, — ftn tore: d: A o : Building 9/24/2018 0:00:00 $65,00 212 Main Street,Picone(413)587-1240,Fax: (413)5871172 Louis Hasbrouck--Building Cotr►issioner t n Z • a File#BP-2019-0363 APPLICANT/CONTACT PERSON PAUL�:('HMIDT q ADDRESS/PHONE 24 CHESTNUT ST ' ATFIELD (41: •247-57-T9 PROPERTY LOCATION 121 LAKE ST MAP 17A PARCEL 225 001 ZONE URB;,100)/ THIS SECT ION FOR OFFICTA.L USE ONLY: PERM:*TAPPLICATICI' CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: 660 SO FT 5"LAYER OF R-19 ADDED TO ATTIC,OPEN BLOW CELLULOSE 374 SO FT' 14"LAYER R-49 KNEEWALL FLOOR;AIR SEALING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 174415 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: /Approved Additional permits required(see below) y PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Pldn 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 Demolition Delay 21-4 rySignature of Building Official 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 au thorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. - Depa only City of Northa pto ECEIV ' it Building Depa me sy it 212 Main St et semi Septa Availability_ Room 10 SEp 2 1 ell yailabift Northampton, M 01 0 is of Structural Plans phone 413-587-1240 F 41 e Pla is DEPT.OF BUILDING INS F""! 1" NORTHAMPTON,MA _ -_ APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH AI ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION b P— (� 1.1 Property Address. Tkis on to be , 4Q-pct— S .- map �7 14 Lot Z Unit �-n ii' Zene OVedwD Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner-of Record: /.::Ii )A Name(Prin Current Mailing Address/ i` Telephone Signatur �t 2.2 Authorized A ent: Sb�. — �+�ti'r �f C�rf-�,-R s✓�v�S T�� Name P zz Current Vailing Address: dJ L3 ci gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building -1SW Q D 00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee D 0 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 000 Check Number This Section For Oficial Use Only Building Permit Number: Tissued: ate Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) t S UECEIALD Section 4. ZONING All Information Aust Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front _._.._ Side L:.. -- R: - L: _ _ R:. .. . Rear - Building Height -- - Bldg.Square Footage -___ % Open Space Footage % ---- (Lot area minus bldg&paved parking) #of Parking Spaces - - Fill: volume&Location __ _ +._.._ . ... _ A. Has a Special Permit/Variance/Finding ver been issued for/on the site? NO ® DONT KNOW YES IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW (2� YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® 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 ® NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, on, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO j 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 Alterations) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding 04 [ Other4[MIK l (� U Brief Description pf Proposed �D&O � cT 5 1 r 61- -4-h r i 2—1 9 d °� ��10.'4— Alteration of existing bedroom Yes No Adding new bedroom Yes No (fin I I P U`l J Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet &r �IL[x L_n "A- 6a.!fr_� 'iillrikU , �p ftie e_� -t 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. Z Dimensions e. Number of stories? f. Method of heating? Fireplaces or Wocdstoves Number of each I g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 7flobelow ? Yes No. Is construction within 100 yr. floodplain Yes No I j. Depth of basement orfinished grade k. Will building conform t 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 to act on my behalf, in all matters relative to work aut orized by this building permit application. Signature of Owner Date I.MT/ � � 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. �� Print Name t-19 Sig ure of Own / nt Date it p. SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Su isor: / Not Applicable El Name of License Holder: 4/4G — _ l o,3 6,35— License Number Addres Expiration D to SiVature Telephone 9.Rsanders4 ;Elotrsra i CcRaC60r: Not Applicable ❑ Comoany Name Registration N mber Address Expiration 0ate SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(6)) Workers Compensation Insurance affidav' must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build' g permit. Signed Affidavit Attached Yes....... No.... i City of Northampton S" Massachusetts ,{ DEPARTMENT OF BUILDING INSPECTIONS 212 Main street •Municipal Building \, Northampton, MA 01060l�`� 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: Z,2�I iA K-k-, S-47 --/�tpz-e-� (Please print house number and street name) Is to be disposed of at: (Please print name and locationofof fad Or will be disposed of in a dumpster onsite rented or leased from bL---.. nk- (Company Name and Addresj ignature of Pe it Applica-n-f 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 City of Northampton Massachusetts !c� x: DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building 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:��-SLA1,OI-A n Est. Cost: DUe::) Address of Work: �� .� 44 f f- �at✓cn ems. — -- Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded bylaw(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 p t as the agent�of the oWn�er: Date Contractor Nime c#oKS� 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 21 Canton, TMA 02021 339-502-6335 ENGINEERING www.RISEengineering.coin OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: (Property Address) (Property Address) hereby authorize (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. //----------- Owner's Sig to Date The Commonwealth q .Massachusetts Department of Industrial Accidents l),ffice cif Investigations 600 Washington Street r - Boston, .MA 02111 www.mass.govldia Nkorkers' ('ontpensation Insurance Affidavit: Builders/('ontrat:tors/Electricians/Plumber, Applicant Information Please Print LepiblN Nanie(Busing cngatti"ioiv1nJi\itiwiw SDL Home Improvement Contractors Inc Address: 24 Chestnut Street Cite/State/lip Hatfield, MA 01038 phone ; 413-247-5739 Are you an employer"Check the appropriate box: Type of project(required): I. I am a employer with4. F-1I am a general contractor:end I with ----t�_.----LL 6. E] New construction employees(full and'or part-time)." have hired the stab-contractors 2.❑ 1 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 workery ❑ Building addition [No workers' comp. insurance comp. insurance,Z* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 1 1. Plumbing repairs 3.F-1 I am a homeowner doing all work ❑ 8 pa�rs or additions myself.[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]4 c. 152. §1(4),and we have no employees. [No workers' 13.C8 Other Insulation -�--- comp. insurance required. 'Am appltcvn that,Meeks txrn#I mast also fill out the wctitm helo-A ,hoes attg their vvsul:ers'etrmttensatiort policy inliKmatnon Homotiuners%I%%submit this affidavit indicating they are doing all Work anJ chert hire outside crnttracion truest wbmit a twxv affidavit indicaing such t"t raactr)n that check this box must attached an additional shett shoes inu the mane t4 ttw sub-4vitracttxs and slate%vixther or no thou entities have awlnyees If the stab-amrutors have emplovecs tix_s must pro%itk their v%(wkem omp rmhci number ttaa:em I am an enrplover that is providing workers'compensation insurance for nn-emphtees. Below is tke polic•i•and job She information. Insurance Company Name: Selective Insurance Co Policy n or Self-ins. Lic WC9024456 1,xpiration Date. 02/23/2019 Job Sits Address: .�_._ K--t-,._ S� City`State/Zip+_'lCUL('1C�v m Attach a copy of the workers' compensation policy declaration pine(slowing the policy number and expiration date). 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$1.500.00 ancfsor one-year imprisonment.as well as civil penalties in the form of STOP WORK ORDER and a fine of tip to 1250.00 a day against the violator. Be advised that a copy of this statement mat be forwarded to the Ot}ice of Investigations of the DIA for insurance coverage verification. rna�er�-�—i �do herebyi,cert' nder t Pains andpenalties ofperjury that the inforination preovided above n true unit carrcri. _ _Date:_ 7 , Phone Ojft ial use onlr. Do not write in this area,it,he cu»rpleted hr city or town official. City or Town: _ PermitiLicense tt Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. ther Contact Person: Phone#: ACII DATE(MMIDDINYYY) �- ^U CERTIFICATE OF LIABILITY INSURANCE l/ls/zole 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 I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les)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 Y -NAMEA T Cynthia Henderson. CISR !Webber 6 Grinnell I V110;'No..Eall. (413)586-0111 �� 1;(413)Se6-6481 ,8 North King Street AgogESS chenderson@webberandgrinnell.com !45URER(S)AFFORDING COVERAGE NAIC N Northampton MA 01060 INSURERA:SeleCtive Ins Co of S Carolina INSURED INSURER 9:Selective Ins CO of Southeast 39926 SDL Home Improvement Contractors Inc. INSURER 24 Chestnut Street INSURER INSURER E ,Hatfield MA 01038 NSURERF COVERAGES CERTIFICATE NUMSER:Maeter Exp 2019 REVISION NUMBER: '.HIS 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 EXCLUSION AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN$p TYPE OF INSURANCE AOOL:SUDR POLICY N R POLICY EFFyyy. HakY EIIP LIMITS X COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE S 1,000,000 A CI AIMS-MA;, X D::<'..)« DAMAGE TO RENTED PREMi s 100,000 ISES(Es0040rrxe) ii 32204065 1/1/2018 1/1/2019 MED EXP(Anyone Person) i1 10,000 PERSONAL 6 ADV INJURY ; 1,000,000 (,1-N L AGGREGATE LIMIT APPI.IES PFR GENERA:AGGREGATE; s 3,000,000 X PO;ICY OC PRODUCTS-COMPIOP AGG 1 3,000,000 OTHER AUTOMOBILE LIAINUTY CO S44EDt) L 3 1 000,000 (Eaczallar ANY AUTO RODII.Y INJURY IPw pivs m S A I ALL OViMED SCHEDULED AUTOS - X AUTOS A9100328 1/1+2018 1/1/2019 0004LYMUURY(Peracoar-t; _- X HIRED AUTOS X AO OSWNEO �ReOP�E,cident! GE ___� 1 +roared rrglorµt Bi F,a s' 100,000 X UMBRELLA UA8 X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LJAB t.AlMS•MAUF. !;AGGREGATE L 1,000,000 OED i X I RowpoNs 10,000 92204065 11;i 2C:P 1/1/2019 y WORKERS COMPENSATION AND EMPLOYERS'LIAMUTY YON x :STATUTE 1 X ER I ANY PROPRff.TORIPARTNERIEXECLITIVF E L EACH ACCIDENT S 500,000 OFFICERFMEMBER EXCLUDELY) Y N;A H (Mandelpry in NH) WC9024456 2/23/2018 2/23/2019 F L DISEASE-EA EMPLOYE45 500,000 N yes,describe under DESCRIPTION OF OPERATIONS brrnv E L DISEASE•POLICY LIMI' ,S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Addition*!Remarks Schedule,may be attached II more space a 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 1,General Liability t 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 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 r 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401)