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23B-004 (2) 14 STRAW AVE BP-2019-0386 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 23B-004 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-2019-0386 Proiect# JS-2019-000626 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sa. ft.): 11238.48 Owner: CARLTON LAURA Zoning: URB(100)/ Applicant. PAUL SCHMIDT AT. 14 STRAW AVE Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.9/28/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR, OPEN KNEE WALL FLOOR, 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 Signature: FeeType: Date Paid: Amount: Building 9/28/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner City of Northar 1ptoWUS o3 P Building Depa men Curb"Dn� It-- 212 Main Stj eet SEP 2 7 20, Arai Room10 vv t iia Northampton, M 01(� D OF 6UILDING IN�. iii �S phone 413-587-1240 Fa 413-g6TLT-Z72TON.M: y i iOvw sped APPLICATION TO CONSTRUCT,ALTER, REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Prooertv Address: This"athm to be coa*oUdby orize map Lot 6 _ ui* i -777 vu 'n ZOO ovedwolls"Ict- 3 j Elm St.Diabict } SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 12.1 Owner of Record: mA Nam ( r nti ;"i3rrMa g Acfclre s __. Telephone Sig tore 2.2 Authorized A n : tj !YLL A/ )/�3;'�Lti r(r'L C�"yl t.0�?�j-1'•Y/,/�,c_jC Name P current Vailing Address gnature telephone SECTION 3-ESTIMATE[?C01+ISTQTION C08T8 Item Estimated Cost(Dollars)to be_ Official Use Only j completed by permit ap licant Building C�V (a)Building Permit Fee 2. Electrical _ (b)Estimated Total Cost of ! Construction from 3. Plumbing Building Permit Fee 4, Mechanical(HilAC} 5. Fire Protection j 6. Total=(1 +2+3+4+5) s �� Check Number This Seetwi for QUI U"Only Date ! Building Permit Number: Issued f 10 Signature: y 2 7 l> Building CornmissiorwAnspector of Buildings oats EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) �- �� t:!:.tl i �� _:. } � f Section 4, ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete information Existing Proposed Required by Zoning } This column to be filled in by 1 Building Department Lot Size Frontage Setbacks Front _ Side L._: R: L:_--,... R..... :�_ Rgar Building Height Bldg.Square Footage % Open Space Footage % {Lot arcs minus bldg&paved #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Findin ver been issued for/on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO C) DONT KNOW YES a IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (D� YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 Date Issued: C. Do any signs exist on the property? YESNO . 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 constlucfion activity disturb(citaring, grading, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO Ute. IF YES,then a Northempton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(;check all aotNicabie) New House [❑ Addition ❑ Replacement Windows Aheration(s) ❑ Roofing ❑ Or Doors F-1 _ I Accessory Bldg. F7 Demolition. ❑ New Signs jC7] Decks jj� Siding j��Other[ L A Brief Description of Proposed o25-5 WorKbicl-o _ Ll �ssi, .7� f..._�! ,,r t 1�-'- .._. r18d`� 12 026`>` `S�1 _ K,Z, 4'-) -t L S all r-181-EA Alteration of existing bedroom Yes No Adding new bedroom _ Yes No 1 �d C Attached Narrative Renovating unfinished basement Yes ✓ No IZ40�Q l Plans Attached Roll -Sheet V- n' ab� so. KAM- 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? r I f Method of hosting> Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance._ Masscheck Energy Compliance form attached? h" Type of constructor. Is construction within 1Q0 ft. of well tls? vQ Nc is constn ct rr within 100 yr. floodplain Yes No j Depth of basement or cellar fl below finished grade k. Will building conform to th uilding and Zoning regulations^/ Yes.,_ No i I Septic Tank ity Sewer,___„______ Private well_......._.. __ City water Supply 1 SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN T OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i i r I as Owner of the subject property j 1 hereby authorize to act on my behalf; in all matters relative to work aut orized by this building permit application. Si nature of ONmer Date 3 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. I I Sign under the pains and penalties of perjury. l Print Name q h Sig ure of Own / nt Date SECTION 8.CONSTRUCTION SERVICES r 8.9 Licensed Construction Su isor: PP Not Applicable ❑ Name of License Holds : j1„ License Number 741 Addres Expiration Dite T- S11 gatre Telephone 1 f 9 Registered Hang irn��ye�Geargm Not Applicable ❑ /r7-)4 a/ I � , �_ ° Il �1' h � ]C�� 7?,C.5 S LG l 7 /. � om an Name ? Registration N imber .............. Address Expiration Date MIlI4T eie o 5111-3e i 1._ .._ _....� 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 j in the denial of the issuance of the buildinsfOrmit. Signed Affidavit Attached Yes....... No.... City of Northampton Massachusetts DZPARTWKNT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building Northampton. MA 01060 A— Debris Disposal Affidavi`c In accordance of the provisions of IVIGL c 40, S54, j 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 performea at ——--------------------- (Pleas h print house number and street name, Is to be disposed of at: �Pl.ase name and location t facility` Or will be disposed of in a dumpster onsite rented or leased from ;Company Name and Address) q t ................ g1ria-ture of Pe?rrit pplican 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.. City of Northampton. Massachusetts JL c� X 't DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Suxlding yd` Northampton, MA 01060 AFFIDAVIT Horne Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation "OC:ABR")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 Brame Improvement Contractor("NIC"). 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"' he done by register contractors. .Note:If the homeowner has contracted with a corporanon or LLC. thur en ity must be registered. Type of Work: Cai... L2,L� .._. _ _ East. C:ost:.._� � Address of Work:_l�/_ 4S Date of Permit Application: I hereby certify that: Registration is not required for the following reasons i Work excluded by law(explain): , _._. Job under x1,000.00 Owner obtaining own permit(explain); __ w Building not owner-occupied .—­,Building (specify) ..... OWNERS OBTAINING THEIR OWN PERMI3OR 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 pet as the a ent of o �n the T r -ate--� ��,,1~. °,✓. J, � 'ac t° Contractor N rm C c -trrC S HIC Registration No. OR: Notwithstanding the above notice. I hereby apply for,,, ht.tilding permit as the owner of the above property: Date Owner Name and Signature ` The C°ommonwi ealth q/ 1assachusett.s Department of 1ndustrial.4ccidenty Office ref Investigations blip f ashinglon Street Boston. MA 02111 wwatI.mass gov/din Workers' Compensation lnsurancc Affidavit: Builders/('ontractors/Electricians/Plulin bers Applicant Information Please Print l_eeibh Name SDI. Home Improvement Contractors Inc Address: 24 Chestnut Street _ Phone ri 413-247-5739 �'tty/5tate/Zi Haitfield, MA 01038 Are yon an employer"Check the appropriate box: Type of project(required)- am ataployrr vvitta ). © I am it scneral contractor and i b. /yew,construction employees(full and'or part-time).* have hired the subcontractors 2.Q I am a sote proprietor or partner- listed on the attacher!sheet. 7. [� Remodeling 4 ship and have no employees Thesc sub-contractors have g. Q Demolition n working for foe in any capacity. etnplrtyee and have vi<arkcrs' Building addition s [No workers'comp, insurance comp, insurance. required.] s. 7 We are a corporation and its 101-1 Electrical repairs or additions 3.El I ata a hotneavvner doing all work officer,,have exercised their I 1 ❑ Plumbing repairs or additions myself.[?yo workers'comp. right of exemption per M{ii. Roof repairs insurance"- uired.) ' c t`'. §1(4),and we have no 4ntplon,ees. INo workers13.[R other Insulation coral>. mNurance required] *An%aWicant that sit toast uiso fill ottt tate sectim heltm 4ht,tctng their uorkers'.ompcnsown ixwtitn tnttw imus+n. I loa ccssv w%u o sttbma this affidavit indicating Oxy are&Nrig vitt work semi(two Titre,wtsid,:contruion must submi a new affidavit todu=ing,Mh 'ct-41trigtom that check this box niu.«t uttacht.4 an additional shert chow:ting!the name of the sttb•.vantt trtranti state whaher or no thctle entities hasc ernplol%-x+ it'dx sub-conttacttvN have cmplo)°ces.the)num f)t,,6sit fl r1,,r ',t,tnp-poht}nnnthrr s01111mc�^-�e�arKramNrsammt I am torr emplaver that is providing workers'compe}nsurion insurance far My enrhavees. Below is the polis r and,job sire information. Insurance C;ompanx Name: Selective Insurance Co Policy or Self-ins. I.ir WC9024456 I epiration Date: 02/23/2019 Job Site Address: �'� y� !-7Y t it} )hate/Lip' � � ����� M iq Attach a copy of the workers'compensation polio decta ration page(showing the policy number and expiration date). (•'ailuro to secure coverage as required under Section 25A of M61,c_ 152 can It-ad to the imposition of criminal penalties of a line up to SI.500,00:and?or one-tear imprisonment,as mel as civ it penalties in the ft;rm ofa ST0P WORK ORM Il and a fine of up to 5250.00 a day against the violator. Be advised that a cope of dais statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification 1 do herelit t crt' rider, paint and penalties tsf perjun°thin tire=infi)rtnation prtsvided[that,,i% trott!unit cttrrt t'l. t'hcar,eI q-7- Official use only. Do not write in this area. ti,he i wnspleted fit,c•itr or lawn official. City or Town: Permit/License# Issuing Authority(circle one): t. Board of Health 2. Building Department 3. Cits/own Clerk 4. Electrical Inspector 5. Plumbing Inspector n. tither Contact Person: Phone#: A��Da DATE(MMIDD1YY1 I) CERTIFICATE OF LIABILITY INSURANCE 1/15/2018 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(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 - NAMEACI Cynthia Henderson: CISR Webber S Grinnelli�PNRCON+P� 1, t413)586-0111 FAX No): (41])586-6481 8 North King Street s DRESS chenderson@webberandgrinnell.com NSURER(S)AFFORDING COVERAGE NMC N Northampton MA 01060 INSURERA:Select1Ve Ins Co of S Carolina INSURED INSURER a:SeleCt1VG Ins CO of Southeast 39926 SDL Home Improvement Contractors Inc. INSURER 24 Chestnut Street INSURER D INSURER E Hatfield MA 01038 ;NSURERF COVERAGES CERTIFICATE NUMBERXaster 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 POI.IC1ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 1 WSR POLICY EFF POLICY EXP TYPE OF INSURANCE AOOLSUBR `LTR POLICY NU R LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A :aA1M$-!NA;:!- X OCCUR i DAMAGE TO RENTED s 100,000 PREMISES(Es oor,rro) S2204065 1/1/2018. 1/1/2019 jMCD EXP(Any one person) �1 10,000 s1�PERSONAL&ADV INJURY 3 1,000,000 GFN I AGGREGA'F t IMIT APPI IES PER GFNFRAL AGGREGATE S 3,000,000 X -0i icy PRO- JECT UC PRODUCTS COMPlOPAGG 3 3,000,000 OTHER i S AUTOMOBILE LIABILITY (Es wad")SINGLE LIMIT 'S 1,000,000 ANY AUTO j BODIL Y INJURY(Per peroon ! S A f *4EO XSCHEDULED A91002h C' 1/1/2019 BODILYINJURYIPeracl0n), $AUTOSAUTOS X 0RED AUTOS X A0 O WNE0 I PROPERTY DAMAGE $ 4 (Per accdem) sd motorcar 81 epig $ 100,000 X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS UA9 C.AIM£sdMADE j I AGGREGATE 3 1,000,000 _.._.. Ur ; X 41:10110N$ l4 :I'Do 92204065 1/1/20i8 1/1/2019 S WORKERS COMPENSATION X - ! X OTR AND EMPLOYERS'L"UTY Y t N ATUTE ER I ANY PROPRIETORIPARTNERIE-XECl1TIVE E L EACH ACCIDENT S 500,000 OFFICERIME45ER EXCLUDED? y N;A } B (Mandatory in NH) WC9024456 2/23/2018 2/23/2019 E L DISEASE-EA EMPLOYE 5 500,000 H yas.dowAbe under f DESCRIPTION OF OPERATIONS below CL DISEASE-POLICY LIMI i S 500,000 i I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space.s 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 b Auto Lialiblity, 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 G!':.nfttal. -,`.KU, CIC C1 14 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 t70140'; i