24D-238 (4) 182 PROSPECT ST BP-2019-0572
S� COMMONWEALTH OF MASSACHUSETTS
Ma 31Wk:24D-238 CITY OF NORTHAMPTON
I z -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-2019-0572
Proiect# JS-2019-000933
Eg. 'ost: $20QQ.00
Fog;$65.QO PERMISSION IS HEREBY GRANTED TO:
Cg_nst.class: Contractor. License:
Usq grgug: PAUL SCHMIDT 103635
Lot Size(sa,ft,); 7056.72 Owner: BOULAY ROSE
Zoning;URIOO)/ Applicant: PAUL.. $CHMIDT
AT. 182 PROSPECT ST
Applicant Address: hone: Insurance:
4 C STNUT ST 413 247-5739 WC
HATFIELDMA01038 ISSUED ON:11/14/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:162 LINEAR FT BASEMENT SILLS 162 CRAWL
SPACE, RIGID BOARD (FIRE RATED)
P STT IS CARD SO IT IS VIS LE FROM TTREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meters
Footings;
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: i e e l Fireplace/Chimney:
Rough; 2:11,:, Insulation:
Final: }i Zak Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certifiqatq of Ocougangy §iggature:
Feel e: Dat Pal : Amou t:
Building 11/14/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
J7NVJ UG47- 01tl
City of Northa pto
/� Building me t NOV - 8 20
212 Main St eet
Room 10
Northampton, 01 oFsua��Nc 1Ns
phone 413-587-1240 F T ON.'A'
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR/�TWO FAMILY DWELLING
SECTION l-SITE INFORMATION 600- /% -57..>
60 Mix
1.1 Darty �to
12— Lot—
Ekn ft Diftirt ce
okbwt-
SECTION 2-PROPERTY OWNER3HiP1AUTHORIZED AGENT
2.1 Owner
Name(Prin Cunt"MaNing
��e�c- ct-- ..Q--1�.�_ Telephone
- lv`7- � Co 7 0Telephone
Signature
2. nd Agent 10 -�nt J G�>c.S.::�NC-
Name Current aging Address'
Telephone
-ESTIMATED COI+I�OflON CMTS
Item Estimated Cost(Dollars)to be Official use Only
compleW by permit applicant
1. Building O�qr(�-��CK) (a)Building Pem*Fee
2. Electrical (b)Estimated Total Cost of
Condrucb e-f m
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
TIS f#'000
Building Permit Number. Dat
Issued:
Signature:
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AR Wwmabw Must Be C=pWW.Permit Can Be MaW Due To kxwplete MfwmtW
Existing Proposed Required by Zoning
Ibis cohm w be MW in by
Building Dqmtnat
Lot Size
Frontage
Saks
L: R—
Building Height
Bldg-Square Footage
OpenSpace Footage %
(Lo area mum WS&paved
MEW
#Of Parking Spa-m-
Fill:
Ly2Lume&Lomfion)
A. Has a Special Permit/Variance/Findi been issued for/on the site?
No 0 DONT KNOW YES 0
IF YES,date issued:.
IF YES: Was the permit recorded at the Reg!"of Deeds?
NO 0 DONT KNOW t YES 0
IF YES. enter Book Page.' and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES,has a permit been or need to be obtained from the Conservation Commission?
0 Obtained 0 Daft issued:Needs to be obtained
C. Do any signs exist on the property? YES No (D---
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. VO the conshx9on SdAy dIMurb(Ckwing,Wading, ,or ON)over I acre or is it port Of a common plan
that vA dWirb over I acre? YES 0 No 0
IF YES,Vwn a Nort1wripton Sbwm WOW Managairrwrt Permit from the DPW is required.
SECTION$-DESCRIPTtON 9E EBQeM=&L1hM ad. e►
New House ❑ Addition Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs jo] Decks Ifs Sidingf�'`Other
Brief Description of Proposed f' S
Work: =cd a.Le,(1-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
GoIL
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. Is construction within 100 ft of wet! s? Yes No. Is construction 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.
L Septic Tank dy Sewer Private well City water Supply
SECTION Ta-OWNER AUTHOR17ATUM-TO BE COMPLETED ti1OKN
OWNERS AGENT OR COKMAC7*R APPLM FOR BURM40 PERMIT
I, ,as Owner of the subject
property "
hereby authorize
to act on my behalf, in all matters relative to work nutho by this building permit application.
mature 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.
Sign under the pains and penalties of perjury.
Print Name
5ig4kfure of Owne(Moillk Date
SECTION 8-CONSTRUCTION SERVICES
.1 Not Applicable/13Name of License N C � 4L4),3&
,3 ,3
license Numbe
Addres Expiration C4te
S ature r Telephone
IL Not Applicable ❑
j '
r-amapy Nan* IF Registratioen Nlmmbber
Address E)iration Date
'A+14 1 d i Mt4 Dl dZ8' Te � 7'5X3
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.154 S 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 build6 ermit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
r l Massachusetts
t AWAR2UMT OF BUIZDXNG INSPaCTZONS
i 212 Main Stre*t •Municipal Building `
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGI.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:
PIV-saLc-4-- S-I-
(Please print house nu ber and street name)
Is to be disposed of at:
A14- e7 ac—hv'�--
(Please print name and location of fa 'lity)
Or will be disposed of in a dumpster onsite rented or leased from:
—Z L-jr-,
(CUmpany Name and Address)
ignature of PeMft ApplicaW 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 " L h,
� 4
D"AR22AWNT OF St7IZDXNG INSPECTIONS
212 Main street • Municipal Building
Northampton, Mil 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, demd ion, 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 rezistend contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity mast be registered
Type of Work: 5ct�� cY1 _ Est.Cast: C='QtCC-0
Address of Work:—,Lfa Pro-1,0&,Q-4-S f' �kAayn e-��j m i4 (-)I 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.Chnpter 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 buildingt as thea nt f the o*Vr:
t 1. L rv\.l d--t-
5
Date Contractor Nkne K 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
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I; Rose Bou!ay___,..............
(owner's Name)
owner of the property located at:
182Pros eot street
(Property Address)
Northampton, MA 01060 ..... ........... . ...............
(Property Address)
hereby authorize
....................................... ...............
(Subcontractor)
an authorized subcontractor for RISE Engineeing, to act on my behalf to obtain a building
permit and to perform work on my property ThIS far M is only valid with a signed contract,
Ciwners`SigWaiu�i...........-
.... .........
Date
RISE Engineering, 4 Dwisii:w,or 'U.1hoeisch Engineering, Inc.
60 Shawrout Road Unit 2 1, Canton A.A.4 02071, 1 339-502-6335
%Nww RISEenginepnngxorn.
0" The C"ommonivealth erf Vlassachusens
Department of Indsistrial Accidents
` * Office of Investigations
600 Washington Street
Boston, MA 02111
..x wiviv.mass.govIdin
Wi'orker%' Compensation insurance :affidavit: Builders/('ontractors/Electricians/Plumbers
Applicant Informati-on Please Print Leaiblv
'game niu inc,,t,rvanizition,Indic idt.ah; SDL Home Improvement Contractors Inc
Address: 24 Chestnut Street
C ltd�`Stateilip: Hatfield, MA 01038 Phone 413-247-5739
re you an employer:'Check the appropriate box: Type of project(required)'
;i i ttt a :general contractor ,trid I
1.[ l am a employer with t, k Nieto construction
emplo4ees(hall and.'or part-time).* Rase hired the,ub contractt,rs � r-
2.❑ ! am a sale proprietor al,partner-
listed on the attached,heet. ,. ;.� Remodeling j
ship and have no ernployees [hr c ;ub-contractor hate g. ( Demolition
mpl ,eead have % ore '
workingfor me in any cafacit� cJ I
Building addition
t'tiaJ
r, .ttntlt. m,urztn��.
workers`comp,insurance
required] �kc,4;o.; c otpofation and t', MJ Electrical repairs or additions
3 ❑ I :ten a hatneo"ner doing all caork officer, hacc C,ercised their 1 l.0 Plumbing repairs or additions
tight oemptiopevol
fmsci :(do ticorki ti' comp.
12.F7 Roofrepair,
insurance required.J '
employees. I'vo workers 13.(�thher Insulation
I corrin. insurance req►tired]
\ttv applicant that th"ks i-n'«a I trivet ai w till om the.vennrt h ov, 'h t�111;,2 th¢ir uorkir ccn;pint42gi.m prtiiv worsen tievn
it,irwo%%ruts"W suhmA thio affidavit indicating thea are dwl)g all stork amt ih,p omtracaor,mint,uhmit a neN alfida%it radteattnr wch
t ontractorc than eheA thts het:must asitulxd an additional.hoot auouim-,the uattur of th.,�uh• ontrik;ww and state"limiter or not thow cystines have
,mplmtiw. It filo cmployecc,the} inuct jvot itte there �%orkt:r, romp p,-1io )wether
l am an empla},er thaw is provWng workers'c-ompensation insurance.for w em rkrees. Below b the poticl,and job sure
information.
insurance Company tame: Selective Insurance Co
Policy . or Sell-ins t.ic. #: WC9024456 1.spiration Date. 02/23/2019
Job Site Addrt,s:._._.._..._ _. _ . .5�' --- t it\ 'State ZipGR. ._ _
rj
Attach a copy of the workers'compe�tion policy declaration page(showing the policy number and expiration date).
Failure to cure coverage as required under Section 25A of,Ml.,c:. 15'can lead to the imposition of criminal penalties of a
fine tip to 5,1,500.00 ane prone-year imprisonment, as well as c6,11 penalties in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a day against the violator_ Be advised that it cope of this statement may be li»svarded to the Office of.
Investigations of the EIA for insurance coverage verification
I do hereh=certnder pains andpenaldes r,.f`perjurr that the information pre>tshkd above is true and correct.
r.
'+Ynat `: _ ._)ate'--
f cf7-5-937
Official use only. Do not write in whfs area,it)he completed hY rill,or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of litcaltb 2. Buftld*Mpartment 3. C:ity./Tovi n Clerk 4, Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
.4 / -0 CERTIFICATE OF LIABILITY INSURANCE lls /ole )
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: It the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 endorsemo s).
.PRODUCER
NAME: Cynthia Henderson, CISR
Webber & Grinnell PHONE Exry: (413)586-0111 FAX,
� NC);t413)S89-6487ox.09 .
ie North King Street NiA1Ess:chenderson@webberandgrinnell,com
s
;NSUREMS)AFFORDING COVERAGE NAIC s
'Northampton MA 0106D
i th�P INSURERA:SeleCtiv'e Ins Co of S Carolina )
:INSURED s INSURER a:Selective Ins Co of Southeast 39926
SDL Home Improvement Contractors Inc. !INSURER C:
24 Chestnut Street INSURER
+NSURER E
Hatfield MA 01038 INSURER I
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 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.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR iADOLBUAPt�_ POLICY EFF t+OLFCY EItP LIMITS
LTR TYPE OF INSURANCE POLICY NU R
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
1 A CI A+MS=NAL'P X C)+",f;JR DAMAGE'0 RENTED 100,000
PREMISES(Ea xrwm—'.;
52204065 1/112018 111/2019 : WIT,fxP,Any n-WDetn,, y 10,000
k P=ESONA: x ADV;NJURY g 1,000,000
6f N A4 c RFCASE;I IW APPI IES PFR G4'N-13A,. A(aGR;-C3AT� S 3,000,000
x Po!.ICY EGT- r,.- 1R^9UC1S CQMvr;c'ni;t... 3 3.000,000
OTHER
AUTOMOBILE LIABILITY '`: _I' F L)) 't 5 1,000,000
(i•:a aa:iadoMj
A ANY AUTO 40D0 Y INJsjRY 1P 7a Se 5
At 1 OV*4U X SCHe00 FC: A9100328 2019 ROI)/Y INA,RY P x...rr•nr; S
AUTOS ALTOS
NON-OWNED nROPERTY DAMAGE
X HIRED AUTOS X AUTOS (Par = j
41n;,,zr,'+tsured Tra4ro,a�8 -pod $ 100,000
3� X UMBRELLA LIAO X OCCtiR :EACIi OCCURRENCE $ 11000,000
A EXCESS LIAO C':A)VS•MADE w Al;C;REGATE i 1,x00,000
X I"or ILN!1UN$ 10,000� S2204065 I 1 2018 1/./2019
V WORKERS COMPENSATION
i AND EMPLOYERS'LIABILITY Y I N X STATUTE X
ANY PROPR?ET ORIP*WT*RIi XtC-T!V^ E1 FACH AC(,IDENT. 5 500,000
OFFICER)MEM®ER EXCWDEDI x -NIA
S (Mandatory in NH) 1009024456 2/23/2018 2/23/2019 fl /)!BEAST-EA EMPLOYEE,$ 500,000
Ryas descr5e under
i1-Sf,R",PTK)N OF OPERATIONS Wx,w E DISEASE-POLICY L)MI', S 500.000
DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORO 161,AddlUonal Remmits Schedule,may be attacMd If more space Is♦squired)
The Workers Compensation policy does not include coverage for Paul Schmidt, Kendrick Dempsey and Douglas
f Schaxi.dt.
'Columbia Gas of Massachusetts is hereby named as Additional Insured per written contract with respects to �
'General Liability & Auto Liaiblity, for work performed, and per the terms and conditions of the policy.
I
s
t
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 j ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough, MA 01581
P AUTHORIZED REPRESENTATIVE
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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