10D-005 (2) 81 WATER ST BP-2019-1112
GIS#- COMMONWEALTH OF MASSACHUSETTS
Mao:Block: IOD-005 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-2019-1112
Proiect# JS-2019-001804
Est.Cost: $1000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sp ft.): 13024.44 Owner: WILLIAMS DEANE A&JEANETTE S TRUSTEES
Zoning URB(IOOV Applicant. PAUL SCHMIDT
AT. 81 WATER ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED 0N:41W2019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC SPACE,OPEN BLOW
CELLULOSE, 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 4/920190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
VG
14 A—
City of Northa ptonRECEI
Building Depa men I 444
212 Main St at
Room 10 APR 8 2
Northampton, M 01 0
phone 413-587-1240 F 41 EP, s;
n of ac me
NOS H4\arON MA
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTIONI -SITE INFORMATION INSULATION PERMIT
'#Alt RRclf YR1sM s�glRp�ISeaew
1.1 ProwrN Addnse.
Mw 10 Lot 0057 U�
ee c(s m,q o io S 3 ZOR. eNt..rF.I�RBt
Eat as Maim CCB Dwasa
SECTION 2-PROPERTY OWNERSHIPIAUTNORI2ED AGENT
24 Owner gf Recordj
f
Name P 1 j Cunent Meilinggtli remiss: 7 � i
Teleph� -l'
' Signature
2,2 Authorizad Abal
Name(Prim) Current Mailhg Address:
Signature Telephone
SECTION 3-ESTBIATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to Offiaal Use Only
ram feted b nrit a licent
'. Building / OpO (a)Building Permit Fee
2. Electrical (b)Estimated Total Coat of
Construction from B
3. Plumbing SuMn PwmN Fee
I c. Mechanical(HVAC) S
5. Fire Protection
'i6 Total=(1 +2+3+4+5) U Chad Number !7
This Stclf s,Far OBktal use Oft
Building Permit Number
Signature: ✓-2619
anan
Eing Canbamomr sdbsp of BL"rV Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION s-CONSTRUCTgN BERYICE3
8.1 Licentiate!C r: Not Applicable ❑
Name of Licama"C'",NOr: ) 1 C. ,— I D�3�
License Nu ber
Dress Egpnetro Date
���
9rgnatu4 Telephone '
9. Not Applicable ❑ —
rqC J {,� ^1nJe� f4pY Lel<A'i.Clt h egistrabon Number
Yll -�--Y�L.Li' S1 r..', . [y o�
A`dtlr`e�— 6Wnatio ate
C" U3 ielephe44 i 3-,D 7- S'/3
SECTION S-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.162,§26g6))
Workers Compensation Insurance alfida t must be completed,and,submrtled wiM tha application. Failure to provide this affidavit will result
m the denial pf the issuance of the bui - g pennn.
Sign ed Affidavit Attached Yes_._ ty, No._... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
g g f /a rl L6a-��I a-' e�
,A',- a_CAn5' aha n Aci
I. \ )IA ( a,Ay"—, �� as Owner/AuMonzed
Agent hereby declare that the statements and information on the foregoing application are true and accurateto the best of my knowledge
and,belief.
Signed under the pains and,penalties of pequry. -1
C
—0— l7 \. Yw^C fY-1 fl'�'- �-(CIC�C S, �r)C
anm Name
-i
Signatu f OwralftAgert Date
I as Owner of the subject
property
hereby authonze
to ad on my behalf In all matters relative to work authmmued by this building permit applicabon.
Signature of Owner Data
City of Northampton
Massachusetts
�ANTDffilT OF BUILDING INSPECTIONS
31'1 M>n St eet 6N 1capal Builaiq +
Borthu ton, M 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.
O ) t U � k
aA7e- S"1— o o �-S_ 'Li4
(Please print house number and street name)
Is to be disposed of at:
(Please pdnt n me and Iota' n of facility)
Or will be disposed of in a dumpsigir onsite rented or leased frgtn
(Company Name and Address)
Z s-
Signature of Permit Applicant 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
i
212 min strut 4 romicieuildinp
North�tnn. PIA 01060 03060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
I he Office of Consumer Affairs and Businms Regulation I"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").
N.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 bud not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by rethitered contracton.
Vote:If the homeowner has contracted wiNr a corporation or LLC,that entity must be registered
I:vpe of Work: 3;iC10.�c9��. _ __ __ ___Es[. Cos[:_
Address of Work:.
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
_Ownerobtainingownpermit(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 RESPONSIBHATES 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 pe t as the gem of the otyn r
Nft'"A d.
Date Contractor Name 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
G
DBAR39RNT OF BMWZNO ZNSFaCTZONS
212 W— 9trtit a q nmipal Building _ C,
Northampton, M 0106
MANDATORY FOR HOUSES 'BUIL T BEFORE 1945
Property Address44-✓' S� L,R .S �[1l A-
Contractor `
Name:
Address r
City. State: c�
Phone. �') l �' 01 '-� `3
Property Owner
Name: D/1 /lQ.t ly. „ ( 0 )l �LI0.rv1S
Address: r �S' 1 (A
LIS ,
City, State: - .V 5
I. �Q ) nl � CY (contractor) attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature /
qA
Date
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Jeanette Williams
(Owner's Name)
owner of the property located at:
81 Water Street
(Pmperry Address)
Leeds, MA 01053
(Property Address)
hereby authorize 5))L-
(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.
Own s ignaarre
Date—'
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 02021 1 339-502-6335
www.RISEe.ngineering.com
The Commonwealth of Massachusetts
r- Deparlmem of/ndustria(Acciderns
` I
I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.goi din
;y Mur6ers Cocpensa tion Insurance Affidan it: BuildersA to trvetots/t:lern cia is,Plumbers.
I O IIP FII F II N ILII MI.1'1_B,AII I flA(: AI III I'll.
lnnlica tInfcroatiun Please Print Imi'ihh
,Name On,.ina...I innLIndy.wa,n.SDL Home Improvement Contractors, Inc
,Wdr-Qw 24 Chestnut Street
l fil 'suile Zip Hatfield, MA 01038 Phone ,,413-247-5739
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.%hash a cope of the sorhers' compensation policy declaration page(showing the policy number and expiration date).
1 s tin m idol wider MO I,' q_'i-\ is a mntlnal slid n nn prmkhahl,Fs a line up l0 31 S00 00
and one-yen,tap rlsonment;uHalla,'i"Ipendues Io the Ibnu of aIs.TOP Ak(W K ORM R and a los of op r S'k).non
day vain_+t file t h tenor .A cup) of eaa,loew al t e tontarded to in,'Mlles '.1 I t "aigwirIn.of Iter ULA for owl w�cc
aorercc s entication
lato Ceretec'(vvntt ir�ertinraies f pe jun•II the mJlmruarm prmtidednMrn is fear and corm T.i�nanl C; 341 -24
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Cit,if, lowm Perot i 1/1 wen se q
Issuing_luthorrh (circle one):
1. hoard ol'Health 2. Building Department 3.CIRr`fnwn( Ierh 4. Electrical Inspector .i.Pinching Inspertnr
6.Other
('onta,t Person: _.___ — Phone a:
ACRO` CERTIFICATE OF LIABILITY INSURANCE G"It »Hlnnn✓."
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THIS CERTIFICATE IS ISSUED ASA 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,Ne"Isyges)..at have ADDITIONAL INSURED provisions dr M enddrsea.
If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endonerma . Astalerm nt on
this cenilicate does not confer rights to the CenBKaM holder In lieu of such endorsements).
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLER BEFORE
THE E%NM110N DATE THEREOF NOTICE WILL BE MUVEREO IN
IIAll, Yr9,nr.'rI ACCORDANCE WITH THE POLICY PROVISIONS.
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