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38D-009 (4)
17 REED ST BP-2020-0438 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 38D-009 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-2020-0438 Proiect# JS-2020-000744 Est.Cost: $3000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq.ft.): 10018.80 Owner. DUNPHY JOHN A Zoning: URB(100)/ Applicant. PAUL SCHMIDT AT. 17 REED ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:10/9/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR AND 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 10/9/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building Department 0 x212 Main StreetCj . JM�WLATIION ' Room 100 ^r �1 Northampton, MA , X01'9 phone 413-587-1240 Fax 41 � r ti ONL ; oti APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY OWEL NG ONLY el C7 -"/3Y7 3 SECTION 1 -SITE INFORMATION INSULA ON PERMIT 1.1 Property Address This section to be completed by office Map 3,90 Lot cc? —Unit zone Overlay District Elm St.District ca District SECTION 2-PROPERTY OWNERSHlP1AUTHOftIZED AGENT 2.1 wr -�L . ��. Name(Print) Current Whihng a: Q -7,5`7 Telephone Signature 2.2 Authorized Anent: JU4u ' ' f lr(Z!,+ e_ k ,�- h c,-t, S�- Name rint) ,I L(-0,SCurrent Mailing dr s: 1rC_ 7r3-- aq-7- 5-73° Signatur Telephone ECTiON 3-ESTIMATED CONSTRUCTION COSTS Item ) Estimated Cost(Dollars)to be Official Use Only completed by permit appiicant 1. Building QU (a) Building Permit Fee p CXR . 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) V 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number T#Is Section For Official Use Onty Building Permit Number i Date issued: Signature. lo/ 9/I I IV Building Commissionerlinspector of Buildings gate EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-COMMUCrAM 40MM 1 Ll r Not Applicable 0 Nam-of Limme Halder: t. - I D';Y-A 3,5- License Nu bar & C20 a t dress Expirati Hate 413� gnature Telephone Not Applicable 0 "Registration, Number + r=,4,- � � �� oZ O a I Address {{� j Expiratia ate � � Telephone'T l,�� )-'S' SECTION ti-WORKERS'COMPENSATION ROURANCE AFFIDAVIT(M.GA-c.152,§2SC( )) Workers Compensation Insurance affidayftmust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil it. Signed Affidavit Attached Yes....... No...... O Brief Description of PropoW Wark OTE INSULATION ONLY 93`l roo--'-- I. as Owner/Authonzed Agent hereby dedare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signatur f own&TAgent Date 1. , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Omer Date RISE ENGINEERING" OWNER AUTHORIZATION FORM 1, John Dunphy (Owner's Name) owner of the property located at: 17 Reed Street (Property Address) Northampton, MA 01060 (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. X4wner' nature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com City of Northampton Massachusetts DEPARTMNT OF BUILDING INSPECTIONS 212 Main Stroet s.14un.1cipal Building Northampton, HA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40. S54, 1 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: ........................ (Please print house number and street name), is to be disposed of at: C�- YY\ (Please print n4rn-&and locaNn of facility) Or will be disposed of in a dumps r onsite rented or leased fr9p: VC (Company Name and Address) SIgn4t-64-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 w DEPARTM UT Off" BUILDING INSPECTIONS r 212 Mair. Street w 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 dvv"ng 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 ✓ �u Type of work: L, l rte, Est. Cost: O O 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 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 buildingpet .t sthe�,o the o� 01 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 _why �r Massachusetts ! y DEPAR2WNT OF BU LDZNG XNSPECTZONS 212 Main street • Municipal Building Northampton, MA 0106' MANDA TORY F R HOUSES BUIL T BEFORE 1945 Property Address: / e S� Contractor Name: ' Address: City, State: - CD u Phone: Property Owner Name � 1 N I� Address: l � � �e_a S � City State: �>n rnpc� C ( ) Ct (contractor) attest and affirm that the building I intend to insulate oes 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 �,10, I/jz ©ate The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.govIdia Workers*Compensation Insurance Affidavit: Builders/Contruett)rs/Electriciani/Plumbers. TO BE,FILED WITH THE PFR.N1IMNG,k I-THORITV. Applicant Informati011 Please Print L.,wility Name(Bu.,iiwssf'Organi,,-atiorCindividual):SDL Home Improvement Contractors, Inc Address:24 Chestnut Street —........... ....... City/State/Zip:Hatfield, MA 01038 Phone#:413-247-5739 ................................... Are you an employer?Check the Appropriate boa: Type Of project(required): l 10 1 am a employer with 8 employees(full and/or pan-time). 7. [] '4ew construction 2,C]I am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity.(No workers*comp.insurance required.J 9. El 1,)ernolition I am a homeowner doing all work myself INo workers'comp. insurance required.] 10 C] Building addition 4111 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers`compensation insurance or I we sole I LE] Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5,[:]l am a general contractor and t have hire'd the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 14.[2]Other Insulation &.0 We are acorporation and its officers have exercised their right of exemption per MG1.c. .......__...... 152,§l(4),and we have no employees.lNo workers`comp insurance required I *Any applicant That checks box#1 must also fill out the section below showingpensatio their workers'com n policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then lure outside contractors must submit a new affidavit indicating such :Contractors that check this box must attached an additional sheet showing,the name of the sub-contractors,and state whether or not those entities have employees, If thes"ob-contractors have employees,they must provide their workers'comp policy number I am tin emploYeriltay is providing workers'compensation insurance.jor i�v employees. Below is The policy and joh site injormation. Insurance Company Narw:Selective Insurance Co .............................. ................ ...... Policy#or Self-ins.Lic.i4�-WC9024456 Expiration Date:02/2312020 Job Site Address: Statc/7 City! �ip:m haa-4�� Attach a copy of the workers compensation policy declaration page(showing the policy number and expire date). Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify rtiel in.A andpenald^of'perjuj,that the inji�rjnathon provided ahove i.s Irtie and correct Si nature; o 2LZ2.4 Date: Phone#:41 -247-57r9 Qfjirial use only. Do not write in this area,to he completed ky city or town offirial. City or"Town: Permit/License# Issuing Authority , (circle one): I.Board of Health 2.Building Department 3.City"Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: phone 0 DATE(MMMUNYYY) AC<>RJ-r]' CERTIFICATE OF LIABILITY INSURANCE 01/03/2019 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 have ADDITIONAL INSURED provisions or 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 1 CO'NTACT Cyndre Henderson CISR;CPIA .-NAVE' . Grinnal' PHONE (413)SN-011'I i FK-i 14 3)586-6481 WCNoExti No 'I Nontri Kmg Street EMAIL SS: chendersonowebberandgrinnell.cor, ADDRE INSURERS)AFFORDING COVERAGE NAIC# Northampton MA 01050 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER 8 Selective Ins Co of Southeast 30926 SDL Home improvement Contractors,Inc. INSURER C 24 Chestnut Street INSURER 0: INSURER E Hatfield MA 01038 INSURER F COVERA,GES CERTIFICATE NUMBER: Master Exp 2020 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 Or ANY CONTRACT OR OTHER DOCUMENT VVITH 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 SHOVvN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR AIDDLSUBR POUCYEFF POLICY F)(P LTR TYPE OF INSURANCE__„, NSURANCE -,--!N,§P-AMID JM!MD—WM-yL A!tm-�ym LIMITS COMMERCIAL GENERAL LIAMUTY EACH OCCURRe4CE'. 1,000,000 COMMERCIAL CLAIMS-MADE OCCUR PREMis'E 'a="rrancs) $ 500,000 WE.')E,",P{Arty one person} $ 15,000 A 52291509 0110112019 01/0112020 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. 13ENERALAOGWEGATE $ 3.000,000 P ICY Ro, -�LOC PRODUCTS-COMPIOP AGG $ 3,000,000 ou M PE F OTHER AUTOMOBILE LIABIAJTYCOMBINED SINIGILF UMff— 1,040,000 Ilia aoc4em ANY AUTO BODILY INJURY(PW PWSM) $ A OWNED r"-=;SCHEDULED A9105420 01101I2019 0110112020 BODILY INJURY(Par SeddWM S AUTOS ONLY AUTOS HIRED NON-O%NED PROPERTY DAMAGE —X AUTOS ONLY AUTOS ONLY !'sr WNdool) Underinsured motorist BI $ 100,000 X UMORELLA LIAO OCCUR .Underinsured 111 1,000,000 A F-xCESS UAS S2291509 01101/2019 0110112020 1,000,000 CLAIMS- AWREGATE S DED RETENTION $ COMPENSATION uTE ORTii- AND EMPLOYERS'LIABILITY YIN t 57* PROPRIETOR)PARTNER)EXECUTIVE 600000 SER EXCLUDED? NIA 2o2 V�CW24466 0=312019 02J2W o EL EACH ACCIDENT $ 7y 500,000 awJatory in NH) EE S E.L.DISEASE,EA EMPLOY '-"ON OF OPERATIONS imtcx E1 DISEASE.,POLK'Y LIM, IT $ 500,000 ......... OESCRlPTION OF iONS;LOCATIONS I VEHICLES(ACORD 101,Addiliontl Remarks Sctiadule,may be attached if more spa”is eliquirod) The Workers Compensation policy does not Include coverage for Paul Schrirdt,Kendrick Dempsey and Douglas Schmidt Thielsch Engineering is hereby named as Additional Insured per written contract.for work petformed.and per the terms and CondbonS of ttl.,e policy, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Thiersch Engineering ACCORDANCE WTH THE POLICY PROVISIONS. 195 Francis Aven Lie, AUTHORIZED REPRESENTATWE Cranston Iii 02910 u 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) Th,',,AC'ORD name and logo are register"marks of ACORD