35-285 (10) 28 SYLVAN LN BP-2020-0478
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-285 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-2020-0478
Proiect# JS-2020-000814
Est.Cost: $5000.06
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg. tt.): 33279.84 Owner: LEVAY BRADLEY JJ
Zonine. Applicant. PAUL SCHMIDT
AT. 28 SYLVAN LN
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.10/11/2019 0:06.00
TO PERFORM THE FOLLOWING WORK.-ATTIC INSULATION 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 10/1 li2019 0:00:00 $65.00
12 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
c�yofNo �, '�CEIVE ZOO
Building DT rt�e�r �`
212 Mai t
Room0
/�,NISU"LA-A
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Northampton MA 10P&T 1 ?019
phone 413-587-1240 Fax 13-587-1272
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DEPT.OF BUILfW; (-.IN?PrG � :
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY 09—2q--—CO�
SECTION 1 -SITE INFORMATION I T V LA 1 IO • PERMIT
1,1 Property Address This section to be completed by office
�-•
Map Lot � � Unit
i 1 Zane Ovary Dist
Elm St,Distrk t
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
i s t0. t
Name rint) Current Mailing Addre
Telephoned
Signature
2,2 Authorized Agent: v}tl..
Name(Pri Current Vailing Address:
y�3
(4
Telephone Sia^atu Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be OfftW Use Only
completed b ermit applicant
1. Building vv OV (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
'. Plumbing Building Permit Fes ,J �
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) p L) O _ Check Number a
This Section For Official Use Only
Cate
Building Permit Number, Issued:
Signature: _
Building Comrnissionedinspector of Buildings Date
ENTAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECT 14-COMTRUCTION SERVICES
8.1
I
Not Applicable CI
- IDS
License Nu bar
i .� 7qQ(1--)Qe-' MA
Ac
dress Explratlo Date _._
413- .
gnature Telephone
Not Applicable Cl
egistration Number
Address
a� a�
j Expirabowb �Telephone l - 4?`' A
SECTION 5-WORKERS'COMPENSAT 11R*KCE AFFIDAMT(M.GA—c.152,§25C(6))
Workers Compensation Insurance afttda must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the build' it.
Signed Affidavit Attached Yes..,.... W No......
Brief Deectipbon of Propaasd Work rNOTE: INS ULA TION ONLY
Y
Loci C s to-Ll G l�l '� �c� aL V1
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 WWI.
Signed under the pains and penalties of perjury. -
Print Name
Signatur&6f Own&TAgent pate
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 Owner Date
„ .. City of Northampton
Massachusetts x�e
t
DEPARTMENT” OF BUILDING INSPECTIONS r �
212 Main Street *Municipal Budding �L b
Northampton. %IA 01060
a
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40. 354, 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:
a Vr,, t-�
(Please print house nuinber and street name),
is to be disposed of at:
(Please print n me and lova n of facility)
Or will be disposed of in a dumps r onsite rented or leased fr
A CD 1 C.1
(Company Name and Address)
Z'//<zet'
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
L�PAR2'�X1' OF BrJZLDZNG ZIVSPECTZONS �
212 Main 8troot • Municipal Building
Northampton, MA 01050
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 dweNing units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Voter If the hvmeo'"wer contracted with a corporation or LLC,that entity must be registered
Type of Work:_ io��� ___�,..... Est.Cost: �c) C)b 3
Address of Work: <CS'JIr1
Date of Permit Application: t O 1
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):. _
_Job under$1,00.00
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 peimit as the gent of the ovnr
S .
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
D"AR21MNT OF SUILDING INSPNCrIONS
212 Main Street • Municipal Building
Northampton, MA 0106P
MANDATORY FOR HOUSES BUIL T BEFORE 1945
Property Address. v7v? F 6\-
Contractor Contractor w
Name:
Address: r ` -
City, State: YY\or CDS u os
Phone: _ 1 ' - 4
Property Owner
Name: Va l I
Address: oC
City, State: k1 nLPGL rn Dn m'4 d CJ
i (contractor) attest and affirm that the building I intend to
insulate&es not have any open air (knob and tube)wiring in the spaces to be insulated and that i nave
provided the property owner with a copy of this affidavit.
Contractor signature
Date
Permit Authorization
a yi i
mass save Form
Site ID: 3895695 Customer: BRADLEY LEVAY III
1, EvJ(ti Vc,-,, owner of the property located at:
Owner's Name,print )
28 Sylvan Ln Northampton, MA 01062
(Property Street Address) (city)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature:
Daae: l� htGIL
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only
Rev. 102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
lot
Boston,MA 02114-2017
www.mass.gov1dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
'170 BE FILED WITH THE PERMITTING AUTHORITV.
Avrmation
Lficant Info Plea.w Print 1,gliblN
Name(BiL,;inessw"C)rgmi?AtiorVindividual):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 box: Type of project(required):
1,E]I am a employer with 8 employees(full and/or pan-time),*
7. 0 New construction
2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity (No workers'camp. insurance required.]
9� 0 lgo3,[:][am a homeowner doing all work myself (No workers'comp.insurance required.] 10[] Buildiaddition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have wt-frkers'compensation insurance or We sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5,[31 am a general contractor and I have hired the sub-contractors listed on the attached sliect, 13.[]Roof repairs
These sub,-contractors have employees and have wtirkers'comp,insurance.1
14.[Z]Other Insulation
5.0 We area corporation and its officcm have exercised their tight of exemption per MGt.c, -------__
152,§+l(4),and we have no employees.]No workers'comp.insurance required I
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowiters who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
k7ontractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have
employees. Ifthesuh-contractors have empiolyces,they must provide their workers'comp.policy number
I am an et*oyer that is providing workers'compensation insurance for W emplayee.s. Below is the policy and joh site
inji7nualion.
Insurance Company Name:Selective I I n I S-u 11 r I a.,n c I e 1-11 C,o ............... .......... . .......
Policy#or Self-ins.Lie.4:WC9024466 Expiration Date:02/23=20
Job Site Address: ...........'S MrJGc city/state/zip:,) P
Attach a copy of the workers'i mpensation polity declaration page(showing the policy number and expiration date).,
Failure to secure coverage as required under MGL c. 152, §25A is a critninal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties in the farm of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of(his statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerrif'y er the iris told Penalties ofperjuty that the information provided above Lv true and correct.
Y e
Ce 4f
Signature: e)
Phone#:4.1 A-247-5i739�
-—----—-
Qfjirial use only. Do not write in this area,to be completed b.V tiny or town official.
City or Town: -—- Permit/License#_.______
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person; Phone
ACC R" CERTIFICATE OF LIABILITY INSURANCE DATE(MWUQ;YYYY)
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 pollcy(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 !121,01,1.14CT CyndleHenderswCISR,CPIA
FAX
PHONE (413)586-0111 (413)586-6481
Webbef&Grinneli I
("I
8 North King Street AF-DORES&
MAIL criendersor,,,4webberandgnnnell.com
.........................---............................................................",___..W._
INSURER(S)AFFORDING COVERAGE NJUC a
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259
INSURED INSURER 6 Selective Ins Co of Southeast 39926
SOL Home Improvement Contractors,Inc. INSURER C
24 Chestnut Street INSURER D:
INSURER E:
Hatfield MA 01038 iNSUfWR F:
COVERAGES CERTIFICATE NUMBER: Master Exp 2020 REVISION NUMBER.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEOTOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT 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 TYPE OF INSURANCE POLICY`"9'Ff POLI Y UNITS
LTR INSD POLICY NUMBER jj�meqiy
2L�Yj tm YYYL
jRqN
X COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE. 1,000,000
I ';' —
OCCUR S�Ea
500 000.
CLAiMS4AADE !.'7jd
MED EXP("and Person) S 15,000
A S22915011 010112019 01101/2020 PERSONALS ADV INJURY S 1,000,000
GEN1 AGGREGATE LIMIT APPLIES PER. GENERALAGGREGATE It 3,000,000
JECT I
POLICY 0 1"0' r LOC PRODUCT -COMP7OPAGG S 3,ODO.000
OTHER I I s
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1�000,000
ANY AUTO BODILY INJURY(Po Person) s
A OWNED -SCHEDULED A9105420 01101=19 01101/2020 BODILY IWURY(Per*W9WM) S
AUTOS ONLY AUTOS
HIRED NON-OWNED
PDAMAGE
,
AUTO$ONLY AUTOS ONLY ,�PROPERTY
I,
Undennsured 100-000
UMORELLA LIAO OCCUR "C"W,�&URRENCE s 1,000,000
000, ,
A -1 EXCESS LIAS CLAWS-MAIDE 52291509V
01 /2019 01MI12020 AGGREGATE 1 000
I
TDEID1 bRETENTION III
VKWERS COMPENSATION
PER OTH-
AND EMPLOYERS'UAWLITY STATUTE �
YIN 500,WO
wc
ANY PROPMETORiPARTNE o2r
Y NIA WC9024466 nmo E1,EACH ACCIDENT
OFFICER�VEMSER EXCLUDED? 500,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S
if yes,ownoa tmdoi 500,ODO
OESCRIPI ION OF OPERATIONS below E.L.DISEASE,POLICY LNIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES fACORD 101,Additional Remarks Schedule,may be attached if mare spaco Is required)
The Workers Compensation policy does not include coverage for Paul Schmidt Kendrick Dempsey ana Douglas Schmidt
Thielwh Engineering is hereby named as Additional Insured per written contfart.for work performed.and per the terms and conditions Of the policy,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Thielsch Engineering ACCORDANCE WtTH THE POLICY PROVISIONS.
195 Francis Avenue
AU U-IORIZED REPkESENTAI I'VE
Cranston
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ACORD 25 J2016103) The ACORD name and logc,,are registered marks of ACORD