36-313 (5) 169 CARDINAL WAY BP-2020-0654
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-313 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-2020-0654
Proiect# JS-2020-001111
Est.Cost: $1000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: PAUL SCHMCDT 103635
Lot Size(sq.ft.): 18905.04 Owner: KATES ERIN
Zoning. Applicant: PAUL SCHMIDT
AT. 169 CARDINAL WAY
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC
HATFIELDMA01038 ISSUED ON:11/21/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATIONNVEATHERIZATION
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 11/21/20190:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northam tan
y
Building Depa ent
212 Gain Street NOV TMN '2
Room 100 "3 '! �r
v
Northampton, MA 0
na rrnrg �,.�
phone 413-587-1240 Fax-4 B r t �'G ins.,
i
y
ll
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 9 -SITE INFORMATION INSULATION PERMIT
T
1.1 Property Address This section to be complWad by offlee
Map Lot Unit j
zone Overwy District
Elm SL District, CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Own r f Record
:
ka �s b- 9 cq k3a,
Name(Print) Current Maih69 Address:
Telephone
Signature
Name Pri ) Current Mailing Address:
V
sig ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com letrsd by permit applicant
1. Building / D (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fes
4. Mechanical(HVAC) Q/►(tet
5. Fire Protection
Cl
6. Total=(1 +2+3+4+5) / DDU Check Number 7
This Section For Official Use Only
Building Permit NumberI.' �(' ( / 5 sssuel:
Signature: '- Ila
Building Commissioner/Inspector of Buildings Oate
EMAIL ADDRESS (REQUIRED, EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-c+F msne CroN wwms
r: Not Applicable ❑
Narrre of Licettae HcWer: 't--
License Nu bar
dress --
E)OratiortDate
9ne Telephone
Not Applicable ❑
• `-1YLrz/tWITaCCIZA egistration Number
y
Address Expiratio ate
SECTWN 5-WORIKISMI COWVXSATM MiSURANCE AFFIDAVIT(M.G.L c.162,§25g6))
Workers Compensation insurance afi4da must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the bui ' permit.
Signed Affidavit Attached Yes....... tV No.,.... ❑
srW Description of Propo"d Wo* NOTE:TE INS ULA TION ONLY
5 7 > 9 `' & �- � , W� a'' rip d bra-rd
as Owner/Authorized
Agent hereby declare that the staterrA
and belief, ents and information on the foregoing application are true and accurate,to the best of my knowledge
Signed under the pains and penalties of perjury.
Print Name
y /
SignatureF6f Own r Agent Date
I, , as Owner of the subject
piny
hereby authorize
to act on my behalf, in all matters relative to worts authorized by this building permit application.
Signature of Owner Date
City of Northampton
rr
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS w �
212 Main Seroot •Municipal Building by
Northampton. MA 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:
LP � 0" ,"j",, o. (A 1::4
( lease print house number 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 dump%pr onsite rented or leased fr
C) -
(Company Name and Address)
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 y _
DEPARTMWT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Narthamptan, MA 01060 ^.. a`
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 Horne Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, akeration, renovation, repair, modernization, conversion,
improvement,removal,demolition, or construction of an addition to any pre-existing cwvner-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 registered contractors.
Note:If the homeowner Inas contracted with u rvrpvratirun or LL,C, that entity must he registered
'Type of Work: ��/l7lGt�1C/��.._._ _..Est.Cost:
Address of Work: z b ( A r c(f n
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(slecify) _.._....
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 pe uttaas�the igent,af the oworr: t
Date l� 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
,J
1 n
DEPARTMENT OF BUILDING ZNSPECTXONS
212 mainortreat 0 Municipal building
MR
MANDATORY TORY FOR HOUSES BUIL r BEFORE 1945
Property Address
Contractor
Name: �-
Address:
City. State:
'hone. � � � q 1 ��
l
Property Owner
Name ., /1 �(,4-e I-)
Address _ �0 Li k
City State d I O Cv C
l y
(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
Date '/
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Erin Kates
(Owner's Name)
owner of the property located at:
169 Cardinal Way
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize Sb
(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.
2�2a '_0 /,-, 4
Owner's Signature
Date —'
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.RISEengineering.com
The Comnizinwealth of Massachusetts
Department qf IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov1dia
Workers'Compensation Insurance Affidavit: Buildtrs/Contractors/Electriciaiis/Plumbei-s.
TO BE FILED wrnurtw PEWMI'MNG AUTHORITV.
Applicant Information Please Print LeL'ibIN
Name(Busirws,�'Otganiixioff/individual):`SSL Home Improvement Contractors,.Inc
................
Address:24 Chestnut Street
................................... ..............
CjtN,,!StaIe//AP:Hatfield, MA 01038 413-247-5739
' ... Phone#:
.......
Are you an tmplover?Check i lit aiwroprime box: Type of project(required):
I [Z]I am a employer with 8 employees(full andlor part-time),• 7. [] New construction
2,C]1 am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling
any capacity,[No workers'comp.insurance required.) 9. ❑Demolition
3,E]l .hwivowrierdoing all work myself:[No workers'cotnp.insurance required.)
1 1
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LE] Electrical repairs or additions
proprietors With nal emplcrvees. 12.n Plumbing repairs or additions
5,[:]1 am a general contmtor and 1 have hired the sub-contractors listed on the attached sheet.
'('hese sub-tontmtors have employees and have vAvrkers'comp.insurance.! 13.Fj Roof repairs
14,R Other Insulation
6,[:]We are a corporation and its officers have exercised their right ofexemption per MGI,C. ...................
152,91(4),and we have no employees.[No workers'romp.insurance required I
"Any app)icant that checks box#I must also till out the section below showing their workers'conipensation policy information.
forawi ion.
+Homeowners who submit this affidavit indicating they are doing all work and then line outside contractors must submit a new affidavit indicating such.
'Contractors limit check this box must attached an additional sheet showing the name of the suh-contractors arid state whether or not those entities have
vmployees It'the sub-contractors have employees,they must provide their wotkers'conip policy nuinhel,
I tiny an employer that isproviding workers'compensation insuranceft;ir Mv employees. Below isthe polity and johsite
injorination.
Insurance Company Name:-Sole,ctive Insurance Co
o ..............................................
Policy#or ielf-ins.Lie.#:VVC9024456 Expiration Date:02/23/2020
Job Site Address: /& Y......... , citylstate/Zip:-/-"� CV0
Attach a copy of the workers'compensation /W V�-age(showing the policy number and expi ation
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
an&or one-year impriscinment,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.
TZ herehy cerdf'�V- er I le J., ins and penalties qj'perju ty that the inji)rmafion provided above A trite and correct.
...... .. ......
Pholle 41 -241-�67i V9
......................................- ----
Ofyi,cial use only. Do not write in this area,to be completed by city 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
0.Other
Contact Person. Phone#:
.............
CERTIFICATE OF LDATE(MMXXWYYYY)IABILITY INSURANCE 0110312019
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 cortificals holder Is an ADDITIONAL INSURED,the policy les)must have ADDITIONAL INSURED provisions or be endorsed.
0 SUBROGATION IS WAIVED,subject to the ternts 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 landorsomengs).
Cynd,,e Henderson CISR,CPlA
u NAME
--70 ,3
Webber Grinnell AIONK �14
0?11 {413)588 64I39
�IERZI
8 North King Street
IN U
IN U
Northampton MA 01060 1E1 S
S ICcct'
"Sur n c,' Southeast 26
59
INSURED
SDL Home Improvement Contractors,Inc, INSURER C;
24 Chestnut Street INSURER 0:
INSURER E
Hatfield MA 01038 INSURER F
COVERAGES CERTIFICATE NUMBEW Nllaster Exp 2020 REVISION NUMBER.
THIS ISTO!-t',f4T!FY THAT"THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INOCATED. NOTWITHSTANUNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO"ICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED RY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSItONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS
0 POLICY EFF
9�x 'TYPE OF INSURANCE I.WTWID POLICY NUMBER UMITS
LTR 1tMM-DNYYYL A-M�Llp2cffKvy
CON, EACH OCCURRENCE $ 1,000,000
I— DAVAGEE 17$
MCR�IAL GENERAL jA8I1TW
..___...._...,.I
.......}SI..........I I S 500,0w
(�LA�MSWADE =UR PREMISES ff*
..........
I 5�000
MED EXP LAa oils parwQ) S
52291509 01/01!2019 01/0112020 PERSONAL&ADV INJUR 1,000,000
GENERALAGGREGATE 3�OW,000
GEN'LAWREGATE LIMIT APPLIES PER.
POLICY J£CrLOC PRODUCTS..COMPJOP AGO S 3,000,000
HER
COMEA 5—SINGLELIMfT 1,000,000
AUTOMOBILE LIAOILI'TY (FA wodwlt)
ANYAUTO I SOMLY iNjURY(Par pemoni S
A OIANED r;Z;;SCHEDULED A9105420 01101120I9 01101/2020 SOOILY iWURY(Pot wzdooint) S
AUTOS ONLY AUTOS -090-PERTY DAMAGE
HIRED NON-OWNED S
AUTOS ONLY AUTOS ONLY 26f---It)
Undermsured motorist 81 s 100,000
1,000,000
X UMBRELLA UAS OCCUR EACH(X=RRENCE
S2291509 01101mig 0 i,000,000
A EXCESS LJAB 110112020 AGGRIGArE $
$
INGWERS COMPENSATION i AT TE ERH
AND EMPLOYERT LIABILITY Y�N
ANY PROrl-i,,E',IOP,,'Y,,AP,,TNMEXECUTNE — NIA WC9024456 020V2019 02/23120W E.L EACH ACCIDENT S 500,000
OFFICEWMEMSER EXCLUDED I y500,000
j
(Mandatory in NH) E.L.DISEASE-EA EWLC�YEF $
if Tax,descnbe w4w 500A0
.',�ESCRIPTiON OFOPERArONS boioft E.L.DISEASE,POLiCl�LIMIT Is
OE-SIGRIPTION OF OPMKIIIONS I LOCATIONS i VEHICLES(ACORD 101,Addihonal Remark'$Schedule,may be*ttwzhW if"Wft SPW4 Is required)
The Abd ^S Compensation,P01MY IDES not Include Coverage for Paul Schmidt,Keridricic Dempsey and DoWlas SCI imidt
Thielsch Engineering is hereby named as Additional Insured per written Contract for work performed,and per t,
he terms and Conditions of the policy.
CERTIFICATE HOLDER �wwCANCELLATION
SHOULD ANY OF THE ABOVE DEWRISED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Thteisch Engineering ACCORDANCE WITH THE POLICY PROVISIONS,
196 Francis Avenue
Cranston RI 02910
0 INS-20illl ACORD CORPORATION. All rights reserved,
ACORD 25{201810"3) Trio ACORD name and logo are registered marks of ACORD