32A-232 40 POMEROY TER BP-2020-0656
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-232 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2020-0656
Proiect# JS-2020-001111.3
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.): 183561.84 Owner: SHOUL PAULA
Zoninjz: SC(90)/URC(IO)/ Applicant: PAUL SCHMIDT
AT: 40 POMEROY TER
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:INSULAT IONNVEATHERIZATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspecior 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 Paidr Amount:
Building 11/21/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of'No am-tole
Building D part ent
212 M In Si et#0V y �
Ro in 14
" Northairnp on 60 o�y
phone 413-587-1 4t-'
AMp7-0N MA o CT/ON �,
APPLICATION FOR INSULATION FOR A.ONE OR TWO FAMILY ING ONLY
SECTION 9 ;'SITE 1111FORMi iTIt1N INS
L TION, P T
a .� ,� 'secor �ipfetytice'
1.1 Proodd Address ! yy P 4� d� k
/ � / /�m�i�)'1 �/ / �`��� .>F h� ,.,��1s.�' � °`./�. /s✓ �•.,r/ y � � � F3� �r ri N`fj
WOD
SECTION 2-PROPERTY.OWNIER01 09RIZEa.k3ENT
2.1 Owner of Record;
4&/ .s jr), c,C 46 M,e
Name rint) Current Mailing Address:
Telephone
S nature
2.2 thorize&A en. ;`�l�/l�►1 i C64--
Name(Pri ) 'Current Mailing Address-:—
Signature
dress:Signature eiephone
SECTION,3;ZttIit`CTEO-,•Ct��COSTS
!tern Est9rrtated Cost(dollars)to be OfficlaY»s:'Oniy
com leted"b ' ermit applicant
1. Building (a)`;i3uilding Perm>f,�ee
2. Electrical {la)Estn118tad Total:Costaofi"
,'Con uction', ffi 6
3. Plumbing OuOinE}?ermlt F
4. Mechanical(HVAC)
5.Fire Protection
6. Total,-(1 +2+3+4+5) Niamlier ;.
Sd6dow Fbr,O I&IaI,*a
p /,, Date
Building Perth N9u ber.. +� �� J�(X
.. "Issued:
Signature; I �!
Buildln i✓a�r'miss)aner�ir� tgro€Bualtl3ngs _ N)ate;
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION A:�C4MS't 2l CTit N SEij i
8.1 Licensed;:Constructio Su_ervisor: Not Applicable ❑
Name of License Holder;
License Nu'ber
�.
dress , Expiratioff Date
gnature Telephone
Not Applicable ❑
I1 �OI 5�
crtn an Nametin C)M, 1YbCUV"RegistratJon Number
Address
Expiration/l ate.
Telephoneq� -� `
SECMN 5-INOFiilE}23'CDMPE...... t7N;IN5t112,i12ANCE AFFiflAViT(N!GcL.c 15 ;§
Workers Compensation Insurance affida must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes,...... No...... ❑
Brief Oescription of Proposed Work NOTE: MS LA TIOM-ONLY
6� 3,�" , - `1�-�.��( less, --h.�,, a„ r1P5,'d
r� Q
00-rd ff
Zy
as Owner/Authorized
Agent hereby.deciare,that the state»ertts end 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
is
Signatur of Own r/Agent, 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 Owner Date
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Paul Shoul
(Owner's Name)
owner of the property located at:
40 Pomeroy Terrace
(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.
Owner ature
It �
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 ( Canton, MA 020211339-502-6335
www.RISEengineering.com
City of Northampton
�4
F ?N Massachusetts ::%`cr
w DEPARTMNT OF BUXZDING ZNSPECTZONS
212 Main street *Municipal Building �
Northampton, MA 01060 .'
Debris Disposal Afft(Uvit
1n 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:
n �.
(Please print house number and #rest 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 frqm. 3
C)lC 3`
(Company Name;and Address)'
_19
Signatureof 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 ddbd§will-b6 disposed.
_ City of Northampton
Massachusetts
DEPAR2mw or BuzzDxmG zxspzcT oNS � d
212 Main Street • 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,contractormust be registered as a Home Improvement Contractor("HIC").
YI.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 more1han four duv lling:units....or to structures which are.adjacent tolsuch residenc&orbuilding"be
done by registered contractors,
Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered
6
Type of Work: c.t ( L)r) _Est.Cost: 5Oc-)
Address of Work: U 1 Aa P �--
Date of Permit Application:
I hereby certify that:
.Registration is not required°for the-following reason(s):
_Work excluded by law(explain):
_Job.under.$1000.00
_Owner obtaining,.own permit(explain):
Building not owtier-occupied
Other(specify):
OWNERS OBTAINLNG THEIR OWN FERMff OR ENTERING INTO:CONTRACTS_WITH UNREGISTERED
COiVTRACTORS OR;SUBCONTRACTORS I'UR APPI ICABLE=HOMLIMPROVE NT WORK AEtE NOT
•
ELIGIBLE FOR AND DO NOT HAVE ACUESS,TO THE ARWRATION PROGRAM tW GUARANW FUND
UNDERM,G.L.Chapter 142A,SUCH OWNERS'-ALSO ASSUME THE-RESPONSEBH ITES.FOR.ALL WORK
PERFORMEEDUNDER THE,BUILDINGPERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
t
I hereby,apply for a building pe t as the`� f the o=.—
.!j4j,,4 � ----
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:
Bate Owner Name and Signature
Nr City of Northampton
•, d
' Massachusetts
DEPAR2MMT OF BUILDING INSPECTIONS
212 Main ytreeetni
Street * Municipal Building
01060
MANDAT6RYPOR HOUSES RAIL r BEFORE '19A5
Property Address:
Contractor
Name:
Address: t -
City, Stater Cit is
Phone:
Property Owner JI
Name:
Address:
City, State: z
ry)iq o) c'Co- U
Ir j C (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
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
>'. I Congress street,suile 100
Boston,MA 02114-2017
J. wwlM.`naSM-ov/rlia
V NVorkers'Compensation Insurance Affidavit:l3 iliderslCantrtti�torsl.FlectrteinitsiPlumbeis.
TO BE FILED WI'I'II'I m.PEI3.M1i1"1""Ni G AU"1'ICOM`4''.
A Meant Information Please Print Legibly
Narne(Busines&JOrgani ti( , d", idutti):SDI Home Improvement Contractors, Inc WV��
Address:24 Chestnut Street
City/State/Zip:Ha#field,SMA 01038 Phone##:413-247-5739
Are you an employer?Cheek the appropriate box: 'Type of project(required):
l,0✓ t all,a employer with_8 .. _gmployces(full and;or part-time). 7. Q New construction
2.01 am a style proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity,[No workers'comp.insurance required.)
9, ❑Demolition
3,0 t am a homeowner doing all work myself:[No workers'comp.insurance required.j 4
10 El Building addition
4.[]11 am a homeowner rind will be hiring contractors to conduct allwork on ray prolrerty. I will
ensure that all contractors either have workers'compensation insurunce or are sole 11.0 Electrical repairs or additions
,proprietors with no em loyces.
i p p 1.2.❑Plumbing repairs or additions
5. 1 am a general contractor and S have hired the sub•contractars listed on the attached sheet:
'These sub-contractors have employees and have workers'comp.insurance.• 13.ORoofrepairs
6,❑We erre a corporation and its officer's have exercised'their right of exemption per ML GL c.
14.0✓ Other Insulation
152,§l(4),and we have no employees.[No workers'comp,insurance required,]
"Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit#naicating they are-doing all work and then hire outside contractors must submit a new affidavit indicating such.
>Corrnactors that check ibis box must attached an additional's act showing the name of die sub-contractors and state whether or not those entities have
cntployces. tf the suh-contract6r-s have employees,they must provide their workcrs'conrp,policy number,
l trate riar eniployer iliat ire prnvidli#i bookers'eiiinlaearsatxvri insiirancefor nsy.emplriyees. Below is thepolicy anrl,/ob site
inforination,
Insurance Company Name.Selective Insurance Co
Policy##or Self-ins.Lic.##:WC9024456 ;Expiration Date:0272312020
Job Site Address: .0 D 4 Com- City/stat ip /4A�-p
Attach It copy of the srrrcrkers'ctiulpensatioJ(310 olicy ticcla tlon pale(sltorving the poliey;7tutnber;enra�ttutt date).
Failure w secure coverage s rccltiircd iandi�tL c. 152,§25A is a criminal violation punishable.by a fine up to 51,500.00
and/or one-.year imprisonment,as well as civil penalties in the form.of'a STOl?��" ORK OI I-R and.a fine of up to x;250.00 a
day Against the violator.A copy of this stateineru may be forwarded to the Office of lnvestig�tions of the DIA for insurance
coverage verification.
I do hereby cerew er21410, ins and pen alt es ofperjury that the Mformatio aprvvided above as Irise and correct
.Sianature: Date:
Phone t#:44-247-67T9-
9
Offlzial useosi1y. Do not write its this area,to be completed by city or town official.
City or'T ow w Permit/License i'#
Issuing Antlx64ty(circleone):
_
L'Board of Health 1.Building Departtnent.3.Cityf'ovvn Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
6ntact Person: Picone##: