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17A-218 (4) 160 NORTH MAPLE ST BP-2020-0698 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-218 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-2020-0698 Proiect# JS-2020-001193 Est.Cost: $1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sa. ft.): 11369.16 Owner. GERSTEIN RICHARD zoning: URB(100)/ Applicant. PAUL SCHMIDT AT. 160 NORTH MAPLE ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC' HATFIELDMA01038 ISSUED ON:12/5/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:WEAT HERIZATION/WEAT HERIZATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Budding 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: FeeTvpe: Date Paid: Amount: Building 12/5/2019 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dj�City of Northam ton Building Departmen 1212 main S*eet SEC 4 "N i ,i _ Room 1 tl0 �(� INS ULA Tho" Northampton, MA 0 6 F� phone 413-587-1240 Fax 4 BaUn, 7r �Nsp_ fONLY oN APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLiNG-ItINLY sECTI©N, _SITE INFORMATION INSULATION PERMIT I 1.1 Pro a Address This seen complated b+office Flap I � Lot al � Unit l Zane_ Overpay mstrict Elm St.,Disirict� _ CS District __._....._.__.... SECTION 2-PROPERTY OWNERSHIPIAUTHORiZED AGENT�� 2.1 Owt of Record: � a n Name!Pruni) Current Mailing rasa. r/y I Telephone S;grature .2.2 A th rued Agent: , ��- j Name t) Cu t ai g rens. - 6?q7-51,5 __ I Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Otltriai Use Only completed by permit applicant 1. Building D�v (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 3 d. Mechanical(HVAC) S 5. Fire Protection 6. Total=(1 +2+3+4+5) / ���D _ Check Number This Section For Official Use Only 1 Building Permit Number. 01 y Date Issued: Signature Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTMJCTION StlCES 8.1 Licensed C n r: Not Applicable ❑ Nam Naof License Haider: f L - D aj o 3-5- License Nu bar -5C r Cna dress Expiratio Date gnature Tebphone Not Applicable ❑ egistrabon Number Address E)pratiorvuate Telephoner't j 3"�.�z/-2`�� SECTION 5-WORKERV COMPEMATM WSURANCE AFFIDAVIT(M.G.L.c,182,§2SC(*) Workers Compensation Insurance afflda must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bus permit. Signed Affidavit Attached Yes....... tV No.,..., Brief Description of Proposed work NOTE INS t LA TION ONLY ,,,,/ ,SI i1�11 job- C"rgyv 1 �a c j am-. a S7 s� � l V j')71, U 1 {- �(,(rYl�� OV--e' op- � r�Jd ! ►'1 l v S p - - ao� �Fe-e. ray F, d) 4-0 c� ll ZU�44U,7 vc- e �vl sir�-' ''`�' t' l-h�- s�`�Q ;S "`- 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 belief. Signed under the pains and penalties of perjury. Prins Name �zgl � ( Signatur f Own r Agent Date I s l"�!�/ as Owner of the subject property hereby authorize S� L— to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner bate City of Northampton Massachusetts T DEPARTMENT OF' BUrLDING INSPECTIONS 212 Hain Stre�—, a municipal Building Northampton, I'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: AP () A /J)4I 02cq?LQ- (Please print house Inumber and street namb) Is to be disposed of at: U&-jtA- ---rt-?,4 (:!" (. c U, AAV�Ctgc, rA Y'Y\ (Please print nllmeand locat�n of facility) Or will be disposed of in a dumps�r onsite rented or leased frAm: Ll V :V_ (,-i (Company Name and Address) S7jgn&dre-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 f Massachusetts r MWARTMLVT OF BUIZDZNCr ZNSPBCrrDNS 212 Main Street • Municipal Building ItowNorthampton, Mir 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 dwelling units....or to structures which are adjacent to such residence or building"be done by rezistered contractors. Note;If the homeowner has contracted with a corporation or LLC,that entity must be registered _.. 5L.,(- , / > _ _....... 11/ OU � Type of Work: A 5L.,(-t Od-t e- Est. Cost:__ Address of Work: / ( 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$1,000,00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): ___._.... OWNERS OBTAINING THEIR OWN PER'NIT 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 peau the ent,of tifthe owner: +� .� .. ..� � 1 Lly i . 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"ARTNXNT OF 8UrLDXN4G ZNSPZ=XONS 212 Main Street 4 Municipal building 1, Northampton, MA 0106r MANDATORYFOR OUSESBUILr BEFORE 1945 Property Address Contractor Name: Address: c City, State: A C LI Phone NaProperty 0wneII---Z,—'k,,, me Address :S 4- /�0 (-e�-;L City, State (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 RI � E.z = ENGINEERING" OWNER AUTHORIZATION FORM I, Richard Gerstein (Owner's Name) owner of the property located at: 160 North Maple Street (Property Address) Florence, MA 01062 (Property Address) hereby authorize SIS`_ (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'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 Commuinivealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017 wivi,v.mass.,00vIdia Workers*(7ompensation Insurance Affidavit: iuildersi(..ontractors/Elettricians/Plumber.,,. TO BE FILED WIT11 THE PFR.MI'MNG AUTHORITY. Applicant Information Please Print Leatlylyr Name(BusirwssOrganizati<)mlndividoul):SDL Home Improvement Contractors, Inc ................. Address:24 Chestnut Street City/State/lip:Hatfield, MA 01038 Phone#:413-247-5739 -.................. Are you an employee Check the appropriate box: Type of project(required): I am a employer with employees{full and/or part-time).' 7. 0 New construction 2,C]I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.Ileo workers'comp.insurance rquired.1 9. 0 Demolition 3.01 am a homeowner doing all work myself [No workers'comp. insurance required.]s 10 C] Building addition 'I,El I am a homeowner and will be hiring contractors to conduct all work on rity property. I will ensure that all contractors either have workers'compensation insurance or are sole I LC]Electrical repairs or additions proprietors with rto employees. 12.C]Plumbing repair-,or additions 5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C]Roof repairs Ibm sub-ontractors have emplerytes and have workers'comp insuraricc.', 14.[Z]Other Insulation We are a corporation and its officers. have exercised their right of exemption per MGU c ............... 152,§1(4),and we have an employees.[No workers*comp insurance required I "Any applicant that checks box 01 mast also fill out the section below showing their workers'compensation policy inforniation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such :Comactors that chock this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have employees If the sub-cmitractom have emplciryvs,they must provide their workers'comp policy ntimbci I am tin employer than is providing workers'compensation insurance ft;ir my employees. Below is the polity anti job site in,fi)rmafion. Insurance Company Name:,Selective Insurance Co ..............................­...................................................­­........_­­­........................... ........... Policy#or Self-ins.Lic.#:VYC9024456 Expiration Date:02/23/2020 Job Site Address:—1&6 A 4-- City/stateizip: Attach a copy of the workers'compensation policy eclaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 152, §25A is a criminal violation punishable by a fine up to$1.500.00 andJor one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line 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 cerfij.i, car the M.N and penalties typerjuty that the infiwination provided above is frue rend vorrect Signature: Date: Phone;�:44-247-57 39 0f)icial use only. Do not write in this area,to be completed liv city or town official City or Town: Permit/License Issuing Authority(circle one): I.Board of Health 2. Building Department 3.C'itvrtown Clerk 4. Flectrical Inspector 5. Plumbing Inspector 6.Other Contact Person- Phone##:—-----_—-----___--____------------------ -� ACORN► CERTIFICATE OF LIABILITY INSURANCE GATE(1 11126120 YYYY) 26120 19 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(ies)must have ADDITIONAL INSURED provisions or be endorsed. IfSUBROGATION 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 , CONTACT Cyndie Hendemon CISR,CPIA Webber&Grinnell ' PHONE (413)586-0111 A/C No: (413)586-6481 AiC.No rt: 8 North King Street ADDRESS: Chanderson(✓ilWebberandgrinneu.CAm INSURER(S)AFFORDING COVERAGE NAiC A Northampton MA 01060 INSURERA: Selective Ins Ca of S Carolina 19259 INSURED INSURER B: Selective Ira Co Of SCutheast 39926 SOL Home Improvement Contractors.Inc. INSURER C: 24 Chestnut Street INSURER D INSURER E Hatfield MA 101038 INSURER F COVERAGES CERTIFICATE NUMBER; Nasser Exp fl212020 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS,ED BELUW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIDO INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED Ht REIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N. I I CY EXP LTR i TYPE OF INSURANCE ,IND WVD' POLICY NUMBER MM M O/YYYY UNITS X COMMERCIAL GENERAL LIABILITY F-F,CHOCCURRENCE $-ffXMAM'TO REN-EU 1'000'000 CLAIMS-MADE r -+OCCUR PREMISES Ea occurrence $_500.000 j MED EXP( one Parson) $ 15,000 A 52291509 01101/2020 O1t01/2021 PERSONAL&ADV INJURY s 1,000,000 GEN'LAGGREGATE UMiTAPPLES PER GENERAL AGGREGATE $ 3,000'000 POLICY a RO- P LOC PRODUCTS-COMP/OP AGG S 3,000.000 ROTHER: $ AUTOMOBILE LIABILITY COMBINED LE LIMIT g 1,000,000 ANY AUTO BODILY INJURY jPer Person) $ .. A OWNED SCHEDULED A9105420 01/01/2020 01101/2021 BODILY INJURY(Per a=aent) $ AUTOS ONLY AUTOS --- HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLYM — I AUTOS ONLY Per acr seri) Underinsured motorist BI s 100,000 X UMBRELLA UAB ODOUR EACH OCCURRENOE $ 1,000,000 A I EXCESS Lw6CLAIMS MADE $2291509 01/01/2020 01'01/2021 AGGREGATE $ 1'000,000 DED RETENTION$ 5 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ATUTE ERN YIN 500,000 ANY PR3PRIETOR?PARTNERIEXECJTIVE E.L.EACH ACCIDENT $__ B OFFICER,IMEMBEREXCLUDED? Q NIA W09024456 02/23/2019 0223/2020 500,000 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE 5 _ tyet.describe unser 500,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt. Columbia Gas of Massachusetts is hereby named as Additional Insured per written contract with respects to General Liability&Auto Liaiblity,for work performed,and per the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Columbia Gas of Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. 4 Technology Drive Ste 250 AUTHORIZED REPRESENTATIVE Westborough MA 0158' �� 1 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD