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36-111 (8) 223 BROOKSIDE CIR BP-2020-0720 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36- 111 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-2020-0720 Proiect# JS-2020-001225 Est.Cost: $3000.00 Pee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sa.ft.): 18251.64 Owner: TOWLES SUSAN Zoning: Applicant. PAUL SCHMIDT AT. 223 BROOKSIDE CIR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.121912019 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC FLOOR 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 12/9/2019 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner . City of Northa pton 1r° Building Depie me ' 212 Main Street, �E �� � Room 00 C 9 �" wr+l►L ATION Northampton. M,4CO F X01 r phone 413-587-1240 Fax- _ , ' I & Y pN M`���T ON APPLICATION FOR INSULATION FOR A ONE OR TWO FAMIL !°!!W ELLi ONLY j SECTION 1 -SITE INFORMATION I;NSI.J�A �TIO PERMIT 1.1 Property Address This section to be completed by office �^ ,l ' Map_ Lot ur.' Zone Overpay District__. EIm Stu DWrict_ CS District SECTION 2-FROPERTY OWNERSHiPIAUTHORIZED AGENT 2.1 Owner of Records --�� I �a a a3 KJ.44 -- Na^^f�,'print) ,umlng �C� (JL. Telephone Signature j 2 A7 authorized Ag-ent; ��. rvL,'d-4— Name ) Current Mailing Address: m J�j UI 03 Signature Telephone �.- SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 16 cel (a)Buiiding Permit Fee CZ 2. Electrical (b) Estimated Total Cost of Construction from 6 1 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+d+5) CSC X� Check Number Q r� This Section For Official Use Only j Building Permit Number: y y r D 1Ussued: i Signature I Bolding Commissioneriinspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTM 4•CONSTRUCTM WAME3 —7 81 L r; Not Applicable ❑ M of Umn s•Herder ad 1 D, 3 S" License NU bei a _ dress Expirati Date gnature Telephone Not Applicable ❑ Y` L a It egistration Number _ a va Address ��(( Expiratio a#e �� ��Uj Telephone'? SECT11 N 5-W©RilMM COWENSATM iN8llElAmE AiFFWAYiT M.G.L.c.152,$26g6)) Workers Compensation Insurance aft4da must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buikft permit. Signed Affidavit Attached Yes....... No...... ❑ Brief Description of Proposed work NO TE INSULA TION ONL Y 1�e" Qox G2.I tu10 s_< c V `.�y 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. .�' Print Name signatunk6f own 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. /,a . -7-17 Signature of Owner Date __,.. City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS � 4 217 Main Street *Municipal Building Northampton. MA 01060 � w Debris Disposal Affidavi'c in accordance of the provisions of MGL c 40, SO4, 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: (please print house number and street name) is to be disposed of at: L (Please print n rn end 1 n of facility) Or will be disposed of in a durraps r onsite rented or leased fr � `` (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 DEPARTMENT OF BUILDING INSPECTIONS 212 Ma-,r. Street 0 .14unicipal Building Northampton, MIL 01060 AFFIDAVIT Rome 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 registered contractors. iVote:If the homeowner has contracted with a corporation or LLC,that entity must be registered C,0 'Type of Work: ----­­ Est.Cost:-­ 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 building pe t as the ent,of the or: /C;)- ?- Date Contractor Name I-11C 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&PARTMN"T OF SUZLDXNG Tbf5PSCTZONS 5 212 Main strut s Municipal building vim' Northampton, MA 0106` MANDATORY FOR HOU- S-ES BUIL. r BEFO E J 945 Property Address: o? L Contractor , Name: Address: City, State: Phone: , Property Owner Name: Address: City, State: rx CA Cj U& iIP,, (contractor) attest and affirm that the building I intend to insuiate 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 Ir7a#e RISE ENGINEERING" OWNER AUTHORIZATION FORM I, Susan Towles (Owner's Name) owner of the property located at: 223 Brookside Circle (Property Address) Florence, MA 01062 (Property Address) hereby authorize 5 (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 Commonwealth of Massachusetts Department qf Industrial A ircidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov1dia Workers*Compensation Insurance Affidavit:Builders/(..ontrac.tors/Electricians/Plumbers. TO BE FILED WITH THE PERNarnNG AUTHORITV. Applicant Information Please Print I's y -ibly Name (i.3tisiriess,."(:)rgani7atiorvindividual):SDL Home Improvement Contractors, Inc ............. Address:24 Chestnut Street City/State/Zip:Hatfield, MA 01038 Phone#:413-247-5739 Art you an employer?Check the appropriate box: Type of project(required)- i [a I am a emplover with._.....__..__._....employees(full andfor part-time)." 7. 0 New construction 2,0 I am a sole proprietor or partnership and have no employees working for me in 8. [] Remodeling any capacity,(No workers'comp.insurance required.) 9. C1 Demolition t.OI am.tuimeowner doing all work myself.(No workers'comp. insurance required.) 10 C] Building addition I am a homeowner and will be hiring contractors it)conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions S 0 1 am ageneral contractor tor and I have hired the sub-contractors I isted on the attached sheet. 13.f—1Roof repairs These sub-contractors have employees and have workers'comp.insuranceJ 14.[Z]Other Insulation 6 E]Wcare acorporation and its officers have exercised their right of exemption WM. Gt.c. IS2,§1(4),and we have no employees.[No workers*comp insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners;who sub nit this affidavit indicating they are doing all work and then lure outside contractors must submit a new affidavit indicating such. Chose, e ties I i Contraclors that check this box must attached an additional sheet showing ft name of the sub-contractors and state whether or not t riti u ve efirploytes. If the sub-contractors have emptovees,they must provide their workers'comp Policy number Below is the policy rural job site information. Insurance Company Nanw, Selective Insurance Co .................. ..........................- Policy#or'Self-ins.Lie.h.,WC9024456 Expiration Date:02/23/2020 Job Site Address: -2615 A K— ICJ--9—city"Statezip: irt Attach a copy of the workers'compensation policy declaration page(showing the policy nit in be r 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 form of a STOP WORK ORDER and a fine of up to 5250.00 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 c eft y rte , ins and penalties#J'perjury that the infir)rmation provided thrive is true anti rorrect. S 117- Phone 9:41 -247-57r9 ........... Official use only. Do not write in this area,to be completed lav city or town official. 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 Ptrson:---, - --------------- Phone#:11111-1-11.1.1............ ,15 CERTIFICATE OF LIABILITY INSURANCE F A7E(.MIoDfYYYY) 1 11;2612019 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. 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 I NA"1CO"T,CT Cynoie Henoerson CISR,CPIA " PHONE (413)586-6481 ,it,: l413)5W0,111 FAX Webber&Grinnell (AIC,No (AID,No): 8 North King Street ADDRESS chenoersong-webterandgrinnell Corn , INSURER(S)AFFORDING COVERAGE NAIC 6 Northampton MA 01060 INSURER A: Selective Ins'Cc of§Carolina 19259 ...........................*.. .............. INSURED INSURER 8: Selective Ins Co of Southeast 39926 SDL Home Improvement Contractors,Inc, INSURER C 24 Chestnut Street INSURERD; INSURER E: Hatfield MA 01038 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Exp 02'2020 REVISION NUMBER: THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN iSSUED'I 0 THE INSUREDI,NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,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 AULILIbut5ml POLICY EFF ICY LTR TYPE OF INSURANCE IVSD i WV0 POLICY NUMBER (MMIDDIYYYY) IM LIMITS x JAL GENERAL LIABILITY COMMERCIAL EACH OCCURRENCE $ 1,000,000 r DAMAuE TOP NTED CLAMS-MADE X!OCCUR PREMISES(Ea pcwwrar4el $ 500,000 MED EXP'Any c4w person) 111 15,000 A S2291509 01/0112020 01;i/01/2021 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 3,000,000 PRO- POLICY 7 JECT LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER, AUTOMOBILE LIABILITY Ex SINEO SINGLE LIMIT 1,000'000 ( ANY AUTO BODILY WiURY(Per perscn) S • OWNED SCHEDULED A9105420 01101/2020 0410112021 BODILY INJURY,Per accident) $ AUTOS ONLY X^1 AUTOS X HIREDNON4)MEO PROPERTY DAMAGE AUTOS ONLY X $ AUTOS ONLY (pot rg) Underinsured motorist 81 s 100,000 X UMBRELLA LIAS OCCUR EACH OCCURRENCE $ 1,000,000 • EXCESS LIAR HCLAIMS-MADE 52291509 0110112020 011/0112021 1 AGGREGATE 6 1,000,000 DEDI RETENTION$I I F $ WORKERS COMPENSATION S.01 PER STATUTE ER OTH_ IN AND EMPLOYERS'LIABILITY I X ANY PROPRiETORiPARTNEIYIN ICUTIVI F7y El EACH ACCIDENT 111 500,000 8 OFFICER MEMBER EXCLUDED? NIA WC9024456 0212312019 0912312020 ;Mandatary in NH) 500,000 El DISEASE-EA EMPLOYEE S M yes,describe under DESCRIPTION OF OPERATIONS bisiow E,L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additkmal Remarks Schedule,may be attached if more spate Iis reqwriad) The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Sthmidt. Thielssch Engineering is hereby named as Additional Insured per written contract,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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Q 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD