18C-154 (5) 28 WARBURTON WAY BP-2020-0765
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block: 18C- 154 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-2020-0765
Proiect# JS-2020-001319
Est.Cost: $3000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg. ft.): 0.00 Owner: AUBREY CHRISTINE
zoning:URB(100)/ Applicant. PAUL SCHMIDT
AT. 28 WARBURTON WAY
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC
HATFIELDMA01038 ISSUED ON:12/30/2019 0:00:00
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:
Cas: 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 12/30/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I
City of Northam
Building Department
, ,Roams Street
et aEC 2 �LJL 770
Northampton, L 1060 2019
p �
phone 418-687-1240 Fax_4Izll.M272
r
P&I y
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELONG ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMI T
i
1.1 Property Address hC.."
is/section to
be completed py ice
II P - `' Lot II Unit
Zone., Covefty District
Elm St-Disaict CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2..1 Owner of Record:
Name(Print) Current Mailing Address:
I Telephone
Signature
Name ri Currerri Mailing Address:
irz:2�78`-��
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost;Dollars)to be OffCiat Use Only
Competed by permit applicant
1. Building d � r (a) Building Permit Fee
ODO
2. Electrical (b)Estimated Total Cast of
Construction from 8
3. Plumbing BuI#ding Permit Fee
4. Mechanical(HVAC) 4
5. Fire Protection Zqq
lJ�
b. Total=(1 +2 +3+4+5) Number
This Section For Oficial Use Only
Date
Building Permit Number Issued:
p
Signature: 1 a 3Q UUI
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION,3l EMMES
0.1 Licensed C
!! Not Applicable
Nam Naof License Haider,
License Nu bar
AC dress 001, ---,----
Expirati Date
gnatwe Telephone
y
Not Applicable
egistration Number
Addressl
Expirationo ate T
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(IM.G.L.c.152,§2SC#8N
Workers Compensation insurance affidaylt 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....,.. No...... 0
Brief Description of Proposed Work NOTE:TE INS ULA 'ION ONLY
wlctlos'e - All-
1 — L 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
Signalurdh6f OwneArTAgent Date vv
I , 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
4,
DEPARI"PSNT OF BUILDING INSPECTIONS
212 Main Street eMumic;.pa' Building
Nortnampton. xM 01060
Debris Disposal Affidavi 'c
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:
(Please print house number and street name)
is to be disposed of at:
t 0-"
(Please print nllmeand lova n of facility)
Or will be disposed of in a dumps r
ump§Wr onsite rented or leased frqjn:
(Company Name and Address)
SIgnSfu're-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
X15 =ir:<
Massachusetts
DEPAR71aWT OF BUILDING INSPECTrONS
212 Main Street • !,fun;czpal Building
Northampton, MA 01060
AFFIDA'V'IT
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 registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
11 -0 oil
..hype of Work: ul V�'`- .............d__,..._............ _., �_.......Est. Cost:._. �,.�CC-
Address of Work: �-, W(:� ` tar,
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Mork excluded by law(explain):
Job under S 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 penury:
I hereby apply for a buildingper�pt``���
10-1
the;Sent of i�heov�m�
9 � +��", -Ccw�. a-- -ter
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 M
Massachusetts
,DEPARTWNT OF BUI LDZNG ZNSPNCTZONS
212 Main Street • Municipal Building
Northampton, MA 0106f
MANDATORY FOR HOUSES BUIL T BEFORE 1945
Property Address:
Contractor
Name:
Address: f
City, State: AA—a—Am yn or cDl
Phone: l
Property Owner /1
Name
Address c��g f a' ra � rl
(ity Mate i / "J mock o/ ou
I �; � (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 /j-r/
Permit Authorization
mass save Form
Site ID: 3924268 Customer: Christine Aubrey
ALJo�Lj ,owner of the property located at:
(Owner's Name,p Inted)
28 Warburton Way Northampton, MA 01060
(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: ,' )
Ai��Z
Date: f l ��'
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 Fcf Cffice Use Cnly
Rev.102015
The Commemwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www,.mas,8.gov1dia
Worker.%*Ctimpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
1`0 BE FILED WITIVIME PERIMITTING AUTHORITY.
Agglivaut Information Please Print Legibly
Name(Bm,;ifwss/OtguniuioWindividual):SDS 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):
1,E]I am a ernplover with,8 employees(full tialoi part-time).'
7. New construction
2,n 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. 0 Demolition
.1.0 1 am a homeowner doing all work arywif,[No workers*comp. insurance required.] 10 Building addition
4.[]1 am a homeowner and will be hiring contractors to conduct all work on my propeq�. 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
5.[31 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs
These sub-contractors have employees and have workers*comp.insurance.:
14.[Z]Other Insulation
6,E]we are a corporation and its officers have exercised their right of exciption per MGG.c. ............
152,§1(4),and we have no ernployces,(No workers"comp.insurance required I
'Any applicant that checks box 41 most also fill out the section he ow showing their workers'compensation policy information.
*Homemxwrs who submit this affidavit uidicating they are doing,all work and then luic outside contractors must submit a new affidavit indicating such,
%Conuactor,,that choA this bo-must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
ctinployees 11'the sub cortaraetors have employees,they must provide their workers'comp policy number
I tiny an employer that iv providing workers'compensation insuranceftor my employees. Below is The p4iry andjoh site
injvriflation.
Insurance Company Name:.Selective- 11 Insur I a I n 11 c I e-Co ............................. .......................
Policy#or Self-ins.Lie.#:WC9024456 Expiration Date:02/23/2020
Job Site Address: lo(-)I) ),k)L,2 ;-j
citystate/Zip.
Attach a copy of the workers*compensation policy declaration age(showing the policy number an expiratioeZe).
Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by a fine up to$1.500.00
and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORI)ER 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.
I do hereby certift er t e ins and penalties ofperjui-y that the inji)rMation provider!above is true and correct.
Signature__
Phone#:413-247-5739
........... ............ ......
Official use only. Do not write in this area,to he 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
6.Other
Contact Person:---- Phone# ..........
�,.1 T 4 DATE(MMIDDIYYYY)
A
LLllR" CERTIFICATE OF LIABILITY INSURANCE 11.2sr2o1s
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 NAME T Cyndle Henderson CISR,CPiA
Webber&Grinnell AHDNIC,No,Ext FAX
1413)586-0111 AIC.No: (413)586-6481
8 North King Street A'DOARESS: ChendersOn@Weoberandgnnneii.com
INSURERIS)AFFORDING COVERAGE NAIC N
Northampton MA 01060 INSURERA: Selective ins Co of S Carolina 19259
INSUREDINSURER B: Selective Ins Cc of Southeast 39926
SOL Home improvement Contractors.Inc. INSURER C
24 Chestnut Street INSURER D:
INSURER E,
Hatfield MA 01038
INSURER F.
COVERAGES CERTIFICATE NUMBER: Master Exp 02/2020 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF'NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR 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
IOILICY EXP
LTR I TYPE OF INSURANCE IN O IN POLICYNUM8£R (M MMO/YYYYPOLICY MWDOIYYYY) LIMITS
X1 COMMERCIAL GENERALLIABILITY EACH OCCURRENCE is 1:000,000
500.000
_F..i1.A 5-MADE
PREMISES IEa occurrence) s
MED EXP IAay one person) S
15,000
A I 52291509 01;0112020 0110112021 PERSONAL&ACV INJURY s 1.000,000
GEN LAGGREGATE LIMIT APPLIES PER GEN=_RAL AGGREGATE s 3.000,000
I POLICY [7 R4 LOC PRODUCTS-COMPIOP AGG s 3,000,000
OTHER
I 5
AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT 5 1,000.000
WttEa auiC )
ANYAUTO SOD;LY INJURY iPer person.) 5
A OWNED SCHEDULED A9105420 01;0112020 0110112021 BOD:LYINJURY;Peracciaeni) S
AUTOS ONLY AUTOS
I\/ HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY X AUTOS ONLY Per awidenU
Underinsured motorist 81 s 100,000
X1 UMBRELLA LIA8 OCCUR ECM OCCURRENCE $ 1,000,000
A EXCESS LIAB CLAIMS-MADE S2291509 01101;2020 01101/2021 AGGREGATE $ 1,000,000
DEDRETENTION $ s
WORKERS COMPENSATIONPER 0TH'
AND EMPLOYERS'LIABILITY X'STATUTE ER
v I N 500,000
B ANY PROPRIETOR'PARTNEWEXECUTIVE NIA WC9024456 02,23,2019 02/23/2020 E.L EACHACCIDENT 5
OFF'CERIMEMBER EXCLUDED> ,
(Mandatory in NH) I ( E DISEASE-EA EMPLOYEE S 500.000
if yes describe under 500,000
1 DESCRIPTION OF OPERATIONS below I E DISEASE-POLICY LIMIT S
1
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remanis Schedule-,may be attached it more space is required)
The Workers Compensation policy does not inciude coverage for Paui Schmidt.Kendrick Dempsey and Douglas Schmidt
Coiumbia Gas of Massachusetts is hereby named as Additional Insured per written contract with respects to General Liability&Auto Lialbiity.for work
Wormed,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 Gds of MasSacnusetts ACCORDANCE WITH THE POLICY PROVISIONS.
4 Technology Drive Ste 250
AUTHORIZED REPRESENTATIVE
Westborough
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