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29-117 (6) 88 FOREST GLEN DR BP-2022-0084 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29- 117 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-2022-0084 Project# JS-2022-000150 Est.Cost: $2000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(su.ft.): 14157.00 Owner: STEPHANIE MARTIN-LUCEY Zoning: Applicant: PAUL SCHMIDT AT: 88 FOREST GLEN DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:7/26/20210:00:00 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. ) i Certificate of Occupancy Signature:'' FeeType: Date Paid: Amount: Building 7/26/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ' �\ City of Northampton ,. Po, py„ "e,- ,`- Building ©epa+`tmer}z� t/Go i`' a i 212 Main 5�#rera C') ,,,'?,,,;,..or ' r... Room 100 .-)i- _ [ Northampton. MA O 'fi phone 413-587-1240 Fax 413- 7/ 1 `� _ APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELL! G ONLY d SECTION 1 -SITE INFORMATION INS LA TION PERMIT 1.1 Property Address� This section to be completed by office Map aC"l�y� Lot /77 Unit Zone Overlay Disttict Fi ru k--,c—c, , I`l\ A v I o Ca a- j Eri St District__.. _. _._ cS District SECTION 2-PROPERTY OWNER:aHIP1AUTHCRIZED AGENT j l 2,1 Owner of Record: Name(Print) Current Mailing Address, / e/ (..R-)- +S. Telephone Signature 2.2 Authorized A ent: -Prt 0., _�_.... ! eiblij---1-1AA)-- S + Name(Pr t) Current Mailing Address. Sl a e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant ". Building (a)Building Permit Fee i 3 f , 2. Electrical (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee �. 4. Mechanical(HVAC) 5. Fire Protection 6. Total -(1 + 2+ 3+4+5) II 0 0 0• Check Number I This Section For Official Use Only Building Permit Number i$, - '' '..'1'. Date Issued:. Signature. ///12 g 7 Z3 Zozl Building Commissionerlirispector of Buildings Date EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) [SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Constructio p- upervisor: Not Applicable c? , < Name et License Holder �d t�j� :,_Yl ii CI i ' C,..s j L7,i.' .> '.S ! License Nu ber A cress f , Expiratio Date gnature Telephone f 9.kiraiiiimaidNirlis4liveravermint Comillialmg Not Applicable l Cornpan Name r- r '' ! g �/ 7 I �� Jl�`,� - �yY"1 : '>,�; .-li1r...lt kir1e istration Number A L/ (2110 Address Eirpiratio+ ate k----k-G---,.\ ct.l ck 01 U , Tolephonel`}i -c;)U'7-,-c `i t SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§25C(6)) 1 Workers Compensation Insurance affida t 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 a i ;Brief Description of Proposed Work ; NOTE: INSULATION ONL Y 1 . c li eitp‹___ d I 1 ) c�i Eck/oS . (�9lp s5 `-� Pc/'` 14,,,s.� pac_.t7 4.4' f 5,2.ek Lit r).. O - rw- cy , ,,,,,, I 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. ' .,) -1 AC1 ___ -L‘rt\fi_, 171-0,„,9,z.N-( (y-) ...i-yk-- (ity4(4(bC.S, loc Print Name ' Z 7-/4- a / Signatur f Own r/Agent Date �/� (S_e c_ l 1 C.- I. .5�e_rka.i 1/ Li / ► I a(r--1-7 �1 LA r(.` . as Owner of the subject property ff hereby authorize L_ to act on my behalf in all matters relative to work authorized by this building permit application. '_,�t._ o - c- 8 '7 - / / Signature of Owner Date City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS x 212 Main Street •MunIcIpal SulidIng %-7"'" Northamptor, 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: 88 (Please print house number and street name) Is to be disposed of at: YY\A (Please print n4me and locaticn of facility) Or will be disposed of in a dumygor onsite rented or leased fr m. tc-;. (Company Name and Address) a, — 9 - 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 .. Ope Massachusetts DE'PARMIENT OF BUILDING INSPECTIONS ,, ..,,, ••:,. ,:', 212 Main Street • MunIctpal Building Northampton, MA 0106( MANDATORY FOR HOUSES BUIL. r BEFORE 1945 Property Address: 8s1Contractor Name: .‘7:"St:: 1---, VhAC,-, --VfiTh )11-\_r, '.__.rt's,k-. 4-\:..-A- Address: r-J LI C --\--\- -- ,k6 City. State: sk--r>,.v..,,L-YA- A,"-*`- -•- cf\ u :!.) , Phone: '''' I , 3 LI-1 - '-'5 ri :-? C) Property Owner Q Name. __..)4---Q.40 i---,0—r-o e__ rYi col.,1-1,---) Co cQ___si Address- City. State. /--).. ) ) 1 I ii:.,,, ; ,--4--,,nif C.0' (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 7--- Date City of Northampton ii.‘,.,. A r Massachusetts" ! ,..„te fi . �_ °,; DEPARTMENT OF BUILDING INSPECTIONS �t " 212 MAir. Street • Municipal Building .F ‘N. ,,� N" Northampton, MA 01060 "• w�y1`'' 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 CHIC"). 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. :Vote:lithe homeowner hus contracted with a corporation or LLC; that entity must be registered. aO "I ype of Work: �1.4r1 S[.t,l(Al cyu Est.Cost: c C O Q c Address of Work: O -���.- (2,(..... f., ,,r *...._ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work 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 perjury: I hereby apply for a building pewit as the entof the owner: 1_/7- .a-1 _..�t\\. \-\td•=-' ,,-", L -,,,,.,....<--\-i--- �]' L/y / 5 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 I`)a'i c Owner Name and Signature DocuSign Envelope ID:E0904BFB-E4E8-40E3-8B81-E892530FB22F \wt RISE ENGINEERING` OWNER AUTHORIZATION FORM l Stephanie Martin-lucey (Owner's Name) owner of the property located at: 88 Forest Glen Drive (Property Address) Florence, MA 01062 (Property Address) hereby authorize SD\ Subcontractor(to be filled in by office) 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. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. ,.—DocuSigned by: OtiesstSeli re 7/14/2021 1 5:18 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com The Commonwealth of'Massachusetts _ 1 Department of Industrial Accidents •..., 77...-TiAltZ7' i Congress Street, Suite 100 Boston, Iti 02114-2017 : Ir.:7,1—•-• ,..;' It'ww.mass.gov/dia •......- . Worisers• Compensation Insurance,kffidavii: Buildersitontractors/ElectririansiPlumbers. !ORE HEED II II Ili+ PERNIII DM; %I THOR!IN, ADDIteattl Information Please Erin( Legibl% Name SDL Home Improvement Contractors, Inc i BusincssiOrgaoriariontindi\mit/a I/: ...,. Address: 24 Chestnut Street City/Suite/Zip: Hatfield MA 01038 Phone #: 413-247-5739 .: Are'Ira an employer?Check the appropriate hos: r ; Type of project(required) i a I am a employer 1.‘ith 8 employees(ridi and/or part-time i• 0 .".ew onStruttIOn ' 0 I an a!rote propleVOT or wartrieterhip and have no employees working tor me in fi. 0 Remodeling :;)1":OtpOcrty,INo workers comp insurance scooted/ 9 0 Demolition 10 I am a homemywer don*all wort myself I No workers eomp 'irstrrrince waived 1' i 0 0 Building addition 4 0'am a homeowner and w tll be hiring contractors to conduct all work on my propem I will ensure that all comae:ors tither have workers'compenvtion Insurance or are sole I 1,0 Electrical repairs or additions pompoms with no OVIC)Y('C's 12.0 Plumbing repairs or additions 5 0 I am a general eoritractor and I have hired the stirs-voraradors listed on thr attached sheet . 13.0 Roof repairs Thew suMeontrimators have employees and have'workers'comp insurance ,., 6,0 We are a corporation and its officers nave exercised their right or exemphon per Mt i I C 152,§1(4),and we Wave no employees INo workers'comp insurance required I 1 4 El(:)thcr 1 . 04.5411Aht.ip4 I : •Any aerricant that cheeks hos II must also fill out the seenon helms showing their t1tIftetS' 11TiptilSatIOVI pOlso.intormanon 'Homeowners who submit this affidavit indwating they are doing all wort and then hire ouaork contractors mist submit a new affidavit trmikaumg such Contrariots that cheek this hot must attached a)litldillMill Shtet showing the name of the sub-eon/rat:tors and i:ra.te whether or not thrwe ensues have ,;,rmlmem, if tiltr.mb.4:mmavionr,hose Cr pi. em-,tiK' ‘n.,A, Ff A:,t}' '..",, i,,CC, .Orrir poiii:,:: nuiiihti I ant an employer that k providing worAers*compensation insurance jiff iris'employees. Below is the policy and job site infOrmalion. Insurance Company Name. Selective insurance Co , Policy li or Self-ins. Lie, : WC9024456 Expiration Date: 02/23/2022k .----- ------ , Job Site Address: e 61 -/-6 re----s4- 62.1'7 CityState/Zi • Fb"1....e._ri , M 4 Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date). Failure to secure coverage as required under MCA.,c. 132,*25A is a criminal violation punishable by a hue up to S!.500.00 and/or one-year imprisonment,as%Nell as civil penalties in the form of a STOP WORK ORDER and a tine of up to$25000 a day against the violator, k copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce •:, inder Milt%1111ii peOlti fO fti" leriUly thin the infOrmation provided above is true and corretl. ,iiIIP:414 .... phonc.,..,: 413-24 - 739 f ....— I Official use only. Op not write in this area,to he completed by city or tows.official I ii city or Town: Permit/License 0 Issuing Authorit) (circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6.°the.: if i I i 1 k ontact Person: Phone 4: ,4 , DA T Ty:TM T,UDDT‘C".'Y sr ACC)RD CERTIFICATE OF LIABILITY INSURANCE 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 INSURERIS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 4 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policyties)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 E CONTACT Cynde Henderson CISR.CP1A Webber&Onnnell i PHONE iCNo.Eat) (413)586-0111 TTAT— t413)586-6481 ,qk , . [EAlC.Noy 2 North King Street !EiMAIL chendersortigvvehherandgrinnell corn I ADORES& ,--- . , I ! INSURERiS)AFFORDING COVERAGE NAiC is , Northampton MA 01060 INSURER A- Selective Ins Co of S Carolina 19259 INSURED INSURER 8 r Selective Ins Co of Southeast 39926 SDL Home Improvement Contractors,Inc INSURER C 24 Chestnut Street INSURER D: INSURER E, , Hatfieicr MA 0103E I INSURER F I COVERAGES CERTIFICATE NUMBER: Master Exp 2022 REVISION NUMBER: ii-us.is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYWTHSTANDING ANY REQUIREMENT TERM OR CONES TION OF ANY CON FRAC(OR OTHER DOCUMENT WI i H RESPECT TO VVHICH 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 1 IALJUL Eio. LTR I TYPE OF INSURANCE IIPIP__LYYv' POLICY NUMBER T-MMIDONYYY MMIDONYY;), LIMITS — 1,000.000 1 XI COMMERCIAL GENERAL LIABILITY T I EACH OCCURRENCE S t I 1 I ,175XMAGIE TO REN i et) t I I CLAIMS-MADE I X occuR I PREMISES iEa cazurrence) S sea°°°I MEC EXP kAny are p $rson) 15.000 ! A Y S2291509 01/01/2021 01101;2022 .2ERSONAL&AOV IN.IURY Is 1,000,000 s GENE.AGGREGATE LIMIT:APPLIES PEP- i 1 GENERAL AGGREGATE 3.000,000 POLICY I j vi I I Lc, I 1 PRODUCTS i cume;oPAcd $ 3i000,000 ,OTHER Jr i t,— CE $ ..- 1NIBINED SINGLE LIMIT AuTdoitOeiLE LIABILi TY ! S 1,000,000 Ita acc:/deno — ANY AUTO I 800iLY INJURY cPe+be,son) $ A cAriS60oNLy f x SCHEDULED Y A9105420 01/0112021 01101/2022 BODILY INjORI. Pr),accident) S ...,... , HIRED "Ne !VC/N.01,04ED I ROPERTYTAMAGE. S AUTOS ONLY 1."-N AUTOS ONLY 3•>er amnant Underinsure motorist BI s 100,000 — I Xi UMBRELLA LIAR 1 •- u.,,, i_s 1.000,000 E ACH OCCURRENC E A EXCESS LIAR r 1 CLAIMS-MADE S2291509 01/01/2021 01;0i/2022 AGGREE.A" TE 1,000,000 S ; T T LED I i RETENTION IS ,_.. WORKERS COMPENSATION t -*--. PER T- AND EMPLOYERS LIABILITY YIN STATUTE -Ell ANY PROF,RIETORIPARTNER,EXECUTIVE MBER 1 y 1 N,A WC9024456 0212312021 02/2312022 E L EACH ACCIDEN, s 500,000 cr OFFICER/ME EXCLUDED"' __„,_ (Mandatory In sii) 1!-----J EL DISEASE•EA EMPLOYEE S 500,000 if-yes,descRbe oder DESCRIPTION OF OPERATIONS:Ado* F.L.DISEASE•POLICY LIMIT $ 5°°'We _ i i I I ______________ _ L DESCRIPTION OF OPERATIONS 1 LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space ns required) . • The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt Thielsch Engineering is hereby named as Additional Insured pet written contract for woik.performed..and per the terms urid conditions of ihe policy. Umbella is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Thieiscn Engineering ACCORDANCE WITH THE POLICY PROVISIONS 195 Francis Avenue AUTHORIZED REPRESENTATIVE Cranston /RI 02910 Alt- 7) i . ©1988-2015 ACORD CORPORATION, All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD