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29-541 (4) 59 INDIAN HILL COMMONWEALTH OF MASSACHUSETTS BP-2021-1748 Map:Block:Lot:29-541-001 Permit: Alts Renovations CITY OF NORTHAMPTON Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1748 PERMISSION IS HEREBY GRANTED TO: Project# Contractor: License: Est.Cost: $3500 SDL HOME IMPROVEMENT 103635 Const.Class: Exp.Date:05/20/2023 Use Group: Owner: BATSON CAROLINE W Lot Size (sq.ft.) Zoning: FFR/WSP Applicant: SDL HOME IMPROVEMENT Applicant Address Phone: Insurance: 24 CHESTNUT ST (413)247-5739 S2204065 HATFIELD, MA 01038 ISSUED ON:08/1912021 TO PERFORM THE FOLLOWING WORK: 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. Signature: f t 1 � Fees Paid: $65.01) 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner w}e D City of Northampton ,,. _,:___ ''' .' 4W Building Department 212 Main Street INSU �/ Room 100 j Northampton. MA 01060 phone 413-587-1240 Fax 413-587-1272 oNLy . a i APPUCATIDN FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION SITE IIJFORWIATION INS ULA TIO ' PERMIT 1,1 Property Address 6� This section to be completed by(Mice / 0_0 --14-i t ( map 2-1 Lot Jl ( Unit Zone 1.65P Overtay District Elm St.District CS District SECTION 2-PROPER rY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Recortt: Hil( Name nnt) Current Mailing Add a: _-- o Telephone Signature 2.2 Authorized Alien : Pew, 1\M,t l n C‘ilaln,-(=1-' 4- 1 \-' -i- -( - Name(�' Current Mailin{ Address. Sf'r2 ___,,____-- , ____. 'elephone , SECTION 3-ESTIMATED CONSTRUCTION COSTS .� r . ( item Estimated Cost(Dollars)to be Official Use Only completed bypermit applicant t. Building 'DS--- -) ' (a) Building Permit Fee 2 Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Budding Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6, Total=t1 +2+ 3 4-4 �� 5) � � �_.. i Check Number ##33� D This Section For Official Use Only Building Permit Number Date Issued._ i 1 � �' Signaturei'Ds- .�. i', 8/6/a Building Commissionerdlnspector of Buildings Date EMAIL ADDRESS (REQUIRE©; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION, ERV3 S 8.1 Licensed Cons'tructiu JNigeer. Not Applicable 0 Name of License Holder: (1 j t �,h u cll. 1.:'.: 1 0,'p 3`C License Nu ber 1 4 (i1 hi 4Li- S -- + C.'f d CcL, )'� 4 v0 U3 -/2 )/ 3 AtTdress Expiratio Date /....... gnature Telephone 1j 3 333 ram_ ..._._._.... ._..,,,,__. .. ... _____,I9,Raq*s i 'Inver I CgntractOr: Not Applicable © _____,I J Compan Name '}y -,-�+�. �Y1� d � qYi�•'j.x/`e-J'YLe.It egistration Number 71, Address Expiraticuv�ate j ��( y C \---.\-ek, ..Y} ...� C.._, hr\� C�1 �'a Teiephone�7 j.�iµQU '� � i SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affida t must be completed and submitted with this application. Failure to provide this affidavit wilt result l in the denial of the issuance of the build g permit. Signed Affidavit Attached Yes No ❑ Brief Description of Proposed Work - NOTE: INSULATION ONLY bt-I Le s -P-4- P-0 1-0-Lf"-- g- q c yqd --e--8. -to 74-thc- —tcri, - /kir ...,€__,,x,,c,,,i.e-)3 CL__,. r)_j_K_CL(_ -- • � apq �1 c'+ (,_ r- ,- - J Le. n --L_ ,K r��t_c)c3LK\ pc,Lk, cs2_A l' S- _ . fi r S-o-c_ t r1 cj ate-- --L 6- c) ) c:-..„ \ I O �.., -hNi \ c•-' as Owner/Authonzec 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. c- 't,v, q ' l.1 �Y2.>y�� i�1 t i� .,.., (tyt(at(' �7 Print Name :z2z,/ -,--,. SignaturieOwngent Date CA-1(t)LArAL teDr c f . as Owner of the subject property hereby authorize -----'_, to act n my behalf in all matters relative to work authorized by this building permit application. Sign ture of Owner Date City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 22 Main Stroet •MunicIpa: Budding ":,•' Northampton MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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. TAI K) (Please print house number and street name) Is to be disposed of at: , Q_. c (Please printname and locat}ibn of facility) Or will be disposed of in a dumps r onsite rented or leased frri. ( -Ur\C._ , 21-1 A.0 (Company Name and Address) 13 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 ,t.',' :,. , DEPARTMENT OF BUILDING INSPECTIONS (4. , 2:2 Mar. Street 110 Municipal Sualcitng Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation I"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 he 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" he done by registered contractors. Note: If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost. 1 Address of Work: I- _ _ ---)1 .i..-,oz---/Th_ VI I . t ---- 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 LNTO 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 agent,of the owner. r-11%).--, \ "5C,krA...), d-‘ - S'1ifr,--)-6 c9-( '': \\"\,-. 'Vkc.",(N\ft_,-L"-:T ct,Nr-d'i -,,,r\4--- 1191 / 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 t: ta K 05 DEPARTMENT OF BUILDING INSPECTIONS , 212 Ma rr Streat 4# MunacIpal BuridIng Northampton, MA 0106( MANDATORY FOR HOUSES BUIL r BEFORE 1945 Property Address: `.-i(i _1--nd-t a4c_) I-11 I Contractor Name: .:_:: il-„1-..., \-"kt.:1-%i. -Y\ -, Address City State: , Phone )--1 ‘ 3-- ; LI—I ' .245- 1-3- 9 Property Owner Name Address: 36) -a7-1 )a / -1 ti ti City State: --/-- I (*) I , '')C.C\n,A, /- ', ' (contractor) attest and affirm that the budding 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 Date 6---- / 0 -"c,_-0 ,D_ / DocuSign Envelope ID:36109168-351F-4727-A51A-54AD9DD1A54E RISES ENGINEERING" OWNER AUTHORIZATION FORM Caroline Batson (Owner's Name) owner of the property located at: 59 Indian Hill (Property Address) Florence, MA 01062 (Property Address) hereby authorize J 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: Ca1d,iuu NW+ O neeSf 6Y6re 7/13/2021 1 5:39 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RISEengineering.com The Commonwealth of Massachusetts Department of Industrial Accidents 111•111•1%; .,...•••••111 1 Congress Skeet, Suite 100 Boston, IVA 02114-21117 www.tnass.gov/dia - kimpenssition Insurance Affkiavit: Builderrotontractors/Electrna,Plumbers. ID BE I II.ED WITH THE PERNIITTING AI THOM 11, Applicapt)pf9rtustivii Please print. Lei Name SOL 140the Improvement Contractors, Inc BiesinestslOrganbrationIndis Address: 24 Chestnut Street C'ityiState/7„,ip: Hatfield, MA °I°38 ('hone 0. 413-2474739 Are yea an employer?Clerk tat appropriate trust Type of project (required) I am a employer with 8 empkmsttul andou parbtime ' I 7 New construction 2E1 an sole propnetor opartratcthip and have no employees working for Inc in 1 8. Rerrnxieling air:capacity (No workers'comp insuranee reqtared I ), DI am a homeowner doing all work myself,(No workers"comp insurance required ' Building addition 4 I am a noinecr.vocr and land be hinng contractors to conduct all work on my property I will ensure that all conelleilibicathet have workers compermItun 1113111211C4 Or XV sole I I.0 Electrical repairs or additions moor/eons with no employees LLD Plumbing repairs or additions 50 I am a general contractor and I base hired the skr.64,Amt odors listed on the attached sheet 13.0Roof repairs These suh-euntraerars have employees and have workers'cum, insurance 14,el Other,. .iistikaAita, , wc.are a corporation and sts ortreers haw exetersed their rt,ant or exemption per Mai„C 52,§1(4),,and we haw no employees (No workers'domp trISVITOACC required.] -\'s tpriicant that checks box 11/i must also fill out the secuon helou shovong their owlets',sompensatton polies mictrrotation Ilorneowners who submit this affidaytt rodicairrig Ines are doing all et ork and then hire outSttie evaaractors arse submit a new affidavit intheattog streh ontractors that check this box must atrached an additional sheet show mg,the name oldie sub-etrotraetots and state whether or not those antines have emplenees lithe,titroaanutsetras hase employees,thev nuest pros site own workers":mtrip.polio- I am an cn04;,yer that is providing worliers'compensation insurance jar Inv emplovee%. Below is the polity aml job site information, Selective Insurance Co Insurance Company \ Policy or Self-ins I 1‘.:` WC8024488 Expiration Date: 02123/2021- Jon Site Address: 7.„ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder!Wit, 152.. §25A is a criminal L irdation punishable 1.1y a tine up to$1,50000 and/0f one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator, A copy of this statement may be forwarded to the Office of investigations of the DR for insurance coverage venuierstion, I do hereby inder ins god penalties of perjury thin Me information provided above is true am!correct S' at _ Doze: Phone": 413-24 - 739 Official use Only. lb,Writ write in this area to be completed by till,or is offitial City or"Fawn: Perm itiLieense Issuing Authority(circle one): I. Board of Health Z. Building Department 3,City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other /intact Person': Phone 0; - - 0 ACC7RE) CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDNYYY) I I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A NO 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(les)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 endorsementist, PRODUCER ,( E Cyndie Henderson CISR.0 P IA NAMCONTAOT „ Webber&Grinnell PHCYN£ (413)586-0111 -1-1-"'----74-1-5-1513t-37--6.473-1--- 8 North King Street t'f'all- cheridersorvenberandgrinnell corn , ADDRESS': , I INSURENS)AFFORDING COVERAGE 4 NAiC, Northampton MA 01060 iNsuraER A Selective Iris Co of S Carolina I 19259 , INSURED INSURER B: Selective Ins Co of Southeast --- 39925 SDL Home Improvement Contractors,Inc INSURER C 24 Chestnut Street INSURER D: — --, INSURER E: Hatfield MA 01038 INSURER F. COVERAGES CERTIFICATE NUMBER: Master Exp 2022 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED 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 INS Fi i A,IX-SUBR I POLICY Err ' POLICY EXP LTR 1 TYPE OF INSURANCE INSP AND POLICY NUMBER I IMM/DTVYTYY) (MWOO/YYYY) LIMITS I X COMMERCIAL GENERAL LIABILITY I EACH OC,CuRRENCE s 1,000,000 1 - DAAIAGE-TO RENTED 500,000 I CLAIMS-MADE 5(-1,OCCUR PREMISES(Ea 04:o.,ffence) e --, MED EXP(Any roe oefson) $ /5,X° A Y S2291509 01/01/2021 01/01/2022 I--•-I PERSONAL SAM/INJURY 5 1,°°°,aa° I ‘9ENtP AOGGICREGATE LIMIT APPL IES 'PEP' G ENERA .AGGREGATE - E7a : I CDTE-COMP/OP A(2 II,' s '3',' 000000 w,00 0000 - OTHER, 1 1, • AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO I IEa aocidentl BODILY INJURY(Pa/oceson) 5 , A OWNED ONLY SCHEDULED ' Y A9I05420 01r01t2021 01t01l2022 BODILY INJURY(Pe`000AM100 $ AUTOS ;,,,,fr HIRED 1 N./ NeN,OwNE0 ' PROPERTY DA A,..1 $ r.`,_,AUTOS ONLY '12-• AUTOS ONLY /Per taxidera) _.... I 1 I Underinsured motorist S) $ 100,000 L X.- i__. - ,. ..., , ,UMBRELLA LIAB I 1 oce,LiR EACH OCCURRENcE 1,000,000 A I EXCESS LIAR t-1 CLAIMSNA DE, S2291509 01/01/2021 01/01/2022 AGGREGATE S1,000000 DED i a_PETENTION$ 4-1 s WORKERS COMPENSATION ...,„,,, OD-1, K PER /0-N.,ER' AND EMPLOYERS'LIABILITY YIN 50 00 ,,, ANY PROPRIETOR/PARTNER/EXECUTIVE i-v-i E.L.EACH ACCIDENT E " D OFFICER/MEMBER EXCLUDED7 ; , I N/A WC9024456 02/23/2021 02/23/2022 (Mandatory in NMI E.L.DISEASE-EA EMPLOYEE 3 500'000 f yes.dea.^-Mm undet DESCRIPTION OF OPERATIONS Wm.: EL.DISEASE•POLICY LIMIT 5 5°D'°°° I I I I I I I , - -- _, DESCRIPTION OF OPERATIONS i LOCATIONS i VEHICLES(ACOR0 101,Additional Remarks Salemaia,may blt attached II more space.%ntquired) The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt Thielsch Engineering is hereby named as Additional Insured per written contract.for work performed,and per die terms and conditions of the policy Umbella is follow form, CERTIFICATE HOLDER CANCELLATION 1.--------- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN Thialsch Engineering ACCORDANCE WITH THE POLICY PROVISIONS 195 Francis Avenue AUTHORIZED REPRESENTATIVE , 4 , 1 i I.: '-'s , . yi,' Cransion H (.)2CriuT) " I ,//,, i.,..) -i.,., 4, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORO 25 i2016/03) The ACORO name and logo are registered marks of ACORD