22D-055 7 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS BP-2021-1812
Map:B lock:Lo t:2 2 D-05 5-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Pennit# BP-2021-1812 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost: 4900 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
Use Group: Owner: QUALLIOTINE, CAILIN
Lot Size(sq.ft.)
Zoning: WP/WSP Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413),-17-5739 4.111111E2204065
HATFIELD, MA 01038
ISSUED ON:08/30/2021
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ERI ZATI ON
•
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:
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
,
/.City of Northampton /
Building Departm-
,i ?-t., 212 Main Street, ,-,
4 -v ..„,,,,,t' 4' -4.
Room 100 •,„,?(,,,
Northampton. MA 01060
,,„/''
phone 413-587-1240 Fax 413-58 (-41-(-7 .' ,o,
.... ..,
1
),
APPUCATION FOR INSULATION FOR A ONE OR TWO FAM Y ihNELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
This section to be completed by office _
1,1 Property Address
Map 2Z' 0 Lot 0 6 . Unit
7 /.— / A--te.__(..._ x---
Zone Overfay District
.7v Elm St District CB District
1 - .1
, SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Onr of Record:
, t-ca, ' 41 t- _-,(.__.,
c 1 Mailing '2---C' 11 Na int)
738,9-3_ -70 i 5
Telephone
ature
Authorized A e t: P141_,L1 SC- rVC--A ---1-- A
Stes.t.___-7 \ CXYA.t... s, L4-v-‘enDkr-e--1 -k- CbrA-hrk-(4tic-S C_-
Narnp, v.) Current Mailing Address:
.--Ii-1--,d----ce_i
ig t,ture Telephone
SECTION 3-EsnmATep CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant ,
1. Budding 4e c,o q -°
(a) Building Permit Fee
2, Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 40<
5.Fire Protection
• 4,
6. Total=(1 +2+3+4+5) q 0 9 60 Check Number :334//
This Section For Official Use Only
!
Building Permit Number fp'..-0?)-iii,.1 Date
Issued
Signature: . .....___
Budding Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Constructiop- uperveor:
i ,3 Ll , ,. . .1___
i Not Applicable 0
Name of License Holder: -g 4 i t.., (24-ift(-4 a 1 C..,.
License Nu ber
..2.4-1' () hicif-2cLi- -s, -4- -1- 041--hre\ id i
Expiratio Date
gnature Telephone
'Homorvement cofl . Not Applicable 0 --
V17/1 'L3
Company Name ...,:: i,, A ---ty-tfL. _ '2,kt- in.i.,./1 '—' i'lk - egistration Number
,
1-1-Address ...
i Expiration/Date
‘ , 0
..,, -6
‘),)'-. Telephoneki!3-- 4.-7---c9
1
1 SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) 1
I
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 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
boi/ 7 174 / 51` tALL.1_,..„- K_. Li 1 A c:_1 J_f_c:1 -k 41---ic__ _ LC v)
0()-(--'-' It-.01./Li c-,--t-LLA h.)%-iz._ . Ai
Lied/ S 4,,
e_e_I Li-t to S.--- -.
as Owner/Authonzeci
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 ,
,-----"''''
Signatur,of Own r Agent Date
n
. as Owner of the subject
property
hereby authorize L — _
to ct on my behalf, in allmatters relati to work authorized by this building permit application.
--(.._— -
Ci.___ A-e-Le,._..1....x____a_
ignature of Owner
(e
. Date r a I t
City of Northampton
Massachusetts
V'.
DEPARTMENT OF BUILDING INSPECTIONS
212 Man Stroet •HunicIpa1 Building b".
Northampton, HA 01060
Debris Disposal Affidavit
in accordance of the provisions of MGL c 40, S54, 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
-1—/G-LL41
(Please print house number and street name
Is to be disposed of at:
IYVA
(Please print n me and locan of facility)
Or will be disposed of in a dumps r onsite rented or leased fr
, e
ft-xi-4, 4,rk- s n
k- clle IcY\ 14 0
•
(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 main Street • PtunActpal Bualding
Northampton. MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
"['he 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"he
done by registered contractors.
Note: If the homeowner has contracted with a corporation or LLC. that entity must be registered
cz6
"I-ype of Work: •_ _ c-v&----) Est. Cost: 01-1 90o
Address of Work.
le'A.
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 pet as the gent of the owncr:
ti.kt43 :›C,N1YL:k
a /pit-0s
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, [hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
�,��� City. of Northampton ,
- , H x.
DEPARTMENT OF BUILDING INSPECTIONS 5, b
212 Mein Street • Mun.a pal Building '-gyp �> r
Northampton. MA 0106- y3V 2
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 7 &ci eA, iL c
Contractor \
Name. 5�t., -i-c-- \a_. -- '1 Q iel ie .1"r` it--i -}---
Address: 14 C�I G `c, --ran ``"t-
City, State: 1 ' , - x. i CD\ U e
Phone: )`t l,"" ; q 1 ' _45 7 3
Property Owner C , 1
I I
Name / .,1 Lif nec- U Q,L I A�0`�' LJ
Address: 7 t- L rL-(,ri C-& I`--
City, State: A/ rp1ci' 01 DC°
I, Oa I , )erni' ,` ,--'.. (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 `o� 1./-
DocuSign Envelope ID:2797D661-A9E8-4489-A234-0694B96067BE
Permit Authorization
mass s Form
Site ID: 4229388 Customer: CAILIN QUALLAOTINE
CAILIN QUALLIOTINE
I, , owner of the property located at:
(Owner's Name,printed)
Florence Rd Northampton, MA 0106,.
(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.
DocuSigncd by
(J(U aaWo-lnif
Owner's Signature: \_5ABB1180 115L488
6/16/2021
Date:
% 4r1,rs•a111+r1041,w00••••s•+•s1101140•0***•••••s•••E••r••••••••40.•••0*******0
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 For Office Use Only
Rev. 102015
The Commonwealth of Massachusetts
==` .. Department of Industrial Accidents
a M. I Congress Street, Suite 100
\iiil„
Boston, 41.4 02114-2017
wwt+.mass.got'/dia
Workers'Compensation Insurance Affidavit: Buildersl('ontracturs!ElectriciansslPiumbers.
I()BF.FILED Ilit. PLitAllI VI USG At 1111)RI11.
Applicant Information Please Print Le2ibh
Name(Busineait)rt;anirAitwn Individual►: SD- Improvement Contra tors. Inc
Address: 24 Chestnut Street
City/State/Zip:_ HMiield,MA 01038 Phone#: 413-247-5739
Are yea as employer'(beck the appropriate box:
Type of project(required)
t 0 I am a employer with__8____._empioy (full andinr part-time)" 7. 0 11ew construction
2 0 t am a sole proprietor or partner hip and have nn emprovees owl:mg for me in 8. 0 Remodeling
ant rapacity l?`o workers'comp snsuramx required l
9. 0 tyermoiition
+_rj 1 am u homeowner doing all wort.myself (No work'comp insurance required.)'
10 0 Building addition
4 01 am,_homeowner and will be hiring oxttractnrs to Conduct s,t work on my property I will
ensure that all contractors either have;makers'compensation ire:armee or are sole 11.0 Electrical repairs or additions
proprietors with no shnployiecs
12.❑Plumbing repairs or additions
4O I am a genera,contractor and I have hired the sub-contractors listed(in the,attached sheet 13.0 Root repel
rs
These sub-contractors have employees and have wasters'comp insurance t
0 We are a carpi/ration and as onions hove exercised their right of exem ption pet Moil.c 14 El()tier pt , ,_ _
I s2. I t 4 t.and we have no employees !No w*witera'comp i stuance required i
'Ain applicant that checks box 101 must also fill out the section helms stowing their stockers'compensation policy information
'Hemeowness wtso subnin this affidas is indicating ties are doing all work and then hire outside contractors must submit a new affidas it mdicating such
''Contractors that check this box must attacdod an addrumtat sheet showing the name of the sub-contractors and state whether or not those entities have
employees if the sub-contractors base empknsees.Met must provide their worker,'.satin policy number
/am an employer that is providing workers'compensation insurance for tat'entplloyees, Below is the policy and job vile
information.
Insurance Company Name: Selective Insurance Co
Policy tt or Self-ins.Lie.#: VV0024456 Expiration Date: 02/23I2022.
Job Site Address:..__._.__L t-1 rut-‘e-.._ ( City/State:lip: 240„4-,„,_y,p},�l�J
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MCA_c. 152,§25A is a criminal violation punishable by a fine up to S 1,S00.00
and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S 50.00 a
day against the violator. A copy of this statement may he forwarded to the Office of inn estigations of the DIA for insurance
coverage verification.
I do hereby ce ' oder ins and penalties of perjury that the information provided above is true and correct.
5ig.n4tu ___.. Date S- ay- C4-
phone.,: 413-24 - 739
Official use only. I)o not write in this area,to be completed hi-city or town official
City or Town: _ Permit/License if
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.Cityrfown Clerk 4. Electrical Inspector 5. Plumhinp,Inspector
b.Other
Contact Person: Phone 4:
AC D CERTIFICATE OF LIABILITY INSURANCE GATE(MMRJD/YYVYI
12/02/2020
THIS TIFICATE 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 CONTACTNAME. Cynd/e Henderson C)SR.CPIA
Webber&Gnnneli PHONE (413)586-0111 i FAX No} t413)586-6481
(AIC,No,Ext).
8 North King Street a-MAIL chenderson@webberandgrinnel)corn
INSURERISI AFFORDING COVERAGE NAIC I
Northampton MA 01060 INSURER A Selective Ins Co of S Carolina 4 19259
INSURED INSURER B: Selective Ins Co of Southeast 39926
SDL Home Improvement Contractors.Inc INSURER C —
24 Chestnut Street INSURER 0: ^..
INSURER E:
Hatfield MA 01038 INSURER F: i
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
ADDLISUBR POLICY EFF POLICY EXP LIMITS _
LLTR TYPE OF INSURANCE INS() WVO POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1 000.000
DAMAGE 10 REN I'ED 500.000
CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $
I MED EXP IAny one person! s 15.000
A S2291509 01/01/2021 01/01'2022 PERSONAL&ADVINJURY s 1,000.000
GENII AGGREGATE LIMIT uMiT APPLIES PE GENERAL AGGREGATE p 3,000.000
POLICY El PRO- PRODUCTS-COMP/OPAGG $ 3,QOG,000
JECT LCX:
$
OTHER'
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT `$ 1.000,000
ANY AUTO BODILY INJURY(Par person; 5
A OVNJED SCHEDULED A9105420 01/01/2021 01/01/2022 BODILY INJURY(Per acudenli 5
AUTOS ONLY AUTOS PROPERTY DAMAGE
X AUTOS ONLY AUTOS ONLY (Per accident) $
Undennsured motorist BI S 100.000
X UMBRELLA LiA6 OCCUR I EACH OCCURRENCE S 1.000,000 ."-
A EXCESS LIAB CLAIMS MADE S2291509 01101/2021 01/01/2022 AGGREGATE 5 1 000.000
DEO I RETENTION$ 5
WORKERS COMPENSATION X STATUTE X ERH
AND EMPLOYERS'LIABILITY V I N 500,000
B ANY PROPRIETOR PARTNER/EXECUTIVE l �r ( NIA WC9024456 02i23/2021 Q2%23/2022 E.L EACH ACCIDENT .$+
OFFICER/MEMBER EXCLUDED', ( 500,000
(Mandatory in NH) El DISEASE-EA EMPLOYEE $
It yes detcnW under 500,000
DESCRIPTION OF OPERATIONS Wow E.L.DISEASE-POLICY LIMIT S
1
{ t
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached if more space is required)
The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt
CLEAResult.Eversource and National Gnd,NSTAR.Boston Gas Co.Colonial Gas Co.,Essex Gas Co.and Western MA Eelectric are named as
Additional Insured per written contract with respects to General Liability 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
CLEAResult Contractor Services ACCORDANCE WITH THE POLICY PROVISIONS.
50 Washington Street.Ste 300
AUTHORIZED REPRESENTATIVE
Westborough MA 01581 Zii,,-D " /
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD