18C-069 (5) 2 GLEASON RD COMMONWEALTH OF MASSACHUSETTS BP-2021-1887
Map:B lock:Lot: 18C-069-
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
Permit # BP-2021-1887 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 4000 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
Use Group: Owner: MCNALLY JOHN D&CATHERINE
Lot Size (sq.ft.)
Zoning: URB Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC9024456
HATFIELD, MA 01038
ISSUED ON:09/17/2021
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ERIZATI 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:
, • Ta� �
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/.....,-, r-5"er oft 1
i4
a� - -. City of Northampton S c�� x�
):..� Building Department F,o
I 212 Main Street, lNSULA TION'
{; , ? Room 100 6�Q., ,. /
,.
- . Northampton. MA d'1•(l6 ;'/tt,
-' _ phone 413-587-1240 Fax 413-58'7�.4' ,,0
ONL.
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APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION 1 INSULATION PERMIT _
1.1 Property Address This section to be completed by office
CIMap Lot Unit
G(eeizs. )
Zone Overlay District_____
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
--"CCIJ--1-).(L5‘.-k r\.e _ MC-- X__)0L( (c r- (-Lea_ f'_)'-‘ e----CIL
Name(Punt) Current Mailing Addre s
-� �L �ci ___2 SAS' /�
Telephone
Signature
2,2 AtttIrlsed Agent: Petal cLA-
I . ' rai-efr c ,/ ei[LtS-1--i-u...d- S-1-- . f--Ce(dl
Name Current Mailin90g Address
'- 1 4 fl,...___----
1
Si. 0(/7_ ,i5-71-
'nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1, Building J 2 l Dcc) 0 (a) Building Permit Fee
2. ElecMcal � (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Cis
5. Fire Protection
6. Total=(1 +2+3+4+5) � DDU• U Check Number
3409
/J 7 This Section For Official Use Qlrll�r
6j d
Building Permit Number: . ;Al`-1 51 / Date
Issued
Signature. /I/7 1- 1l� 0z_•
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Constructio upervisso�or:,�� Not Applicable 0
Name of License Holder: t1J .iJ c... l t C1. (.1 3
License Nu ber
Address" c ¢+ .64-i - 4C(.-14-\e- C CI 1 Mil of 0 � ," - r.2 0 k›?
�� Expiratio Date
gnature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Com an Nam ; jam, YY'L-aL. _ 2V-('..i►'Jk_ftl 11. egistration Number Zo b
Address "Y uJl- Expiratio�at
k- t.X. -gt k. C_, °I U g' Telephony 7 I3 o4t7-J 9. /'
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidayit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build ig permit.
Signed Affidavit Attached Yes r5 No 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
/,3 3 3 s , -F-1-, / .5" e-r 12- L/ 9 t4,%-,ol - 1 c_-
b►(-It_i ) eiLl f_Lt
/US_JZ CUL((I __ _ _
sue - •
l 14. 1 'V\ON.-\ 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. A-_„,,
(tyttakcixs,
vir,e,, tYl.c.ryk-
?rint Name
L PrukL -3- L 9 - ii-a®3 )
Signatur f Owner Agent Date
I C__, ' mot�-S ., nnC IOC{- L L . 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
ovcusign Envelope ID: rana�op�*pz��cc������s1roFA3ooEs
H�U����U� ��U��U����^%«���~K�U�
Permit Authorization
masssave Form
- '
Site ID: 4l4l738 Customer: [ATHER|NEMCNALLY
Catherine McNally
L ' owner of the property located at:
(n*ne�Name,printed)
2 GLEASO0 RD N0RTHAMPTON' MAOlO6O
(Prope,-ty Street Auurm) (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 onmyproperty.
� D. "vw" d by.
Owner's me; �`-- -- � - -7
-'�'-'- `-'r,cPS^ onaa4po
2/2/ZOZI
Date,
'
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor tmthe |
above referenced project:
Participating Contractor Date
Nnnne: CLEAResu|t
Phone: 80O-480'7472
Email:
raoo I of FmoffueUse or/,
City of Northampton
f
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building'ej GCf-• Northampton MA 01060 +"y s:•
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:
((Please print house number and street name)
Is to be disposed of at:
- c� r1 (k)e ,k- Wit— l at- `1 , )(AA-
(Please print n me and loca n of facility)
Or will be disposed of in a dumps r onsite rented or leased frgm:
C 4 ruK-t— Sr , � -e td Y`n 164 0
(Company Name and Address)
C� - ava/
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
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w
Massachusetts �° �._
G
i c
` e DEPARTMENT OF BUILDING INSPECTIONS '
S...
212 Main Street • Municipal Building
Northampton, MA 01060 44..t-0Y
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OC'ABR")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"I.
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: If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: 1� d
I�S c.�-1 obi __--Est. Cost: l l nU[] ---
Address of Work: c)-- GI Le a."& ' fe - 8
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):_
_Job under S1,000.00
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 I.MPROVEMENT 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 peRvit as the agent of the owner:
r � -.ht
9-i4/-aO'a_" -==)h�, Tt r m.fa_A-1-t— i 'r `�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:
Date Owner Name and Signature
City. of Northampton
" 4 Massachusetts .� . .._
4 L
t ` ` .' DEPARTMENT OF BUILDING INSPECTIONS Z.
212 Main Street • Municipal Building vbr t
Northampton. MA0106C Y �
MANDATORY FOR HOUSES BUlL T BEFORE 1945
Property Address v LeCr. --- A
Contractor
Name: c.D `\Ci... - niifit' d- —
Address: r-,)L4 C. hi, Su -
City, State: Akra-A �.... �\, A" CD\ Cs 3 e
Phone: l .'" 3 `t 1 , s-- 1:.? 5
Property Owner
Name (1:,L)U---1- (ASL. nlAC 7\i/Cc-- ft\
Address: (AU c(mac.).-- � c\,_-
City, State: 1\in o-,Czr-„e\- . 3 m *4 c. t °co C�
I I, � cj+iCi 6"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 , /<_/, a 0 4_1
The Commonwealth of Massachusetts
�• t Department of Industrial Accidents
1 Congress Street, Suite 100
�: "• Boston, M.9 II2114-2017
•
�= www.mass.gol=Via
1%orherc'Compensation Insurance Afftdttsit: f3uilders,`( ontractorsJF:Iectricians/Plumbers.
ft)BE FILt:I1 1%1 t 1t IlIE I't hts111 I I\t. xt omit!
tuplicant information Please Print Leeibls
Name tl3uxittess attizarianrindividual►._ SDL Home Improvement Contractors, Inc
Address: 24 Chestnut Street
City/State!I,ip: Hat881d,MA 01038 Phone#: 413-247-5739
Are sou an earptoyer'Check the appropriate box:
Type of project(required):.
II Q I can a employer rvtth 8 employees lfutl tnldiot purl-timel• 7. New construction
' 2❑1 am a sok proprietor or psrtnesship and have no employees working for me in s. Remodeling
am capacity INo workers'comp insurance maimed)
3.a 1 am a homeowner doe all work on (No workers' y, ❑Demolition
rag comp insurance rtequrnl.I
4 01 am a homeowner and will be luring contractors to conduct an worst on my property_ twill 10 Building addition
ensure thatal.lcontractorseitherhave*utters'compeneaucmu►ntsancroraresole I 1.0 Electrical repairs or additions
propr'riots with no employees.
12.0 Plumbing repairs or additions
I am a general contractor and I have hired the sots-contractors Wad am the icached chest
3.E1 Roof repairs
these subtaitractors have employees and base workers'coop maws tcet.t
0❑we are if COrplicattcm and as officers have exesciaad their right of exemption per Mt it.c 14.Ell)thee.
I;2.;;li d t.and we have no employees INn workers'camp insu ranee required I
'Ain applicant that cheeks hcrs it mt�t also flit tut the section behave showing then workers compensation pone}uiknnnatam
s Homeowners who submit this affidavit indicating dxv are doing all work and then hirt outside contractors must submit a new afftdasit indicaiin such
;Comraciors that check this bos must attached an arkiiunnal sheet showing the name of the sub-contractors and stale whether or not those entities have
emplosccs lithe uh-comtraelarstautr a °tes they roost pros hie their ssorkcr, crar,tt re.hii :wm?ey
I am an employer that is providing workers'compensation Insurance fier►o employees. Below is the policy and job site
inf tumatina.
Insurance Company Name: Selective insurance CO
Policy#or S If-ins. Lie. 4. M9024458 E<pirat(on[sate:__0 3/29221..
Job Site Address: oR ._..64 __.P-8 Cit. State,/sip: 4-6-)eLir �t
Attach a copy of the workers'compensation policy declaration page(*awing the policy number and expiration date).
Failure to secure coverage as required under\IGL c. 152, §25A is a criminal violation punishable h) a tine up to S I.500.00
andior one-rear imprisonment.as well as pis it penalties in the form of a STOP WORE.ORDER and a fine of up to$250.00 a
day against the violator, A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
.craw.
I do hereby ce eider im and penalties of perjury that the information provided above is true and correct.
-
Phone . 413-247= 739
• (Vidal use only. !)o not writs in this area,to he completed by city or town official
City or Town: Permit/License#
lsatuing Authority circle one):
I. Board of Health 2. Building Department 3.( ityrrowa Clerk J. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone t:
* "
DA"TE IMM/CDIYyr:,'
Acc)REP CERTIFICATE OF LIABILITY INSURANCE 12/02i2020
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 1
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. J
i
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 rebNTATT Cyndie Henderson CISR CPIA
1.,NANIE
Webber&Grinnell 413 r586nl-0we
i(Aic,No
8 North King Street r ^ edeso bberandgrnnetcom
INSURER(S)AFFORDING COVERAGE I NAIC*
Northampton MA 010t30 INsuRER A; Selective Ins Co of S Carolina , 19259
F—•
INSURED INSURER a; Selective Ins Co of Southeast 39926
SOL Home Improvement Contractors,Inc INs;uRER C: -1-
4-- -
24 Chestnut Street INSURER 0:
INSURER E, +
Hatfield MA 01038 INSUFtER 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. NOMITHSTANDING 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
IADDLISUBR i TETF—FAULICY Ezr-r—
I TR. TYPE OF INSURANCE; illi§.PIMP POLtCY NUMBER Mat/DOrYYYY (MM/DEXYYYY,) UNITS
I><1 C.OMMERGAL GENERAL LIABILITY I
EACH OCCURRENCE s 1.000,000
mPREEDMExiSpES,AtiE,:.07,0:30,70: ;s: 15,0,0000,m
„ DAMAGE TO'RENTEr) ' 050 ,000
CLAIMS-MADE [-5,< OCCUR
A , I S2291509 01/01/2021 01/01/2022 PensoriAL a ADV INJUP,Y
i GERI AGGREGATE LIMIT APPLIES PER GENER4LAGCRECAyE f,. 3,000,000
nOtic-y ri PRo' 7 ,
JEcy L.„, ,
PROoucTs_comp,,pAG. s 3,000,000
i OTHER:
AUTOIXOBILE UABIUTY , 01 ON 0 SINGL UMt I S 1,000,000
, Eattocx,rx —
ANY AUTO I BODILY INJuR,,We(peram, S
.,
A OWNED SCHEDULED ; A9105420 01/01/2021 01/01/2022 BODiLY INJoRY Wig atl:Awntl $
I AUTOS 1
NON-OWNED PRCP6TTY bAkAZE $
X AUTO OR AUTOS ONLY ONLY AUTOS ONLY IPIP tRekke,”
Undertnsured motorist El $ 100,000
-f
) 1 UMBRELLA LIAB OCCUR EACH OCCURRENCE 1.000,000
S
F----1 , ._,
A S L. I EXCESS DAB ' CLA1MS-MADE S2291509 01/01/2021 01/01/2022 AGGREGATE I 1,000;000
'
L.
1 ; 1---- I
j 0E0 1 I RETENTION S S
I ,
I WORKERS COMPENSATION 24"-
l AND EMPLOYERS`LIABILITY Y/N E3WiNge
1 —
,,„ ANY I,ROPRIETORMARTNER/EXECUTIVE EL EACH ACCIDENT 500 000
s ,
0 OFFICER/MEMBER EXCLUDED) Y NIA I WC9024456 02/2312021 02/23/2022
(Mandatory in NH) EL DISEASE-EA EMPLOYEE $ ""ae
II yes deacnbe lIndof .
DESCRIPTION CT OPERATIONS below El.DISEASE POLICY LIMIT S
—
•
JillI i I 1
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached it more apace ia required)
The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt.
CLEAResult:Eversource and National Grid,NSTAR,Boston Gas Co,Colonial Gas Co.,Essex Gas Co.,and Vtkstern 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,
i
i
......j
CERTIFICATE HOLDER CANCELLATION
— .,...7
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED N 1
0 LEAResult Contractor Sennimsi ACCORDANCE WITH THE POLICY PROVISIONS. I
50 Washington Street.Ste 300 —I
AUTHORIZED REPRESENTATIVE
i
vvettiorougli MA 01581
4r)i- '7)
0 19$11-2015 ACORD CORPORATION, All rights reserved
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD