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35-008 (2)
BP-2022=0021 • 35 WEST FARMS RD COMMONWEALTH OF MASSACHUSETTS . Map:Block:Lot: 35-008-001 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-2022-0021 PERMISSION IS HEREBY GRANTED TO: Project# 2022 INSULATION Contractor: License: Est. Cost: 900 SDL HOME IMPROVEMENT 103635 Const.Class: • Exp.Date:05/20/2023 Use Group: Owner: ROSS, SEBASTIAN • Lot Size (sq.ft.) Zoning: WSP Applicant: SDL HOME IMPROVEMENT Applicant Address Phone: Insurance: 24 CHESTNUT ST \ (413)247-5739 WC9024456 HATFIELD, MA 01038 ISSUED ON:01/11/2022 TO PERFORM THE FOLLO WING WORK: AIR SEAL ATTIC &BASEMENT ONLY 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: 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 212 Main Street (;;: i i'V .1 1'4P ',S7",V,4, 14:fle: Room 100 " y, ,,/,,t ii;.,,,, ;0,,---` 5..fx,.‘ /. :-. /.5T;ifl ' ,11,,,,.41 0' / xf,r,,%/2;%1- rX, „-A',/,,4,/,'„<,.(: -,e,...4;7,:, -,: ,•-'" . Northampton, MA 01060 .';j-,44,-,/,,,zw/,%,,',--/y-4t ,:15,p5.,,,</,,/ ,,,,'/„Ateg,,,,,-.Ar-,--. .! phone 413-587-1240 Fax 41a-587-1272 1 -., e,',,ti;. xf , ,'„if i .,i/P;57- •f:f4d4, /,4f.4„:,,,, ,,-4,1, • APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY OWELUNG ONLY - SECTION1VE INEDTIGN . INSULATION PERMIT - ; w: - I ))1 ',4:, ' '-'.4, ',.-,, '.,/,t :ni,*##:1.i-Properjv Addrest -t11- L 4 "0'-:,,,„iiiii.t,,,,,.0 _ . 5 tc.) Ca—cry-)„S 72'd -,,-, ., ,:,.:,- yi,;-_;.',-,'''';--;•,,.4,A,,'F!,4,5t;.,,,,''v:,',,-,!:',.•.-', :,...,,, , ., ri) ,atine:4::,1/0:5- .P.;-44,,-4...tlarstifetfam-,7-"7::;''''• ' /C . 7-j!;.-..: • ,. ..,/1 ;;2"'%:'*'`];r cif'(.(_49 (- Atmiiiex . . : ., ::,OiiiSs:trio , SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT , 2,1 Owner of ord: C. 5 LA___D Name(Print) Current Mailing Address: ( --e,—E, 07-44z%L-0--k-e-C4 Telephone Signature 2,2 Au orited, t: i) Name(Pri Current Mailin Address: 5,z-z-7----------------- /3- 07-a---73 , Sig re Telephone .SECTION3-,: ,,IMATEDONSTRUCtoNieoSTS UseOnly .. ., . ,. ...,..,,.... ,...., ..„.., ,„ Item Estimated Cost(Dollars)to be tiffici4C, corntiletedloy permit applicant 1, Building 9/2) ec:, <04111101I1gRetrnitFee, . . '. - . 2. Electrical (b)PStirnated:Totarcost of' COnstrtictiOth4ebrI/(6) 3. Plumbing •EtrildlI190eIrkfe,0' 4. Mechanical(HVAC) 6. Fire Protection 6. Totalli(1 ÷2+3+4+5) "Plke*NurrOer . This Section OffitiliktisoinlY , . Bete B.4iidingPerrnOttgrOr,5P-2-9 2-2 . - 1//:;.-Z Signature: / / , /-/0-loz-Z__ .,-Etuildirocoitily*po-w0c,t9r,:offmonp : , . Date, EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4 CONOUtvIPES 8.1 LicensedConstructlo , urvisor: Not Applicable El Name .icense-Holder: g / ?A .. d ~ , 1).. 1....03 S License Nu ber C ill 4-11k - 4-, •)404.1-lre,id, nliq 010,?-)e5 c 9,3 A dress 1400007,..„4"../ Expiratlo Date 4/3- 1',9-'523, gnature Telephone 'J[s"i.I +aI7ifSZr ''i } �i _..,...., '' {r l'�4, a..�.c.7y ; ,0t,<✓;' r `,.a _i :; N;,x� Not Applicable El N e f /9 V / Gompan � �ri- r. registration Number A it C}ALS4-rtt,,,k..÷ .S-f- r2 Za p Address ��`` Expiratiorate 14t$1.- � i"� t Teiephon l.3"` `7 S 39 SECTIONS WORKEi S'CQMPE 4 ATtO ,INSURA E AFFIDAVIT( . L.c.182i§25C( )), Workers Compensation Insurance affida 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...... ❑ Brief Description of Proposed Work NOTE: INSULATION' /14 rK ( AMC 4 6 .-i- -c, 7-1-- cy•-, LAI I, •1" as Owner/Authorized Agent hereby declare that the statern nts APO information on the foregoing application are true.and accurate,to the best of my knowledge and belief. Signedjunder the pains and penalties of perjury. rigi (21,7--/-k-- ct,„1„,../. Ackcx,E, *:c;;(119,0.-:,,„refyl,,,n-k-- itytkAcfocs, 1.4/1: Print Name , /' Signatur of Own r Agent Date I, La1'90 3.4-1 Q.n }e0 S as Owner of the subject property . hereby authorize S 1 to act o y behalf, in all:matters relative t work authorized by this building permit application. Signs re of Owner Date City of Northampton 414 fir 1, Massachusetts » , . uti ,°4,54P DEPARTMENT OF BOTZDING INSPECTIONS 212 Ma..n Street *Municipal Sui.ldiny � Northampton, MA 01060 sip Debri_s 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: 3s- (i( tarrn.s (Please print house number and street name) Is to be disposed of at: USA' C. 1;jX,r‘ 4: '- .-L c ., 'r Y\# (Please print n me and:loco n of facility) Or will be disposed of in a dumps r onsite rented or leased fr , -Ij „, b{r� \\cam - , - %,Y. A 0't (Company Name and Address) Signatureof 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 Northamptonzrz Massachusetts DEPARTMENT OF BUILDING INSPECTIONS x, 212 Main Street a Municipal Building .f Northampton, Mid 01060 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("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. oU Type of Work: c_fi it,Lct_41C_ Est. Cost: G'fcz_ Address of Work: 3 (j -' may,--) gyd 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 T 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 R:ESPQNSIBILITES FOR ALL WORK PERFORMEDUNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building peinit as the t>of the wn Avt„X Nrikit Date Contractor NameHIC 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 Y � � City. of Northampton . a ,a DEPARTMENT o BUILDING INSPECTIONS , a ii 212 Main Street • Municipal Building '3e C"� Northampton, MA 0106� 44 .1 MANDATORY'FOR HOUSES BUlL T BEFORE 1945 Property Address: L35 LLD > . �i h n- Contractor —..---- Name: �� .... ry- pa\f . -rve- l--i-- Address: r 4 C int o`s‘-r .,4 - City, State: ,&l- CD\ U 9 Phone: l:, `- aql `5 `( 9 Properly Owner Name: aCLS 1'B eos Address: L3S L� ra,+-m S iecL City, State: n-c-,,>1 ' I \ C)) c LQ O I, P dal 50i 8 (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,4e--' The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THEPERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business1Orbanizatian!individual):SDL Home Improvement Contractors, Inc Address:24 Chestnust Street City/State/Zip:Hatfield, MA 01038 Phone 4:413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): 1.9✓ I am a employer with 7 employees(full and/or part-time).` 7, ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 'Q Remodeling any capacity.[No workers'cofnp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 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. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ® 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.0✓ Other insulation 6.0 We area corporation and its officers have exercised their right of exemption per IvtGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Selective Insurance Company Policy#or Self-ins.Lic.#:UVC9024456 Expiration Date:02123120023 Job Site Address: "v l't'� '� City/State/Zip: Xforf1l4yl. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expira ion date). Failure to secure coverage as required under NIGL 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 ORDER 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 certify unde the ains and penalties of perjn' that the information prov ded:above is true and correct. Signature: Date: I Phone#:413-247- 739 Official use only. Do not write in:this area,to be 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#: ,------- ' ACORE)0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/TYYY) Lime-^'*---- 11/23/2021 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 CONTACT Cyndie Henderson CISR,CPIA NAME: Webber&Grinnell PHONE Ext) i (4t-i 3)586.„011.1 N'‘tX (413)586-6481 • (AIC.No, : ' (A/C.NO • 8 North King Street E-MAIL SS: chenderson@webberandgrinnell.com - ADDRE INSURER(S)AFFORDING COVERAGE NAIC U Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B i Selective Ins Co of Southeast 39926 SDL Home Improvement Contractors,Inc. INSURER C: 24 Chestnut Street INSURER D: INSURER E: - Hatfield MA 01038 INSURER F t . COVERAGES CERTIFICATE NUMBER: Master Exp 2023 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. INSR , ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYTY) IMMIDDIYYTY) LIMITS ' X i EACH OCCURRENCE 1 000 000 , ,COMMERCIAL GENERAL LIABILITY , 5 DAMAGE TO RENTED 500 00 • CLAIMS-MADE 0 OCCUR PREMISES/Ea ocrsuren=1 S .° MED EXP(Any cne person) $ 15,000 A ' S2291569 01/01/2022 01/01/2023 I 0 PERSONAL ki ADV INJURY S 1,° CO00 GEWL AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ 3*000°000 POLICY X 2E-, LOC • PRODUCTS-CCMP/OPAGG $ 3,00 CO00 OTHER: • $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea= ANY AUTO • BODILY INJURY(Per person) $ A OWNED ONLY i x SCHEDULED , A9105420 01/01/2022 01/01/2023 BODILY INJURY(Per accident) $ AUTOS AUTOS ••,,,, HIRED (...,..0 NON-OWNED PROPERTY DAMAGE $ .." AUTOS ONLY I•*-", AUTOS ONLY (Per accident) 1 . Underinsured motorist BI $ 100,000 • X UMBRELLA 1.1413 , X OCCUR ) EACH OCCURRENCE s 2,000,000 —% A EXCESS LIAB S2291509 01/01/2022 01/01/2023 2 000 000 CLAIMS-MADE AGGREGATE $ „ DED XI RETENTION$ ° . S WORKERS COMPENSATION XI PER, TUTE **se' ER OTH- 0-s-__ AND EMPLOYERS'LIABILITY YIN 1 000 000 B Orf:1 FC'Re PARATEICaPARUCDREigE CUTIVE T,, N IA WC9024456 02/23/2021 02/23/2022 EL EACH ACCIDENT $ ' , (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 1' 0° °'°°0 If yes,ee=lhe under DESCRIPTION OP OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000.000 Pollution Liability I Per Occurrence $500,000 A S2291509 01/01/2022 01/01/2023; General Aggregate $500,000 I I . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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 Grid,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 11ZD I • ' • • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • i . it DITIONAL CO VERAPES • Rof t. Description Coverage Coda Form No: Edition pate • ;, -Bic PIP , Limit t . Unlit Limit •De doctiblo Amount Cocainale Typo Premium 8,000 • Ref 4 .Description• • Coverage)cede • Form No. . Edition Date Mledicecal.p3yrnentts MEDPI4,11 Unit _Limit 2 Lard 3 Dedtrctible•Arnottnt . tactitite't Fret/limn r • i of Dstscrtptiort -r overage a Fem No. . -Edition Date. Uninsured motorist SI split limit. Utt ISP ,Limit I Limit 2 Limit 3 tteductibte: rtaew t Deductible Typo Promiutn a Raft. . Description ' Coverage Code :Form We. 1 Edition'Date WC&Employers liability WtEi. Limit r Litriti2 Limit 3 Deductibte-Amount uctibte Type Prpmium 03,000 S 0,000. 500,000 Rot St • t9 er iiee Covorago Dodo Form No Edltien.Dit Expense COP.Stant r ".1. mit:2 Lirrtit3 . • Donuctibic m ttxt nt � Deductible'C o Front-urn 8333.00 4 et:#' t Description I Coverage Code Foram No. - Edition Date Premium discount PINS , • 1 Limit Limit-2 Lirnt'3 `Deductib s*le unt ttntibleT o Premium • , • € 1 rd Rot : 'Peo a piste rrs e b. •� pertxa of Edition•D a#ste•star a e I TS t •Line . Li t 2 •.rLlmit3 Deductible Amount • _ D daot€blee:'i' pa'- .s Premium " • tr•Re .`Dosotiptiett Cove o.,. F rmt'No= k Edition pate , - pet°i n Mod"Factor 4 09, - Lltrtut1 Limit2 €Limit:3 Deductible mount •7 Deductib?eType . •Prernitii s- . _ ,D0 r RetDose-RP/ion Coverage'Cod . form t ;- tifittertOste. _, • I . Unlit 1- ' t LIMA.2 Until '•Deductibie Amount ttble't pp ,:Pro iitm •' . Ref "D ptfets overage , ,•Fotm ,. 11on Dons a Limit I '.Limit 2 a Limit:3 Ded€ctible tuft:., DedE tottbio Z pe , Premium j. • .. `z riese fpdpn •.- Done e , r r .bto»•,.- _Edition Dim . Limit i i Lar t% Limit 3' • `P t ctibto.Amount. • `-btedt lble-Type _0 °•Promitim ' ' C FAtl Copyright tat,AMS;Services,Inc.