29-486 (3) BP-2022-0377
580 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-486-001 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-2022-0377 PERMISSIONIS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 2500 SDL HOME IMPROVEMENT 103635
Const.Class: Exp. Date:05/20/2023
Use Group: Owner: A ADAM ETZ, GAIL
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:04/12/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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:
gt, • • .52 . a
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of Northampton RECE ;!.7iv :::
Building Department --- : 451' ,
212 Main Street A,, ,
1'
Room 100 4 rR 1 1 %/7'!'"/I.,' '',,,/,- , / ,71,-,--•i ., ''''7'/;;,'202,14''' / '-; 44'Ai / A4,44,,,4",,' ' ' ',;'"%,
Northampton, MA 01060 --' ', 'phone 413-587-1240 Fax 41344W-2--_,...
,/,,,,,.„..,,,,.;.4,,,,,,.,,,,,
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
This sectiori to be •. ,..,,'. by office
1.1 Property Address el (C,
Map. Al , Lot Unit
Zone Overlay Disterft
.,
Elm St District CS District
' SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
f',-; i
Na ' I Current Mailing Address: .s-----S154.- g7 S-----
J IL-- r-k-4- --ki---d-- Telephone
Signature
.2 uthorized en * iii:Li c01) /1 - 4----- cit7,
NWT! ''IY\P-DP-e-rlrkj\-j-f— Current Mailing Address:r ----------)
43•J`17--573 (3
grature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COST4
Item ' Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building
07/ -?-')( c-4.__) (a) Building Permit Fee
•
2, Electrical (b)Estimated Total Cost of
Construction from (6) .
Boliding Penult Fogi
3. Plumbing
4. Mechanical(HVAC) ,
5. Fire Protection
6. Total=(1 ÷2+3+4+5) c)? C>0-
Check Number -;-,
This Section For Official Use Only
Budding Permit Number; Pi,__ - :91, ,' "-1 7 Date
issued:
Signature:
Budding Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-C 'IiJ ES
8.1 L.icer*4d C bon Not Applicable 0
Name of Lice Helder: €1 1 &` jx Al— C - 1°.N.,p 3 S—
License Nur9ber
Add s" (.kicMua` -S+ )4 .I- e id, rn i1 0o 1. , c2 o aZ3
res
,� Expiratio Date
nature 4. Telephone
u4* Not Applicable 0
/ WI 1 ...-
Canna
i � 1-y-t f... 1 • egistration Number
Ig PAddress Expiration ate
V--- -1:"1 g"C ..l C71 U Telephone/413- 4 a128,?
SECTION b-WORKERS'COMPENSATIONURANCE AFFIDAVIT m e i,c.152,$25C46))
Workers Compensation Insurance affda must be completed and submitted with the application. Failure to provide this affidavit will result
in the denial of the Issuance of the bui permit.
Signed Affidavit Attached Yes No 0
Brief Description of Proposed Work NOTE: INS ULA TIO1 N ONLY
L59V c•S 44) ..L/i( &L,td,c,L. g -/5-- 74) -eicZe --/-0 ,,,,b,_
46„,),i Oep, kLit_t_j 0_)21L,LIzos_c_. ip -- .:cre, 'r\) a_A---)
i. ll.a 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.
PaL•ki ' L-V.-..-pNri... 1 Y ,`e.„.ry- .. 1 k- (Lyt,fre(c.focs, 1E171
Print Name
zif- -,) --
Signatur f ONANgent Date
(1-
i. 00 J ` r i of -___7,__-_ , as Owner of the subject
property
hereby authorize S I
to a n my behalf, in all matters relative to ork authorized by this building permit application.
Sre_e. (�. 1- a----
Siature of Owner Date
City of Northampton
Massachusetts
A .4 DEPAR24ENT OF BUILDING INSPECTIONS
212 Main Street obtanIcIpal
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the budding
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:
i•j—ECO P-i (,_r-1C
(Please print house number and street name)
Is to be disposed of at:
L,L-1 Le0,,,Ksk- YY\
(Please print n4me and looaKn of facility)
Or will be disposed of in a duapt,or onsite rented or leased frnIzA.,(..A. ...)e
.4--y-Nk,Lk-- C)tC)-
(Company Name and Address)
Signature of Permit Applicant or Owner ate
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
Op* Massachusetts '�Y
DEPARTMENT OF BUILDING INSPECTIONS r
212 Main. Street • Municipal Sualding
Northampton, MA 01060 �t�
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:lithe homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: ....-.-. ` -I c-) ..... Est. Cost: 4-9c:j7,_Y)
Address of Work: U_II--3 P1 7'
Date of Permit Application: 4.- ?'d'
,)--
1 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 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 per,�t �the kf the owner:
�""4 f--, - --- t,-,5-\\‘_._, ,7
Date Contractor Name HIC Reustration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property
Datc Owner Name and Signature
City. of Northampton
1 .. Massachusetts �•. � ,
4 d ';
=PARDO= OF BUILDING INSPECTIONS '^ ,
212 Main Strost a Municipal Building
. � Northampton, MA 0106P 44 1
MANDATORY FOR HOSES BUlL r BEFORE 1945
Property Address: ) ()IL),1 S + f 1-7,-„,,,,...w
Contractor
Name: . t-_, tY\,(L -- (1 C�wa-1" '1- -
Address: r",9 4 i k, ..4-„,..,,A- .. 4--
City, State: AA-CLA ,-mil. c 4A- CD1 U
Phone: +`( 1 . '.` ; `I-1 - .45 1
Property Owner I7)dJ inkName: ci 11
l--. 7-,__,2
Address: !j �"� / ' 7-- Pa
City, State: t PZit-i't C--I, a v ' D/(-) D—
I, aa 1 Ai'} 1;',,.,j di--`" (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
"v"-
Date_ (c � —
DocuSign Envelope ID:67F59B32-B119-4833-9E7D-E0BB246125CC
411t
RISE
ENGINEERING'"
OWNER AUTHORIZATION FORM
1, Gail Adametz
(Owner's Name)
owner of the property located at:
580 Burts Pit Road
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize
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:
‘;ia aL t
O fresi gPigtdrre
3/25/2022 17:38 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
.__ Department of Industrial Accidents
1 Congress Street,Suite 100
---;s Boston, MA 02114-2017
wWw.mass.gov/dia
`"" Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):SDL Home Improvement Contractors, Inc
Address:24 Chestnust Street
City/State/Zip:Hatfield, MA 01038 Phone#:413-247-5739
Are you an employer?Check the appropriate box:
Type of project(required):
l.D I am a employer with 7 employees(full and/or pan-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required]
9. 0 Demolition
3.01 am a homeowner doingall work myself.[No workers'comp.
y insurance required]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10[] Building addition
ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.a Plumbing repairs or additions
5.0 I 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.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.D✓ Otherinsulation
152,§1(4),and we have no employees.INo 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 i.,providing workers'compensation insurance for my employees. Below is the policy and job site
ire formation.
Selective Insurance Company
insurance Company Natne:.._�
Policy#or Self-ins.Lie.#:WC9024456 Expiration Date:02/23/2023
Job Site Address: / k f ,a_d City/State/Zip: 7'
7-Q_/-7(?-e--
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL 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.und the wins and penalties of perju that the information provided above is true and correct.
Signature } 'L7 Date: f
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#:
ID 1
ACORI3 CERTIFICATE OF LIABILITY INSURANCE DATEIMM/ODlYYYY)
,,,. 02/08!2022 I
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 poiicy(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: y
Webber&Grinnell PHONE (413)586-0111 I FAX (413)586-6481
{{A/C,No,Ext): 1(A/C,No):
8 North King Street E-MAIL chendersonwebberandgrinnell.com
ADDREss:
INSURERIS)AFFORDING COVERAGE NAIL#
i
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 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:
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 I TYPE Of INSURANCE ADDLISUBR POLICY EFF POLICY EXP) LIMITS
LTR INSO I WYL1 POLICY NUMBER (MM/00/YYYY) (MM 00/YYYY
XI COMMERCIAL GENERAL LIABILITY 1,000,000
EACH OCCURRENCE $
DAMAGE TO RENTED 500,000
CLAIMS-MADE i XI OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $ 15.000
A Y S2291509 01/01/2022 01/01/2023 PERSONAL&ADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
I POLICY PRO- 3,000,000
JECT LOC PRODUCTS•COMP/OP AGG I $
i OTHER: $
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
I ANY AUTO BODILY INJURY(Per person? $
A OWNED X' SCHEDULED Y A9105420 01/01/2022 01/01/2023 BODILY INJURY(Per acc,dent) $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
i Underinsured motorist BI $ 100,000
X UMBRELLA LIAB 2,000,000
OCCUR EACH OCCURRENCE $
A EXCESS LIAB CLAIMS MADE S2291509 01/01/2022 01/01/2023 AGGREGATE $ 2.000,000
I I
1 DED I 1 RETENTION$ $
WORKERS COMPENSATION X STATUTE I X ERH-
AND EMPLOYERS'LIABILITY YI N 1,000,000
B ANY PROPRIETOR-PARTNER;ExECUTIVE Y NIA WC9024456 02/23/2022 02/23/2023 E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED, 1,000,000
(Mandatory in NH) E.L DISEASE-EA EMPLOYEE $
It yes.describe under 1,000,000
DESCRIPTION OF OPERATIONS below _E.L.DISEASE-POLICY LIMIT _
Per Occurrence $500,000
Pollution Liability
A Y S2291509 01/01/2022 01/01/2023 General Aggregate 5500,000
DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached II more space is required)
The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Jeannette Lawrence.
Thielsch Engineering is hereby named as Additional Insured per written contract with respects to General Liability,Pollution Liability&Auto Liaiblity,for work
performed,and per the terms and conditions of the policy on a primary and non-contributory basis, Umbrella 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
Eversource ACCORDANCE WITH THE POLICY PROVISIONS.
247 Station Drive
AUTHORIZED REPRESENTATIVE ) �)
Westwood MA D2C5' lit_
yi.lf _ -D ` t-L.,__.,+'. '
A 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD