43-134 (5) BP-2022-0660
33 LONGFELLOW DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
43-134-001 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-2022-0660 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 2000 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
READE NATHANIEL M & MICHAELA M OBRIEN
Use Group: Owner: TR
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:06/07/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ER I 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
• r . 2 - 1 '
I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
ryAAAfp y:, City of Northampt n C .
1,4, ,�, >`,. Building Department
';, 212 Main Street J(JN
Room 100/
Northampton, MA101 r Op `t
phone 413-587-1240 Fax _____ :,,,,,„ , ,
41f� � ING INc, : oNL
wk,t,,
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1,1 Property Address This section to be completed by office
3 .. , �l‘c maP 43 Lot 13(14 Unit
r-n y� Zone Overlay District
7\f-n-Pinco_
P 1
c_-___t c)Le-a-- Elm St. District _ CB District
--•-,
SECTION 2-PROPERTY OW NERSHIP!AUTHGRI;LED AGENT
2.1 Owner of Record:
Afa--1. "Ift_r\ -e—Q- ----K)2,_a___ L_fi,_ 3,__3 Lon cv. .,1, [sJ-L-) 4-- ,
Nam Print) Current aiNng Addre
a rtC �1 Telephone
Sig tune
,2 orized A ent: PaLA •SQ \r-Nry\ 6•
� r - -± 3dacL,S1-1---24-k+ ',Sri-
Name(Pri ) Current cling Address:
it--ti __J ---- /c3 (9 V.7-6—1 2
AA.4_,(
signs Telephone
SECTION 3-ESTIMATED CONSTRUCTS COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ��v (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing wing Permit Fee
/ ,s
4. Mechanical(HVAC) 1(�
5. Fire Protection
�U
6. Total=(1 +2+3+4+5) ,-i 000 - Check Number ,366
This Section For Official Use Only
Building Permit Number: 5 RA' Q Oa Date
Issued:
/2 6-7- ZOZZ
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4- * y-. *-y �;
8.1 C icened rvisor: Not Applicable ❑
jq/ oi /i( * C. - !°a P 3 Sa-
Ucense N ber
A 'I Ci e tf' £4-y 4aL+i4Lc11 fh i y o3 5- .20 JJ)d�3
dress J
Expirati Date
-7 1//3- , 2,3,
gnature Telephone
Not Applicable 0
CO 1. Ii1 i S �, egistration Number
/=
Address f e
r� JL.�
�{{�� ��[j r�Expiratio ate
k \Ct.k"�'Yl"(... .C rn Oi U g- Telephond1i3-, 4')S l
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT .L.c.152,§25C(6))
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 bul • • permit.
Signed Affidavit Attached Yes .. ► No 0
Brief Description of Proposed Work NOTE:Er INSULATION ONLY
C z.,H,LA,[c.,%.--(_ . A r .-cic,Cf, s„....
71_41-) a 1 c_- __) re._, Dp-e_
1, ' )U u l a-V vi (.-, ,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.
Pribd 3c,:: 6-A- (‘',4,,,. -‘-korN4L., .7rra.f),(CxrefriRfik- (Detk(docS, '1;1
Print Name
Signatu Agent Date
i y,,,,.14-.024_ ,,,, ,LL__.
`� , as Owner of the subject
property Sss
hereby authorize -�lJ
to act on my behalf, in all matters to work au rized by this building permit application.
Signature of r Date
City of Northampton
Massachusetts f,
<V
t• , 1.;
rfSPARTMENT OF BUILDING INSPECTIONS
212 MaLln Street 4,Munlcipal
Northampton. MA 01060
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 numbe and street name)
Is to be disposed of at:
uc -12\Q ox. rA ,SA -St 44-CC CN-QL ,
(Please print n me and lope n of facility)
Or will be disposed of in a dumps r onsite rented or leased fr
*024 (7 ‘C\k , --A- k-y-e,A6 fNeN 14;
(Company Name and Address)
(s) -
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
N 'r'i.
Massachusetts -
DXPAR27d&NT Of BUILDING INSPZCTIONS
212 Main Stroat a Municipal Building .P',,
Northampton, MA 0106r s,'"""1.
MANDATORY FOR HO11 ES lull T BEFORE 1945
Property Address: 3-3 r1 C ((c _) l ,
Contractor J
Name; t ti t rt .i ..rt- ..a'"`~-
Address: ,-. 2 Li ( 1G..4-r"k�.. ' }
City, State: AA-tt-A V- ,..t, ( CD\ U 3 e
,Phone: )4 i .��" 3 LI 1 • .`".5 ' C
J
Property Owner N2)-2
Name: 0, I \l G7Address: : -A�jTL S r
City, State: P .-4-10 N "(NA A CI Ckca
I. l ,L"3tv,..,i 8+ (contractor) attest and affirm that the buddingI intend to
t ��'
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 reet:L______
Date b- 1 - „3_,09--
City of Northampton
Massachusetts
4
DEPARTMENT OF arrzwzNG INSPECTIONS '
212 Main attest • Municipal Building r
Northampton, MA 01060 w' 44
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 CHIC"),
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:.I,f'the homeowner has co acted with a corporation or LLC, that entity must be registered
4)6
Type of Work: II (_,� ...'...., Cost: c3 t C �(�
Address of Work: 33 1--2l -1 Q � [r
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'I'Hi.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 pe the entgf the
(0- \ 46\\ •V‘OrNAA-.: 1"\J?rt"\i-LtYY-f4-r\ 11/ 9L/ / —
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
Permit Authorization
mass sav Form
Site ID: 4500224 Customer: NATHANIEL READE
Nathaniel Reade , owner of the property located at:
(Owner's Name,printed)
33 Longfellow Dr LOT 13 Northampton, MA 01062
(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 weath&rization
work on my property.
Owner's Signature: Alalhatdel Reade
Date: 05 / 18 / 2022
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
.A The Commonwealth of Massachusetts
Department of Industrial Accidents
i 1 Congress Street, Suite 100
r 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):
I.o I am a employer with 7 employees{full and/or part-time)." 7. 0 New.construction
2.Q 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 El Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof 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.ID Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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.#:WC9024456 Expiration Date:02/23/2023
Job Site Address: -t n[ C 3 City/State/Zip:
Attach a copy of the workers'comp nsation policy declaration page(showing the policy number and expirat on date).
Failure to secure coverage as requi nder 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,unde the ;ins and penalties of perju that the information provided above is true and correct.
Signature: -7k1/4, Date: (4 '-j -a D--
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#:
ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MM10DNYYY)
- 02/08/2022
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 (413)586-0111 FAX (413)586-6481
(A/c,No,Exu: (A/C,Noy
8 North King Street ADDRESS: chenderson@webberandgrinnell.corn
INSURER(S)AFFORDING COVERAGE NAIL#
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: I
24 Chestnut Street INSURER D: i
INSURER E: i
Hatfield MA 01038 1 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.
POLICY EFF POLICY EXP
ILTR 1 TYPE OF INSURANCE INS)i AN POLICY NUMBER (MM/DO/YYYY) (MMiDD/YYYY) LIMITS
X`COMMERCIAL GENERAL LIABILITY 1>,000,000
EACH OCCURRENCE 1 5 •
DAMAGE TO RENTED 500,000
I CLAIMS-MADE I X OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) s 15,000
A Y S2291509 01/01/2022 01/01/2023 PERSONAL BADVINJURY } $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
POLICY PRO- 3,000,000
JECT LOC PRODUCTS•COMP/OP AGG $
OTHER'. $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000
(Ea ac::ident)
ANY AUTO BODILY INJURY iPer person) $
A ' OWNED .I SCHEDULED Y A9105420 01/01/2022 01/01/2023 BODILYINJURY(Per accdeni) $
AUTOS ONLY /'� AUTOS
X HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
Underinsured motorist Bl $ 100,000
I
X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 2,000,000
A EXCESS LAB �1 CLAIMS-MADE S2291509 01/0112022 01/01/2023 AGGREGATE $ 2,000,000
I DEL) 1 RETENTION $ S
WORKERS COMPENSATION PER + OTH-
ANO EMPLOYERS'LIABILITY X STATUTE ER
i ANY PROP iiETOR?PARTNER'EXECUTIVE YYN N.A WC9024d56 02123/2022 02/2312023 E.L.EACH ACCIDENT $ 1,000,000
OFFICERimEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,O0Q000
iIf yes,riescnbe onoer 1,000,000
DESCRIPTION OF OPERATIONS below 'E.L.DISEASE-POLICY LIMIT $
Per Occurrence 5500,000
Pollution Liability
A Y S2291509 01/01/2022 01/01/2023 General Aggregate $500,000
DESCRIPTION OF OPERATIONS I 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 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
Everso rce ACCORDANCE WITH THE POLICY PROVISIONS,
247 Station Drive
AUTHORIZED REPRESENTATIVE
Westwood MA 02090 ���1
1988-2015 ACORD CORPORATION,<AII rights reserved.
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