25A-066 (3) BP 022-0787
46 HUBBARD AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25A-066-001 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-2022-0787 PERMISSIONIS HEREBY GRANTE P TO:
Project# INSULATION Contractor: License:
Est. Cost: 2500 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
Use Group: Owner: WAGMAN COTE,KEVIN G. &ALISA, M.
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:07/05/2022
TO PERFORM THE FOLLO WING 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:
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 VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
JO
.; ir )2 . 3:At,
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
> � ; City of No
,, Building Departin"
CEIV
y 212 Main Str __ .__ i INSULATION
c t Room 100
47 ;� Northampton, MA 01 Q . - 1 2022
phone 413-587-1240 Fa1413-587-1272
rrPT 07 rUILDING INSPECTIONS
NCintlaA"rr'TON,MA 01twi:!
APPLICATION FOR INSULATION FOR A/ONE-OR TWO'fAMILYDWELLING ONLY
SECTION 1 -SITE INFORMATION !NS LA / ION PERMIT
1.1 Property Address / /1 This section to be completed by office __
,[f� C bbQ'cJ 1 '�'= map (5/ p` Lot 66_0 Unit
,)V21 / k 0 Zone Overlay t> tr et
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
2.1 Owner of Record: Ft:ere-0
Kv S -- �S Ai. ►�Y _.p�L.e �--' e--&----
Name(Print) Current Mailing Add L. _ /
Telephone
Signature
2,2 Authorized A nt• Foes I _i v -A'e-f' a`' C ¢tt S1
BSI\ I ,{nl -,0-cc �z�s .c� III --z-.�J. ►�n4
Name(P ) I Current Mani Address;
Si tune Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee i
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �>r 1
6. Total=(1 +2+3+4+5) ,_) `57)O Check Number 3 s 7✓
nn -}, �/ This Section For Official Use Only
Building Permit Number g/ - 9' - !v7 Date
IIssued:
Signature: .....,/,/ -7-5- Zoz 7
Building Commissioner/inspector of Buildings :ate
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4 -CONSTRUCTION SERVICES
I 8.1 Licensed Construct*o uoervisor:f
Not Applicable 0
Name of License Holder ta i',/i t,:::`, „/Ifte_,,i 0/,„ 1--- C„,`,;:s- )0:3Li.,3 T
License Nu bar
22, 4 cv-us4-7-ii.bi- ....s-4-. a - d.; n1,1 0)03e
-i--
,
Ador:se„...„.--) „,./ Expiratio Date
3-,:,?-zo- ..5-?
1ature Telephone
HtiAllbilistefed#40011/44,00,COOtraotact 4'''' '
Not Applicable 0
, /17 VV1 6
Number
.__F . (s2 a `3
Address ExpirationMoate
Telephone/4e'c)11"7---51 7:719
L.,--
I
SECTION 5-WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) 1
Workers Compensation Insurance affida "t must be completed and submitted with this application. Failure to provide this affidavit will result 1
in the denial of the issuance of the build g permit, 1
1 I
i Signed Affidavit Attached Yes„„.,
fi
No.__ 0 i
Brief Description of Proposed Work NOTE: INSULATION ONLY
1 , ,
- , (1 ,___,,,_, ur
r--,
i I Y 6— '
1, Ac .,.Js, c,!,,„:-\--
" ---.X , as Owner/Authorized
Agent hereby declare that the statements and information or the foregoing application are true and accurate. to the best c) my knowledge
and belief,
Signed under the pains and penalties of perjury.
i
,-,
,_„„„„
; , , C:4 „,,,
vid. -,..--)c Au ,.- ( 2,:k---. 4,_ 4-- - L', .., 4-)1"Yea-Ve_„/Y1 .%111---- ( , 0 4-(4C.ficS, ..f....0
Print
Signatur of Own r Agent Date
I I.1 r-\ C.,0 ) --- , as Owner of the subject,
property
hereby authonze
to act on my behalf, in all matters relat, e to work authorized by this building permit application,
(S--e—ie_. CL=L-6-Q___k_ ct .z,-.)-
. _
Signature of Owner Date
City of Northampton
Massachusetts
s
r DEPARTMENT OF BUILDING INSPECTIONS
212 Ma:.r. Street • Municipal BulldIng
Northampton, 1.111. 01060 ,
AFFIDAVIT
Home Improvement Contractor Lav
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.
ex.)
Type of Work: Est. Cost:
Address of Work: z-/L0 Pt-t b
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 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 perit as the gent of the°wry-
I c/
Date Contractor Name HIC Registration No,
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above propert.
Dace Owner Name and Signature
City. of Northampton
„ , ,5
Massachusetts
ti
Y4'1.' -t"
,• 4' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Streat * Municipal Building '
Northampton, MA 0106 44 4e‘
MANDATORY FOR HOUSES BUIL r BEFORE 1945
Property Address: ij CO 14ku)01-3(2K---c--1 p.cbi--e_
Contractor
Name: ,....›T'4,1.---, .4"4-"--; --T -ao(iN!,excvl-r1/4,1---
k
Address: 1 4 c 1 0 .(4-r -A-
City, State: \\Phone: )4 t 3, Li 1 - !--i- / '',') I
Property Owner
Name: KL,R ‘,71 r)
Address:
City, State: 77 //LC/I'? e,e__, ill 4q- 01 o d-
(contractor) attest and affirm that the building I inten 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
Date
City of Northampton
" *C. Massachusetts or
i DEPARTMENT OF BUILDING INSPECTIONS
r
212 Hair Street •Municipal 5uLidng AA\
Northampton, MA 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.
41,/
(Please print house number and street name,
is to be disposed of at:
C?„ CCV- ‘&,L
(Please pnnt n4me and locat)4,n of facility)
Or will be disposed of in a dumps ter onsite rented or leased friArTy
C 't
(Company Name and Address)
Ci
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,
lottPermit Authorization
mass save Form
S*vW ps e,*erf±csenc
Site ID: 4512168 Customer: SUSAN COTTONBENCH
Kevin Cote , owner of the property located at:
(Owner's Name,printed)
46 Hubbard Ave Northampton, MA 01060
(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 weatherizatidn
work on my property.
Owner's Signature: Key& Cafe
Date: 06 / 15 /2022
*,..ar*a.rwe11rs.sss. . trsa.,*.*a.,+ .r.i,e. ,...... ats.► ,....sss.w.s.•
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 Ube Only
Document Ref ZBKXC-5361U-VADFB-VQK9P Page 6 of 16
'\ The Commonwealth of Massachusetts
►�__ Department of Industrial Accidents
..- 1 Congress Street, Suite 100
a = Boston, MA 02114-2017
.4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lenibly
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(requred):
ED I am a employer with 7 employees(full and/or part-time).' 7. New constructs n
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.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ❑Demolition
10 Ei Building addition
4.0 I 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 arc sole 11.1=1 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c.
14.[]Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#i I 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.#:WC9024456 Q - Expiration Date:02/23/2023
Job Site Address: /71Z, City/State/Zip: \ (�T r _
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ation 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify,unde the ains and penalties of perju that the information provided above is true and correct.
: j Signature Date: CO `01CD
Phone#:413-247- 739
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACOR>D� DATE IMMJDDIYVYY)
�. CERTIFICATE OF LIABILITY INSURANCE 2/0612022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PbLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A Statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER ` CONTACT Cyndie Henderson CISR.CPIA
NAME:
Webber&Grinnell PHONE (413)586.0111 FAX (413)586-6481
AIC No,Ext): (A/C,No): _
8 North King Street "All- chenderson@webberandgrinneli,com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC$
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 D: 1
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 WHIR THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TE MS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR ADDL SUER" - POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MITS
INSQ,WVQ, (MM DDlYYYY) {MM ODIYYYY)
X COMMERCIAL GENERAL LIABILITY 1,000,000
EACH OCCURRENCE $
r-- -; DAMAGE TO-REN rED 1
500,000
CLAIMS-MADE I X) OCCUR PREMISES(Ea occurrent J�, $
1 MED EXP IAny one person) $ 15.000
A i S2291509 01/01/2022 01/01/2023
PERSONAL RADVINJURY— $ 1.0(30,000
I GEM.AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 3,000,000
POLICY JETO- J LOC3,000,000
PRODUCTS-COMP;OPAG�
OTHER. $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
tEa accident)
ANY AUTO BODILY INJURY(Per person) I $
A OWNED X SCHEDULED A9105420 01/01/2022 01/01/2023 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS _
X R NON-OWNED PROPERTY DAMAGE I $
HI
AUTOSED ONLY X AUTOS ONLY iPer accident)
I Underinsured motorist BI $ 100,000
Xj UMBRELLA UAB OCCUR EACH OCCURRENCE $ 2.000,000
A ' EXCESS UAB CLAIMS MADE S2291509 01/01/2022 01/01/2023 AGGREGATE $ 2,000,000
DEO RETENTION $ _ $
WORKERS COMPENSATION XI PER >4 OTI+
AND EMPLOYERS'LIABILITY Y/N /�j STATUTE /�(ER
B ANY PROPRIETOR>PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? Y 1 N/A WC9024456 02/23/2022 02/23/2023
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,descnbe ureter '
i DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 1,000.000
Per Occurrence $500,000
A ' Pollution Liability S2291509 01/01/2022 01/01/2023 General Aggregate $500,000
I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES IACORD 101,Additional Remarks Schedule,may be attached it 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
Westborougr MA 'J15B1 la....,, '- :C {
ID 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD