11A-036 B ' 2022-0833
3 LEONARD ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
11 A-036-001 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-2022-0833 PERMISSIONIS HEREBY GRANT l I TO:
Project# INSULATION Contractor: License:
Est. Cost: 2000 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
Use Group: Owner: GL ERDIL MICHAEL& ELIZABETH
Lot Size (sq.ft.)
Zoning: URA Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC9024456
HATFIELD, MA 01038
ISSUED ON:07/14/2022
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:
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:
lY >2 3-''� •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of No amp n
Building Depa ent ,/
i N ! INS
212 Main • 1 , '
Room $),:'6, <--o, 7,
Northampton, MA
,., ',, „weer:',//,„*
'''''' ,;-,-;::''' phone 413-587-1240 Fax 41 itk
-,, -<- ,
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
, SECTION 1 -arm INFORMATION INSULATION PERMIT
1 1 P Add ss This section to be completed by office
.
+ map 1 1/A--- Lot 0 (_. Unit
0 /i 4 C.)\S-3 Zone Overtey Otstrtot
Elm St Distritv .., CS District
-----i
SECTION 2-PROPERTY C,WNERSHIP/AUTHORIZED AGENT
- i
,1 Owner Of Record:
.4.:7/(e--0.1-De---1-1--) Q 1 0 Ck-1 ri ii• 2) • 6--6t(_. 3‘749//
Name(Print) Current Mailing Ad 7
Telephone
Signature
2.2 A, . orized A t L: ?t__r--(1 S C-111-K--if d---+
---
' . Alr Ilia ' ffatilAs I A • C-01-4-Ya--e--=•I 0 4--S, i -/-1 (__,
Name / / ciu...25..41,4_C14_irrent Mailing Address/A ,i.% •., (4 )---v-04]
• ./ 5.... '1-1-37/.- --. ( 4/--7-c5-73
' nature Telephone
SECTION 3 -ESTIMATE)CONSTRVCTION COSTS
Item Estimated Cost(Dollars)tore Official Use Only
completed by permit applicant
1, Building c.s2-, (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Buildine Permit Fee
Iti(Jr,
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2 4-3+4+5) --,,
„,/ DC)a - uc.>
Check Number -3676
This Section For Official Use Only
Building Permit Number: 619- .9Y.9?T' t3, Date
Issued.
Signature: 7- Hi-zozz
Building Commissionerilnspector of Buildings Date
. _
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4- a _,'`' '.' 4:
INERMan
8.1 M,Uce d ' .N •r: Not Applicable
Nam.of License Heider: .41 n'd t- C�- 1£ S--
r Ucense ber
2/ ( h, ti s4 4CLt,1of id., n1ll ofve3 - :� o
1°7
Acidness E�iratioate gnature Telephone
Not Applicable
I VVJ
Co Name, J L. ,0 . - egistration Number
ALI 611)
zp /07
Address i Ec rstiorYl�ate
\cx gr....l+`_., i-Y\-6 01 c)"3g' TeiephonI13-v4'7--5':34
SECTION 5-WORKERS? 4 AFFIDAVIT Mei.c.1b2,#23CtO?)
Workers Compensation Insurance Wilda must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the Issuance of the bui-• permit.
Signed Affidavit Attached Yes ► No
Brief Description of Proposed work NOTE: 1NSULA T/O?1 ONLY
0 1 7 ,„,,, h - ac�_ �
c�-L ( � 4'1- I
kth
I, Pa U. 1 tVQk �*".- .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.
r �-�"' C� Ott r:i a..rY� l s* , LtC4CX.S, 2:1
Print Name
Signatur f Agent Date
I, k.:_lt TA_ -1-4) C-I V--t_ _, as Owner of the subject
property C
hereby authorize J t—
to act my behalf, in all matters relative t• work authorized by this buildin permit application.
Signa ure of Owner Date
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
Elizabeth Glackin
(Owner's Name)
owner of the property located at:
3 Leonard Street
(Property Address)
Leeds, MA 01053
(Property Address)
hereby authorize S lJ
(Subcontractor)
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.
ati
Owner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
City of Northampton
Massachusetts c.
4 DEPARTICNT OF BUILDING INSPECTIONS ik 4
212 Mean Street eltanacapal Sualdang
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 150 .
The debris from construction work being performed at,
(Please print house number and street name)
Is to be disposed of at:
C—
I A' (A 1- 14 4( , 'OA
12\52 -
(Please print n me and looaNn of facility)'
Or will be disposed of in a dumps r onsite rented or leased from
(r) r-L.,LiA, (.1.-C,ry• t/(:4(-*( c4)(1.c„))
\t-N.Q cy-e_ k3
(Company Name and Address)
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
Massachusetts 4i,""
• '3:
IYE -.-
PARENT OF BUILDING INSPECTIONS
212 Main Street 4# Municipal Budding
Northampton, KA 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" he
done by registered contractors,
Note: If the homeowner has contracted with a corporation or LLC, that entity must be registered.
c,c)
ype of Work:_ brksu, Est. Cost: cs?,000
Address of Work: 3 Leo,
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 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 as the uent,of the pin4L
i 1 /
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
pwr,` r ... s ., .,`i
mot , , �< - Masssachus etts v .`._ `'-
e.
'ARTMENT OF BUILDING nisprcTTONS �.
"of , 212 Main Street • Municipal Building
Northampton, M7► 0106-
44
MANDATORY FOR HOUSES BUIL r BEFORE 1945
Property Address 3 L le orlc_r-d "-i--
Contractor
Name: I..., k\-4 Y\.., p iC ri-Vt—rk.1
Address: 4 C lc S --r'k.k.-
City, State; -\—\--ct,--k - ...1. +4)t" CD\ C.)?- ts
ei
Phone: 4 t ..5". 3 LI 1 y5 1 e3
Property Owner 1.---
J (---;
I 1aGLName: L l 7.0 s
Address: t 3 L•e-C-1)rThCL r'd +
City, State: e f S, r-Y) i� I c 5� 3
1, (2a1 niu 8 (contractor) attest and affirm that the budding 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 izetL_______
4.
Date rI - //r a-g--
The Commonwealth of Massachusetts
t►_' /, Department of Industrial Accidents
_•- != 1 Congress Street, Suite 100
Vitt ' 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):
1.0 I am a employer with 7 employees(full and/or part-time).* 7. New construction
2.0 i 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. 0 Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]f
10 0 Building addition
4.0I 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
5.0 I 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.:
14.D Other Insulation
6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box in 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 Expiration Date:02/23/2023
Job Site Address: L-e-Drv-x r74 T City/State/Zip: S
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 D1A for insurance
coverage verification.
I do hereby certify,unde the sins and penalties of perju that the information provided above is true and correct
Signature—: f Date: / — I( - 02 a-
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#:
'- -, '�
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYVY;
�_- uz3/2oz 1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLE ER.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 orlbe endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. Astratement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER I
CONTACT Cyndie Henderson CISR.CCPIA I
Webber&Grinnell I PHONE 413)586-0111 FAk (413)586-6451
``ix..k Lo,Extra. ' i (A/c"No):
8 North King Street ADDRESS: chenderson@webberandgrinnell.com
l
INSURER(5)AFFORDING COVERAGE I NAIL K
Northampton MA 01060 INSURER A; Selective Ins Co of S Carolina ( 19259
INSURED INSURER B Selective Ins Co of Southeast 1 , 39926
SDL Home Improvement Contractors, Inc. INSURER C:
24 Chestnut Street INSURER D: I
1 INSURER E:Hatfield MA 01038 i 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.
NSR 'ADDLISUBR I POLICY OFF POLICY EXP
LTR- TYPE OF INSURANCE INS°I WV°, POLICY NUMBER L MMIDD/YYYY)-IMMIDD/YYYY I LIMITS
XI COMMERCIAL GENERAL LIABILITY I 1,000,000
EACH OCCURRENCE $ ,
j 500,000
I CLAIMS-MADE 'X OCCUR PREMISES(Es occurrence 1£
MED EXP(Any ons;Ammon) ; $ 15,000
A Y S2291509 01/01/2022 01/01/2023 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE
' $ 3,000,000
POLICY X JE i 1 LOC ) PRODUCTS-COMPiOP AGG $ 3.000,000 —
1 OTHER:
_
AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT $ 1,000,000�
4 £j (Ea tweIdeml
I I ANY AUTO BODILY INJURY(Per person") $
A I OWNEDONLV i X SCHEDULED AUTOS Y j A9105420 01/01/2022 01/01/2023 BODILY INJURY(Per accIdenil $
AUTOS
X HIR NON•OWNESD PROPERTY DAMAGE $
AUTEDS ONLY O ONLY (Per accident)
I �/1 AUTO Underinsured motorist BI ' s 100.000
I X UMBRELLA LIAB 1 X OCCUR EACH OCCURRENCE $ 2,000,000
A 1 EXCESS UAB I CLAIMS-MADE S2291509 01101i2022 0110112023 AGGREGATE 5 2'000,000
' 3
I CEO X RETENTION $ 0 }£
1 WORKERS COMPENSATION X STATUTE OT
ER
I AND EMPLOYERS'LIABILITY YIN
IANYPROPRIETOR7PARTNER;EXECUTIVE I S E.L.EACH ACCIDENT $ 1,000,000
B I OFFICERVEMBER EXCLUDED? Y NIA WC9024456 02/23;2021 02/23/2022 ---(I(Mandatory in NH) I EL.DISEASE-EA EMPLOYEE t.000,000
1
It yes,des,ribe under ! 1,OOfl,000
DESCRIPTION OF OPERATIONS Wow 1 E.I. MIT DISEASE•POLICY LI I$
III Per OccuI ence . S500,000
I Pollution Liability I
A I 52291509 01/01/2022 01/01/2023 General Aggregate S500,000
i ,
DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more apace is required)
The Workers Compensation policy does not include coverage for Paul Schmidt,Kendrick Dempsey and Douglas Schmidt.
i
Thielsch Engineering s 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
I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Thlelsch Engineering ACCORDANCE WITH THE POLICY PROVISIONS,
195 Francis Avenue
AUTHORIZED REPRESENTATIVE / )
Cranston i<! '.12>i)( 1 i If,... _ice ,t�:-,., P.
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD