10B-035 7 UPLAND RD BP-2017-0219
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 10B-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: INSULATION BUILDING PERMIT
Permit BP-2017-0219
Project# JS-2017-000376
Est.Cost: $3500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 30448.44 Owner: ROCKETT THOMAS K&ELLEN E
Zoning: URA(100)/ Applicant: PAUL SCHMIDT
AT: 7 UPLAND RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATF I ELDMA01038 ISSUED ON:8/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK: ,INSULATION, AIR SEALING AS NEEDED
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: FeeTvpe:
Date Paid: Amount:
Building 8/19/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
File 4 BP-2017-0219
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 7 UPLAND RD
MAP IOB PARCEL 035 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid CC- err d'oS
Building Permit Filled out
Fee Paid
Typeof Construction: ,INSULATION, AIR SEALING AS NEEDED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103635
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO&IATION PRESENTED:
4 -Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:$
intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D-volition Delay
Sign. - of:n .n g Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning& Development for more information.
RECEIVEDC+ Nerthainpian
1368ding Department
AUG i 8 2016 212 Nin
Room 100
�, MA 01060
DEPT CF({y.➢es .[cwWna nyo13587-1240 Fax
APPUCATION TO CARBTROCT,AL1 ,REAR,RENOVATE OR OBAOLJ&I A ONE OR I O That ENIELUNG
Z
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Item Ee ,NeeeCod(Dolss)m be
M
C4 2dmiF aPCbrAtd
1. BuidAgJ'' -T/l oD of +.
, q �l ti
2. Efercat
3 Plumbing
4 %%cheek*(HVAC)
5 Pre PrcteS4on
B. Total1+2+3+4+8 1_3 .,;, '00
tu-
. _ . ,
Section 4. ZONING All Information Ann Be Completed.Penna Can Be Denied Due To incon ptete Information
Existing Proposed Required by Zoning
This column to be Bei in by
am'ldingDepanment
Lot Size
Frontage
Setbacks front
E
Building Delta
Bldg.Square Footage
Open Space Footage
Ped®PadM
Bi
#of Parking Spaces --__ ..__._ __._�
For:
(vA. Has a Special Permit/Variance/Fi been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES,date issued::
IF YES: Was the permit recorded at theRegi ry of Deeds?
NO O DONT KNOW YES
IF YES: enter Book " Page'. and/or Document a=
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW G YES 0
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued: ..�_.._.._,�.....
C. Do any Signa exist on the property? YES V NO Gr"--
If
:!IE YES,describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0"
IF YES,describe size,type and location:
E ME the construction activity dtabnb(bearing, ,grading, or Wing)over 1 acre or is it part of a common pian
that vial*Erb mer 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONSDESSItriteltOPPRDPOSSISSINVEddissesekamelimegiti
New Novae ❑ Addition ❑ aReplacementevidows A*wtao.gs) 0 Reefing ❑
Doors
Accessory BWg. ❑ Demoildon 0 New signs ryi Decks Maj Other t�
Md atestrOA /
Sad Desaipdm of Proposed 3-3(0 vciviL-s` —4-tenor �.rtlfs ; air seatti a • .,..�+.
Aeration of misting bedroom Yes ✓ No Ackig new Yes No /
flecked Nemative Renorad g unanmhed basement Yes ✓ No
PWisACadied RoY -Sheet
a. Use of Wang:One Family Two Friday Oder
b, Number of roans in each tom'unit Nimbler of Bathrooms
c. Is there a garage meed?
d. Proposed Square footage of new cohort. Dimensions
e. Number of stones?
t Meana of hFireplaces or Wdoestooves Number of each
g. Energy Conation Comipilace. Manche* Energy Cornpfianoe ram attached?
h. Type of construction
I. is consbi tnwithin 1®8 of .... .. _Yes _No is construction vimin 100 yr. dooslaan Yes No
). Dep,oIb aneitor•- bSowtnWiedgede
k. Wal building conform wig aria Zoning reguialio. ? Yes No.
I. Sep&cTs* City Sewer Private wee City water Supply
85:GMONT*-efflHt-MfIN9 alfa ,tow BkEPD WEN
OWNERS SOW OROS RYCICIRAPPISPCiR PBh1IT
t, --Coma + etc.(0t es Owner oldie subject
properly 1 '
hereby What* , /�A,.. i-Ic>•r1JCvexl /i r'n�/errrt:�n-4- �"k,,e..s, Jon e.,
to as on my behalf,in
aA m afters sedative to by this bupglna permit:..;- .:
Oma - J
ad1ma'd f' as oe remAutha;zed
Agent hereby declare that
� hrilanents and MiMmatM1 on the foregoing application are tore and accurate,to the best of my kno.Medge
and belief.
Signed under the pains and penalties of perjury.
'Tsai &Anict-1
PM Nana /
...'rA..;.
Dais
Li tlaprd Confl tlonNot Applicable 0
Bae d l.eaesHeider: ALrtl &.hrntCL-1— 9O Ce35-
Ueeme Number
a 'k j nod- ', 4-lakRci aftPIA otos A ( 'JT
Address ,e./ EWiaton Dale
./�/�i:% i I If - r Al -5
Telephone
Not Applicable 0
*omen Nina Registration Number
ate[ ,g'freef- rati 24.71 /1
Address 1-#Q4C.1 MA 0103c) relapnond-/i3t7'5l39
Workers Compensation Moreno,affidavit must be completed and submitted with this apptiostion. Failure to provide this affidavit will result
in the decfal of the issuance of the b permit
Signed Alfidav*Abed/veld Yes IV No 0
The current exemption for` ,o urns"was extended to include Owaencenaded Dwain=of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
es sunervken CMS 7*. Sttlh Edition Sedlon 108.3,54,
Ratinitiou aftonteoweir Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
stmebaes.A penes wheselegrnets mens nen eat home to a two-year period shalt a at be tonsidered a homeowner.
Such"homeowner shall submit to the BmIding Officio',on a form acceptable to the Building Official,that hei he shall be
As acting Cemarediee Stmervhor your presence on the job site will be required from time no time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,aquae be Bak for person(s)
you hire to perform work fix you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature ^_
City of Nortilumpton
idusaahumens
masm a.ISMS aaaSEDaas -
2h2 Naha Stat • int a.11etaa
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rmem s: '7 wpLtni i K-dt
COMPS Pau( 5C-11/7 iCL+
Name: S`d --kC«-r,:e-.` nprtlremver tufikarika ,Zne., •
Adding 2 0.1,Th.esr-nah-
car,smtx r rt ead , NIA 0t0.'
Phone: 4J3• a47-67,39
Address: 7 /"f i 1 ,Zoctrk
cars Lack m-R vs
r 4
I,—Pad -mnie.#" (ooatradar)sent and a_Rte that the belay I Mend to
insult oiliattletbanty meta Ombra tube)miring.m ,ki the ipeces to be bnidandtitIhave
protidedtteptepertramstalli a cepre►fiaaedavit
Caramotor aiguatare/a/k
Date g,, CO_ ,
RISE60 Shawmut Road,Unit 2 I Canton,MA 02021 1339502.6335
ENGINEERING www.RiSEengineedng.eom
OWNER AUTHORIZATION FORM
1, ( - s- � __�1 �I
(Owner's Name)
owner of theI
Property located at:
1 0 pkAkkot &1,
(Property Address) \-54-
^ /y
lb
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on mJy�/prope((rrt//�tyy..`hiiQ(s foam is only valid with a signed contract.
Owneis Signature
Date
The Commonwealth of Massachusetts
, Department of Industrial Accidents
f/ 1� 1 Congress Street, Suite 100
,fa 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): SOL Home Improvement Contractors, Inc
.Address: 24 Chestnut Street
City/State/Zip: Hatfield, MA 01038 Phone 4: 413-247-5739
Are you an employer?Cheek the appropriate bon
Type of project(required):
L�✓ ant a employer with 8 employees(fun and or pan-Inlet r 7. 0 New construction
I sol netor or partnership and have no employees working forme
'_❑ ityr[p p p p in 8. Remodeling❑
capacity [No - k - p insurance required'
0 am a homeowner doing all work myself[No workerscompinsurance required9. ❑DemolifiOv
1.❑I am a homeownerand will be hirine o cd r p I will 10 ❑ Building addition
ensure that all contractors either hrkrs compensation insurance or are sole I1.0 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 13.0ROof repairs
These subcontractors have employees and have workers comp isuance.
o.❑We are a corporation and its officers have xsed theirr:ehro exemption per er MGL c. 14.❑,. Other Insulation
152. (41.and we have noemployees.[No workers'comp insurance required
*Ana
surancerequired*Ana applicant hat chocks box=I must also fill out thc section below show'aie their workmcompensation policy information.
anon -su
whobmit this affidavit indicating they are doing all work and then hire outside contractor,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
employes. If the sub-contractors have employees.they must provide their workers'comppolicy number.
I am an employer that Ls providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: Selective Insurance Co
Policy#or Self-ins. Lic.#: WC9024456 Expiration Date: 2/23/2017 -�/�
Job Site Address: / ap fi- ci / City/State/Zip: 5, -NOP oiC S
Attach a copy of the workers'compensation policy declaration pag showing the policy number and expiration date).
Failure to secure coverage as required under MGI.c. 152. :25A is a criminal violation punishable by a fine up to 51,500.00
and or one-year imprisonment,as well as civil penalties in the fort of a STOP WORK ORDER and a fine of up to 5250.00 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 r the p s and penalties of perjury that the information provided above is truer " and correct
Signature:r� �lY✓/ / Date: �' ) L2 — I C.Pc__
Phone=: 413-247-5739
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):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Ade CERTIFICATE OF LIABILITY INSURANCE NTEWIAN200RYY=Y1
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 It an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condldons of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in)leu of such endorsement(s).
PRODUCER 1 NDUA AcT Cynthia Sanderson, CISA
Webber & Grinnell PHONE (413)58fi-0131 FAINGat (113)586-6au
8 North KingStreet DV ($ chevdereon webber
a0pxg;g g andgrinn.11.cw
INSURER(')AFFORDING COVERAGE RUC
Northampton MA 01060 INSURER A:Selectiw 19259
INSURED INSURER s'.
SDI, Home Improwmeat Contractors Inc. INSURER c.
24 Chestnut Street INSURER o:
_._ _. .
INSURER .
Hatfield MA 01038 INSSMEPf:
COVERAGES CERTIFICATE NUMBERMaster 2016 REVISIONNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT LITH 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.
AMR _ - ----.
LTR TYPAL GENERAL CE PO4CY NUMBER SYMTMNYYIi( Y P ---UNiR
X CWYERCStLOENEMLLM&Ury ' EACH OCCURRENCE '...b 3,000,000
A -.....CLAMS-MADE X ''..OCCUR PREMISES .AI 5 500,000
92206065 2/1/2016 2/1/2017 MED EXP)mum prem) $ 10,000
PERSONAL 6Anv INJURY f 1,000,000
GENL AGGREGATE LIMIT APPLIES PER. ''. L ' GENERAL AGGREGATE 5 2,000.000
X POLICY LOC PRODUCTS-COMP/OP AUG 5 2,000,000
OTHER 5
AUTOMOLFUATLRY COMBINED WOLF LAM_GALEPOSUI __ $
1,0007000
A ANAAUTO 90015. NJURY ivr person) $
ALL
O EO - SOHEW.ED --- __-.
E AUTOS iA91003213 2/1/2016 2/1/2019 BOOLYNJLent) $
X HRED AUTOS gl ALUTTOS ED -`PaI2DnN6OADAMAGE IAGAG E acod —_
''.
UnUntletUundmantst&Lnp ...E 100,000
X USeIELLALuc X OCCUR EACH OCCURRENCE 5 1,000,000
EXCEbWB CWYS-MACE •-A_ — _-_ -
A AGGREGATE f
DED X RETENTIONS 10,000.. 82204065 ', 2/1/2016 2/1/2017 ', 5
RAOERS COMPENSATION ND EMPLOYERS UA UY
TY ON'.. 8. STATUTE X. ..'..,,,,ER
ANY PN CPRIETORFARTNEREPECUTVEH)A
A . E'_EACH ACCIDENT 5 500_700 0
FICOfERIMEMBER EXCLUDED, y —
IW,WIayNNH) NC9024456 2/23/2016 2/23/2011 E DISEASE.EA EMPLOYEE S _ _500,000
H yes Omuta Toe/ _._—..
DESCRIPTION OF OPERATIONS beim E L DISEASE.POLICY OMT,1 500,000
OESCNPtEX OF OPERATIONS i LOCATIONS J YFMOE6 IACOm101.Aanenl lemons emawa,may M ehtlW N mon weanmonad)
The workers Compensation policy does not include coverage for Paul Schmidt, Sindrick Dempeey and Douglas
Schmidt.
CLEAAesult, Zversource and National Grid, NSTAR, Boston Gas Co., Colonial Gas Co. , Essex Gas Co., and
Western NA Belectric are nand as Additional Insured per written Contract with respects t0 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
CLEARasult I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
Contractor Serviced I ACCORDANCE WITH THE POLICY PROVISIONS.
50 Washington Street, Ste 300
Westborough, MA 01581 AUTHORGEOREPRESENTAIWE //����������
C Henderson, CiSR/CIN —j^�—
O 1988-2014 ACORD CORPORATION. All rights resolved.
ACORD 25(2014401) The ACORD name and logo are registered marks of ACORD
INS026 onunt.