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17A-220 (10) 172 NORTH MAPLE ST BP-2019-0200 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-220 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cateeory. INSULATION BUILDING PERMIT Permit BP-2019-0200 Project JS-2019-000331 Est Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(su.8.): 21692.88 Owner. MCALLISTERIOHN zoning: URB(1001/ Applicant. PAUL SCHMIDT AP 172 NORTH MAPLE ST ApplicantAddress: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.811512018 0:00.00 TO PERFORM THE FOLLOWING WORK:1564 SQ FT EXTERIOR WALLS, ASPHALT SIDED AIR SEAL 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: FeeType: Date Paid: Amount: Building 8/15/20180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner a NIV SU(�/�7 City of North mp n Building De rtm nt ' i� ;✓r. / 212 Main tree AUG 15 2018 Room 00 Northampton, AB405�muuoiNGIN r Fr {' phone 413-587-1240 0 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION !ry 1.1 Proorrenv Addreae: ��Thiis a-aelion to be compplatadby dfla c + '. U� Map Lot GI 4�3© it 'C/�-L✓� �.�I 1177 I Q tF 7— zone ovatw Det . O Elm St Dienkt CB Distinct - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Queer of Record: -I� 1 .,hn Mc K�1liS� r / 7Dim( 0--f � } Name(Prnq. 1 I 1 current Maw Atlprogsf _ �� ��� Signature �r 2.20,IhorizedA ent: SbL m.2. !1,-L`J'c/✓Le�f tA✓}.(yA�-�i�s,�y�/G MA Name Curent Mailing Address: �jlV3si nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cast(Dollars)to be Oficial Use Only com feted by oermft wolicant 1. Building D� (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Consbucow from.6 3. Plumbing Building PermN Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This SecDon For 0111ciet Uses Only Building Permit Number. Data Issued: Signat B.eding Cam-' repedor of Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All kftrmdon MuBe CwnptetW.Permt Can Be DenW Dm To inmniptete hforrnadon E,dsdng Proposed Requuvd by Zoning Thi$Cvl W h tdlei m by BwldiMDVuEmnt Lot Size -------- Sedmis Front ------- - side L:,.- R: L: R-- Building Height Bldg.Square Footage % Open Spam Footage ------ % ------- (La..i..bidg&pa� -- ---- #of Parking Spams Fill: A. Has a Special Permit[Varlance/FindLin0wr been issued for/on the site? NO 0 DONT KNOW E3 YES 0 IF YES,date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO C) DONT KNOW YES IF YES: enter Book Page and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO, 0 DONT KNOW 0� YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Date Issued: C. Do any signs exist on the property' YES 0 NO (D-� IF YES, describe size, type and location: D. Are them any proposed changes to or additions of signs intended for the property? YES O NO IF YES,describe size,type and location: E NAI the oonavuotion acth*diabst,(Clearing,grading, orfilling)over 1 acre or is it part of a common plan acre? YES( NO IF YES.dw a NonhampbDn Stonn Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doom D Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [q Siding Other[ U BBrief De cn 'on of roposed r1_ U S �.-1� n fjr ���'(n Work: i RS hL5 - Alteration Narrative betlroom_Ves No Adding new nishedbedroom Yes No Attached Naed Ro Renovating unfinished basement —Yes ✓ No Plans Attached Roll -Sheet 6&IfNewhotme4indeu.a eisexffiffia m itBfikoeyina: a. Use of building: One Family Two Family Other b. Number of rooms m each family unit: Number of Bathrooms a Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 700 R of well a? Yes _No. Is construction within 100 yr, floodplain_Ves No j. Depth of basement or cellar flo below finished grade k. Will building conform to th wilding and on regulations? _Yes No. L Septic Tank_ ity Sewer Private well_ City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work a p rized by this building permit (�applicatiyo� y,/ Signature of Owner Date I, l S M! �.�� 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. Sigf Q under the pains and penalties of perjury. F�Ltcc � Print Name Name `I 3- Sigoure of Ovm nt w Date SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Sunilsor. // Not Applicable/❑� Name of License Holger: Oconee Numbs 5lncC¢ /etc/ -21) � Adtlres Expiration Dine ature Telephone =red HIems hmrowmert Contraebm Not Applicable ❑ Sbr ` 1pryu, Znarnii Com Na Registration mbar 07 �� �t 41-n r t�- Sf Pcr c) r Address Expiration Date {�pi�ielcl _M/4 D/63Ff Teleb� �?�� '3 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide Mis affidavft will resu8 in the denial of the issuance of the building permit. Signed Affidavit Attached Yes,....... ❑ No...... ❑ City of Northampton j Massachusetts s/ ^'•L, D ANTWXT OF 37LL1XrM INSPECTIONS �? \. 212 Nein Sh eat . N cipal Building 'fix '' Northampton, Na 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, ataration, renovation,repair, modernization, conversion, improvement,removal,demolition,or construction of an addition to any pre-existing ownenoccupied building containing at least one but rail mare than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner hos contracted with a corporation or LLC,that entity must he registered �� ou Type of Work: 140 11 Est Cost. Address of Work 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 TRE RESPONSIBH.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Sighed under the penalties of perjury: I hereby apply for a building t as thea ant f the o r. Date Contractor Nime ,}.(AcfoKS% 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 Massachusetts cii!V IRNT OF aalLDINO INapacTiOaa 313 Main STi •Municipal Building Noitha ton, MB 01060 �l't 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: / I a Z � W o--p l_e_ s (Please print house number and street name) Is to be cis osed of at: �Q C- / 7? l�e�� �+ J ,fi4C c� ( lease print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) .�/ p 3 I §ignature of er �it plica 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. RISE ENGINEERING' OWNER AUTHORIZATION FORM I. John Mcallister (Owner's Name) owner of the property located at; 172 North Maple Street (property Address) Florence. MA 01062 (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 my property. This form is only valid with a signed contract. Owner's Signature RISE Engineering,a Division of Thie)sch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 02021 1339-502-6335 www.RISEengineering c )m " The Common wealth of Wassachnsents "--, Drparltnrnt of IndustrialAccidents Office of Investigations 600 Hds'hington Street Boston, ;ffl 02111 . www.muss.gov/Aia Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plumbers ADnlicaut Information Please Print Legibly Name Me,inc.,Oreanlmtion:hwl\;duan: SOL Home Improvement Contractors Inc Address. 24 Chestnut Street l IIN Stale Zip. Hatfield, MA 01038 Phone =- 413-247-5739 Are von an employer?Check the appropriate hos Ty pr of protect(requircdl -- pmer w 10, 1. 1 un . ,rnerw cuntraator.rod I I'`R I am a eml $ - u. Q u, Sew luvuunon j emplo,Cas(full and or part-Time).' have cored the,ub-mmrenuo =.❑ 1 am a sole proprietor or partner- listed un the aruched sheer 7 Q Remodeling i Ih,,, ,uh-Contractors hale '. ship and have no employees %- ❑ Uemniiti,rn I un In,te* wlaw for r in am cnpaciry. P and la"eo'k'r' a Q Building addition INo„orkers' comp. insurance ml aures 1. , cumor,nin:vndt, 10.❑ EIc.lncal rcPUus ur sddltiuns requl red I .- 1 }.Q ala n h,n,enwner doing all work A11111,11,1\111111111111111,1 1 Plumbing repairs ..additions uisell: .Vo workers' comp. ripht it ,wn pnon per MOI. l I P L❑ R1xd repairs Insurance required ` _n, e IN).an 1 hate no pinnti. IN. trkeo CAher Insulatlpn sump. mswaixe required.I '\m atrylmmd that tivckJ ,,-I.... o fill nm,hc msuon Rin.. .) snuu lauon IniM,wnrr,.huw1,.""ai,alEdu.d mdmMme IK" ary dont all 11,10"',tivm ',lbnul alae Ahilmn mW',au,.> h 1ixwrz thmlha,k ol,d„ m,mlaWatl anohv d,han all dvw mu then �,the ,h.:.nn nelnna `md muxhnr n a1a, onM.,e cvam.h:n. .makoua It the xnhmnmtacu•rplmve umPlayuu.thY nuiw MoCul�lieu � mk rn. mm0 I�'Ln n anis 1 am an<ntpbyrr Ihm 4 provlddrlt workers'cnmpensallon imarurtcr for nn•empinrees. Below Is thetalks and job site injormmion. Insurance Company Name: Selective Insurance Co Polio a ur Self-ins. Lic. r_ WC90244561-� I-spiralion Date- t 02/23/2019 lob Sae Address'. _"--I- �__- _1..1. 1. c�'t t'it, slate;Zip:.! "J—.4rU_'\C_X' Attach a copy of the workers'compensation policy deelaratioo page(showing the policy number tad expiration date). Failure to secure coverage as required under Section '_iA to YCL c I5^_can lead to the imposition oferiminal penalties of a lineup to SIS00.00 and,or one-year imprisonmem. Us writ as ch it penalties in the form ofa STOP WORK ORDER and a tine of up to$250110 a day against the violator. Be ad,ised thin a copy of this statement may he hnsrarded to the Office of investigations of the DIA for insurance coverage,erifrcat ion I doherl rein' oder I pains and penahln of Pierian that informal provided abboosr is Inn,and Qcorsets. -- Si. Ira ' Phone .3' X17' S- 7 3 q9 Official use only. Do am write in this urea,ar he onmplesed in efrr or town afficiui City or Town: Pereant License h Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.C'itylfa.n Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Cnames Person: Phone n: `C)r CERTIFICATE OF LIABILITY INSURANCE wT isizolB 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 certl0ob hol0ar le an ADDITIONAL INSURED,the pohcy(ias)must Be endorsed. If SUBROGATION IS WAIVED,subject to the terms antl conditum of tM POLICY•conal^PPlbles may roeuire an endonament. A statement o^this cenlficate dwa not confer rights to IM certificate holder in Thu of such andenamenl(s). PRODUCERCONTACT Cynthia HanGreon, CISR FARM Webber 6 Grinnell ARMSas FVC�APERP (413)586-0111 S MI_ %n Tl seo-6ee: 8 North King Street APAi chendersonfrebberrncigrinnell.cos iWURERISIAFFDI1gNOCOVERAOE NAC/ Northampton MA 01060 MSURFR A'.SalaCti Ve Ina CO Of S Carolina INSURED R.A.ERa Selective Ine Co of Soutbeast 39926 SDL Home improv nt Contractor. Inc. INSURERC. 24 Chestnut Street smaenD .n.mA E Hatfield HA 01030 :wuRERF COVERAGES CERTIFICATE NUMBERt4aeter Exp 2019 REVISION NUMBER: 'HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY HE Rion INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPLCT TO WHICP THIS CERTtFICATE MAY BE ISSUED OR MAY PERTAIN. `HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJEC' TC ALL THE TERMS EXCWSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS (LTR iYVE pF IN3URAYCE AOeVWM PW6Y XU PgKY 6ii gXICY EAP Y11S X COMMERCIALDENERAi LIASILIry �[)ixkNO- a 1.000'0001 RA AL,, RExrzo A .,1A. IA,' x oCuii REMISES IEz ar.,,n^,xi = 100,000 9240416, 1n/1NIF i10,000 I'. -111A I All.N,.,N 6 1.000,000 NI, k IfiILR r 9.000,000 %Vr0,v At t :m' _ r our 3.010,DDo� OtefR Fundi eILE 1.111 fx¢:uMNl A ANY AU-,, nOvweo X S XYnuc A9100326 `3 2 -9 OI: 1. $ JO6 AL 1.1N IEIi % HIR�C GL'O6 % . BIOS ire.,r—awl'. PV e�mcN iB n- 1 100,000 X UMBaELLA U. X P,U" .A.,,awL09R11i E I 1,000,000 A EXCESS IABc AIIS Au ,. k --IIIItl I 1.:00.W0 ". 0k) % a-} '0 t ] 00 52304065 1/:/Ni9 Am.aER'COMKMyTLOi % 5*ATILT 'Y R ANOEYPLOYERS'LAw Yla - PI 0 T" V -1_ C A - S 500,000 B pFSIC E E .JR'I Y 'xIA VC9024456 2/23/20:F 2/29/1^19 I 1 11 A M I Ix),wPNN tip - _ - .v.G f 500,000 W SC. nCN or"'PAT ON6 oa- FI 0111,11E ipVCY.IMF 3 500 000 OESCILefgN OFOKMiIONS I LOCATONe I VEX I.I.NC01101.1 AP —..3cMOW,mry M[N[ME it m AAA.A osiM1 The Worker. Compensation polity dote not include coverage for Paul Schmidt, Fandrick Denapaey and Doug-im Scheidt. 'Columbia Gas of Massachusetts ie hereby named as Additional Insured Per written Contract with respects to General Liability 6 Auto Liailt"ty, for work performed, and per the terms and conditions of the policy. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOYE DESCRIBED POLICIES BE CANCELLED BEFORE Columbia Gas of Idassechumatt5 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4 Technology DriVa Ste 250 ACCORDANCE WITH THE POLICY PROVISIDN5. Westborough, MA 01581 AVTXOIe1 mRkmENTATNE C IOM2014 ACORD CORPORATION. All rights Fesamed. ACORD 25(2014101) The ACORD name and logo are regiatered marks of ACORD INW25 nD m-