17B-020 (5) 447 BRIDGE RD BP-2019-1002
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao Block: 17B-020 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permh4 BP-2019-1002
Project JS-2019-001655
Est Cost: $5000.00
Fee' $65.00 PERMISSION IS HEREBY GRANTED TO.
Const Class Contractor: License:
USe GrOnp: PAUL SCHMIDT 103635
Lot Size(sa. ft.): 9234.72 Owner., ROGERS ANNE
Zoning:URB(100)/ Applicant: PAUL SCHMIDT
AT: 447 BRIDGE RD
ApplicantAddress: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:3/15/3019 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATION TO ATTIC SPACE, AIR SEALING,
EXTERIOR WALLS
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:
Drivnvay Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: insulation:
First: Smoke:keke: 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 3/15/20190:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
l' s
tQ
� BuildinjDepa en�IAfl #1¢ t
RIp�a�lNorthfafcmepp 10 0 ;-'�
\\ p�'–'17 riY l 1Ddb sad'"AB413 587-1272
O P P N. 1
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I -SITE INFORMATION INSULATION PERMIT
1.1 ProoerNAddress: Tiftsacilift'D be ame~hv Dmaa
�q/ 3nd? 2 MAP J! /j Lot D Unit
�l ou n c Q M A o & a zol °..rte MIS
Elm St.QYQkY—_—___ CB QMBfer
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Own r of Record:
Name(Print) Cu A tl nt Mailing 07 S-5_
/e Telephone
Bigna
2.2 AuthorlZed Agent:
Name(Print) C.mart Mailing Address'.
Sgnature Telephone
SECTION 3-ESTMIATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offiaal Use Only
completed by per-hit applicant
1. BuildingoQQ� (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction frau 6
3. Plumbing Sluicing Permit Fee 'l
(IS,n C� V
4. Mechanical(HVAO) (L J, O
5, Fire Protection Cnq
6. Total=(1 .2+3.4+5) Q Check Number
This Section For Official Use Only
Date
Building Permit Number Issued'
Signature: 3-
Building Commisaimedkupector of Buildings Data
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construcdo rvl n Not Applicable 11Name of License Holder'. CS- jo— 3S
License Nu ber
A dress Expiratiar Date
� l3 07 f 7 5� j
grgnalure Telephone
S.ftHwAmad Not Applicable ❑
/V L/V/
Comte n N me mom, egislrabon Number
1-2
,
Addressesn ,1 Expiretia��
�hi'�.lel �� C71U3� Telephon�'{13-aU�-S'J3
SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.163,§36C(S))
Workers Compensation Insurance affida t must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes....... ty, No...... ❑
Brief Descripdon of Proposed Work NOTE: INSULATION ONLY
1,11Vsf r4, 1411 Lada-/ Il cL-d
(Will S,dEd/ 'Yo Ur e 6LXfY (OL(f --,I 9
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 untler the pains and penalties of perjury
co- S >'U.('2_rY1e1l'F" 1n2l C�CKS, -1—♦1C.
Print Name
S,gratun,PGfOwn rAgent Date
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
Massachusetts � cf�
a
DSPABTNNNT OF BDZZDZM INSPECTIONS
212 qi. 9tnaet •MunicipalIla Butitling n3*� i
Nerthe ton, M 01060 1
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 numb and street name)
Is to be disposed of at:
'A
(Please print n me and Iota n
n of facility)
Or will be disposed of in a dumpster onsite rented or leased frAm ` S
(Company Name and Address)
��Os� '5-/ a-r 9
Signa ure 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
p
Massachusetts
c
L
!ffi12 train S OF BUILDING INBPBCTZONS
lding
232 Nsin i, in • Municipal auiltling
la NerNev¢Con, em 03060
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 Pour 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 mast be registered
m
v
Typeof Work 3u,Ltx./ti�rJ Est. Cost. OocC )
Address of Work: 44
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_lob 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 RESPONSIBH.ITES 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 t as the ygent o tthhe�oWncr:
�F�t�,�c.�d�,t- ,
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
Massachusetts
x
D ABTNBNT OF BUZWZM ZNSP&CTZONS f^
212 Main Street a Municipal Building L` BCS
Northampton, M 01060
MANDATOR/Y/ FOR HOUSES BUILT BEFORE 1945
Property Address:
Contractor
Name: n-1—
Address C
City, State: 1 ' '� -i-�Zl c�r yy\q0' CD1 V 3
Phone: ^t l 'J' o� `t
Property Owner /.,�7
Name: /'1 n'4 / IJ) r
Address: --r��rl A-4 01
City, State: /!/I e 2 a Jj11l n�/ CL,? -C)--
I, f (contractor) attest and affirm that the building I intend to
insulate oes 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
Date 3 �3
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Anne Rogers
(OwnP,rs NamP�
owner of the property located at
447 Bridge Road _
(Property Address,
Florence. MA 01062
!Property AdTms,i'
hereby authorize_ S b L. _
(Subcor+trnc(oq
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. 1 his form is only valid with a signed contract.
—At -----__
Owners S'grrahue
i J
at, 1
RISE Engineering, a Division of T,eisch Engineering, Inc.
605hawmut Road Unit 2 Canton, MAD2021 '.. 339-502-6335
www PISEeng'meermg.com
life Commonwealth of.M1fassaehusetts
IE ' h Department of IndustrialAccident,
I Congress Street,Suite 100
e Boston, M..4 02114-7017
= www.mnss.goe/din
1\'m'III I car penwlion Insurance Affcim'it: Ituilders/Cuetrarmrs/Eleclrieians/Plumbers.
f0[IF. !ILIADAt I IIt l IIf.PFR>II I I'ING %t l IIOR1'll.
lonl' aidInformation Pleaic P,in( Lceibh
'slams oel.incs.+) ( Idrntlon Irdl duah.SDL Home Improvement Contractors Inc
Addr.'ti5.24 Chestnut Street
l rt\ Sinfd/.ip Hatfield, MA 01038 Phone ,:413-247-5739
tto,kth PP.xi t 1 1c pe of project (squired)
Q1 S _ .......
'. . m:,. ,• 7, Aca ..,,,trusion
r �s �n � z ,d i 4. ❑Dcmolllion �
d
It Q cuddle WSCaI
! ...
,
.I'l 11 1 kPL I 1 11 Lll. i II �Il cjxal r.pah rtlitian.
Ierraio orjdditions
ml J e, 'i n< 1 ,.. .h.0
❑ II13_�R,xif rcpnim
li
II.QOthcr lnsulatiOn
El11 1pa r 111, r lillrt ,I h,,
0,1
... li �' � ,
u„ deo ,—,kiIPdl , . .J „r-1: ..,,Ir.w, .III
il, "kl 11ILIk 111l,[n :.I:<h' n.JJI nvl eM1 ♦ beCM1C I< , Ic
ml 1, r vM1' 'I: .-h,n mal _I-c eP' U tui l%<IFklII, Aillil IlIllLN IL51YI
I urn un entplrtrrr lluu is pmviNng n•orkers'eonrprns'mion invrrmee(rr ne enrplgrees, fte•lon•is the M'lir;e mud job Bile
irrforrrrallnn.
In.urancc Coupons nolo.,Selective Insurance Co
loho i; it,self-in. 1 is IT WC9024458 L,pow,eo Durr 02/23/2020Joh —
na,oc Address._ _. 1.._ �11 p— lL._ _ CIn SIaic lip. (/L.f_K(2Q
h a copy of the workers' cumpensati policy declaration page(showing the policy number and expiration date).
Failure to secure coscruee as re,plired under N161. J. I5°, �25A is a etiminat s,,IdDon poninllahle by a tlne up la SI500.00
and o, one-dear rornnonment.as ,It as ci,d pemkwI,is the farm of it SfON U ORK()RDI$and a hoc of up w S'ln.hll a
dna against the s,ol,00r. k cop) efthis statement max he fon,anled to the 011ice of Im'eaigxlens of the DIA tar luxumcc
eocerye cerifwa[ion
I do herehr terrific erl a rm and pennies ofperjun'flint rhe mfirrmnlion pro aided atil is true andel Lorre f.
Phone-_41 -247-57
L
unI Do nor nvite in this arta,m he c"fridoed hr wr ,,ton•a oflioial
n: PermiVl irease 4hnrity(circle one):
fleafth 2. Buildig Deparinleol 3.('al%rinwn(lerk 4. Electrical Inspector 5. Plumbing Inspectorrson: Phone
C"ROR CERTIFICATE OF LIABILITY INSURANCE n"sC1 D3 '0.9 '
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 D0ES N0T CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISI,AUTH0RQED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the cerhficals holder Is an ADDITIONAL INSURED,rile policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED.subject to the terms and conditions of Me polity,certain policies may require an endomemant. A statement on
thn,certificate does not confer rights to the certificate holder In lieu of such endomement(s).
1TJCFa A y de He de 5p1 GISP CPIA
n • 5 I°R�E E� 15868 11 .. IAC 19 bU8c.
------
IN,Y""e't �Ioo, 4 d ;wry+ d P3 n 11
w 11
I 1p1 MA 011110 szsn
N511 PA
c
rAEo I SV EP a Shea"a I C 016 Nhaa \ � >9s:B
SO Home lnb Cpn0aGO51ne T�PEa^
I:c111:..u1 SPK.
HeKiel; MA 0103B wsVRFAF
COVERAGES CERTIFICATE NUMBER. Mader Exp 2J20 REVISION NUMBER'.
IS- E 11 YTM4T1FP01 CIES OF INSURANCE LGIFED BELOWHAVE BEEN ISSUED IO THE INSURED NAMED ABOVE FAIR THE POLICY PERIOD
CS N TNIH 'ANDNGAN RECUIREMENT.TEP.M OR CONDITIONOF&NY CONTRACT OR OTHER DOCUMENT ENITH RE5PEC' TO NHICH THIS
IIFI ?T MAY 9E ISSUED ORh14Y PERUWlHE INSURANCEA FA20ED BEEN PE IES BESCAD L4EREIN IS SVBJEG TV AL�LME TERNS
;..I;SIONS,NO cp4DtTIp:AS OF GUCH POLICIES LIMITS SI10WN MAY WNF BEEN VEOUCED BY PAD CLAIMS
'YeF s TFb R�,), ,,i F6
5 vivo - _ F Dwvvrv!IL _-
x� 1000 TOO
X11
_
i 92211503 O'.I1112019 HI 01 OWB R DTT
J c JWC ODO
u _ _
WtOT
m
O 001E B
A A91J5620 1 L!2019 J1 0
x FE I LF F OPT
I I a
nf�ude ed ns Rlo0GITO
X .�. _ ---� roo00
Ls ka22111 O211, z1 Dco
--I- FY�.L.� AAPNN
.—
e '
L _ y-,�,N VVCSU244o 11 'X. Oz,IJ-m 19I
_ k s
H,171 L T5oo.For,
LLI
I
exwr,o«or reERnror+s;Loc.nrn:alvERkr.Fs acoan,w.Aae—„I+.m.n<am.am..m,1 r +
reTWOMe_6I1-c Do",wit,does re. "one PHRI,,le,P111 SM-1 KendncA DA,opsey a rd Coug:es SU v1
I I.
ells E1; AE"1 Is nereby named ae Addtor,InsuRa per wrMen entrotI eY vnM periwmed Ond ML toe Hem¢ant condNOns of v e wll,cy
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE
EXPIRATIONE% RATION DATE THEREOE NOME WILL BE OELP ERED IN
TOlels�FI'.Qlncx^rrvj ACCORDANCE WITH THE POLICY PROVISIONS,
1n9 FPvos Aveo:;e
rNONufO PENiEs'[NTnT,vl
..ansLnn RI C2610 J 1
198&2016ACORDCORPORATION. "rightsress"mi
ADDED 25(2016103) The ACORD name and logo are regiMered mark.of ACORO