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13-018 (2) 2 LAUREL LN BP-2020-0851 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -018 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 Permit# BP-2020-0851 Proiect# JS-2020-001460 Est.Cost: $3000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq.ft.): 15202.44 Owner: GERTZOG ELLEN Zoning: Applicant: PAUL SCHMIDT AT. 2 LAUREL LN Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.112712020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR, 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: FeeType: Date Paid: Amount: Building 1/27/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton/ Building Department ��N \ " 212 Main Street �4ALJ IN SUL A T101V Room 100 Northampton, phone 413-587-1240 Fax 41'3,-4-,7/1,a A#w&No,L , y 4 YA IV APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY D_WELi..i�G ONLY s SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address Q Map � Lot C) U Zone Ovey ltrictmA � Eim St.District____— Ce District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2. { 1 Owner of Record: ZL N e; nni �— Current Mailing kddre4s: 9-9 17 Tele hone ' Signature 2.2 thorized Age : G�l.�-rte ' �,n�t�►�t— S Na -rint) Current Mailing Address: _ ©(O 3 O I S : tore Telephone SECTION 3-ESTMI ATED CON3T_4LQft CO:_TS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 0 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) O _ Check Number &9- 40- � This Section For Official Use Only Building PertJmit Number - 4 0- �J^� Date Issued. Sigma. Building CommissionerAnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensers Construction-Supervisor: Not Applicable Name of License NoldBr 'License Number I A dress Expiratio Date gnature Telephone i 9 RMIRMafd Hqm# Not Applicable 13 i Comoanv Name y%—Q— „3'y~L ' , x_1114./1 ..,` egistration Number , 3 Address' ExpiratioN�ate Telephony . SECTION 5-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 this affidavit will result in the denial of the issuance of the build]ig permit. --a Signed Affidavit Attached Yes........ / No...... Brief Description of Proposed Work N OTE: INSULATION ONLY �L- , � 5 3 �-w 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 Print Name Signatur of Own (Agent hate l 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 Daae I City of Northampton Massachusetts DE'PARTWXT OF BUILDING INSPECTIONS 212 Main Street r Mumcipa1 Building ,•,.y,,,,. '.;� Northampton, MA 01060 • 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 1500 The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at. (Please print n me and lova ll n of facility) Or will be disposed of in a dumps r onsite rented or leased fr Ll (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 DEPARTWNT OF BUILDING INSPECTIONS 212 t-%-,r. Street. * 'Municipal Sualding 4a Northampton. M& 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"be done by registered contractors. Note. If the homeowner has contracte4 with a corporation or LLC.that entity must be registered Type of Work: -h Est. Cost.- -a_ 0_00�­­ Address of Work: ---,2-- /, 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 OBTALNING THEIR OWNPERMIT 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 penury: I hereby apply for a building perr it as the gent of the ownt�r Date Contract or Name HIC Registration ?tits, OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature -q� City. of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street BuildIng Northampton, KA 0106" MANDATORY FOR HOUSES BIUIL r BEFO RE 1945 Property Address C,� Contractor Name'. Address: C City, State: t C Phone H q 9 Property Owner Name Address ............ City, State: CP C (contractor) attest and affirm that the building 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 Date ,;,2 cq The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov1dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED"I'M THE PERMITTING AL'THORIT`k". Applicant Information Please Print Lep-ibh Name(Business/Organization/Individual): SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street City/State/Zip:_ Hatfield, MA 01038 Phone#: 413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): I Q i am a employer with 8 employees(full and/or part-time)• 7. New construction ❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.]No workers'comp insurance required] 9. El Demolition 3.Q t am a homeowner doing all work myself[No workers'comp insurance required.]' it) E] Building addition 4,01 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 i i.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the suh-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp..insurance.* 6.E] We are a corporation and its officers have exercised their right of exemption per MG1.a 14-E]Other 152,§i(4),and we have no employees.tNo workers'comp.insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policw information. I 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 emploEces-they must provide their workers'comp policy number 1 um an employer that is providing workers'compensation insurance for my employees. Below is the polh 1-and job,ite information. Insurance Company Name:_,_ Selective Insurance Co Policy#or Self-ins.Lic.#:�WC9024456 Expiration Date:_ 02/23/2021 Job Site Address:, � t ---kAnlC _ City/State/Zip:_.. _ J Attach a copy of the workers' compensation policy declaration page(showing the policy num er and expi ation date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine 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. 1 do Itereby ce tnder ahm and penalties of perjury that the information provided above is true and correct. Si anatu Date: /- a r -,2 J Phone#: 413-247--5739 Uffrcial use only. Do not write in this area,to he completed ht'vitt,or town official City or Town: _ J Permit/l,icense#� _ issuing.Authority(circle one): L Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other _ Contact Pet-son: Phone#: * DATE fMM)DD1YyYY) ACC>RV CERTIFICATE OF LIABILITY INSURANCE 0111 OJ2020 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., It the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed, It 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 endorsenrient(s). PR0,0i"CER i C NAtTACT Cyndie Henderson CISR,CPIA V*bbei&Grinnell (A/C,N "ONEq,EA1Ji41�1`,5W-0111 FAX (413)586-6481 - 8 North King Street I 1 E-MAILADDRESS: ciienjei,wn@webberandgnnnell,=n I iNSURFR(S)AFFORDING COVERAGE SAIC 0 Northampton MA 01060 iWSURERA. Selective Ins Co of S Carolina19269 INSURED INSURER B: Selective Ins Co of Southeast 39926 SOL Home Improvement Contractors,Inc INSURER C: 24 ChesInUt Street I INSURER D INSURER E: Hatfield MA 010311 INSURER F COVERAGES CERTIFICATE NUMBER- Master Exp 0112021 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'fO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCLO,'R'(PAQC,,,CLAIMS AVUL'buBR __P(6 ff-y ff .. ..................... VM TYPE Or INSURANCE W x POLICY NUMBER mm!aqy' mmiaofyyy ---- LIMITS COMM IALGENERALUAS#UTY aEACPOWURPEocE $ 1,000,000 1 ES CLAIM"ADE OCCUR PREMISES IEa —'d S 5M.000 MED EXP iAny WA S 16.000 A S2291 MIS 01;0112020 0110112021 PERSONAL&ADV INJURY S 1, 001000 I-GEN'L AGGREGATE LIMITAPPLIES PER GENERALAGGREGAE S 3,,000 POLICY O- 0 LOC PRODUCTS-�-OMPIOPAGG S 3,000,000 FIPRJECT HOTHER, I $ AUTOMOOKA UABILFTY 4 BtNED SINGLE umrr S 1,000,000 ANY AUTO BODILY INJURY{Par Payson) S A OYMED SCHIEDULrD A9105420 0110112020 0110112021 emiLy fN.4uRy(Pa 4=40M S AUTOS ONLY AUTO$ HIRED NON-OWNED PROPE TV AUTOS ONLY AUTOS ONLY I Par au-,<sdn Undennsured motorist B1 s 100,000 X UMBRELLA LIAS96W& URRENCE III OCCUR, A EXCESS LtAB i 522915090110112020 0110 112021 AGGREGATE 5 1,000,0W I7E.1 7­I—11TENTiONI S WORKERS COMPENSATION A T UT X SER AND EMPLOYERS'LIASICITY YtN E 15&ER AN'Y,PRC)PRIErOWFARTNLP,!FAEC,iTIVE y f NIA WC91,24456 OV2312020 02j2312021 CLEACHACCIDIENT S 5W,000 OPF CFR4AEMSER EXCLUDED' 500,000 I{Mandatary in NH) E L DISEASE-EA 9APLOYEL S, . yvs,dest-abe LI(X*f DESCRIPTION OF OPERATIONS W10- IEL DISEASE-POIiCY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES tACORD 101,AdditMfliii ROMAITUS Schodilia,may be aftac"d if MOre 4PAc'O Is Mquirad) The Workers Compensation policy does not include coverage for Paul Schmidt Kendrick Derrnpsey ano Douglas Schmidt Columbia Gas of Massachusetts is meret)y named as Additional Insured per written Contract with respects to General Liability 8 Autn Liaiblity,for work performed,and per the terms and conaitions,of the pollcy, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Co;Lmbia Gas of Massaviusetts ACCORDANCE WITH THE POLICY PROVISIONS. 47echnology Drive Ste 250 AU THORVED REPRESENTATIVE Westborough MA 315+8' 1988-2016 ACORD CORPORATION. All eights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD RISE ENGINEERING OWNER AUTHORIZATION FORM I, Ellen Gertzog (Owner's Name) i owner of the property located at: 2 Laurel Lane (Property Address) Northampton, MA 01060 (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. (2,/ �rA Owner's Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com