23A-120 (2) co - Op rev
POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
Affidavit of Waste Disposal
I Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co-
op Power will remove all waste from the job site located at:
14 M` ' i, m e f =7.4y1.tiu c , f 4 0106 2
Owner Name Street Address Town /State/Zip
Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our
removal service is Waste Management.
(2 /
Paul Schmidt Date
Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302
ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop
:::: City of Northampton r -.„
/ it; Massachusetts A `v' *
t C.
liglt ,� "" / DEPARTMENT OF BUILDING INSPECTIONS 5 ' . Y' r
212 Main Street • Municipal Building :P
" `, _. - "* Northampton, MA 01060 '� 'P)%� c
Property Address: C c 0 0 1 4.= r l, n't/riLi t , Ill /1 v r C Z
Contractor
Name: c - (.l11M ca
Address: 7-..1 WFit S cr
City, State: C {4ir�'r 6. ✓�
1 ' j / 4 1)/ 3 0 /
Phone: (L//3)
Property Oner
Name: IV r It A - 00,, t /-
Address: t 3 Vin, rr✓014; - T
City, State: "o"'" ( , /4 f D Z
I, kelt, rOY (contractor) attest and affirm that the building I intend to
insulate does not have any open air- -(ttnob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of t affidavit.
4'Y /
Contractor signature " j
Date
/ ,f
1 ,
CO-OP
jr■ POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
City Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
April 13, 2012
RE: Building Permit for Insulation Work at 8 and 8b Middle Street in Florence
We are submitting these applications to obtain permitting for insulation work at the
properties of Nora Kalina.
Enclosed please find:
1. building permit applications
2. debris disposal affidavits
3. copies of CSL and HIC licenses
4. certificates of Workers Compensation
5. certificates of liability
6. stamped return address envelopes
7. check numbers 3208 and 3209 in the amount of $55.00 each.
Kindly return the authorized Building Permit to Co -op Power in the enclosed envelope.
Thank you.
l !
'1
Sincerely,, i i -
If , / //' i
d ,
Kathe n�'Policy
Energy Efficiency Ad inistrator
katherinep@cooppoWer.coop
Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302
ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop
...,
a
SECTION 8 - CONSTRUCTION SERVICES
Licensed Construction Supervisor: —
8.1 Licensed Construction Supervisor: Paul Schmidt
Name of License Holder : 24 Chestnut St.
Hatfield, MA 01038
:S # 103635 U
Address Exp. 5/20/2013
413- 772 -8898
Signat t Telephone
Home Improvement Contractor:
Co-op Power Inc. / Paul Schmidt —
9. Registered Home Improvement Contractor: 324 Wells St.
Greenfield, MA 01301
Company Name 4 165217
Exp. 1 /21 / 2.-e ( il
Address 413- 772 -8898
/' 1" T paul @cooppower.coop
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 this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes Cd No ❑
11. Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings 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
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: 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
structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to 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, you may be liable for person(s)
you hire to perform work for 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
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [1 Addition n Replacement Windows Alteration(s) [ Roofing n 1
Or Doors El
Accessory Bldg. ( 1 Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D]
Brief Description of Proposed
Work: 3 . 5 `r [ N` ( - 41 7 f �^' � t i✓ +"r c:714,4-791' ,,, y .- — ✓lay ` Jrp /,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If. New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. 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 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, NM. VA, t. i VO , as Owner of the subject
property
hereby authorize # t S 4t ` 0 (_ / (,4 PO44) -C f -
to act on my behalf, i .II matters relative to work authorized by This bull ilding permit application.
4-ial
Signat 0 caner Date
I, L ,12;�'vo/ 7 , as Owner /Authorized
Age 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 Na e AA,'
Signature of Owner /Af -nt Date
.. .
I
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed . Required by Zoning
This column to be filled in by
i4 '
Building Department
�
Lot Size I I I I 1
Frontage I H I I I I
Setbacks Front 1 1 I I I
Side L: I R:I I L:I I R:I I I 1 1 1
Rear I I I 1 I
Building Height I I I
Bldg. Square Footage ( I I I % I I I I I 1
Open Space Footage ( I I ( I 1 % I
(Lot area minus bldg & paved I I
parking)
# of Parking Spaces 1 1 1 ( 1 1
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding er been issued for /on the site?
NO O DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regis , of Deeds?
NO O DON'T KNOW YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
/ .
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
Department use only 1
City of Northampton Status of P ermit :
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic,Ayallabtlity
6 2012 Room 100 Waterltll!ell Availability
Northampton, MA 01060 Two Sets of Structural Plans
of - phone 13 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify : w
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
,' 0,4 , 001- j - ' r --v- M Lot Unit
A afiP �( , A e(GC 7
-r i Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
KR) 'cf\sk g (i�t,�on - tt�t -� ivir, I AAA- c t
Name (Print) in Curr t Mailing Addre
Telephone
Signa 4 -19L e
2.2 Authorized
1" 3 2- Y L ' Sr: illy PI frz Gi ,4 o t :?
Name (Print i 1 Current Mailing Address:
I 6/13) 2 — /'5
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building "' (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) 2' (1 '7 . (� Check Number 3o 05,5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0904
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 8 MIDDLE ST
MAP 23A PARCEL 120 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out j
Fee Paid
Typeof Construction: WALL INSULATION & VINYL SIDING
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
INF RMATION PRESENTED:
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
Demolition Delay
1 1 '26 1 1 2
Signature of Building 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.