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13-023 (2)
tb M r City of Northampton C, ' Massachusetts � ` , * %% vi c 1:41 I., / DEPARTMENT OF BUILDING INSPECTIONS v 1� D '. 7 i 2 12 Main Street • Municipal Building is .,,C` . u Northampton, MA 01060 SNP, '`�\'\'` Property Address: (1 $fl -,h -u I /t r Lc' Contractor " 2�, " Name: k�'c7 ►""a K'" /CV er ovv i� ' , I ,.1 �� , Address: 7 Z v( wirl, 5r. y City, State: (p14 � 1 61 j d Phone: q/ 1) 7 - - (9 '? 7 Property Owner f , p/ 14 4 e- t' v-- N ame: ` Address: ( P r"'i City, State: OW f)i p ri / " 4 I, Dn N � (contractor) attest and affirm that the building I intend to insul p h44., does not have any open a. (k ob and tube) wiring in the spaces to be insulated and that I have provided the property owner wi `a co; of th:faffidavit. Contractor signature (71:1, , Date / $g "'' `b i Sr 'i PARTICIPATING mass save CONTRACTOR Sv,nq' tfuoiiP' 'fle Ptl•[rv?x} PERMIT AUTHORIZATION FORM I, Qek r , owner of the property located at: (Owner's Name, printed) H / Sit neco411 12/1. /V v 1 / 4 d1()en (Property Street Address) (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and /or weatherization work on my property. t Q Own r' ignature Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Osibei l <� co © r0 w Pr MC Participating Contractor Date Rev. 12132011 CO-OP E J 7 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: P filkAn.,- I S ()Levi a - • M vl/147 rrr D ( 1) Owner Nam 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. Paul Schmidt D.te Co -op Power, 324 Well 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� / \j n may+ ( ?, ?/e 041' /!' r , 0 . ,t # , , IJ ( Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ` ' Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2014 Tr# 220702 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Update Address and return card. Mark reason for change. ❑ Address Renewal 0 Employment El Lost Card DFs -cm cj ECM - 04 G1C121E Olae - rrraon.I/, ' ✓ftaaaaclusae1.t Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 4i t _ Registration: 165217 Type: Office of Consumer Affairs and Business Regulation i I Expiration: 1/21/2014 Corporation 10 Park Plaza - Suite 5170 ��j,�/' Boston, MA 02116 CO-OP POWER, INS_._ =',. PAUL SCHMIDT if , 324 WELLS ST - ....7_______..../,-..— _ GREENFIELD, MA 01301 Undersecretary v Not v. • without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 103635 Restricted to: 00 PAUL SCHMIDT 24 CHESTNUT ST HATFIELD, MA 01038 r .� t , ` u r- c-- � —�"'` Expiration: 5/20(2013 ( r■nemi.sierreer Tr#: 103635 The Commonwealth of It `assachusetts Department of industrial Accidents ° ""fir p Office of Investigations ' " 600 Washington Street Boston, MA 02111 ik , ' www. rrnass.govldia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( usiress /Organizationlindividual): C �� .f) 6 1 ,):- 11 C I Address: 3 '-( 0. (C S `t City /State/Zip: C�"t' % "i1 (,-�{ c �-- 1 \ Phone 41: 1( � 7 2 6 E Are ou an employer: Cluck the approlpriate lava; Type of project (required): I. 1 am a employer will ( v 4. 0 I am a general contractor and 1 employees (full andtor pastime). t have hired the sub- contractors' New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have 8. d Demolition working for me in any capacity. employees and have workers' comp. insurancat 9. ❑ Building addition [No workers' comp. insurance p. required.] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.E Other - el; Cif, (!� {'1 icy` employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him 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 employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ---- ,� Insurance Company Name: ( Win C i 1- V . Ft c 6` -l-Y»S - trt,'r OVv\ E- C, 0 Policy # or Self -ins. Lic. #: 0 R t r . , L .. c . & 8 ( p t2 Expiration Date: ('( - [ " 1 2--- - Job Site Address: City /State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andtor one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.04 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby car ' ' under the :: inrjsnd per + ties of perjury that the information provided aba e is true and correct Signature: -_-_._ ' ° Date: I ../ if Phone #: ' ; ` g - 7 ZO 6 i . 8 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone in SECTION 8 - CONSTRUCTION SERVICES _,icensed Construction Supervisor: 8.1 Licensed Construction Supervisor: 'aul Schmidt Name of License Holder : )4 Chestnut St. -Iatfield, MA 01038 /" _.'S # 103635 U Address/ , d 3xp. 5/20/2013 . 113- 772 -8898 Signatu e Telephone -Tome Improvement Contractor: 20 -op Power Inc. / Paul Schmidt 9. Registered Home Improvement Contractor: 324 Wells St. Jreenfield, MA 01301 Company Name # 165217 / / 3xp. 1/2111)4p iii Address / 113- 772 -8898 / f I ` Telel)aul @cooppower.coop SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildin2 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [El Siding [O] Other [O] Brief Description of Pr posed / el Work: 1 /ww f f "t t, 'l/lf O. - M � „, � (52 "1 Ci1'vt' t' r l 6 i ? 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 q, FOR BUILDING PERMIT Cr 0 ' "'7 /to i as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authoriz by this building permit application. Signature of Owner Date S/ as Owner /Authorized Agent here 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 Pe jury. Print Name ArA1/1111P J l 7 r � Signature of Owner/Agent / Date Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by sms S S Building Department i t I_ # Lot Size I L Frontage f Setbacks Front ( 1 1 Side L:[---1 R:! L:I R:I 1 Rear 1 1 1 1 Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces 1 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Findin ver been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis 'of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT 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, excavation, 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. Department use only — City of Northampton Status of Permit No Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability 2 2 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans pEP T.OF BUILDIN " c .NSPECTiot 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans NORTHAMPTON MA 01060 Other Specify 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 l' 1 5-71) kr A j, i- . 1t- - Map Lot Unit t ar, n+11114, � p rm-' A 6 i p �, 1 Zone Overlay District N v r f f ( Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 ./-G7 p — ° 1 '47 . Name int) v Current MailinyfA j •-Q% _ 6 ,y t j> `Y / `VA `}11"'i. t ,�..,1 - ,-. Fig,-,4.--7 Telephone l r (� l !J iG� 7 Signature 2.2 Authorized Agent: 1 %r 71/14-r--, I q 1 rl, L f J i , 6 i '"t-� +�z 7 01 > 0 / Name (Print , . `_ Current Mailing ress: / of 5 j 7 2- *' Signature I ...- Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2- C ( 67 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) (iq 'rZ 5. Fire Protection `° 6. Total = (1 + 2 + 3 + 4 + 5) Check Number L.9_ g l t ,•- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012.1032 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 19 STONEWALL DR MAP 13 PARCEL 023 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Paid (` Building Permit Filled out Fee Paid .go 9 C / ' C Typeof Construction: INSULATION , 1r' j #1 New Construction Non Structural interior renovations tr f t Addition to Existing r �, 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 IN ATION PRESENTED: Ap proved _ 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 7 - ng f ial 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. 19 STONEWALL I)R BP- 2012 -1032 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 - 023 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- 2012 -1032 Project # JS- 2012- 001770 Est. Cost: $2659.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 12806.64 Owner: PARKER MARY E Zoning: Applicant: PAUL SCHMIDT AT: 19 STONEWALL DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:5/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION - FINAL INSPECTION REPORT REQUIRED 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 5/25/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner