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32A-015 ,-,--„,„,,,,, City of Northampton 7�°. 4 2'� r ..• .. t Massachusetts �¢' *�' 'tic {L fi r, , DEPARTMENT OF BUILDING INSPECTIONS 1 ` ?± 4 , 212 Main Street • Municipal Building J d j s ` ^ �O Northampton, MA 01060 W 3� Property Address: ( 3 A" I i m f r i e Sr• / / w v n 7h' 1 J o 10 6f a Contractor Name: (,}€ryt'i. 0 YlAv,0-i' Address: 3 --k+l tent, S S r ` City, State: ITL #7 /4 it Di 3 9 l Phone: (1t) ?" Z - Property Owner JJ � Name: . l Address: V 5 - vi4-1-'rwY rr. City, State: Ahliv✓11Yri' r" -✓-- (18- I, ftt/ttY14' (contractor) attest and affirm that the building I intend to insu ate does not have any open air ob and to • •) wiring in the spaces to be insulated and that I have provided the property owner with - • •y of this - 'davit. Contractor signature / Date 4 5 ( j ZI CO -OP "IV L POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY P Cii`. iti l ELT litate.F Fo I, r y , owner of the property located at: (Owner's Name) (Property Street Address) (City /Town) hereby authorize 6 Ow-)- V C - (Contractor) to act on my behalf to obtain a building permit and to perform insulation and /or weatherization work on my property. 1 (Owner's Signature) u ---2 v (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 CO-OP vi'V ,efrt POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal 1, 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: 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. :Y 3 t 1- Paul Schmidt D -te 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 ii? f t; n n — ' - r Office of Consumer Affairs and Business Regulation gym, 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. 0 Address El Renewal 0 Employment 0 Lost Card cFs -cm 0 ECM- 0444- 61C121E g4, - 6.../,4 c/'✓l'laar ac/uiaetta ,� 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: 9 I 4, Office of f Consumer Affairs and Business Regulation iz t iI Registra 165217 Type: g _ Expiration 1/21/2014 Corporation 10 Park Plaza - Suite 5170 °� : Boston, MA 02116 CO -eP POWER, INC PAUL SCHMIDT 324 WELLS ST \ . ems, ---- _ GREENFIELD, MA 01301 Undersecretary r Not v. e without signature 9 MaLssachusetts - Department of Public Safct■ Board of Building Regulations and Standards Construction Supervisor License ( License: CS 103635 - - I Restricted to: 00 PAUL SCHMIDT 24 CHESTNUT ST HATFIELD, MA 01038 U f "! y � — � ` Expiration: 5/2Qr2013 C ,rnun i.xierner' • Tr #: 103635 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Est 9 ;, 60 Washington Street Y.AiY A �..�:. Boston, MA 02111 wool..' wwzwt . i nass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A • , licani Information Please Print Le ibl Name (Busir- ersiOrganizationllndividual): C r t?''ii 4"'r' r C Address: '3)-- t{ (1&( ( s City /State/Zip: '11 C c 61...\..k Phone #: ' ( -- 7 — c j tE Are an employer? Check the appropriate box: Type of project (required): 1. lam a employer will I L 4. 0 I am a general contractor and I employees <full and/or part. time). have hired the sub - contractors New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet r. ❑ Remodeling ship and have no employees These sub - contractors have g. 0 Demolition working for me in any capacity. employees and have workers' g y 9. ❑ Building addition [No workers' comp. insurance com insuran0e.I f 0.❑ Electrical repairs or additions required.] 5. [] We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their 11.0 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. Other i'1$ fir ( Gt f l tf1 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 hire outside contractors must submit a new affidavit indicating such. tContractors 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. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. C '. Insurance Company Name: f ( {°) C ! � F ` [ C 6- - < t 1^ a," c C Policy # or Self -ins. Lie. #: OR-Irv/6-c, L lt2 +' G (P Expiration Date: Job Site Address: City/State /Zip: Attach a copy of the vF orkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of VOL c. 152 can lead to the imposition of criminal penalties of a fine 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. X do hereby ce ' ' under the s : ins...andper + ties of perjury that the information provided also e is true and correct. j Signature: Date: ,7) Phone #: '4 [ — 7 2— O 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 #: SECTION 8 - CONSTRUCTION SERVICES Licensed Construction Supervisor: 8.1 Licensed Construction Supervisor: Paul Schmidt Name of License Hold: • 24 Chestnut St. Hatfield, MA 01038 CS # 103635 U Address Exp.5 /20/2013 Lir& 413- 772 -8898 Signature - Telephone Home Improvement Contractor: Co -op Power Inc. / Paul Schmidt 9. Registered Home Improvement Contractor: 324 Wells St. Greenfield, MA 01301 Company Name # 165217 Exp. ` 7 Address ,• 413- 772 - i Z @coopp ower.coop p 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 ermit. Signed Affidavit Attached Yes 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House E] Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [O] Other [O] Brief Description of Proposed s �� Work: �. ,�./i. t l '" il 70 •)r 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 r 10 ( fi r " 'VIZ— , as Owner of the subject property hereby authorize _ VAlYvti ti �� ►'` / H�'C • Wilding to act on my behalf, in al matters relative to work authorize by this rmit application. Signature of Owner Date I, .Lfi�Yfiif/✓)'j�� , as Owner /Authorized Agent he by 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 Ap)frij Signature of Owne r- napirr 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 Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding er been issued for /on the site? NO 0 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regis of Deeds? NO 0 DON'T KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 1J IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ` _ { ~^ % Department use only ce- - - `- - C itr of Northampton Status of Permit: Q t . < wildin Department Curb Cut/Driveway Permit a , , JUN " 212 Main Street Sewer /SepticAvailability Room 100 Water/Well Availability _. - -_ Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans 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 131k uurvov+ r (6r . Map Lot Unit J' im O ( 0 Vl / _ Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 1vi F1 K-- 11 A- l -v 'r cT N avt,n- t -n-A waa iti✓+ Name (Print) !y YV Current Mail rgss J �Q t , g 0 ( 0 0 L 6L- r r i-T FO ) Telephone f \ l/( !2�/, ]] x Signature ((( 2.2 Authorized Agent: p L s i/eK" 7 7&( ti/ti ffi C, 12✓ - Name (P ' Current Mailing A di Fa I 413) 7--2---- 9 .----? .i. re Signal a Telephone / SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 2 so , I . �� (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) 7,rd . c 12 Check Number '3,3d a 115c This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -1074 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 13A WALNUT ST MAP 32A PARCEL 015 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE t PL ZONING FORM FILLED OUT S Fee Paid b Building Permit Filled out Fee Paid C � � > [� Typeof Construction:_INSTALL ATTIC INSULATION ° New Construction o� n Non Structural interior renovations �/ I tI ` Addition to Existing WAccessory Structure 0,-1,\‘`cl Q_r 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 INFO ON PRESENTED: pproved 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 i�: lay Signatur of Bui s ing • fficial 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. 13A WALNUT ST BP- 2012 -1074 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 015 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 -1074 Project # JS- 2012 - 001856 Est. Cost: $2504.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 6490.44 Owner: LAFLEUR RONALD J Zoning: URC(100)/ Applicant: PAUL SCHMIDT AT: 13A WALNUT ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:6/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION - FINAL UTILITY SIGNOFF 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 6/7/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner