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37-132 (5) �a�rvt z � Z mass' save PC40"I lPM PERMIT AUTHORIZATION FORM 1, Timothy Deshaies ,owner of the property located at: (Owner's Name,printed) 526 Florence Rd Florence (Property Street Address) (City) 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. X Owner's Signature Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date M1, M o� For Office Use Only Rev.12132011 T h e C'o m m o n w e a k k o f M a s s a c h u s e t t s L� `''n i t t I _ -- Department of-'ndustriaPAccidents ;. Office of Investigations -_ 1 Congress Street,Suite 100 -= Boston,AM 0211 2017 www.mass gov1dia Workers' Compensation Insurance Affida-vit: Builders/Contractors/Electricians/Ptnr=3-iers n DRUcant Information Please Print Lt- Name(Business/Organization/Individua)): 6er Address: C',H c City/State/Zip: h1A4n 90 . AM,Jlarl Phone#: Are you an employer?Check the appropriate bog: Type of project(requir..d-3d , 1.21 am a employer with l 4. Q 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction t 2.F, I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' cam insurance.' 9. ❑Building addition [No workers comp.insurance p required.] 5. ❑ We are a corporation and its I0.❑Electrical repairs ":additions 3.Q I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs=1.-additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]� c. 152,§1(4),and we have no employees. [No workers' 13,(�Othery�, 1 comp.insurance required.] "Any applicant that checks box g1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indica-,i;±-_=such. :Contractors that check this box must attached an additional sheet shoving the name of the sub-contractors and state whether or not those entities save employees. If the sub-contractors have employees,they must provide their n*ftrs'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and-'-b site information- Insurance Company Name: � �i t-,I ' Policy#or Self-ins.Lie.#: f V -6�� Expiration Dater Z� J Job Site Address: C6-1df �✓ City/State/Zip:` �" Attach a copy of the workers'compensation policy declaration page(showing the policy number and expi :€tr ). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pertaities of a hne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fort of a STOP WORK ORDE? 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 Offic°-f Investigations of the DIA for insurance coverage verification. I do hereby cerdry under the PaW aXd enalties eZgejur that the information provided above is true and corms: Signature: Date] ,Phone#: `` VY— -,b 77S-7/ 13 Ci Official use only. Do not write in this area,to be completed by city or town officiaL � City or Town: Permit/License# i Issuing Authority(circle one): t 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 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: IFA o( �[ �'� �) ©3 �3, License Number Add Expiration ate I — dibnattr—eV Telephone 9,Registered Home Improvement Contractor: Not Applicable ❑ TbL N omL -r,mioraj ,&AIT- 7 y Y15" Company Name Registration Number 7,q -7 1 1-5- Address Expiratioh Date Telephone.1"7 g • 7 7 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.....,,: 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors (] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[p] Othe f/ Brief Description of Proposed Work: A r f 11 1" 00131 f✓6 i�i� ,1�✓ �1� �,"+. Alteration of existing bedroom Yes No Adding new bedroom Yes No ° ' Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If Now house and or addition to existing housing, complete the f ilowinst: 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, 5 �,jfKati�. [;S AI F( as Owner of the subject property, r� hereby authorize L LZ V JZ� to act on my behalf, in all matters relative to work authori d by this building pe(mit applicattion. i Kjf- AXE4:461� `7/ I-Z'l ) Vi Signature of Owner Date X57 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 r S7ig­natL rye of r/Agent Date Section 4. ZONING Alt 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 ever been issued for/on the site? NO 0 DON'T KNOW Gf YES O IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 69 DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , 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 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 Q NO /(D IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department trse only City of Northampton Stabs,Of Permit Building Department Curb Cut/Drivy,Permit ���� 212 Main Street Sewerfseptio Avaitabiti#y Room 100 Waiter/well Availability oN orthampton, MA 01060 Two Sets o Sowural Plans NoF�,aM� phone 413-587-1240 Fax 413-587-1272 P1wate Plains Other Spy - 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 5' Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Pnnt) Current Mailing Address: reif, Telephone Signature 2.2 Authorized Agent: Name(Prik Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS . 7 Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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 0 0q 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0082 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 526 FLORENCE RD MAP 37 PARCEL 132 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: AIR SEAL&INSLATE New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 103635 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F MATION 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 ignature of Bui6fing 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. 526 FLORENCE RD BP-2015-0082 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 37- 132 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2015-0082 Project# JS-2015-000145 Est.Cost: $2400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 461910.24 Owner: DESHALES TIMOTHY Zoning: Applicant: PAUL SCHMIDT AT. 526 FLORENCE RD Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.712412014 0:00:00 TO PERFORM THE FOLLOWING WORK:AIR SEAL & INSuLATE 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 Denartment 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: FeeTyue: Date Paid: Amount: Building 7/24/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner