Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
31A-051
OWNER AUTHORIZATION ION FORM (Owner's Name) owner of the property located at `� . (Property Address) • d (PmpefI } hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to ad on my behatf to obtain a building permit and to perform work on my property. Owner's Signature (q — 1, l --- Date D OCT 2 3 2014 oc ) l The Commonwealth of Massachusetts Department of Industrial Accidents Offtee of Investigations 600 Maslungton Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers ARWicant Information Please Print Le `blv Name(Bus iness/organization/Indmdual): L_ - Address: d? Nnp S4—nn 2± City/State/Zip: Q1 b38� Phone.#: 413- y'7• '73 .Are you an employer?Check the appropriate box: Type of project(required): I.1_`S I am a to er with 4. [] I am a general contractor and I � y 6. ❑New construction employees(fWl and/or p tune)." have hired the sub-contractors 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. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'comp.insurance comp.insurance.; require&] - 5.n We are a corporation and its 1013 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1111 Plumbing repairs or additions myself:[No workers'comp. right of exemption per MGL 11n Roofr%s insurance required.]t c- 152,§1(4),and we have no employees.[No workers' I3.�Otller E su 1 oc-�Z`opt comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compamflon policy information. t HonrEowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submita new affidavit indicating such. ;Contractors that check this box must ausched an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. Wthe sub-contractors have esnployees,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: �!� ' T� i✓ Policy 961 Self-ins.Lic.#: � © 1 " j Expiration Date: o� Z,Zi �,� �+I�' . City/5tate/Zip: fi roil Site Address: , t Q Ell 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 e.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 DU for insurance coverage verification. I do hereby certip u r asepauss4andpenattLes ofperfury rliat the information provided above is true and correct- ZSi ature: ✓�-/ .��' Date: Z l Pbone#: %— l?- Official use only. Do not write in tills area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): 2.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone ft. SECTION 8-CONSTRUCTION SERVICES 81 Lcensed Construction Supervisor: Not 1Applicable 13 Name of Ucom Holder: 1 _sc r 103 �! Ucense Number -zu T-1 -z<-j Add Expiration ate rat n3 Telephone 9 Renlstsr+ed Home Maporement Contractor: Not Applicable ❑ ,�� N amE -t ztrl " ice; Company Name 9 Registration Number s �- Jr Address Expiratioh Date Telephone InVI 747 - 7-V-) 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 Dw Mbm 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 faun 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 buildine 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 aggilcable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors 1:3 1 1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[0] OthetN ,�✓,P-) V11W Brief Description of Proposed 'a Work: l ffA Pr OtJ✓S ,S' l 2/ ,�/'OVA) 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 existina 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 �► 1 �/ ) ��U as Owner of the subject property �1 hereby authorize Q L t ct on my behalf, in all matters relative to work a horized by this building permit application. Signature of Owner Date I, tom/ cc 1 as Owner/Authorized Agent h reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed r the pains and penalties of perjury. �f 1. ) 0 P Na 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 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/Findin ever been issued for/on the site? NO Q DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW o YES 0 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 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department uee only L� -- City of Northampton Status of Permit Building Department Curb Cutlorivoway i DEC 2 2 2014 ' 212 Main Street Sew SOpticArrai Room 100 Water/Wet Availabill" EleC:r�. nn c ,r ions orthampton, MA 01060 TWO Sets Of StructuralPt s 587-1240 Fax 413-587-1272 Plots lte Plus tftw sp y , 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: CIA 02A 60417 6 Y Name(Print) Curre res tMajlipy 9dd ^ ,v ? Telephone Signature 2.2 Authorized Aaent: Na a(Pri Current Mailing Address: ^� i ` M 71/7 _ 573 Sig ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1 (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 oq 6. Total=(1 +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-2015-0683 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 226 CRESCENT ST MAP 31 A PARCEL 051 000 ZONE URA(I 00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid �Y Building Permit Filled out Fee Paid Typeof Construction: INSTALL KNEE WALL INSULATION&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accesso1y 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 INFO TION 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 a c 1 .. Si o B g fib D to 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. 226 CRESCENT ST BP-2015-0683 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-051 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0683 Project# JS-2015-001312 Est.Cost: $1900.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): Owner: CUMES CLAUDIA Zoning:URA(100)/ Applicant: PAUL SC H M I DT AT: 226 CRESCENT ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.1212212014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL KNEE WALL INSULATION &AIR SEAL 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 Si inature: FeeType: Date Paid: Amount: Building 12/22/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner