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29-331 (5)
276 ACREBROOK DR BP-2016-1272 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-331 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa:: INSULATION BUILDING PERMIT Permit# BP-2016-1272 Project# JS-2016-002183 Est. Cost: $2500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 10497.96 Owner: GARCIA LUZ E Zonine: Applicant: PAUL SCHMIDT AT. 276 ACREBROOK DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:5/3/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION 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 5/3/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1272 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739 PROPERTY LOCATION 276 ACREBROOK DR MAP 29 PARCEL 331 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 7727 5 Building Permit Filled out Fee Paid Typeof Construction:_INSTALL ATTIC INSULATION 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 INFORMATION PRESENTED: Z,,1Cpproved 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 D mol' io elay Signature of Building Offcial 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. . City of Northampton _� rt Bung Depadment 212 Main Street Room 100 1AK' N rthampton, ARA 01060 hon 41 587-1240 Fax 413-587-1272 h �rc�vs DFP':CF Aga 01060 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMLY DWELUNG SEfrTi "x=" tom, 1.1 Projmw A!MM: v QE/f r"M 1 U.-Z' L r ' elk -7 '�f� e(Print) Current Mailing--'� -'Q— \ Ad�r�s Telephone ' nature 2.2 Audmdzed Agent: JLPrL Name(Print) Current Malting Address: Uig- a47-'s 3 SignahW Telephone Item Estimated Cost(Dollars)to be f3i. Wen jy� compleWd by permit apiplicant 1. Buildiag -�� o (2t 13t3itid >I ee 2. Electrical (tzzCaf 3. Plumbing 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) (=? left . Signal" 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 U.- R: U, Rear ...... Building Height Bldg.Square Footage % Open Space Footage % (Lot area minir.;bldg&paved varking) of Parking Spaces . .......... Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ver been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW � YES 0 IF YES: enter Book Page and/or Document#.- e_sl B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES 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 a twn,or filling)over 1 acre or is it part of a common plan that will disturb over I acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(checkanaoeilipaW New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 13 Accessory Bldg. ❑ Demolition ❑ New Signs [C(] Decks [Q Siding ] Other Brief Descxip' of Proposed CO© 5 �- C 0 " Q — r7 .9 CJ Work: T -� V Alteration of existing bedroom Yes No Adding new bedroom Yes No � Attached Narrative Renovating unfinished basement as -�No Plans Attached Roll -Sheet sa.l#New:hol<Ise;alad:or addlo ta: al Vie.: :ae� a: a. Use of building:One Family Two Family Otl�:r b. Number of rooms in each family unit: Num f 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 of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or Ilar 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 K4LDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to zed by this building permit application. Signature of Owner Date 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 Name -� :Z.,W, _03 Signat&e of Owned Date SECrtW 8-Cgll� 5 8.1 Licensed Construction Su isor: Not Applicable ❑ Name of License Holde10 5 (P,35— License P`)5— License Number . 44a+��C-Ljlmtq 01 !,C5-/gzM7- ;Address Expiration Date 21nature Telephone �. ,. Not Applicable ❑ Company Name Registration Number --g2q OV-4rv-cf — ,-2 Z 7 / /1 AddressExpiration Date - ,�t d , Y1')i4 C%1 a 3� Telephon 113 dy7 573 AFFMAW 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...... ❑ 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 784, 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 homq in a two-vear 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 The Commonwealth of Massachusetts n;z Department of Industrial Accidents 1 Congress Street, Suite 100 F Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): SDL Home Improvement Contractors, Inc Address: 24 Chestnut Street City/State/'Zip: Hatfield, MA 01038 Phone#: 413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): I.[✓ I am a employer with 8 employees(full and or part-time).' 7. [] New Construction I am a sole•proprietor or partnership and have no employees working for me in 8, E] Remodeling an,.capacity [No workers'comp.ir,urance required.; 9. ❑Demolition 3.O I am a homeowner doing all work myself.[No workers"comp.insurance required.]' 10 Q Building addition 4.M I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 1 l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.�✓ Other Insulation 6.r_1We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] `Am applicant that checks box zt I 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 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: Selective Insurance Co Policv#or Self-ins.Lic. #: WC9024456 Expiration Date: 2/23/2017 Job Site Address: ,1 4_�k),K L �,l y' City/State/Zip: M-4 C)l o Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 5250.00 a day-against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify goorr�the p s and penalties of perjury that the information provided above is true and correct. Si Tnature: / i / Date: 'Phone#: 413-247-5739 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.Cite/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northamp K"machumetta or mulToasx z s 212 D/eiu Stet • 2Mmiatp" maild"W NAxtfiium-pbm, D® 01060 Address: ,7,�aS'b K Narrna: --- Address: CRY, staw MA CA�& Ptxm PrOpWtYOwlW Nam Address. , city' state: 1, ,<--r-V-'h15*C . (cordrractor)+fit aid aim#W to btMdkV i ltd to MvJA9 does not twm any open sk(Mob aid tube)whV in the spaces to be kwAsted and#W!have provided the property owner with a copy of this afWaWL C ntracfor signature _ 1 Date *,, ksIV mass save (,0NTflAGJ OR PERMIT AUTHORIZATION FORM I, LUZ E GARCIA ,owner of the property located at: (Owner's Name,printed) 276 Acrebrook Dr FLORENCE (Property Street Address) (City) hereby authorize the Mass Save Horne 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. .. wner's sin ure 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 C]�JD cr ie: ss=0n?y Rev. 12132011