18-035 66 EMILY LN BP-2019-0786
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-035 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0786
Project# JS-2019-001303
Est.Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg.ft.): 42383.88 Owner: VON ROSENBACH SHELBY
zoning: Applicant: PAUL SC H M I DT
AT. 66 EMILY LN
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:1/9/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:1080 SQ FT, 8"LAYER, R-30 ADDED TO ATTIC
FLOOR, OPEN BLOW CELLULOSE AIR SEALING AS NEEDED
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 Sip-nature:
FeeType: Date Paid: Amount:
Building 1/9/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Nort rnp..—EG of y y
Building Dep rtm nt
! 212 Agin treeSAN - 9 201
Froom 1 0
J � Northampton, A 1A 0 06
Isp
phone 413-567-1240 X'rUNWHMAO
✓_ APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR t3Ei1OLl3H A ONE OR TiNO FAIMIiLY I?ILLING
SECTION 1-SITE INFORMATION � ��"` -1 J Y7 0 (y
1.1 Prooert Adcrisaa: �,
LO b:ij � �-hGc jam"°�►, m
SECTION 2-PROPERTY O'WNERWWIAUTHORIZED AGENT
2.1
/
Von
oSenioa c � (r �a 2�.
Name(Print) Current ess i
Telephone �
Signature
2-2 6idbgdW Auent;M)A � t
-i- '71*4 l
� Name Current along Address:�;4611
t3
I
nature Telephone
Item Estimated Cost(Dollars)to be OlkW Use Only
pom~Oy perrnit applicant
Building ¢ (a)Su#dkV Permit Fee
2, Electrical (b)Estimate!Tom Coot of
3 Riumbing Su"no Pecrr k Fee
4. Mechanical(RVAC)
5. Fire Protection
6. Total= (1 +2+3+4+5) ,0 00 ._ Chic Number
Building Permit lumber: Date
Issued:
i
Signature:
EMAIL ADDRESS (REQUIRED, EITHER HOMEOVA4ER OR CONTWACTOR)
Section 4. ZONING All Infontwticm Dust Be Co mpteted.Permit Can Be Denied Due To Incorrrpiatte Information
Existing Pmposed RaqWred by Z
This calu m to be MW in by
"dim Ott
Lot Size
Su"s"s Frame
L,.. R. _ ,. L: _.. . R:.
Building Heig#tt
Bldg.Square Foz _.. . %
Open Space Footage
(Lot rates minus bldg&paved
Eatkia Spaces
Fill:
volume&Lo
A. Has a Special Permit/Yarianceffindi been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued;.
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 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 0 DONT KNOW $,:o YES
IF YES, has a permit been or need to be obtainers from the Conservation Commission?
Needs to be obtained 0 Obtalnod 0 , Date Ism
C. Do any s4m exist on the property? YES NO
IF YES,describe size, type and location:
D. Are there any proposed dvinges to or additions of signs intended for the property? YES NO
IF YES, describe size,type and location:
E. VNI the wnWucWn army dftft( Ism or�9)over t acre or is It part of a common Dian
tf}at w o s atxe'� YES Nt?
IF YES,#wn a Nordwmpts sStorm VVeW Maar hent Permit front tfw C)FW is required.
SE"10N 5-
New House ['-J Addition Replacement Windows Alterations) Roofing
i
Or Doors M
Accessory Bldg. Demolition Now Signs [01 Decks [(3 Sllding`�,,,Zr[
Brief Descripti of Propo ,r
Mork 5 r/ e� /r-z3z AddLd -1be¢1(�Cds-e-
V�n 1 I
9' Alteration of existing bedroom Yes No Adding new bedroom Yes No N ��
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
i
a (Ise of building One f=amily Two Family� Other
b. Number of rooms in each family unit: _. Nornber of Bathroo ns
c. Is there a garage attached?
r'' I
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 foram attached?
h, Type of construction
I
i. Is construction within ;cefiar
.of we s? Yes ,_..,. No. Is construction within 100 yr. floodplain Yes No
i
j. Depth of basement or ft below finished grade
k, Will building confiorm twilding and Zoning reguiations> Yes No .
I. Septic Tank ewer Private well City water Supply
OWNERS Aamak Pawl
I �
I, as Owner of the subject
property
hereby authorize � L
{ to act on my behalf, in all matters rels& Rorized by this building permit application.
Signature of Owner Bate
as Owner/Authorized
Agent hereby declare that the statements and information an the foregoing application are true and accurate.to the best of my knowledge ,
and belief. �
Sign under the pains and penalties of perjury.
r
Print Warne
Sig ure Of ooa~ Date
SECTION 0-CONSTRUCTION SERVICES
8.1 Licemwd C Not Applicable
Name of Ll z 57
License Numbe
Adores Expiration Dirte
S store Telephone
NotApplicable0
NaRegistration tuber
� I � / Xp-
Address Expiration ate
Tele n e
SECTION 10-WORKERS'C OPEN"TION SURANCE AFEIDAWT(M.G.L.c.152,$25C,
1
Workers Compensation Insurance affdavi must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the build' 9 permit.
Signed Affidavit Attached Yes....... No—.... 0
City of Northampton
Massachusetts
tr
=WARTMWT OF BUILT XNG INSPECTZONS
212 Main Street *Municipal Building
Northampton, MA 01060
Debros Disposal Affidavit.
In accordance of the provisions of MGL c 40, S54, 1 acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A,
The debris from construction work being performed at:
/0(0 )EMI'LLJ LQ-eL-'(———---------------------------------------
(Pleaseprinthouse number-frid street name)
Is to be disposed of at:
zi-
(Please print name and location of fa6lity)
Or will be disposed of in a dumpster onsite rented or leased from:
'S +tor� P r-0
q>2LI �/us4-nu�- 6 k 40-f,)q tJ M 0+ 0
(Company Name and Address)
0110
gignZre of A~AppticdW or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
Massachusetts
DRPAR7JWNT OF BUILDING INSPECTIONS �
212 Main Street • Municipal Building 1 '
"Cr Northampton; MA 01060
Property Address:
Contractor
Name:
Address:
Y-1111111-.Laorl
.1 -..._..
City, State: __�..._.._ry-7I'_ 4'_....__...._01aCo U
Phone: g /
Property Owner
Name: ,��l ._......_ !? .....:......._ .0 &tl-?.
Address: �y
'' ll CaI CQ U
City, State:
i, _ {contractor) attest and affirm that the building 1 intend to
insulate does not have any open air {knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
The Comitwitwi!a1th of.1
Departmetil of Industrial
(7rtng"wv9rw UK 1#0
Boslon, .41A 02114-2017
Workers'Compensation Insurance Affidavit,
FO HE FHTD UI I W)1111,Pt,AAMI I VINCAl 1410RITN',
AgWkut WUWMMWII
SDL Home Improvement Contractors, Inc
Address:24 Chestnut Street
HatrielRd, MA 01038 PIUMIC 4:413-247-5735
..... .. ..............
............... ............ ...........-............... .................................................. .......................... ........
................ ............................................
l mi err vmpior r!( hki,h lite a ppi opria Ie boo "1''vpe of project(rettaireil),
[7]l wynk","Oh Cnqnh"Vn thy 00'a rNi my.,
New awmir-uson
mn 'YAW
ED1 on 0 owns""M W."W W"nqwv
101" fluildol��addition
th�n ali "aim:nvm""M� wwu a a,MAC I I 1,E]Fiectrical repairs m�akbfiluon
i:..01 lun lying repmr,ur additwn,�
[31 A;-t?Wwrl unmi aim and 1 no C htted ow MA,W w Vk
1.3.n Roof repairs
)tetA""a 0"Wat on and M, Iwo,We man'"d On 1 qj A an,0 YN Insulation
1 44 arm m ha C W CWW"o $0,umb" �anp myowk-onywyo
........................................... .....................
No 01 must Am N Can the w"-,AN- polio w"lo"Inalo,at
Way"O"n.,who S;Amlit ihw,affidiavi!indIc"'ongth"acj"yaH A"4 At No mw=,A .wnw,muxt wWn a. tc*81€3 +t,Intlahn;MW:
13x,,1,JIln4 th"WX Must MaNd an WISMal A 1110,- V WOWN dw Ww"WOMW MM no"heso W M"how WWWOW
Relow is the^lfit:r andjoh site
Inmirance Wnpaq Nanle:SelectiveI I I nsurance GO
1"WY 0 w W#'iov Lk P AIC90=4456 KOM% Dat,OWN=
Is Sile Ad-dress:
V�e.........
Attach a copy of the workers'ctarrala nsation policy declaration pagw(showing the policy nuffiber arid eNpirltion tbte).
1
Failuic to �.overugc as reqVred under 1-ICH , 112 §25A I,a mminal YKAmm pmkhkk by a Ow up w SLAW%
and1w unnyear impl-Amment.as well as ci1 i!penakws ni Be lknj& a SA OP WORK GIRD Is aW a fine 4 up to S2=0 i
i'lay against the violateg. A wpy of this siaternent nul he JAN"Wed Vo the 011W of Investigatkins of the IMA I'm insutanct,,
�;overagje verilication.
t0h;hereft;tvnqh, r e ins and1lenahMes of perjuri,that the inli)rntafion provided above A�trite anti vorreei�
ignmulw- ........................................ .................................................................... ...................................................
OW
Phone 4�';-247-47
............... ................................................... ................ ...............
Qyhjut Use M not write in this area,to be completed hr city or town qj
Ile rnl IV Lice Ilse
Issuing Authority (circle one):
1. Mmrd of Heolth I Building Department A(Ulflown C to* 4. Elerniml losperaw 5, llumbing lospevior
6.Other
I=I rson: I'llme
LIAM WMAX�Yy:
AC"RV CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
KEPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT., If the certificate holder Is an ADDITIONAL INSURED,the policyfies)must have ADDITIONAL INSURED provisions or be endorsed,
if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s),
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE MSCRIBED POUCTES BE CANCELLED BEFORE,
1 HE EXRRATION DATE THEREOF,NOTICE WILL BE DELIVERED M
ACCORDANCE WITH THE.POLICY PROVISIONS,
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