10B-032 (2) BP- 2011 -0570
GIs #: COMMONWEALTH OF MASSACHUSETTS
2 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit # BP- 2011 -0570
Project # JS- 2011- 000942
Est. Cost: $5041.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 25351.92 Owner: CANBY COURTLANDT & NATALIE CANBY & HENRY CANBY
Zoning. URA(lOO)/ Applicant: PAUL SCHMIDT
AT: 42 GROVE AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739
HATFIELDMA01038 ISSUED ON :1212212010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL 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 12/22/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street ` ` `� �l fiwer /Septic Availability
D ,' 4- i ! I! Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
l' .: ............. . phone 413- 587 -1240 Fax 413- 587 -1272 Plot/ .Site Playas
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
L4 6-- ro , f� A V-` Map Lot Unit
C'
I e e d C Zone Overlay District
J Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Prin Curre a g ddre
Telephone
Signatu
2.2 Authorized A ent:
Name (print) Current Mailing Address:
/- x'13 �Zy?
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by rmit 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
6. Total = 0 +2+3+4+5) `(� �j (,1,� Check Number b ff 5
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r
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
pa rkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 9 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 1711
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Othe 'VNl
Brief Work Description of Proposed o _Cfl/��l(� Iri�I _ ' 04! r✓ �)1 �i�S' / �n gi` f /V .�l /A Pmt
Alteration of existing bedroom Yes _ No Adding new bedroom Yes _ No Dfj' )m e x
Attached Narrative Renovating unfinished basement Yes No CIE n 0A)
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
1, C" �q as Owner of the subject
property r ('
hereby authorize d �in/< `" 1 J Vl L &" 4
to act my behalf, in all afters relative o work at by this building permit ap lication.
20 GO
Signature of Owner Dat
I, Oq LJ ( ' f C'. �J IJl �. U` o) jl!� tAlf as Owner /Authorized
Agent hereby declare that the statementsf and information on the foreg ing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
1n 1 7 0
1 Signature o Owner t Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor* Not Applicable ❑ �1 C
Name of License Holder /� }- 0 v
Licen�e'N mber
�-1 fiYA 7, 0
Address fkp�iation Date
- 7 7z p u
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
r-0-6e & N 61 /6.'� Z I `7
ComDanv Name Registration mber
Z L:U5 >'�A/�i -z i v
Address "�� Expir tion Date
Telephone � / �_ _f!
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
' The Commonwealth of Massachusetts
a
Department of Industrial Accidents
Office of Investigations
600 Washington Street
#; Boston, MA 02111
_ www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Or �
ganization/Individual): � ' f T
Address: q �� ��� ��
�?
City /State /Zip: (�" ', �� Phone #: 7/J �/
Are you an employer? Chec the approp "ate box- Type of project (required):
L ❑ I am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. F] New construction
2. ❑ 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §l(4), and we have no 1 Other sCiI`►/ ! PA)
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.
+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
Policy # or Self -ins. Lic. #: C L_ [ {j Expiration Date: 1 1h, 10/
C/ t Job Site Address: q�_ 1���1 City /State /Zip: /�V_ , �
LI h
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 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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PITTSFIELD Permit/License #
Issuing Authority: Building Department
Contact Person: Phone #: (413) 499 -9440
>ieoorrcae (413) 625 -6527 FAa: (4I3) 625-SM T#W CEWSWIMM 6 AB A UATF8t OF NNKLVMTION
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-Office of Consumer A.f kirs and usiness Regulation
-
10 Park Plaza - Suite 5 170
Boston,,lVIassachvsetts 021 i 6 -
- Home Improvement Contractor Regisu - afion `±
- - _ - _
Re
9istr ti n: 165217
- - -- = -- - = Type: Gorporafion
- -= �'✓ = ExpQa60n: 1/2112012 Tr# 292798
C POWER, INC. -
PAUL SCHMIDT
324 WELLS ST - _ --
_ - GRE €NFI MA 01301
Update Address and return card. Mark reason for change_
j j- Address Renewal ; Employment host Card
v 5OM- 04104. 6101216
✓fie 7�osrt asd aAeut0� �aaareo�.amas -
1. License or registration valid for individul use only
Ofiice of Consumer Aileen iC lla4acss Bcgn>:tioa befort the expiration date_ 7f'foaad return to:
HOME IMPROVEMENT CONTRACTOR - Office of Consumer Affairs and Business Regulation
Re9 o ^ ' -j6521T 10 Park Ph=- Suite 5170
'Explrati_pgRj/2 W2 Tr# 292798 Boston, MA 02216
Types '4FfioTaoii;,
D-OP POWER_lN
4UL SCHMIDT"-
M WELLS ST - -- r-
REENFIELD, MAYF13Df_ do
- Dn - Not valid without signature
- -
if1assaehw;eM- Department.of Public SafM
Board of Building, Rcauia#ions and Standards .
Cormwiction supervisor License
License: CS 103635
Reshicted to: 00
PAUL SCHMW
24 CHESTNUT ST
HATFIELD, MA 01038 -
Expwation: &25r20'l3
Commissioner Tr#: 103635
08/18/2010 03:18, ± IRIGHTSIDE PAGE 02/02
Customer ID 3111 61 Customer Name Address A 1A y,�
KNOB & TUBE WING
During the Energy Survey of your home, indications of "knob and tube" wiring were found. This old style of wiring
involves individual wires that are run through walls and ceilings in a house, with ceramic "knobs" and "tubes" to
prevent contact with wood framing. The knob and tube wiring that has been noted may or may not appear to be active.
Even if the observed wiring appears to be inactive, there may still be active knob and tube circuits hidden inside walls
or other inaccessible areas of the house.
MassSAVE Program requirements require that you have the home checked by a licensed electrician and certified as
being free of all active knob. & tube wiring where needed, before insulation and/or air sealing work can be done. Your
electrician should fill out and submit a copy of this document to the Center for Ecological Technology (CET) in order to
verify the absence or inactivity of the knob and tube wiring in the areas of your home where we are proposing insulation
to be installed. Due to the liability involved in signing suet a form, we suggest you show or describe this form to
your electrician before hiring him to inspect your home to be sure he /she is willing to sign it. The Center for
Ecological Technology (CET) and MassSAVE program will rely on the electrician determination and certification
below and will not be liable if inaccurate.
Your home could benefit from insulation and/or au tng in the:
Open Attic Exterior Basement ❑ Attic Floor ❑ Knee Wall Floor
Walls
** Only after this certification is received by CET can a Contract be issued for
energy saving insulation and/or, air sealing work.
Electrician's Certification
(This form is invalid when any qualifications or aiteradons are added.)
Company Name & Address C A� k- OArvuc- S
'C���tlG`✓VV Y_ X-A Cj i a o—?
Electrician's Name 7T�;� K License # °��
1 have performed an inspection of the wiring at e home of:
C � at � ;� 1 MA 0(053-
is Name) (Street Address) (C
AY)
(— �
Upon completion of my inspection I have found that there is no active knob and tube wiring in the area(s) noted
below.
[II Open Attic Lv7 Exterlo LET Basement C] Attic Floor ❑ Knee Wall Floor
wall
Electrician's Signature G Date 6tS
Please mail this certif ea ' letter to: Center for Ecological Technology
241A W. Housatonic Street
Pittsfield, MA 01201
Or fax to: 413- 443 -8123
Rev. IMS /09
Please call 800 - 238 -1221 with any questions'or concerns.
Customer (mail - when completed) White Customer Copy — Yellow Auditor - Pink