31A-058 ;; City of Northampton ,� w
..i Massachusetts
` �
,. :. DEPARTMENT OF BUILDING INSPECTIONS � ft , 'a '
a � 212 Main Street • Municipal Building �.
v ' '' Northampton, MA 01060 51 '.v 't
Property Address: 01 75 /1 /
b
P
Contractor
Name: /" /
Address: 1 1 4.J , l/ kV GA‘0./`/l1 S
City, State: 6✓ r /0 !1'1 AA `I� f l X /i L
Phone: 77
,/ v ft q J
Property Owner kV)
Name: f1RI
Address: 712 6.1 ' 6 V!
City, State: / V /v A-
I, �A/) Ia,Li (contractor) attest and affirm that the building I 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 :C___
Date
- 2._ / V )"1---
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
r 600 Washington Street
Boston, MA 02111
� % O www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /ContractorslElectricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization /Individual): C ( - 1 0 &{ I't C..-
Address: (J &-((
City /State /Zip: &h. E(J. AA Phone 4: 4 ( 3 — 'Z C
Are you an employer? Check the appr • riate box: Type of project (required):
1.13I I am a employer with C 0 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp. insurance.t
required] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.54 Other V4S (it [ Gi T'iUl'v
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: j i W (n C I F r r �' rS Gvr GVv1 & C
Policy # or Self -ins. Lic. #: O R` i.v e G L c s- ( ce Expiration Date: 2R e T 2
Job Site Address: 1/1 0 C (.eivl 4-5 7 City /State /Zip: Mjy 1 v JV p ,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date)Q/ tibV
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 51,500.00 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. 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 car ' under the - s nd p hies of perjury that the information provided ab e is true and correct.
Signature: ' Date:
i if
Phone #: 4[ ' 7 2 ?Es-
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):
I. 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: :able ❑
Licensed Construction Supervisor:
Name of License Holder :
Paul Schmidt mber
24 Chestnut St.
Hatfield, MA 01038 , sate
0,4 CS # 103635 U
Signature Telephone Exp. 5/20/2013
413- 772 -8898
9. Registered Home Improvement Contractor: Home Improvement Contractor: , licable ❑
Co -op Power Inc. / Paul Schmidt
Company Name 324 Wells St . :ton Number
Greenfield, MA 01301
Address # 165217 ti Date
Exp. 1/21/2012
413- 772 -8898
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 ❑
1 . - ome Owner Exemption
The current exemp i. • for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeo • -r to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Six dition Section 108.33.1.
Definition of Homeowner: Person ho 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 • elling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than , : • home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Officia , an a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the builds • ermit.
As acting Construction Supervisor your presence on the job site 1 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 : • d Chapter 153 (Liability -of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws ...notated, 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 . - Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws otated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition n Replacement Windows Alteration(s) r7 Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E) Siding [f]] Other [X
Brief Description of Proposed n
Work: � r7Svl4 l)vl /31A
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 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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized 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
Signature of Owner /Agent Date
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
•
New House n Addition 0 Replacement Windows Alteration(s) ( J Roofing n
Or Doors 0
Accessory Bldg. n Demolition n New Signs jElj Decks [p Siding ID] Other [W
Brief Description of Proposed A-� / / A '
Work: e■ / /✓5 ✓L- 4-nol/ Ill Cwt . ?1Lt 'V® ,- F/ 1
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 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
t-.
I, e4i) 1 SC V Ci 0 , as Owner of the subject
property
hereby authorize I `ALA �A ; 0.-1 Lep, - Coe,. p �� fA.) e
to act on my behalf, in all m. - relative to work authorized b his building permit . ,plicati. .
y -----
Signature of Owner Date •
I, POW ) Sel VVt )(7U- co op t L A `e , as Owner /Authorized
Agent hereby declare that the statements and info srtion on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u , -r • e pain -, d penalties of perjury.
wr
Print Name
?alQ1 Sr, k . Th 1 d A ---.'
Signature of Owner /Agent Date
A 61-0
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Piot/Site Plans
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
Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Carl GA in v 2 1-0 C(l,,c -4
Name (Print) �w _ .__Current Mailing Address:
Telephone f
Signature 7 /1 / 3 j " 5 ?6, ^/ 9 7
2.2 Authorized Agent:
Co --0P y°,711 / U GP€ G 1ceo-AeAce 014 0)301
Name (Print) Current Mailin§ Address:
611/ 1/43 &el 0
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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 = (1 + 2 + 3 + 4 + 5) 0 Check Number ci /4,4. L s5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
OLD i6 4/ CPea -
File # BP- 2012 -0641
APPLICANT /CONTACT PERSON PAUL SCHMIDT (ZQ 0)1— NHS SIFc
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 N olt Ck
PROPERTY LOCATION 270 CRESCENT ST
MAP 31A PARCEL 058 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid E
Building Permit Filled out � ✓`
Fee Paid {n
Typeof Construction: INSULATE ATTIC
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
IN$ORMATION 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
/// 7/ ?-
Signature of Building 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.
270 CRESCENT ST BP- 2012 -0641
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0641
Project # JS- 2012- 001106
Est. Cost: $1200.00
Fee: $55.o0 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 6490.44 Owner: SAVIANO CARL R & BRIDGIT A W
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 270 CRESCENT ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:1/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: I NSU LATE ATTIC
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 1/18/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner