25C-093 The Commonwealth of Massachusetts
Department of Industrial Accidents
'= ti , e" Office of Investigations
--, ... 600 Washington Street
A Boston, M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organza( ion/thdivida C tom• Q ""
Address: 3. 2, q we---((5
City /State /Zip: t1 YC CCU. (1,f�' Phone #: ( 1 �2-° —
Are ou an employer? Check the appropriate box; Type of project (required):
1. MI am a employer with 1 a 4. 0 I am a general contractor and I
employees (full and/or part- time).* have hired the sub- contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub- contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. D Building addition
[No workers' comp. insurance comp. insurance.T
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 av
employees. [No workers' 13.1A Other
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.
TContraetors 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: ( W fr' C i f /_ t? Cgs,' E - �--YrS (,ti'Y fwd c C
Policy # or Self -ins. Lic. #: l Je" C. 1 G t(' Co Expiration Date: Pt - (- c 1 2
Job Site Address: City /State /Zip:
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 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 cer ' under the ' . • nd p 0 ties of perjury that the information provided also e is true and correct.
Signature: , , ' Date:
Phone #: g '
Official use only. Do not write in this area, to be completed by city or town offaciat
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Wealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
CO-OP ji
1 L
p POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
Affidavit of Waste Disposal
I, Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co-
op Power will remove all waste from the job site located at:
f Ot Owner Name Street Address Town /State/Zip
Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our
removal service is Waste Management.
r Z
Paul Schmidt Date
Co-op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302
ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop
-
Licensed Construction Supervisor:
Paul Schmidt
SECTION 8 - CONSTRUCTION SERVICES 24 Chestnut St.
8.1 Licensed Construction Supervisor: Hatfield, MA 01038
Name of Licerise Hold r :
CS # 103635 U
-, Exp. 5/20/2013
.._ ..
,/ �,� � � - 413- 772 -8898
Addres- / . j
' ' � 2 �` Home Improvement Contractor:
Signat e d . ,W Telephone
o -op Power Inc. / Paul Schmidt
324 Wells St.
Greenfield, MA 01301
9. Re. istered Home improvement Contractor: # 165217
,-) Exp. 1/21/ )- '
Company Nande _.- :._.::_ 413- 772 -8898
i / -- paul @cooppower.coop
Address,
"- - `,,, Telephone .I 3 117- 7' 1 `6
-
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affid vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui ing 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
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 1 r --- I 1
Frontage 1 1
Setbacks Front ( 1 1
Side L:I R:I L:1 1 R:1
Rear ( 1 ' 1
Building Height f 1 1 i
Bldg. Square Footage
1 I 1 % 1
1 1
Open Space Footage
(Lot area minus bldg & paved 1
parking)
# of Parking Spaces 1 1
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Re stry of Deeds?
NO 0 DONT KNOW YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
/
C. Do any signs exist on the property? YES O NO 0/
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, exc ation, 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.
•i • 1LU:!. 1. ..
New House 0 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [M Siding [0) Other [IDly
Brief Description of Proposed
Work: 1 1J { jte �} (7•' 7` , I el it• 1f t 04 S " t�> � i'r 'r? iH en/Kt.
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 Pe'2(L'f Get jC'_7i2 as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this budding permit application.
Slgn • Owner Date
t r , as Owner /Authorized
Agent he by dedare that the statements and Information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pain : • • - aides of perjury..
t/ „-
Print = e /
3 (i7/11/
Signature of Owner/Agent Date
RED • ty of Northampton Status of Permit:
B ilding Department Curb CutlDdraway Permit , �
a 2012. .12 Main Street Se r/Septisa + i i — 20 ic
` - ° Room 100 Water/Well Availability
ort - mpton, MA 01060 Two Sets of Structural Plans � tNSPECnoIS
g �' s;� : - 17-1240 Fax 413- 587 -1272 Plat/ 4e Plans "
„ "" es
Outer Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 1
1.1 Prggertv Addross: This section to be completed by office
3c Ik/0,414 Map Lot Unit
14044 prn t y"r' 0 (0 ( p 0 Zone Overlay District
am tB. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
ea :
g - 1 2 . - - / Core— - Zis Nib Stce. d NnitkaktApiThi, MA-
Name ( ) u Q _t F aLQ�Q
Telephone
Signature
ho
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building i,l O t o (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 7
6. Total =(1 +2 +3 +4 +5) (0 . Q0 Check Number
This Section For Official Use Only
Building Permit Number I
Isssusu
ed:
Signature:
Building Commissioner/inspector of Buildings Date
File # BP- 2012 -0781
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 215 NORTH ST
MAP 25C PARCEL 093 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
8 rZ
Fee Paid /a
Typeof Construction: 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
I■ F RMATION 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
:-1 .1'i eay
/ >Z— /)Z
Signa re 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.
215 NORTH ST BP- 2012 -0781
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 093 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 -0781
Project # JS- 2012- 001367
Est. Cost: $4110.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 9844.56 Owner: CARTER PERRY B
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 215 NORTH ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:3/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: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 3/13/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner