24D-051 The Commonwealth of Massachusetts
:-' Department of Industrial Accidents
t =T ` Of, j`ice of Investigations
1
+- 600 Washington Street
r
K
. ' Boston, MA 02111
' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ( " 0 cPQ �
Z j
Address: 3 t ki (��J p sr
City /State /Zip: G',r ( R )MA Phone #: 1 1U - 7 ) I L ?Y°'
Are you an employer? Check the appropriate box: Type of project (required):
1:Fef I am a employer with d 12 4. 0 I am a general contractor and I Q
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. 0 Remodeling
ship and have no employees - These sub- contractors have 8. Q Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp. insurance.$
required] 5. 0 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' 1 Other Ln)SU)AI ),/li
comp. insurance required.]
*Any applicant that checks bore #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 subcontractors 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: £3 ),A Cx t & .-✓VJ ..
Policy # or Self-ins. Lic. #: 0 ? W G C C ‘)3 K 4 Expiration Date: 1) 1) 20 Y1
Job Site Address: 3'7 S To l7pAT l St City /State /Zip: i r 4 / /
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 0 go)
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.
J do hereby certi der y 1 zfrzs a nd penalties of perjury that the information provided above is true and correct
Signature: Dater f 3 1 t
Phone #: 1 — i i) J-- t� c/7 v 5 7 31
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
g/L ea4;24,1-44zeoet-z&x aitygAzachaea
Office of Consumer Affairs and Business Regulation
10 Park PlRza - Suite 5170
Boston, Massachusetts- 02116 '
Home Improvement Contractor Registration
Repistration: 165217
- _
Type : Corporation
- - Expiration: 1121/2012 Tr# 292798
• - -
CO-OP POWER, INC_
PAUL SCHMIDT -
. . •
324 WELLS ST
-GREENFIELDMA 01301
'Update Address and return card. Mark reason for change..
0 Address 0 Renewal T1 Employment 0 Lost Card
50M-04/04-13101216 „„.
- eoggamonweerid ,1 t&
O Affairs & iness
License or registration valid for individul use only
ffice of Consumer a Bus Regulation
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
IP
Office of Consumer Affairs and Business Regulation
- RegistratIoO 165217
10 Park Plaza - Suite 5170
Explrationv.-1124/2012 Tr# 292798
Boston, MA 02116
Type:,-;ROdiPaoratibti:, -
O-OP POWER-dNak
'AUL SCHMIDT:”
;24 WELLS ST MY.iaf .
3REENFIELD, MA 0130) Undersecretary Not valid without signature
•
Massachusetts - Department of Public Safety
Board of Building, Regulations and Standards
Construction Supervisor License
License: CS 103635
Restricted to 00
PAUL SCHMIDT
24 CHESTNUT ST
- -
HATFIELD, MA 01038
. _
Expiration: 5120/2013
f *oinnibmioner Tr#: 103635
ORCHARD ELECTRIC ANC.
210 FLORENCE RD.
FLORENCE, MIL 01062
(4 4586tl
FAX (413)806262
FMLIC.11At2Dt8
November 17, 2010
Danielle Powers
37 Stoddard Street
Northampton, MA 01060
Re: Residence wiring upgrades.
To whom it may concern:
AI wiring 37 Stoddard Street has been wed frnrn "knob & tube' type wiring to `ranee. Al outside
walls, attic and basement has been inspected for `knob & tube" — none found.
Thank you,
Graig Gooley
Estimating Manager — Sales Associate
MA Master Lic. No. Al2018 (413) 585-9600
(413) 586 -0966
FAX: (413) 586 -2492
ORCHARD ELECTRIC INC.
Electrical Contracting and Design
Residential • Commercial • Industrial
210 Florence Road, Florence, MA 01062
Renovations
New Construction
Service Upgrades
CRAIG F GOOLEY Fire Alarm Systems
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: S10447/157 Not Applicable ❑
Name of License Holder : / I 1 E 3 6
License Number
-7_,4 G i fSTA, " H Air)' r* ��' 13
Address Expiration Date
ad `?. � 7,1 17 - -5
Signat a Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
c orte" s��'- 1 -6,5"'1`7
Company am Registration Number
Address 6 J�- Expira on Date \ ` rn�! C) ( } Telephone w V � re
—
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 ermit.
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
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [0] Other [ III .
Brief Description of Proposed
Work: D 0 / "
fr',Q , / r bdAi LC Ac AiW '7t �p c �� .. ('
F (� � �/1
g Adding Alteration of existing bedroom Yes N Addin new bedroom Yes .4- No !� 1?1
Attached Narrative Renovating unfinished basement Yes No L M P 1 6 Z J
Plans Attached Roll - Sheet OF fAii g) L , ) G £ nag
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, L)fU 1 2t --LA `J N) 5 -- 11 -- 5 , as Owner of the subject
property / (',,
hereby authorize co c ',
►oz, E 2 /} t// �J ekii ri
to act on my behalf, in all matters relative to work auth • d by this building permit applica io n.
C D4 1 pwill t•),)
Signature of Owner Date
1, /401 JJ C H 0 ♦ �j,t/�fr , as Owner /Authorized
Agent hereby declare that the statem a nd information on the forging pplication true and accurate, to the best of my knowledge
and belief.
Signed under the pai s and penalties of perjury.
Print Na nt
4 ; )
r P & 1 / V
/Age Date
Signature of Own g
•
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
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding er 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 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 er DONT KNOW O 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 0 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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exxcav n, 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.
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 - PlgtiSite P ns '�
_10.16errSPee f r
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLI BHAQNE OR TWO FAMILY DWELLING
DEC 1
SECTION 1 - SITE INFORMATION
1.1 Property Address: • _ This section to be completed by office
ST Map Lot Unit
3 / j ( J / Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
U--(. ‘ 37 SoppArp t.yr /yrrivti
Name (Print) Curr actin Address:
Telephone
Signature
2.2 Authorized Agent:
- z-ct c,t,ifsva 5 17 Arr6'f,)
Name (Prin . Current Mailing Address: J
7-3'739
73C
Signatu Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Z L� 1 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
Total = (1 + 2 + 3 + 4 + 5) Check Number /D;5
�!/ ��✓
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Ruilrlinn C:nmmiss nner /Insnartnr of Rniidinns �� +�
� r
File # BP- 2011 -0542
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 37 STODDARD ST
MAP 24D PARCEL 051 001 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 l i p
Fee Paid /Q
Typeof Construction: INSTALL 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
INFOW4TION PRESENTED:
pproved 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
De •• , . s lay
" g n ature 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.
BP- 2011 -0542
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0542
Project # JS- 2011- 000894
Est. Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq ft.): 7013.16 Owner: POWERS DOROTHY
Zoning: URBU100)/ Applicant: PAUL SCHMIDT
AT: 37 STODDARD ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:12/14/2010 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 12/14/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner