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23A-120 (2) co - Op rev 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: 14 M` ' i, m e f =7.4y1.tiu c , f 4 0106 2 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. (2 / 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 :::: City of Northampton r -.„ / it; Massachusetts A `v' * t C. liglt ,� "" / DEPARTMENT OF BUILDING INSPECTIONS 5 ' . Y' r 212 Main Street • Municipal Building :P " `, _. - "* Northampton, MA 01060 '� 'P)%� c Property Address: C c 0 0 1 4.= r l, n't/riLi t , Ill /1 v r C Z Contractor Name: c - (.l11M ca Address: 7-..1 WFit S cr City, State: C {4ir�'r 6. ✓� 1 ' j / 4 1)/ 3 0 / Phone: (L//3) Property Oner Name: IV r It A - 00,, t /- Address: t 3 Vin, rr✓014; - T City, State: "o"'" ( , /4 f D Z I, kelt, rOY (contractor) attest and affirm that the building I intend to insulate does not have any open air- -(ttnob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of t affidavit. 4'Y / Contractor signature " j Date / ,f 1 , CO-OP jr■ POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY City Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 April 13, 2012 RE: Building Permit for Insulation Work at 8 and 8b Middle Street in Florence We are submitting these applications to obtain permitting for insulation work at the properties of Nora Kalina. Enclosed please find: 1. building permit applications 2. debris disposal affidavits 3. copies of CSL and HIC licenses 4. certificates of Workers Compensation 5. certificates of liability 6. stamped return address envelopes 7. check numbers 3208 and 3209 in the amount of $55.00 each. Kindly return the authorized Building Permit to Co -op Power in the enclosed envelope. Thank you. l ! '1 Sincerely,, i i - If , / //' i d , Kathe n�'Policy Energy Efficiency Ad inistrator katherinep@cooppoWer.coop 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 ..., a SECTION 8 - CONSTRUCTION SERVICES Licensed Construction Supervisor: — 8.1 Licensed Construction Supervisor: Paul Schmidt Name of License Holder : 24 Chestnut St. Hatfield, MA 01038 :S # 103635 U Address Exp. 5/20/2013 413- 772 -8898 Signat t Telephone Home Improvement Contractor: Co-op Power Inc. / Paul Schmidt — 9. Registered Home Improvement Contractor: 324 Wells St. Greenfield, MA 01301 Company Name 4 165217 Exp. 1 /21 / 2.-e ( il Address 413- 772 -8898 /' 1" T paul @cooppower.coop 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 Cd 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 r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [1 Addition n Replacement Windows Alteration(s) [ Roofing n 1 Or Doors El Accessory Bldg. ( 1 Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed Work: 3 . 5 `r [ N` ( - 41 7 f �^' � t i✓ +"r c:714,4-791' ,,, y .- — ✓lay ` Jrp /, 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 I, NM. VA, t. i VO , as Owner of the subject property hereby authorize # t S 4t ` 0 (_ / (,4 PO44) -C f - to act on my behalf, i .II matters relative to work authorized by This bull ilding permit application. 4-ial Signat 0 caner Date I, L ,12;�'vo/ 7 , as Owner /Authorized Age 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 Na e AA,' Signature of Owner /Af -nt Date .. . I Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed . Required by Zoning This column to be filled in by i4 ' Building Department � Lot Size I I I I 1 Frontage I H I I I I Setbacks Front 1 1 I I I Side L: I R:I I L:I I R:I I I 1 1 1 Rear I I I 1 I Building Height I I I Bldg. Square Footage ( I I I % I I I I I 1 Open Space Footage ( I I ( I 1 % I (Lot area minus bldg & paved I I parking) # of Parking Spaces 1 1 1 ( 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding er been issued for /on the site? NO O DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis , of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 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, excav tion, 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. a Department use only 1 City of Northampton Status of P ermit : Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic,Ayallabtlity 6 2012 Room 100 Waterltll!ell Availability Northampton, MA 01060 Two Sets of Structural Plans of - phone 13 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans Other Specify : w 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 ,' 0,4 , 001- j - ' r --v- M Lot Unit A afiP �( , A e(GC 7 -r i Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: KR) 'cf\sk g (i�t,�on - tt�t -� ivir, I AAA- c t Name (Print) in Curr t Mailing Addre Telephone Signa 4 -19L e 2.2 Authorized 1" 3 2- Y L ' Sr: illy PI frz Gi ,4 o t :? Name (Print i 1 Current Mailing Address: I 6/13) 2 — /'5 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) 2' (1 '7 . (� Check Number 3o 05,5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0904 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 8 MIDDLE ST MAP 23A PARCEL 120 001 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 j Fee Paid Typeof Construction: WALL INSULATION & VINYL SIDING 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 INF 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 Demolition Delay 1 1 '26 1 1 2 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.