17A-188 City of Northampton
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[ Massachusetts .,, * ' - Cc,
4 r DEPARTMENT OF BUILDING INSPECTIONS y, t' aX
212 Main Street • Municipal Building 4 sr r • �(^
'''''-'.1,111.--..7."* Northampton, MA 01060 , i. k
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Property Address: ''' 14 i S '
Contractor
Name: P "‘-t
Address: Z I tO M r'W L h.
City, State: 4 6/17 r 14A
W
Phone: E.\.41 3) J - T 3 1 ( - 3
Property Owner
\ Name: .�— t.ttvVtL 4 "r'
>>
Address: -3) 9 in/f1 t 5' Sr CfI'1/r - l=1 et , ijL2 it 01 3 v /
City, State:
1, fAta- /! 4 2 (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 cop7 this a davit.
Contractor signature b
Date y/ 2- 6 g 1 2
CO-017
14 POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
Affidavit of Waste Disposal
!; 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:
1 40 g 6mmt,
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.
`-
Paul Schmidt gat°
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
? -e042, •
,
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
'--, ----,- ,
-, -----5_ Boston. Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165217
. Type: Corporation
Expiration: 1/21/2014 Tr # 220702
CO-OP POWER, INC.
PAUL SCHMIDT
324 WELLS ST
GREENFIELD, MA 01301
Update Address and return card. Mark reason for change.
0 Address El Renewal 0 Employment 0 Lost Card
DES-C41 0 ...C114-04,'C4-C1C1216
- 6 - f,wvinoz.raveaa 67_,/ta,..ac4u4a4
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
i-,-a'k' --- -77–== = - : • ',-
■•-'• ._ Registration: 165217 Type: Office of Consumer Affairs and Business Regulation
------i- \ i 16217
.---- Expiration: 1/21/2014 Corporation 10 Park Plaza - Suite 5170
- Boston, MA 02116
COP POWER, iNc„
PAUL SCHMIDT
GREENFIELD, MA 01301 Undersecreta v kiti6.7.------
ry Not without signature
,
___
NIassachusetts - Department of Public Safi:II
Board of Building Reg.tulations and Standard
Construction Supervisor License
License: CS 103635 .
Restricted to: 00
PAUL SCHMIDT
24 CHESTNUT ST
HATFIELD, MA 01038 , 4.
— _..-----....„„ Exptranan: 5/20/2013
r 4.ntrui . Tr#: 103635
S , The Commonwealth or
.,,,.;� Department of industrial Accidents
t r Office of Investigations
r l 6()0 Il'ashington Street
Boston, MA 02111
or. -1 www. ni rass.gov /dia
'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.P.:Pplica»t Information Please Print Le ibly
Name (BusimssiOr anizzi.ionllndividual): li P c�� - C w'1`` . ^ i'k C
Address: ?' (jJG j ( C
City /Stale /Zip: (rYt.= ."'" (4j.- / , — Phone -: ' ( - � 1, 7 -- 8 - 6 — c i E''
Are you an employer? Check the appr' rime box: am a general contractor and 1
1 Type of project (required):
1. 2' am a employer wits: (lam 4. 0 1
employees (fall and/or part- iiMe).4 have hired the sub- contractors Neva con. traction
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. El Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. insurance comp. insurance.t
r uired. ] 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.[ } Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12•.0 Roof repairs .
insurance required.] f c. 152, § 1(4), and we have no .-�
employees. [No workers' 13.0, Other .-F (rtc (4, (GA., +tfl'`•
comp. insurance required.]
Any applicant that checks box 111 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.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or net those entities have
employees. If the sub - contractors have employees, they must pmvide 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[(' C i 6
F ( 4- 1'�S -cyr Uvth e C 0
Policy # or Self-ins. Lie, #: OR- (nv'eC,, L G & si ((t 7 Expiration Date: II -• ( -.2_61 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 $ 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 car ' ' under the :: ` mond per + ltres of perjury that the information provided abo e is true and correct.
Signature: ,- --,- / Date: D Li
Phone #: (g ' 7 2%
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):
1. Board of Health 1. 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: Licensed Construction Supervisor:
Paul Schmidt
Name of License Holder : 24 Chestnut St.
4
Hatfield, MA 01038
CS # 103635 U
Address 7 ( Exp. 5/20/2013
(
L
413- 772 -8898
Sign'kture t lephone
Home Improvement Contractor:
9. Registered Home Improvement Contractor: Co-op Power Inc. / Paul Schmidt
324 Wells St.
Company Name Greenfield, MA 01301
4165217
xp. 1/21/:
Address r (� r Z 413- 772 -8898
A - 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 build 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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [0]
Wor Description of Proposed rr � 1 , � o fft /Z - Yo
Work: P1 /- f t-'� D ,,✓ �fv' �II-Y� ! /'�� ��
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 FQ UILDING PERMIT
1, �C I , as Owner of the subject
property /
hereby authorize 'I L i Ct ' /yy t -1,-N.
to act on my behalf, in':II ma - relative to work auth• ized by this •uildi g permit application.
A f. I I I .._ A
Signature of Owner '✓ Date
I, i, M1(/Jt in , 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 Na e P r4117 Signature of Owne Date
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., e .
Lot Size I I I F I
Frontage I I II I
Setbacks Front I I I I
Side L:I I R:I I L:I I R:I I I I I
Rear I I I I I I
Building Height I I ( I I I
Bldg. Square Footage I I ( I% I I I I I
Open Space Footage %
I I I I
(Lot area minus bldg & paved I I
parking)
# of Parking Spaces I I I I I I
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ver been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 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 0 DONT KNOW 6 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 O V//
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 0, 7"
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
_, 4 li t
Department use only
of Northampton Status of Permit:
RECEIVED Bu ding Department Curb Cut/DrivewayPermit
12 Main Street Sewer /Septic Availability
AFN ;:1 ,; Room 100 Water/Well Availability
1 tsiort ampton, MA 01060 Two Sets of Structural Plans
phone 413 - 5 7 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
L__ 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
2-i V (M e2 t- f r. Map Lot Unit
F L t -( Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
o � I aI k► 0 51- !—
Name (Print) Current Mailing Address /
Telephone —(� _
Signature
2.2 Authorized Agent:
� / 3L cf (,/? t f 5r �� way 1 t &7 2 0 I3o /
Name (Pri ) 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 2 c' 7 2- , i1 (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) Z C > J . d a Check Number �pp,3 5 S
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature: C `f 12711 Z
Building Commissioner /Inspector of Buildings Date
21 KIMBALL ST BP- 2012 -0938
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A -188 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 -0938
Project # JS- 2012- 001636
Est. Cost: $2532.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 14810.40 Owner: MCGRATH NANCY & MARGARET TACY C/O ROSS J BELL
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 21 KIMBALL ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:4/30/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: FLOOR 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 4/30/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner