17A-005 (2) CO-OP de"
J 1
POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
PERMIT AUTHORIZATION FORM
I, E, S e pL 7 � k _ owner of the property located at:
(Owner's Name)
(Property Street Address) (City /Town)
hereby authorize____ f i,) �,✓— ,
(Contractor)
to act on my behalf to obtain a building permit and to perform insulation and /or
weatherization work on my property.
t
(Owner's Si g nat e)
•
(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, _ r _. r ,
j
YHAM :r City of Northampton
?,: ° " X515, r s � ,
L , Massachusetts .. * �" l,-
s
y
D EPARTMENT OF BUILDING INSPECTIONS x':, ! en
\ y r 212 Main Street • Municipal Building x� ;tiS
\ „.m+� :.'”, Northampton, MA 01060 'JY 30
Property Address: II 1/('L')W 11 /14414 FLE1447 lit,
Contractor
Name: ,ifl 0-12 P0YVi - r 4e
Address: '? 2 ({ WrLt- Sr.
City, State: 61 ru ovr Mi9 D / 31 j
Phone: (ii 3 J 3- }Z S 6 i
Property Owner
Name: o t le-
Address: SrvOv1.�� i rs r
l
City, State: do
l
I, kA (contractor) attest and affirm that the building I intend to
insul to 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 co• • : this affil .
Contractor signature i
Date
gi-l/ 2
CO-OP
r_
POWER
BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY
Affidavit of Waste Disposal
1, 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:
Dt t - t S -v ft t,= V37v MA
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 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
7,,
,,,..0) -62 , „b./a of . - ir 4
`gym! -., r Office of Consumer Affairs and Business Regulation
-f 10 Park Plaza - Suite 5170
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 0 Renewal 0 Employment 0 Lost Card
DPS -cm %, ECM- 04JC4- C-1C121E
,p, ,J�te - 0Wi072f✓lulo Ci,ficiaaaciudoet6
:. - Office of Consumer Affairs Sr Business Regulation License or registration valid for individul use only
ilk °, HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
r. Type:
Office of Consumer Affairs and Business Regulation
r — t Registrat 165217 yR
Expiration: 1/21/2014 Corporation
10 Park Plaza - Suite 5170
Boston, MA 02116
CO P POWER, INC
PAUL SCHMIDT
3
1 /
24 WELLS ST ,��
GREENFIELD, MA 01301 - its 1...- Undersecretary Not v. • without signature
'� Massachusetts - Department of Public Safcts
��# Board of Building Regulations and Standards
l"JJ Construction Supervisor License
License: CS 103635 -
Restricted to: 00
,
PAUL SCHMIDT
24 CHESTNUT ST
HATFIELD, MA 01038
�
�-
'!___ `�"'` Expiration: 5/20/2013
C Or nun issiuner Tr#: 103635
The Commonwealth of Massachusetts
Department of Industrial Accidents
.� ; 1 ,_ Office of Investigations
, � ; }} '.� ,i, 600 Washington Street
.1t= A Boston, M4 02111
4 4 „ . W P www. nass.gov /dirt
Workers' Compensation insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leuibly
Name (BusireniOrganizztionlindividual ): �. (i e f POW -I- IA L
Address: 31r c-( 0./& ( c S " f
City /Stale/Zip: 1 -"I't , C"f J , - j/1"\ X ' Phone 44: ( 3 'j 7 2— 6` cj S'". Are nu an employer? Check the appro lox: Type of project (required):
i . I am a employer with I `i• 0 I am e general contractor and I
employees (full andlor Sri- tinne).4 have hired the sub- contactors 11 C New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. ' 7. 0 Remodeling
slip and have no employees These sub - contractors have 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any ap t3 9. [] Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.[] 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.[j Roof repairs .
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.5, Other -1 lS £' ( tll■
comp. insurance required.]
*Any applicant that checks box 01 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 him 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: ( 1 i'1 C (f `j / Y ' F i c 6 , -4---N\ S 'r Ovv e— C., b
Policy # or Self -ins. Lic. #: 0 ki EC, L & 8n (p t Expiration Date: l't "-' (" (5 t 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 andtor 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 cert , under the , : ins f nd pet i Ides of perjury that the information provided abo e is true and correct.
Signature: .---r- Date: .7 I Li
Phone #: '4[; - ` 7 2-' 9
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
Licensed Construction Supervisor:
8.1 Licensed Construction Supervisor:
Paul Schmidt
Name of License Holder : 74 Chestnut St.
Hatfi, MA 0103 8
CS # 103635 U
/ 0
Address Exp. eld 5/20/2013
I 11111111°. 67 Z 413- 772 -8898
Signatur:r Telephone
Home Improvement Contractor:
Co -op Power Inc. / Paul Schmidt
9. Registered Home Improvement Contractor: 324 Wells St.
Greenfield, MA 01301
Company Name
# G
165217
/ Exp. 1/21/
Address � �� 413- 772 -8898
A k t Z Teleplpaul @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 buildin ermit.
Signed Affidavit Attached Yes No El
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 E
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [El]
Brief Description of Proposed
Work: 1 u t el" - Y4 (A..., g-- I al,
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, C r1:% Avt/>lit,.'1-,A - F/Ltiy' 3 , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authori d y this building permit application.
S ignature of Owner Date
dtit7H , as Owner /Authorized
Agent hereb 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 /�� , , i , ,„„irp , ", i; - ,
Signature of Owner /Agent 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
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 Q DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regist f Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ®/
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
ty`' --I City of Northampton Status of Permit:
te r;_: �` - Building Department Curb Cut/Driveway Permit
'L K 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
GcT - Northampton, MA 01060 Two Sets of Structural Plans
- "�'+c� MAC ^ e
413-587-1240 Fax 413-587-1272 Plot/Site Plans
N pS NPM F
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
l TLS Map Lot Unit
/U144, 4- fr d M/ p
Q 2 Zone Overlay District
Elm St. District CB District i
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Rec :
Name (Print) Current Mailing Address:
‘ Telephone
Signature
2.2 Authorized Agent:
� eo va '3 Z Lf (M f Sr. ��yv�'vr`.�'z 1...1,0 Name (Prirft) Current ailing Address: PA 0 l 3 p
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building I qi't/ /� r fro (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) f q (°2 . ev Check Number c 3,1 ( 13 _ S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1098
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 15 LEENO TER
MAP 17A PARCEL 005 001 ZONE RI(100) /URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
,
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
i
Fee Paid
Building Permit Filled out I I
Fee Paid W a `"~ L
Typeof Construction: INSULATION
New Construction
Non Structural interior renovations i t CP /1
Addition to Existing C�
Accessory Structure
Building Plans Included:
Owner/ Statement or License 103635
3 sets of Plans / Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
/ : elay
di e ' ev 6 7--
Signa e 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.
15 LEENO TER BP- 2012 -1098
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 005 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 -1098
Project # JS- 2012 - 001885
Est. Cost: $1746.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 13503.60 Owner: ZIDIK JOSEPH & ROBERTA M
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: PAUL SCHMIDT
AT: 15 LEENO TER
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:6/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION - FINAL UTILITY REPORT
REQUIRED
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 6/13/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner