24A-133 (2) 0' <HAMPT04 City of Northampton
Massachusetts �� {G
1 '4P DEPARTMENT OF BUILDING INSPECTIONS y �
+m ? 212 Main Street • Municipal Building J E,pf 0 C` b
Northampton, MA 01060 Y BO'
Property Address: 397 Prospect St
Contractor
Name: Co -op Power /Paul Schmidt
Address: 15A West St
City, State: West Hatfield, MA 01088
Phone: 413 - 772 -8898
Property Owner
Name: Mark Arsenault
Address: 397 Prospect St
City, State: Northampton, MA 01060
I, Paul Schmidt (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 copy of this affidavit.
Contractor signature
Date 09/18/2012
-e g 0411/122 ♦ of 4"
..:..,
_ _
t1 _ _ 1, Office of Consumer Affairs and Business Regulation
7 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.
❑ Address ❑ Renewal ❑ Employment 0 Lost Card
DF5 -CAI 0 ECM- C4/C4- G1C/�121E /
g/f7,6 -6...a cii.. �.a4,„...Gr„elta
r¢,,, 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 Registration 155217 Type:
Office of Consumer Affairs and Business Regulation
Expiration: 1/21/2014 Corporation
10 Park Plaza - Suite 5170
----- ,•i Boston, MA 02116
CO- P POWER, I .G
PAUL SCHMIDT
324 WELLS ST \ 4
GREENFIELD, MA 01301 Undersecretary r Not v without signature
(Massachusetts - Department of Public SafetN
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 103635
Restricted to: 00
PAUL SCHMIDT
24 CHESTNUT ST
HATFIELD. MA 01038 ei. '
c--
'��- " - Expiration: 5120!2013
C'ontmiodoner • Tr#: 103636
The Commonwealth of Massachusetts
Department of Industrial Accidents
,7' Office of Investigative
' . �. 60 Washington Street
1= Boston, M4 02111
w1t1vy 2aass.go ' 1ia
Workers' Compensation insurance Affidavit: 3uildersiCenkracts,rsiElee r•icians/Plumaea•s
Applicant Inforn xt on CO' Pleasc Print Lea}.
l
Name 3vsires diyidUai): Cj e'W -lit C
Address: 3)- ( I& ( ( s -'
City /Sta Zip: (`c �� 'bone #J: ( l 7 — Z
A.r..eryou an employer'? Check the zippy + mate '; ,ype of project {ref fired :
i . ( 1 am :- employer with 4. 0 1 t;rt� a 2enera1 contractor and 1
p o3' er ' Nevi constnactior.
employees (full and/or - time).* iaNt faired the - contractors
2.0 I arrr a sole proprietor or partner- listed an the attached sheet. .. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
y ap 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.) 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 l am a homeowner doing all work officers have exercised their I I.[,) 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' 13.541011er Vets fit, (4i-r�e,
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.
rContractors 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 ant an employer that is providing workers' conrp'ensatiott insurance for not employees. Below is the policy and job site
irfc'rrnation.
PIQ
Insurance Company Name: ( W (f 1. [ � ' F [ C " -' �st.�'� Cry \ . b
Policy- # or Self -ins. Lie. ft: i � � L- . CO ( Expiration Date: R — Cl '--
sob Site Rtidress: (3 1 7 � cr� J— CityfStat /lip: L I Li. If 1.'' r I 0 1
Attach. a copy of the workers' compensation policy declaration page (showing the policy number and expiration_ date).
Failure to metre coverage as required under Section 25A of c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,50C1.00 and/or one -year irnprisonrnenf, as well as civil penalties in the form. ofa STOP WORK ORDER and a fine
of up to $250.0(} 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 ' ' ureter the e : ' t d p ties of perlary that the information provided oho e %s true and correct.
Simature: Date: _V I Li
Phone #: {. g ¥7 2y 1
Official use only. Do not write in this area, to be completed by city or town official
ial
City or Town: Permit/Liceasse #
Issuing Authority (circle one):
I. Board of Health L. Building lteparttnent 5. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector •
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Paul Schmidt 103635
License Number
24 Chest ut St 05/20/2013
Addre Expiration Date
413- 772 -8898
n ature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Co -op Power 165217
Company Name Registration Number
15A West St, W Hatfield, MA 01088 01/21/2014
A ress Expiration Date
Telephone 413 - 772 -8898
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 ® No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (I) 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
09/18/2012 10:07 FAX 4135860149 2001 /001
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition [] Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [j`] Siding [O] Other [[a]
Insulation
Brief Description of Proposed
Work: Imyrow 201 al, fl. orwall Insulati from 0" to ].S "; improve 1206 sq. fl. of enic 6ominian frame' 1012. install 90 sq. I . or buelnem rim joist Insulation
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll - Sheet
ea. If New.house:and or addition to existing housintii complete tthe
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, Mark Arsenault ,.as Owner of the subject
property
hereby authorize Co -op Power
to act on , in all ma rela ve to work authorized by this building permit application.
Signet OitindF Date
1 Paul Schmidt , 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.
Paul Schmidt
Print Name .
- --y'�� 09/18/2012
S nature of Ow
wned ant 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:
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 ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 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 (j YES Q
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 0
IF YES, describe size, type and location: ?,
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q NO ®
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
RECEIVED ity of Northampton Status of Permit:
: uilding Department Curb Cut/Driveway Permit
SEP 1 212 Main Street Sewer /Septic Availability
LYI2 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
BU ILD IN G I i tr ; •� ' - 4 3 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
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
397 Prospect St Map Lot Unit
Northampton, MA 01060
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Mark Arsenault 397 Prospect St, Northampton, MA 01060
Name (Print) Current Mailing Address:
339-223-2799
Telephone
Signature
2.2 Authorized Agent:
Co -op Power /Paul Schmidt 15A West St, West Hatfield, MA 01088
Name (Print) Current Mailing Address:
413 - 772 -8898
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 7,361 (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) 7,361 Check Number L_gt_57.c vv
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0316
APPLICANT /CONTACT PERSON CO -OP POWER INC
ADDRESS/PHONE P 0 BOX 688 GREENFIELD (413) 772 -8898 0
PROPERTY LOCATION 397 PROSPECT ST
MAP 24A PARCEL 133 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Y (511 Buildin. Permit Filled out
Fee Paid b •" WI
Tvpeof Construction: INSTALL ATTIC & BASEMENT INSULATION �S
New Construction
Non Structural interior renovations �d
'
Addition to Existing r �
Accessory Structure
Building Plans Included:
Owner/ Statement or License 103635
3 sets of Plans / Plot Plan
THE FOL 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
a
" ./0 7(yy
Sig a Buildin: • fficial 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.
397 PROSPECT ST BP- 2013 -0316
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 133 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- 2013 -0316
Project # JS- 2013- 000513
Est. Cost: $7361.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CO -OP POWER INC 103635
Lot Size(sq. ft.): 22694.76 Owner: WILBUR C KEITH & SARAH WILBUR C/O MARK E ARSENAULT
Zoning: URA(100)/ Applicant: CO -OP POWER INC
AT: 397 PROSPECT ST
Applicant Address: Phone: Insurance:
P O BOX 688 (413) 772 -8898 0 WC
GREENFIELDMA01302 ISSUED ON:9/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & BASEMENT INSULATION - in
progress inspection 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 9/24/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner