24D-124 (3) ���E••�n8jyrkk
40
SDL CONTRACTOR
PERMIT AUTHORIZATION FORM
I, ✓ V 44,k Kt V-e owner of the property located at:
(Property Street Address) (City/Town)
Hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor, SDL Home Improvement Contractors Inc.,to act on my behalf and obtain a building
permit to perform insulation and/or weatherization work on my property.
k:2--
Owner's Si natu
Date
City of Northampton
Massachusetts
r
.A w;
DEPARTMENT OF BUILDING INSPECTIONS `
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address:
Contractor )
Name: 1-,i(5YLI)r 22111 :12 RA ZIl
Address: '"l G 1V"ej-TWI1r
City, State: HA/F r "A
Phone: r" � L
Property Owner
Name:
Address: V9
City, State: 4 a r-3',61��� Y74A .!),jQjz2
I, 4!vtl� ��rYl J (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
The Commonwealth of'lilassachusetts � ''riot Farm
Department of industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/-Plur,3"aers
Applicant Information Please Print L.—:Ibly
Name(Business/Organization/Individual):
Address: .
City/State/Zip: y) � c Phone#:
Are you an employer?Check the appropriate boa:
u �. I am a general contractor and I Type of project(requir���):
1.�am a employer with -1 ❑ s b. ❑New construction
employees(full and/or part-time).21 have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
cum insurance.= g- ❑Building addition
i [No workers comp.insurance p
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] c. 152,§1(4),and we have no
employees. [No workers' 13.,-Other !=JA1, ,A
comp.insurance required.]
*Any applicant that cheeks box 41 must also fill out the section below showing their workers'compensation policy information.
Homeon tiers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indica:sns such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitiEF -:ave
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number-
1 am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and'r.•b site
information.
Insurance Company Name: -f TG (-,Aru/Ar1j1 -
Policv#or Self-ins.Lie.#: —0— V.y Expiration Date: Z Z3
Job Site Address: 21 i }�Jui7 r Aid Cit}/State/Zip: r 44 YnA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and tiraaitn date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pero.ities of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of 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 Offc_ :f
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the pal a d penalties!!f ur p that the information provided above is true and corn-?fz.
Signature: Date•
Phone-41-: �`' 7/3�'" 2,V7 3�
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 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Ins-: Ytor
6.Other
Coataet Person: Phone#:
.� i
SECTION 8-CONSTRUCTION SERVICES —7
8.1 Licensed Construction Su_ ep rvisor: Not Applicable ❑
Name of License Holder: �� Ala 1 y�4.3
Lice esn _Number
Addres ` Expirati n Date
Si atu Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration umber
Address J Expirhtion D to
Telephone/`!)) — 7
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(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 rime,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
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[E:3[ Otherd-4
Brief Description of Proposed
Alteration of existing bedroom Yes No Add ni g new bedroom Yes X No ��r� �I '� � �
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, u m/'J 1< as Owner of the subject
property f%
hereby authorize b �
to act on my behalf, in all matters relative to work author ed by this building p6rryTit application.
Signature of Owner Date
jas 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 Name
-72 Y
Signature of Owner/Aden bale
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 ever been issued for/on the site?
NO Q DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW Q YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW jo YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , 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, a avation, 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
City of Northampton Status of Permit:
�--- ,.. Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
_A 1s Room 100 Water/Well Availability,
lll
DAD
orthampton, MA 01060 Two Sets of Structural Plans
one 413-587-1240 Fax 413-587-1272 PlotlSite 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
�) _M647 j1110_� �►►� Map Lot Unit
�� Zone Overlay District
��/'�• ���% �� ' Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addre
,fm c Telephone
Signature
2.2 Authorized A e�nt:
Name( ri ) Current Mailing Address: .'
�.--- 1 -Zy7- 73-'1
Signatug Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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) Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1027
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 21 HOOKER AVE
MAP 24D PARCEL 124 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out i
Fee Paid
Typeof Construction: INSULATE EXT WALLS p (J
New Construction L
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
INFO ATION PRESENTED:
oved 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
D ela
Sign 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.
21 HOOKER AVE BP-2014-1027
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 124 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-2014-1027
Project# JS-2014-001745
Est.Cost: $3800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 5096.52 Owner: KEMP JUSTIN
Zoning.URC(l 00)/ Applicant: PAUL S C H M I DT
AT: 21 HOOKER AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.41812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE EXT WALLS - final 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 4/8/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner