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46-035
City of Northampton Massachusetts a w } DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 AP— Property Address: / Y �A24 �I T7� Contractor Name: -�[`. '� ✓ " �''w? '� �� 1. Address: �' 7,�, City, State: I,/(� t1�'1� Phone: Property Owner Name: Address: City, State: fll)r) g4 /1�.C1� A I, � ,,S�cNl,t (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 � � it! o� s mass save WITRACM M PERMIT AUTHORIZATION FORM I, Andrew Pelis ,owner of the property located at: (Owner' me,printed) 144 Krry St Northampton (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. )" � � L :�JLJ �s Owner's Signature Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Far o.'iice us:Ont�r Rev.12132011 T ke Commonwealth of Massachusetts '"""""' _-u Department of fndustdal Accidents Office.of b vestigations 1 Congress Street,Suite 104 - - -=- Boston,M4 02114-2017 www.massgovldia Workers' Compensation Insurance Affidavit:Bu lders/Contractors/Electricians/Pt>favj,,jers APPUcant Information Please Print Lte4biv Name(Business/Orgattizaaon/Individuat): � L----- jyj r �4,zmz Am 6_ Address: L q a y1i . Ark;44 _ -� City/State/Zip: `°) ',�' . C ' Phone#: �''1S� Are you an employer?Check the appropriate bog: Type of project(requir•=�J-D. I.& i am a employer with 4 4• ❑ I am a general contractor and I 6_ ❑New construction employees(full and/or part-time).:' 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' 9. ❑Building addition [No workers'comp.insurance comp. insurance.+' required.] 5• ❑ We are a corporation and its 1011 Electrical repairs additions .3 ❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs-7 additions myself.[No workers'comp. right of exemption per MGL 12.F1 Roof repairs insurance required.i c. 152,§1(4),and we have no ��T'l'��l employees.[No workers' 13.2-Other comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their%%vrkers'compensation policy information_ Homeowners who submit this affidavit indicating they are doing all wort:and then hire outside contractors must submit a new affidavit indica:„ such, =Contracrors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities ave employees. If the sub-contractors have employees,they must provide their Avorkers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employem Below is the policy and..ob site information. Insurance Company Name: .l- r A J1I.'' r14 C6 Poliev#or Self-ins.Lie. Expiration Date: -a Y Job Site Address: 15 City/State/Zip: /.4 ��w Attach a copy of the workers'eo ensation policy declaration page(showing the policy number and expira iic-a date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pertai ties of a fine up to$I,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDE?=.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 Offic= ;f Investigations of the DIA for insurance coverage verification. F do hereby cedify under the ai d enalties o u that the informaaYon provided ab ve is ue and Sisriattrre: Date >7 4 Phone#• '- V13— �:7 7/ 3 Ct Official use only. Do not write in this area,to be completed by city or town offi'cfai t i City or Town: Permit/License# } s Issuing Authority(circle one): ` 1.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 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �(,� Je Xy ! U ! .J License Number Z , 'T Add re Expiration Date >3-z -73� igna ure Telephone 9.Realetered Homo Improwe-ment tor: Not Applicable ❑ Company Name Registration Number Address Expiration ate Telephone 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...... ❑ 4I 1 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other04 _-V y A) Brief Description of Proposed Work: N�jt11 � � ` �i)fil (11+✓n U)A.1� � T /� .+VSC� -, MAX 750 Alteration of existing bedroom Yes No Adding new bedroom Yes No CND` wAo Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet �T 6a. If New house and or addition to existing housing, complete the followina: 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. 1. 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 as Owner of the subject property hereby uthorize V) J4 to a o i att relatives to work authorized by thi ilding permit 8—nplid5tion. i Sig ure*-owner Da as Owner/Authorized Agent h eby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed und0he pains and penalties of perjury. )G Print ame S--b l Signatu 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/Findin ever 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 Registry of Deeds? NO ® 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 J0 DONT KNOW Q YES Q 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 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 Q 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 Q NO ;[X IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: J 1, Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability' Room 100 Water/Well Availability rthampton, MA 01060 Two Sets of Structural Plans ti® b�gA e -587-1240 Fax 413-587-1272 Plot/Site Plans �ecui Nosh mP�on, 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 Map Lot Unit Zone Overlay District 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing ddrehs- r,�f✓*-P� Telephone Signature 2.2 Authorized Aaent: jr!/1 0 ��/�1�i1 , •� l� �4"I m Name(Prin Current Mailing Address: /-- y)3-- z L 7--s-73� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ` Yo S (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) v Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1307 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 14 FERRY AVE MAP 46 PARCEL 035 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION 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 INFO,RDaATION 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 D ition Delay Signature o ui ding 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. 14 FERRY AVE BP-2014-1307 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:46-035 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-2014-1307 Project# JS-2014-002201 Est. Cost: $2408.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 6882.48 Owner: PELIS ANDREW S zoninp-: Applicant: PAUL SC H M I DT AT. 14 FERRY AVE Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.611012014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 6/10/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner