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43-145 f 'AM t`. mass.save PERMIT AUTHORIZATION FORM - Lec of the property located at: (Owner's Name, printed) (Property Street Address) (Cityfrown) 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 prope Own 's Signature Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above refer6nced project: Participating Contractor Date Rev.5J24/2012 City of Northampton Massachusetts DEPARTMENT OF BMWING INSPECTIONS 212 Main Street • Municipal Building Jds �b� Northampton, MA 01060 Property Address: / 1 Gr' �/L,, �.� ,r Contractor Name: ,J Address: City, State: Phone: )— —`Z 47 J 5�7,75 Property Owner Name: Address: C City, State: – - =--'�- .� (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 Ae Col>r awed&ofMamckmetts - _ D1eparbnent of1xdaWinfAccidents pfflce oflnvesfigadores 1 Congress Seer,Srfte 100 ?-' Boston,MA 02114-2017 www>ltrassgovldja Workers'Compensation Insurance Aff#&ift-Bafitders/Contracto t'tectridanoMforibers Agu eNd InfornUat M Plan Prat L-M- iv Name(BudaeWO%wizatiort/IndividuM): - yin- -r- &? P,,f.T4/C Address: Ci /Stai*Z : A&Z 9-U2 . Phone#: Acre,you an employer?Check the appro riate.bos: Type of project(reguireri : K 1. 'I am a employer with t I ¢. Q i am a general contractor and I 6. Q New construction employees(full and/or part tune* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. employees and have workers' 9. Q Building addition (No workers'comp.insurance comp.insurance.• required.] S. ❑ We are a corporation and its 10.0 Electrical repairs of additions 3.❑ I am a homeowner doing ail work officers have 11.0 Plumbing hairs:r additions myself(No workers'comp. right of exemption per MOL 12. Roof m insurance required]s c. 152,§1(4),and we have no ❑ employees.[No workers' I3 -Other �.aL�L�r`L3it1 comp.insurance required.] °Any applicant that dwb bat#1 mast also fill out the saotion below showing their workers'compensation policy mfomution. Hom wwocrs m to submit lhis affidavit hac Ong they we doing all work and then hire outside contractors maA submit aMv aft+devit 0fflca*i-!scmh. *Coanctom that check this box mat attscbed rot additional shat showingibe carne ofthe sub-cooftwms and store ut4dworra die entitie-have employees- If the sab,coubactom have employem they rmut provide their workers'comp.policy mrmbet: lam an employer,that tspwwAlag workers'compensation insurance.for my employees Below b ikepoly ana, ob s/te inforintt"L Insurance Company Name: aAfL,!An4 , Pollev#or Self-ins.Lic.#: r.a ✓r Expiration Date: �i Job Site Address: � � ) G-.,f A E Py— Cityntatmaip: Attack 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 Offic=If Investigations of the DIA for insurance coverage verif cation. 7 d hereby ceria under ge d ablest that the In rmatlonpmvlded aboue Ist!rae and cane: 5 � Phone#: Offidat use only. Do not wride in A&area,to be completed by city or town oJ,jlc&L City or Town: Petrmivuceuse# Issuing Authority(circle one): ! I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 1 6.Other Contact Person: Phone#• ' SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sunervisor: Not Applicable ❑ Name of License Holder: 03 a V ' l�1 Uc erase Num� t/ -zo �0) ,� Ad;d Expiration bate 1 -- 3 ignat re Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ TbL W amy7L - try-ay i, I Y yI Company Name Registr— at—' ion Number 7,q s Z ) -7 1 1-5 ' Address . piratio Date .3�°— Telephone )—y�3 4- 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.....:016 No...... ❑ 11. - Home Owner Ezemotion 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 Sunervisor 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 Alterations) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[ Brief Description of Proposed j 1�� Al f Work: 71- o m 4 C SD (1Z Alteration of existing bedroom Yes�No Adding new bedroom Yes No,�,+ rt�i Attached Narrative Renovating unfinished basement es (/� No Plans Attached Roll -Sheet 6a. If New house and or addition to existina 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, ED W.MCD J A-Al-t— as Owner of the subject property SOL gayke kl',4 Q r L �,9 hereby authorize to act on my behalf, in all matters relative o work authorized by this building permit application. Signature of Owner Date I 0 �J r` vim'Y� 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. L .� Pri�i' Na4fer � ) Signatu Agent Da Tel 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 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO / DONT KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , 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 0 NO l6 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 © NOP IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only of Northamptontatusaf+errt►it ding Department Curb Cufloriv y Pmt 12 Main Street SeweiitepttAvallalftl SEP -- 2 2014 yJ Room 100 Water/Wel A Wlability rth mpton, MA 01060 TWO Sets of Strucwrat Puns Electric, P umbino fionoA"9158,-1240 Fax 413-587-1272 Plot/Slte Plans Northar,ip,cn- %4A�,Cif Other Spa* 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 l/ Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: i5OWArp L)oQf/- Name Current Mailing Address: Telephone Si atu 2.2 Authorized Assent: Name rint) � � Current Mailing Address: V)?—. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building —2, (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=0 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0241 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413)247-5739 PROPERTY LOCATION 151 GREENLEAF DR MAP 43 PARCEL 145 001 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 INFORMATION 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 oli Delay G Sig of it g fi taI 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. 151 GREENLEAF DR BP-2015-0241 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 43 - 145 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-2015-0241 Project# JS-2015-000451 Est. Cost: $2800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 41294.88 Owner: SAYER EDWARD J&AMANDA REILLY Zoning: Applicant: PAUL SCHMIDT AT. 151 GREENLEAF DR Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:91312014 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 Shmature: FeeType: Date Paid: Amount: Building 9/3/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner