36-265 City of Northampton
Massachusetts
\t DNPAR2241TPT OF Bmz.DING INSPRCTIONS yJ b
212 Main Street • Municipal Building �f. 0
Northampton, MA 01060
Property Address:
Contractor
Name:
Address:
i `
City, State:
Phone: l ( �" o�L ?" 5-r/ /
Property Owner
Name: Y-
Address: (e ' /��' LI--"RA L4
City, State:
.�GNPA, (contractor) attest and affirm that the building I intend to
ins IatL a 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
OwMA
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211 MWb ridge Road
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The Commonwealth of Massachusetts
Department of Industrial Accidents
= Office of Investigations
600 Washington Street
Boston,MA 02111
• www massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information PI lease Print Legibly
Name(Business/Orgartization(ludividual): S�L. — �. (}�}n P mP b�? � 'i���C!t)r,-J!+fie
Address: c— r,l'�P She L+
City/State/Zip: O1 b3 Phone.#: 4413- q-1. 5 73
Are you an employer?Check the appropriate box: Type of project(required):
1.[ I am a employer with 4• ❑ I am a general contractor and I
employees(full and/or p tune).
* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.
t 9. F1 Building addition
required.] S.❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers'comp_ right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.('Other
comp.insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homcbwners who submit this affidavit indicating they are doing all work and then him outside contractors must submit 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
employes. 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: I Q 'Z 'Lr:t) i2.)Q,2 r�� q, L cam.
Policy#or Self-ins.Lic.#: 5 % o Expiration Date:'-'
Job Site Address: ,z2 i I t ITT V1� ,�dRl� Ic 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 ofa
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 fins:
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.
Ido hereby certify u r tire pains ad enal&.s ofperjury that the information provided above is true and correct
Si ature. Di / Date:
Phone
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: Alone N:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction rvisyor: G Not Applicable ❑
Name of License Holder: `mot �-x 11"�\ J
Moen-se Num er
1-,� fi��� 1 L)3 -s-) -)-o� 1
Addres Expiration Date
Si nature Telephone
9.Re istered Horn Im rovement Contractor: Not Applicable ❑
-7441:5-
Company Name Registration Number
{- 4- 12 ,
` Expiration Date
Telephoh2�'
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 ermit.
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 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 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 ver been issued for/on the site?
NO O DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW I YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW a YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , 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 vation,or filling)over 7 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_
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[
Brief Descri tion of Proposed
Work:�llrfA --t12 a7,4i `tea ��-�'� c� `�P�C2• �tJ- <;ec�linc aL fl�Q�s��
Alteration of existing bedroom Yes `INo Adding new bedroom Yes ---'No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. If New house and or addition to existinq 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 CONTRJkCTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
r
property
hereby authorize
to act on my behalf, in a I matters relative to work authorized by this building permit app ica'on. s
_ tee C� [ �� ►�;� �l t t— t ovr
Signature of Owner Date
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.
Sig under the pains and penalties of perjury.
Print Name r
Date
Signature f Owner gent
Department use only
City of Northampton Status of Permit:
Iuilding Department Curb Cut/Dhveway Permit
�t( 2 Lii{4 212 Main Street Sewer/SepticAvai(abiliiy
L j Room 100 Water/Well Availability
rtham ton, MA 01060 Two Sets of Structural Plans
Eleciric ru i7G ng&Ga In�pecilo p
tl „i n h"121�[�4 -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
This section to be completed by office
1.1 Property Address: �,� 1
1 M�� l - '�,�'� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
-&a, �
Name(Print) Current Mailing Address: ,`r \5-940 - '734-3
"Y
0 n �u��� Telephone
�.,,
Signature
2.2 Authorized Agent:
1 f-)C�ffl� A-A- i"
Name(Print) current Mailing Address:
-'It 5�� '��
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Q 00 (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
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0593
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESSIPHONE 24 CHESTNUT ST HATFIELD (413)247-5739
PROPERTY LOCATION 211 MAPLE RIDGE RD
MAP 36 PARCEL 265 001 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 76�34 ON
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL
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:
pproved 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
em i ' clay
Si e of R 6 ff g b ffi cial 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.
211 MAPLE RIDGE RD BP-2015-0593
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-265 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-2015-0593
Project# JS-2015-001125
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.): 151588.80 Owner: FIENGOLD BARRY&MARCIE S YOSS
Zoning: Applicant: PAUL SCHMIDT
AT. 211 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.11/21/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION & AIR SEAL
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 11/21/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner