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23B-042 (3) City of Northampton I Massachusetts X ` DAP RRUBW Or BUXZDING INSPLCTXCW yJ: 212 Main Street • Municipal Building . .. ac Northampton, MA 01060 SNyYj1� Property Address: Contractors Name: Address: City, State: OLA"-IA i miq 0 tc�:'& Phone: -14 Property Owner Name: t' D ( ` Address: City, State: �'h w b(.p 0 1, A (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 f ti VW . mass save -••-- PERMIT AUTHORIZATION FORM I, QJ 4 (mE 6yz DL/SS owner of the property located at: (Ownees Name, printed) qtVol (�I ti N1�F—v,0,A « , (Property Street Address) (City/Town) 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. Owne s Signat [30-2-- Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Rev.12132011 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinessJOrganiration/Individual): - -ne c•`� !�+�� ' ' Address: gQ 0,16,p s4-r ± `---A-r ,e e+ City/State/Zip: VA r' A O 5&' Phone.#: Are you an employer?Check the appropriate box: Type of project(required): I.[_`f I am a employer with 17 4. E] I am a general contractor and I * have hired the sub-contractors 6• E]New construction employees(full and/or p tine). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. employees and have workers' E]Building addition [No workers'comp.insurance comp.insurance.t required.] 5. We are a corporation and its 10.Q 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 I3 Q�Uther -LSi t Gt�1 O✓1 employees.[No workers' comp.insurance required] `Any applicant that checks box#1 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 hire outside contractors mist submit a new affidavit indicating such. tContnictors that cheek this box must attached an additional sbeet showing the name of the subcontractors and state whether or not Own entities have employees. if the subconttctms have employees,they must pnM&their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees!. Below is the policy and job site information. Insurance Company Name: ,- Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: CitylState/Zip: K Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirati date). Q) 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 Office of _ Investigations of the DIA for insurance coverage verification. I do hereby certify u he pains nd enaldes of perjury that the information provided above is true and correct: Signature: Date: — Phone M %- / -2,- 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Ucensed Construction;wpsrvisySor: ii Not Applicable ❑ Name of License Holder tense Rum r I UJ �c � I � Addres � � Expiration Date Si afire Telephone 9.Realstered Home Imiprovement Contractor: Not Applicable ❑ vi 1 -7441S Company Name Registration Number �- J-7 7AJ s Expiration Date Teiepho�h��J 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....... Sz 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 ressuonsible for all such work performed under the buildine 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [[I Siding[O] Othwl Brief D do of Prgpo Work: S �� '►�� i2 I��' -�_ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or additio n 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? L)t l Fireplaces or Woodstoves Number of each g. Energy Conservation Compl' nce. Masscheck Energy Compliance form attached? h. Type of construction 0- —' 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, > as Owner of the subject property hereby authorize P;��jwj i'(4,t Oon h2V (Ae-) to act on my behalf, in all matters relat' a to work authorizqd by this building permit applicati n. 1 �Q• [�-i C �tiF 22'� � Signature of Owner Date t Gh'o-t 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. Signel-li"dnthe pains and penalties of perjury. Print Name /1�5�] Signature of O er/Ag Date Section 4. ZONING Ali 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 Q DONT KNOW YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 Q , Date Issued: C. Do any signs exist on the property? YES 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(dealing,grading,ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES V 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 Room 100 WaterMlell Availability, tv�b�ne a G►M010P� rthampton, MA 01060 Two Sets of Structural Plans tpe hamP�O�' p one 413-587-1240 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 G ( Map Lot Unit 0 / Y Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: i ro IV- � 1 rn S4- Name(Print) I Current Mailing Address: (; t L4+ac� d. Telephone C� Signature 2.2 Authorized Agent: t?LJ -44a ame(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS u Item Estimated Cost(Dollars)to be Official Use Only completed by rmit a plicant 1. Building D �i� (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) C7,�c Check Number This Section For Official Use Only Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0781 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739 PROPERTY LOCATION 184 NORTH ELM ST MAP 23B PARCEL 042 001 ZONE URB(100)/ 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&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 INFOjMATION PRESENTED: r 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 on Delay S ng ffi al 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. 184 NORTH ELM ST BP-2015-0781 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B-042 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-2015-0781 Project# JS-2015-001520 Est. Cost: $2570.00 Fee:$55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 14418.36 Owner: BROUSSARD JAMIE Zoning. URB(100)1 Applicant: PAUL SC H M I DT AT. 184 NORTH ELM ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:21512015 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 Sisnature: FeeType: Date Paid: Amount: Building 2/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner