35-201 (10) 4W rV
:. PAMCMAIIIING
mass save COW RMWIR
savtt,gs F�rou�t�ror�'��n+ �
PERMIT AUTHORIZATION FORM
I, Donna Meisse , owner of the property located at:
(owner's Name,printed)
1300 Burts Pit Rd Florence
(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.
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
q1 -
For Office Use Only
Rev. 12132011
City of Northampton
.5 7: s�
massachusetts
�`.
RPARMearr or BaI2.DIBG nFSFz=CW
212 Main street • Municipal Building
Northampton, MA 01060y .. ��
Property Address: -'-
Contractor 5 Card+
i
Name: 1-- fL1 f'i7 t ,h►��Y'Cc(' i Al .
Address: rr
City, State: f't C3al tAA -j--MA C lat:&
Phone: .
Property Owner
Name: Q ' V �`�.Q
Address: r-�
City, State: P jQ C G ryv 1C)U
I, Tag) a M QO- (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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organi7ation/Individual):
Address: U
City/State/Zip: a
Are ygu an employer?Check the appropriate box: Type of project(required):
1.Q9 I am an employer with 4.01 am a general contractor and 1 6.❑New construction
employees(full and/or pa Mme).* have hired the sub-contractors 7.❑Remodeling
2.Q 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.❑Demolition
working for me in any capacity. employees and have workers' 9.❑Building addition
[No workers'comp. insurance comp. insurance..a corporation required] 5.0We are and its 10.❑Electrical repairs or additions
3.01 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption perm MGL
insurance required]i c. 152,§ 1(4),and we have no 12.❑D Roof repa' s
employees. [no workers' 13.&ther - '
comp. insurance required.]
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If
the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing�wo ers'compensation{assurance for m1 emplo ees Below is the policy and job site
information. 11 Insurance Company Name: r� 1
aa
Policy#or Self-ins.Lic. Expiration Date:
-- --
Job Site Address: I A� _g1±_ C� _ City/State/Zip: � t l C� V 0 1 Dlp �-
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
D1A for coverage verification.
I do herby certify der the pains d penalties of perjury that the information provided above is true and correct.
J
Signature: ! bate: LP
/ f
Print 'dame `L s /Yi lGL" Phone : /��j " �f 7
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):
l.Board of Heath 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: ' ? rn X ! .�J �i 3 5
License Number
Addres!307 Expiration Date
a '
ignature Telephone
9.Registered Home ovem t Cordraictor: Not Applicable ❑ _
Company Name Registration Number
�_ �i :Srra of � -Free+_. -- -- a / -7' 1 -
Address Expiration Date
a -4--e-t d , MA CA a��S' Telephoned/32y7'5137
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 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding Dm] Other[
Brief Description of Pro o �Dd A S
Work: s (lf\�4�,t✓.( I
Alteration of existing bedroom Yes V No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. !f 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
1, n A 1 � �t�� as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to worVabtholized by this building permit application.
Signature of Owner Date J D- I S
yam,d--1— 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.
Print Name
Signa re of(xwier/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/Finding ver been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO a DONT KNOW 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 Q
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
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(Gearing, grading, exfA vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
N City of Northampton
_ Building Department
212 Main Street ` ' '
.et Room 100ti ,
N Northampton, MA 01060 {
1 Ia phone 413-587-1240 Fax 413-587-1272
APPLIC ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Tfiis section to be cold by office
1.1 Property Address: '}}
l --5b6 Pi pl Map Lot Unit
miq D ' �(�� Zone Overlay District
/L [ I Elm St District CO District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: n
Name(Print) Current Mailir dress-
Telephone
Signature
2.2 Authorized Aaent.
Name(Print) Current M icing A Tess:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 60 (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 1S
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-1354
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 1300 BURTS PIT RD
MAP 35 PARCEL 201 001 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 Existin¢
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
INF( i ION PRESENTED:
t 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
n elay
�d 115
Si ature of Buildin 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.
1300 BURTS PIT RD BP-2015-1354
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-201 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2015-1354
Project# JS-2015-002480
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.): 46609.20 Owner: MEISSE DONNA&JOE HAMILL
Zoning: Applicant: PAUL SCH M I DT
AT. 1300 BURTS PIT RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.613012015 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 Denartment 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 Sienature:
FeeType: Date Paid: Amount:
Building 6/30/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner