30B-031 (2) City of Northampton
t MasaachusettS
L :G
t tAj
f VWARD9WT OF BOIIZNG INSPSCTIOe3 y
212 Main street • mmici Suil
Northampton, MA 0 060 ssN •.���^o
Property Address: _ /&
Contractor _E
Name:
r
r
Address:
City, State:
Phone:
Property Owner (,
Name: 2 n n }�r" qc-,A l
Address: i Co �1) o-)cx:A -
City, Stater[ n 1°1c) C-:)1 C) C e
R
(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
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
112 1 ' uQ11,A-
(Property Address)
C:�S�Mlt&)
d
( roperty Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
Otle—es Signature-
Date
� Jq
NI
DNS
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
kv 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/Organization/individual):
Address:
City/State/Zip: L d yl
one#:
Are ycyt an employer?Check the appropriate box: Type of project(required):
1. 1 am an employer with % 4.®1 am a general contractor and 1 6.0 New construction
employees(full and/or pa tme).* have hired the sub-contractors �.ORemodeling
2.01 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers' 9.0 Building addition
[No workers'comp.insurance comp.insurance.+
required] 5.0We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required]t c. 152,§ 1(4),and we have no 12.0 Roof repay s
employees. [no workers" 13.(Other
comp.insurance required.]
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
Momeowners 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'compensado�nsurance for my emplo'ees.Below is the policy and job site
information.
Insurance Company Name:_ � 1f '
i
Policy#or Self-ins.Lic.#: Expiration Date:
/�
Job Site Address: 1� io �1 cxi� __ 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 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 ci«il penalties in the form. of a STOP WORK ORDER and a fine of
S250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the
DIA for coverage verification.
1 do herby certify _ der the pains nd penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Print Name�yLL� �CJ t M t GL� 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#•
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: --R," aivyu a� 10 5 (-0,3
)4a4-r�c4ffltq �+� License Number Qj
Address Expiration Date
ignature Telephone
9.Rectistered Home Im v e t Contractor: Not Applicable ❑
S 6
/�'7 J
Company Name Registration Number
—r2 '7' 1
Address 1 y Expiration Date
C) 3 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...... ❑
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 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 Gable 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 S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding ] Other[ /
Brief Descri of Prop ed �
Work: t_3, n l�" �u.r /t: � 0X --tb ►e ' r
Alteration of existing bedroom Yes t/` No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes k- No
Plans Attached Roll -Sheet
6a.If 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 AG NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, n i- e_r QLxAz)nCU 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
" ° lam
I, c3-Gk1 ��{'1YYL t��� ld .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
/0-
Signat re of Owner/Age 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 ver been issued for/on the site?
NO O DONT KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O 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 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 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 O NO V
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,expdvation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
- # C of Northampton
Bu ding Department
e; 12 Main Street
Room 100
DEPT.aruia. ar c w4f EcT o0 m ton, MA 01060
Nc��Tr+n1��TCr�,n��a��so P
p one 413-587-1240 Fax 413-587-1272
FY
F�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-WE INFORMATION
1.1 Property Address: i
n �fl C ) i v CQ -2)-- �oAe o .
SECTM 2-PROPEL'OPPIERSHINAUTHORIZED AGENT
2.10wner ecord:
0 CP r vvxr) �-
Name(Print) Current Mailing Add
<--', L Telephone
Signature \ ,
2.2 Authorized Anent: S��- 1 ��-rte yD,2� dam' R`f
.2 F!� � 8 )—)--
Name(Print) J` Current Mailing Address:
Signature( Telephone
SECT X 3 f&TiIMA LANSTItt C F10N£f�STS
Item Estimated Cost(Dollars)to be Official Use Only
com feted b rmit a licant
1. Building DD CL7 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construchon from.6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Che&Number Ile 3W 1
This Section For Official Use Only
Data
Building Permit Number issued:
Signature:
Building Commissionerflnspector of Buildings Date
File#BP-2016-0493
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 16 NORWOOD AVE
MAP 30B PARCEL 031 001 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
Tyneof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessoty 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
INFOIATION PRESENTED:
to`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
olition elay
Sig re uildmg f 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.
16 NORWOOD AVE BP-2016-0493
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-031 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-2016-0493
Project# JS-2016-000830
Est.Cost: $2000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(scp ft.): 11717.64 Owner: TRUSHAW JENNIFER R
zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 16 NORWOOD AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.10 11512015 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 10/15/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner