24A-156 (5) OWNER AUTHORIZATION FORM V,-)--
ca►,�s
o �,�
ov+mer of the pmwty beaded at
{Pmperty Address)
o o
(Property Address)
hereby audwrt m
an authartzed subcrontra cWr for RISE EMtneertng,to act on my betud to obtain a bu#ft
permit and to perform work on my property.
Date
COY �
City of Northaptoa
Massaciusetts
212 Street • UM44jpa7, XW IA4a:q
Mores, HL G1060
Property Address: 1 A f,, �w
contractor -Pact f rru -f-
Name:
Address:
cfty, Staff: c - etd rn� O ti �
Phone., �41 3- a4`1,�
Property Owner
Name: 2 vL ca
Address: �o
City, State: �- -0 f U l
i, t1tc1 .`7c• l c�:�" (for)aftest and affirm that the big i intend to
invjkde does not have any open (knob and Um)wiring in the spaces to be ffm&W and that i have
provided the property owner with a cam►of this affidavit.
Contractor sgra�ure
Dade � D
.*I-- The Commonwealth of Massachusetts
zrMbM;-1
Department of Industrial Accidents
Office of Investigations
If 1 600 Washington Street
U Boston,Mass. 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Bu-,iness/Or_--anization/Individual):
Address:
City/State/Zip:
Ar�_yqm an employer?Check the 7 appropriate box: ; Type of project(required):
1.Ul am an employer with 4.01 am a general contractor and 1 6.C3 New construction
employees(full andlor parytime). have hired the sub-contractors
1 0 am a so le proprietor or partner- listed on the attached sheet. 7•E]Remodeling
I
ship and have no employees Thesc sub-contractors have
8.Fl Demolition
working for me in any capacity. employ ees and have workers
9.0 Building addition
comp. insurance insurance.[No workers comp. insu +
required] ons
I OWe are a corporation and its 10.0 Electrical repairs or additions
3.()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 NIGL
r
insurance required]+ c. 152,§ 1(4),and we have no 12.0 Roof 7
employees. [no workers' 51s
Oth LA
comp. insurance required.] 13.d
x:ikny applicant that checks box#1 must also rA out the section below showing their workers'compensation P-lWi information.
+Homeowners 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 these entities have employees. If
the sub-coutraders have employees,they most provide their workers'comp policy number.
I am an enWloyer that isprovidng wo ers'com*wnsation4nsurance for mvenWlx ees.Below is the policy and job site
information !r9* I/ I
Insurance Company Name: "C
xpiration Date:
Policy =or Self-ins.Lic.ii:
Job Site Address: ✓fi-)i cit,,istate/ ip: A,p��-A
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 51,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of
5250.00 a day against violator.Be advised that.a:,op of this staternen-mF-,vb-forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby cert�� r the pains qndpenalties of perjury that the information provided above is tme and correct.
Signature.,
Date. 61--a Lo- I s
Phone --7
Print.Vame: i t
Official use only Do not write in this area to be completed by city or town official
City or Town: Perm it/license
Issuing Authority(circle one):
I.Board of Heath 2. Building Department 3.Citvrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone
SEC'nm 8-coNsveiiumsmim,
8.1 Licensed Construction u iisor: Not Applicable ❑
Name of License Holder: , 10 —'� (--o,3,5-
.Lo 3
License Number
44a+��CLJ 01
Address Expiration Date
1-03
ignature Telephone
`�. �M Not Applicable ❑
�. e�fvRs / ��/'� i
Company Name Registration Number
Address Expiration Grate
YY)14 C)l b 3$11 Telephone�h ay7 5739
SEC rt1WW1ll ' 'f OEURMW. IDi1 V f(IIA.0-L c. (S))
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...... ❑
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 helshe 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 aH awlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ol Decks [Q Skfinqg=ll Other[
tah r3
Brief Description of Pr sed „
Work: l 9 a! r a,,Lm X45
Alteration of existing bedroom Yes No Adding new bedroom Yes No J
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house. or addition to exlsUnubwW-na, complete ftioNowlna:
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 constructio;100 i. is construction witho tlands? Yes No. Is construction within 100 yr. floodplain Yes No
Depth of basement floor below finished grade
k. Will building confor 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, I \�' U -t,j�/✓Yl-t✓ as Owner of the subject
property
hereby authorize k'-
to act on my behalf, in all matters relative to worglatitholized by this building permit application.
a l o-I
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.
Signed under the pains and penalties of perjury.
Print Name
Signat&of OwnedApen 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/Fincinover 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 C) DONT KNOW � YES C)
IF YES: enter Book Page and/or Document#i
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW $,:j YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
0 0
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading e ation,or filling)over I 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.
of Northampton
B iiing Dint
12 Main Street
Room 100
��ptNGp1 ampton, MA 01060
e 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMLY DWELLING
1.1 Procerty A d '
A
y�Al s
2.1 Owrier of
Name(Pn Current Mailing Add
Q P 2=6 LI'Ll '- Telephone
Signature
2.2 Authorized Agent: P(Z7J f1"{-
i fie s
Name(Print) Current Mailing Address:
(
Sig Telephone
Item Estimated Cost(Dollars)to be t # .;
c0mPWGd bY Permit applicant
1. Suildiprg ! (a)
2. Electrical " _
.�30�a1°£E�St of
3. Plumbing
4. Mechanical(HVAC)
5.Fire Protedion
6. Total=0 +2+3+4+5) Cl ctc.
T1iesejA�WK:
Dale
Tier
is �dt
Sigre:
File#BP-2016-0596
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 19 NORFOLK AVE
MAP 24A PARCEL 156 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existiniz
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:
oved 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 li ' el
/C//-P—"00
Signa a of Building 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.
19 NORFOLK AVE BP-2016-0596
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 156 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2016-0596
Project# JS-2016-000994
Est. Cost: $2857.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 13764.96 Owner: FARMER DEVLIN&TAMSIN
Zoning:URA(100)/ Applicant. PAUL SCHMIDT
AT: 19 NORFOLK AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.1012912015 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 10/29/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner