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36-037 (2) OWNER AUTHORIZATION FORM (0wrWs Nam) owner of the property kxmted at (Property Address) (Property Address) hereby auithonze 5 �>L- (Subcorrtractor) an authorized subcontractor far RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. ownees S' ure Date City of Northampton �> Massachusetts or 212 saft Most • a0miatp a building ; Stan, UL 01060 Property Address: pi�-)- - L") Contractora�c Name: ►-� 1 �'1C'� . Address: city, state: MA Q Q?L& Phone: l 3• a '76�7 Property owner ^, Name: r�or t Address: D °D c�✓ City, state: O and aMm#hat the bu I ftmd to ffmAde does rot'hm any Open air(knob and tube)wiring in the spaces to be ffmAsted and I gave provided the property owner wM a dopy of#ht affidavit. Cons tar WWmW ue Data ,A* ; The Commonwealth of Massachusetts 46ffl; 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 A� Name (Business/Or- anization/Individual) Ji Address: —j City/State/Zip: CO 111�i frone#: Are vgja an employer?Check the appropriate box: Type of project(required): 6 am an employer with 4.01 am a general contractor and 1 ❑New construction emplovees(full and/or partAime).* have hired the sub-contractors 1 1 1 1 am a'so)e proprietor or partner- listed on the attached sheet. 7.El Remodeling ship and have no employees T',,.--e sub-contractors have 8.0 Demolition working for me in any capacity. employees and have workers' 1 1 9.❑Building addition [No workers'comp. insurance comp. insurance. required] 5.0We are a corporation and its 10.❑Electrical repairs or additions 3.()1 am a homeowner doing all work officers have exercised their 11.[J Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required]+ c. 152,§ 1(4),and we have no 12.❑Roof re employees. [no workers' comp. insurance required.] 13.eOther *Any applicant that checks box#1 must also rffl out the section below showing their workers'compensation policy 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 mug attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,tbev must provide their workers'comp,poky number. I am an employer that isprovidling wo ers'com*wnsatio&4nsurance for m-emW ees.Below is the policy and job site information. Insurance Company Name: Polic,, =or Self-ins.Lie. Expiration Date: Job Site Address: Z671 54c,—,5 Dad 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 1152 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 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. I do herby certify—=,*r the pains andpenalties of perjury that the information provided above is true and correct Signature: /1,11;�Ir-� Doze. Phone Print Y 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-C0WTRLVnM SUMIM 8.1 Licensed Corw&uctllon So isor: Not Applicable ❑ [ Name of License Holder: —1� �p 3 1 License Number oloak Address Expiration Date 13 a4 -5 ignature Telephone NotA Applicable ❑ ,. 5..w.. PP Company Name Registration Number Address �i Q� �f Expiration Date mrr Cpl02)S Telephoneq/3aayi-fl/ 9 SEC71IX4 1*@-wofws ' ►TIm NGE AFFiDAvrT(IIII.G.L c.152,§2W4%) 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 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 Altemdon(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [C] Siding ] Other[ Brief Descripti n of Proposes tl Work: S f' J� / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ice`No Plans Attached Roll -Sheet sa. If New house and or..addkion th eidsbnci::houssina com aw the foti own a. Use of building:One Family Two Family Other b. Number of moms in each family unit: 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 fr; &wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or,eellar 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, (� as Owner of the subject property hereby authorize -e�+ �S to act on my behalf, in all matters relative to wo ed by this building permit application. Se,e. a 1 �- Signature of Owner Date I, �2f,�I 'SJl!'!Z(�"�' 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 Sig of r/ 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: 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/Finc inover been issued for/on the site? NO 0 DON-r KNOW YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO DON7 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 (D' YES 0 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 Q-- 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 on,or filling)over 1 acre or is it part of a common plan that will disturb over I acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Building Department 212 Main Street 1s Room 100 iectric,Piurn iY 9&Gas lnspe�ions orthampton, MA 01060 Northal PWo') ti1A° ° 3-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMIOLISH A ONE OR TWO FAMILY DWELLING 1.1 PrODW--v Addf"—$' y 1 .t G 2.1 Owner of Record: © b olkf /45 v d Name(Print) Curent Ad drew , / 7 '� `r SS-t-R, Telephone lC Signature 2.2 Audw)d ed Agent: �1��- m2 n Ie-av-12 Lt Name(Print) Current Mailing Address: Signaturev Telephone Item Estimated Cost(Dollars)to be fl , completed by permit applicant 1. Buiidieg (a)'Bt&ckqf*M*fee goo 2. Electrical (b), 3. Plumbing 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) 'e)0 C) Check Nc Date BWdnWf Issued: pale . 1091 BURTS PIT RD BP-2016-0604 GIs#: COMMONWEALTH OF MASSACHUSETTS MQ Block: 36-037 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-2016-0604 Project# JS-2016-001016 Est. Cost: $4800.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sg. ft.): 12501.72 Owner: PROCON EDWARD JR zoninu: Applicant. PAUL SCHMIDT AT. 1091 BURTS PIT RD Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON.111212015 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 11/2/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner