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31A-109 OWNER. AUTHORIZATION FORM 1 ]� { (Owner's Name _. owner of the property located at (Property Add } (Proms Ate) 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. X 1 _ - J�-? Owner's S" natM Date 7 v�w City of North ton Massachusetts DWARUMEr or BUZOM nmrzcr=w 212 Main Stmet • b miatpal su4'A4 Narth=vbm, HL 01060 Property Address: Contractor "PactI nli ;f Name: Address: CRY, state: MA Q Lam& Phone: 13 Property owner Name: Address: 1 City, State: m en� n �,-; �z , O/ Cc C) 1,—T Sal .':�'lv,n i ct:-i- (contractor)attest and affirm thW the buddit l ffftnd to irk does not have any open (lcrrob and tie)wmg in the gmes to be irmAded and that i have provided the property owner with a copy of this aftevit. Contractor si mk" Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: u_ City/State/Zip: Are y an employer?Check the appropriate box: Type of project(required): 1. I am an employer with_ 4.®I am a general contractor and I 6.❑New construction employees(full and/or part ime).* have hired the sub-contractors 7.❑Remodeling j 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. j ship and have no employees These sub-contractors have 8.❑Demolition I working for me in any capacity. employees and have workers' 9.❑Building addition [No workers'comp. insurance comp.insurance. required] 5.0We are a corporation and its 10.❑Electrical repairs or additions 3.0 1 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]t c. 152,§ 1(4),and we have no 12.❑Roof repa' s employees. [no workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill 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,the),must provide their workers'comp.policy number. I am an employer that is providing wo kers'compensatio 'nsurance for my emplo ee&Below is the policy and job site information. Insurance Company Name:_ Policy#or Self-ins.Lic.#: _IJ L1 Expirati on Date:__ Job Site Address: � � >L 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 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 DIA for coverage verification. I do herby certify der the pains qndpenalties of perjury that the information provided above is true and correct Si nature: Date: Jk �j Print -Vame_ l JC (1fV1 tGL Phone !L-5 cam} 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-C0NST) CWK 8.1 Licensed Construction Su isor: Not Applicable ❑ Name of License Holder: li u �`� ! y —� �, License Number Address Expiration Date ignature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date la4,4-e-1 d L ry), ' of a 2)9111 Telephone'y�3 oay�Jr739 SECTION"-WMV4MRV x011 A'IIMMOUR*i CE AFFIDAWT(fA.ML:c.'15Z;§28G(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...... ❑ - Al - 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 betshe 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [C7] Decks [0 Siding ] Other[ Brief Description of Pr Work: �� n d S + Aitera&54 e . iing bedroo� Yes No Adding new bedroom Yes VxNo Attached Narrative Renovating unfinished basement _Yeso Plans Attached Roll -Sheet 6a.If New house and or addition to exilwUna:housim comafete the fo aMdnsa: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathroomsi. c. Is there a garage attached? d. Proposed Square footage of new construction. mensions 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 constriction within 100 ft of tiands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or r floor below finished grade k. Will building con 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, al, '7t as Owner of the subject property hereby authorize k-, to act on my behalf, in all matters relative to wo ed by this building permit application. Signature of Owner Date I, � / '5!'6 M 1 Cli"f•— 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 az Signa of Owner/Agen 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 U.__ ..__.< R: L:. R: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 0 DONT KNOW YES IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW G� YES IF YES: enter Book ? Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 11,::9 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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. Nil the construction activity disturb(clearing,grading, ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. of Northampton _ B r" Department 212 Main Street 9 2015 Room 100 N ampton, MA 01060 nEPr czF r.:_crra�iN 1 587-1240 Fax 413-587-1272 N4R?};%+P9PT'pN,M1179iiE0 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING -„ tillO . 1.1 Property Address: r j y, ail, v! D 21 Ownff of rn L-1✓vim S + Name(Print) ' Current Mailing Address: J - aL �j - a �� Telep one Signature 2.2 Auttorized Anent: dv 2 C1�— - a 4atQe c Name(Print) Current Mailing Address: Sign Telephone Item Estimated Cost(Dollars)to be tllr completed it applicant 1. Buildivig (a� Fee 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Don ©O Ctc; DaW Bia'lctrngf,"TAIMS01w lsstaed: vs S�getat�re: File P BP-2016-0775 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739 PROPERTY LOCATION 76 VERNON ST MAP 31A PARCEL 109 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid i Building Permit Filled out Fee Paid_ lyl)eof Construct10I1:_INSTALL ATTIC INSULATION 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 INFORMATION PRESENTED: _proved 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 Demolitio Delay Sl ur of uil ing Of 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. 76 VERNON ST BP-2016-0775 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 109 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-2016-0775 Project# JS-2016-001310 Est. Cost: $7000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 6054.84 Owner: DEMURO JOSEPH 7oninu: URB(100)/ Applicant: PAUL SCHMIDT AT. 76 VERNON ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:121912015 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 12/9/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner