36-038 City of Northa ton
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Massachusetts
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212 Main at:..t . m=tj Lpa MMUiidiaq
Eton, ML 01060
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Phone: '4)�!2• a 4� 9
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OMER AUTHQRIZATK! FORM
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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/Organization/Individual): {
Address:
City/State/Zip: y/4� one#: / 15 21
ArW"_ an employer?Check the appropriate box: Type of project(required):
1. I m an employer with _ 4.®1 am a general contractor and I 6.❑New construction
employees(full and/or pa ime).* have hired the sub-contractors 2.[1 Remodelin
?. t am a sole proprietor or partner- listed on the attached sheet. g
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers' q p Building addition
[No workers'comp. insurance comp.insurance.a corporation required] 5.0We are 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]+ c. 152,§ 1(4),and we have no 12.❑Roof reps' s
employees. [no workers' 13. Other
comp.insurance required.]
*Any applicant that checks box#1 must also rollout 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.
$C.ontactors 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 kers'compensatio "assurance for my emplo ees.Below is the policy and job site
information.
Insurance Company Name: _ 1 v --�
r
Policy#or Self-ins.Lic.#: - �- Expiration Date: f(Q
Job Site Address:— _ ( }" � �, � 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
D1A for coverage verification.
I do herby certify der the pains nd penalties of perjury that the information provided above is true and correct
Si nature: / Date: l'l��
Print Name._ ,L t .�U 1/y1 t CL� 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#:
SECTtm 13-covils 1 .Ctfm sommS
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /YLA 10
License Number
�,�/2-
Address Expiration Date
1-0 5
%ignature Telephone
Not Applicable ❑
Company Name Registration Number
,Lj r,tv- a2 'y J 1
Address Q Expiration Date
m4 oZ o 3U� Telephone�/J aay/�f',5739
SECTON WWes' 3'IROAI+ NGE-AFF1DA (M G.L.c.IS2,f 26q6))
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 ofone(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 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 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
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 ( 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 Cr
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,ex ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® 1,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) 7
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding ] Other[
Brief Description of P posed
Work: joqF2 3,' 2- ► L' as ry -Ae- .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6a.If New house and or addition to existma housing.cofnWete the:followina:
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
f`
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 fL of ands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar oor below finished grade
k. Will building conform t, 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
r
hereby authorize -ems � ;k
to act on my behalf,in all matters relative to wo 'zed by this building permit application.
Signature of Owner Date
1, �c�GL �Y12[GI;'"� 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
01-x/ - r5
Sig re of Owner/ Date
-�
•;¢ 1 City of Northampton
Burkjmg Department
212 Main Street
` Room 100
,Northampton, AAA 01060
�E T i,'� --'�413-587-1240 Fax 413-587-1272
APPLICATION To CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S�TizF�,9- �IEif.011it
1.1 ProawW AddcBS.4.
ARMAMENT
M1 4
/ a J yw/ �� aJ / ' / �D�J.^� Y! �Mi 4y �y r '�yt. 4 X 1 i�'#�-Ln •.� f�-
21 QWX of
1 r o)t /y7 6i�r+5
Name(Print) Cunent King Address: p q
S,L,Qj j. Telephone
Signature
2.2 AudtoftW Asott: Sl�t n,�S e�l� rl"
I lrn i -f- C �'- fi c' c
Name(Pni Current Mailing Address:
Sig Telephone
Item Estimated Cost(Dollars)to be ttgr
completed by permit applicant
1. Buildixg OiJ (a)8t"% -Pee
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) L?Q . ) Che&Npabw
Deft
Builcing..l?
lsscmd
File# BP-2016-0795
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 1079 BURTS PIT RD
MAP 36 PARCEL 038 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT o
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction:JNSTALL 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:
pproved 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
DemolitiQ.n Dela
Signature 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.
1079 BURTS PIT RD BP-2016-0795
GIs #: COMMONWEALTH OF MASSACHUSETTS
Nlap lock: 36-038 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0795
Project# JS-2016-001338
Est. Cost: $2400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sc. ft.): 12501.72 Owner: THORPE DARLENE
zonin": Applicant: PAUL SCHMIDT
AT. 1079 BURTS PIT RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.1211612015 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 12/16/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner