12C-022 (2) 14 BURNCOLT RD BP-2016-0989
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-022 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,ory: INSULATION BUILDING PERMIT
Permit# BP-2016-0989
Project# JS-2016-001674
Est. Cost: $2300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 13024.44 Owner: LEWIS TAMARA M
Zoning: RI(100)/URA(100)/WSP(loo)/ Applicant: PAUL SCHMIDT
AT. 14 BURNCOLT RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:2/5/2016 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 2/5/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
' OI6 it of Northampton
FEB Wing nt
212 Main Street
DEPT OF BUILDING INSPECnoNa Room 100
NORTHAMPTON MA 01060 ampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAM LY DWlELUNG
1.1 PcbDeity Addeess. ;r
SECTM. �,
2.1 ( w ice[O� :
Name(Print) Current Mailing Address: G
Telephone
Signature
2.2 Atiftnized Armtt: PrZ�e dv �
f
Name(Print) Current Mailing Address:
Sig Telephone
Item Estimated Cost(Dollars)to be OU§ Orr
completed Permit applicant
1. Building
OCA .
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) DaW
Circ
8t�ikIrE
Se:
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: U- R:.
Rear ---- -------
Building Height
Bldg.Square Footage. %
Open Space Footage %
(Lot area minus bldg&paved
-parking)
--7
#of Parking Spaces
Fill:
I (volume&Location)
A. Has a Special Permit/Variance/Findinizhver been issued for/on the site?
0--/
NO 0 DONT KNOW YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW G� YES C)
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 4,::9 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 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. Will the construction activity disturb(clearing,grading,a vation,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.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacernent Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [ol Decks [[] Siding ] Other[
'o
Brief Description of Proposed ,
Work: l C. A
Alteration of eiasting bedroomYes No Adding new bedroom Yes No A
Plans Attached Roll -Sheet S 1� A-c, eco
Attached Narrative Renovating unfinished basement Yes No
Plan
ea.._1e�v_1� se -at" t to#a#It�ii�ci
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. imensions
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 wetiands? 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.
1. 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 -J
as Owner of the subject
property
hereby authorize .
to act on my behalf,in all matters relative to 'zed by this building permit application.
Dt a - Z. - )
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.
iia t'cL�
Print Name
Signatffe of Odw-dAgenfDie
Sit 8•C `" �'�IQ� rF.
8.1 Ucensed G rmbuction Su ' or: Not Applicable 0
Marne of License Holder: { ��
License Number
Address Expiration Date
ignature Telephone
�.. � " � ... Not Applicable CI
Gomaany Name Registration Number
;2Z I J
Address Expiration Da� to -Y�T
1'YlI-� C)t ? Telephonel/!3 aZ/15739
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...... 0
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 Edi>ion 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-vearperiod 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): �
C�
Address: Y
City/State/Zip: Mlq C."OO ne#: ( " - -
r
Are yg�t an employer?Check the appropriate box: Type of project(required):
1. I am an employer with `� 4.01 am a general contractor and 1 6.0 New construction
employees(full and/or p ime).* have hired the sub-contractors 7.0 Remodeling
2.O I 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' g.0 Building addition
[No workers'comp.insurance comp. insurance.+
required] S.( We are a corporation and its 10.0 Electrical repairs or additions
3.0 I 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 rep ' s
employees.[no workers' I3.eOther
comp.insurance required.] �-`�—
*Any applicant that checks box#1 must also rdl 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.
1 am an employer that is providing wo rs'compensad assurance for my emplo em Below is the policy and job site
information.
Insurance Company Name:_ (� Q� �' 60 4�4
Policy#or Self-ins.Lic.#:� �j0 0 Expiration Date:
Job Site Address: (I Cc C D�it City/State/Zip: ncet !Mlq O I ULA�-
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
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 cert der the pains d penalties of perjury that the information provided above is true and correct
S'i nature: Date: c !
Print Name ,l .��/y� 1�,", Phone#: l �j - a I -/'
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.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
City of Northampton
Rh�s
a:acins*tt: _
carr moe�c3�s
212 Win Stra t . emaiclpla MuLZdiaq
JKortbNxvtcn, D4 01060
Propwty Address: K cL --- VO(f-ne.AP
Gontradtor K I � -
Name. ` _ U � � ��.. .
Address:
cfty, state: a,- - A b VbS& ...�
Phone:
PMPMYOWDW
Name: I [i ,c�I)_( O---Y
Address: .�.. —. cE��r c-O l f
City, State: +fr['4 A1' 0
1: <:C (COnftvdXW)attest ark stun that the binding I k*WW to
mstiMs does not hm mW open ak ai anti tube)wig in the speces to be msutaW and#W i haws
provided the property owner wfth a copy of ttds aMdaviL
Gontrac W sWah"
IV
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R1 SE
60 Shawmut Road,Unit 2 j Canton,MA 020211339-024=
ENGINEERINGr wwwMSEengineering.com
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the properly located at
I ,-A
(Property Address)
0
(Property 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.This form is only valid with a signed contract.
Owner's Signature
Date