17A-067 (10) 22 MOUNTAIN ST BP-2020-1276
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-067 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-2020-1276
Proiect# JS-2020-002135
Est.Cost:$5000.00
Fee:$65.00 PERMISSION-IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sg. ft.): 22999.68 Owner: CQIzWIN JULIE
Zoning: RI(100)/URA(100)/WSP000)/ Applicant. PAUL SCHMIDT
AT. 22 MOUNTAIN ST
Applicant Address: Phone: In.vurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON:6/22/2020 0:00.00
TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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:
FeeTvipe: Date Paid: Amount:
Building 6/22/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
ZBuilding Department
T 212 gain Street
c f UL-A TION
Room 100
Northampton, SIA, 01060
IL Af
phone 413-887-1240 Fax 413-887-1272ON-L' Y
�'f o
APP, ION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTIillizNFt)RNilATIC3N INS.L.I.I.A TION PERMIT
1.1 Propart Address This section to be col ted by office
a2 A map Lot 00 e7 Unit �
cJZ 1�2 r� Com, rn Zone overlay t1 91rftt
Elm St,0tWict _.__. cls owict ..��._w,_ 1
SECTION 2-PROPERTY C31iVi ERSHIPIAUTHORIZED AGENT �
2.1 Owner,of Reco d:
3
j Name(Print) Current Mailing Address:
Telephtinr
Signature _
2,2 Authorized Agent: a�[��-� j
fes_ -J l�C )-4
J Name ;
SECTION 4-CONSTRUCTION SERVICES I
8.1 Licensed ConstructionSuipervisor. Not Applicable 0
-tci d, -3
Nome of LicenseHoWor hl
-
A
te
LcensLer
dress, Fx:piratio Date
0?
gnatara Telephone
Not Applicable 0
offloany Nam
C 71�4"fk- ""-Registration Number
Address= Z'
Expiration ate
-ek Telephone*4
-------------
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, 25C(6))
J Workers Compensation Insurance affidaylt must be completed and submitted with this application, Failure to provide this affidavit will result
I in the denial of the issuance of the build" permit.
Signed Affidavit Attached Yes....... No...... 0
-------J
Brief Description of Proposed Work -k&T-E: INSULATION
aq
7q'.'
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 Narri�,,
Signatureof Own drlAgent Date
as Owner of the subject
,property
hereby authorize
. act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City oforthampton
Massachusetts
r _ srr`w
DEPARIMUT OF BUILDING INSPECTIONS
212 Main Strout *Municipal Su-iding � �•
`= Xotthamptan, MA 01060
Vft
viebris Disposal Affidavit
In accordance of the provisions of MGL c 40, 854, l acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, B 150A,
The debris from construction work being performed at;
(please print hous1e number and strut name)
Is to be disposed of at:
(please print n rn-and loca n of facility)
,Or will be disposed of in a dumps r onsite rented or based fr
(company Name and Address)
L v
,S�ignaturd of Permit Applicant or Owner Cate
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City f Northampton
Massachusetts �
�• F
DEPARTWAVT OF BUILDING INSPECTIONS
Mzir; Street s 1tur..^.tpa3. Bua"ceding
Northampton, �O01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
'The Office of Consumer Affairs and Business Regulation("OC;ABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four fatnily homes.Prior to
performing work on such homes,a contractor trust be registered as a Horne Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization. conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than tour dwelling units.. or to structures which are adjacent to such residence or building"be
clone by re2istered contractors.
:fitter If the homeowner has contracted with a corpvradon or LLC,that cntitj�must be registered.
'Type of Work: Est.Cost: ,LO, Q
Address of
Plate of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):__.......__.....__
Job under S1,000,00
Owner obtaining own permit(explain):_____
Building not owner--occupied
__........Other(specify):. ........... _ _....W..,..
OWNERS OBTAINING THEIR OW"IN PEI2mn,OR t°N TTERING,INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE 140ME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M,G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME T IE RESPONSIBILITES FOR ALL WORK
PERFORMED-UNDER THE BUILDING PERMIT.SEE NEXT PAGE:FOR MORE INFORMATION.
Signed under tbie penalties of penury:
I hereby apply for a building;pet as thegent,of the o�nr
Contrac;torName HIC Registration No,
OR;
?notwithstanding the above notice,I hereby apply"for a building permit as the owner of the above property.
>- ; Owner Name and Signature
I,_..._. a.t . of Northampton
Massachusetts
1
DxxzMErrr OF BrxzznzxG zrrspEcTzorrs
2:2 Main Street • Municipal
Northampton. MA 0106(' +'
MANDATORY FOR HOUSES BUIL T BEFORE l 945
Property Address
Contractor , ,
Name: J .. ,.�
Address: C ,
Y
City State;
Phone: '`t �-
Property Owner C'C)ru--D
Name: 71 3
Address:
��- o�vC.oc�
City State:
(contractor) attest and affirm that the building I intend to
insulate cies not have any open air (Knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date U _ f S� �C 0
DocuSign Envelope ID. E7422347-102A-4348-B5BF-84F86BCE6CFE
Permit Authorization
mass save Form
Site ID: 3939190 Customer: Julie Corwin
Julie Corwin , owner of the property located at:
(Owner's Name,printed)
22 Mountain St Northampton, MA 01062
(Property Street Address) (City)
hereby authorize the Mass Save Nome Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a buiiding permit to perform insulation and/or weatherization
work on my property.
DocuSigned by:
Owner's Signat e Doc
2ABBi98061D8460_.
Date: 2/21/2020112:01 PM EST
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FOR OFFICE USE ONLY
We have assigned the following Mass Save Nome Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Nalne: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 Fcr Office Use Orly
Rev. 102015