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25C-106 • CO-OP Ji" I i - POWER BUILDING COMMUNITY-OWNED SUSTAINABLE ENERGY PERKET kUTRONLASLOR FOR14 I, l NIA - 149 , owner of the property located at: (Own6r's Name) I c\--. vim, 04 riw /IAN" (Property Street Address) (City/Town) hereby authorize C4) - 1 ( 7\iv- ' - 1 0 4)4 - A 0--v (Contr ctot) to act on my behalf to obtain a building permit and to perform insulation and/or weatherization ri: on my property. ,-- ( ha -- eia1 (Owner V # ' gnature) (01 L)/ I60/ '-. '_ , 9 (Date) Co-op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info@cooppower.coop, www.cooppower.coop CO-OP ■ J I A POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY City of Northampton Building Permits 212 Main Street Northampton, MA 01060 June 19, 2012 REs Building Permit for Insulation Worb at 228 Bridge Street We are submitting these applications to obtain permitting for insulation work at the property of Arley Eward. Enclosed please find: 1. building permit application 2. l,NOp g w e ' -nv / / h - 3 . debris disposal affidavit 4. copies of CSL and HIC license 5. certificate of Workers Compensation 6. certificate of liability 7. check number 3368 in the amount of $55.00 8. self- addressed and stamped envelope. Kindly return the building permit in the enclosed self- addressed envelope. Thank you very much for your assistance. Sincerely, Kath- in: Pol 'y Energy E icie cy Adm nistrator katherinep @cooppower.coop Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop The Commonwealth of Massachusetts w :,,� _- Department of h utustrial Accidents Office of Investigations I ir?' 600 Washington Street .+ yt :. . `.rte 4; www rnass.gov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organizaiion /individual): lr O •- h l . ^ 11 L Address: '3-2- .( � W el (S S City /State/Zip: 6' c m E- (J-. Phone 44:_ (1 — 1 . 7 ' '� j I Are ou an employer? er? Ch eek the a r I i mate box: ,..,, lama employer with p � pp Type of project required): . I i . [ ts If t '4.0 1 am a general contractor and l employee: ( andior part ime�.' have hired the st h- contractors ' b. 0 New construction 2. D 1 am a sole proprietor or partner- 'listed on the attached sheet. 1 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 0 Vtre 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 per MOL 12.0 Roof repairs _ insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. Other �lo comp. insurance required.] 'My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached 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 workers' compensation insurance for my employees. Below is tke policy and job site information. .-----". �, Insurance Company Name: t Win C i F i r & - \\S -'y` GrM. E c n Policy # or Self -ins. Lie. #: 5 R" iv e c L �� c fps Cp 6 Expiration Date: II— (— er i -- Job Site Address: City /State/Zip: Attach a copy of the Corkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMMMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 anclfor one -year imprisonment, as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby car ' , under the :: ' s , nd p r of perjury that tke 'information provided abo e is true and correct. Signature: .- �- ,, Date: 7-2 fi Phone ti: - 4 (g — 7 2- '' 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone it: ',..-,, ( C . ;, j (fite - 6 7 / 0 op 0/ OP if 4 ', `'— —0- Office of Consumer Affairs and Business Re , =: = Regulation ,, g y 10 Park Plaza - Suite 5170 - - -= Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2014 Tr# 220702 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 — -- Update Address and return card. Mark reason for change. 0 Address 0 Renewal ❑ Employment 0 Lost Card DPS -CAI Ca ECM- 04/04- `` G , 1 10 0121€ - 6 , co aznoouve Azaaacfutaetts Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: R --- -- - - - 21 - _.„---, Registration: 165217 Type: Office of Consumer Affairs and Business Regulation f Expiration: 1/21/2014 Corporation 10 Park Plaza - Suite 5170 _ /' Boston, MA 02116 CO -0P POWER, I N D . PAUL SCHMIDT 324 WELLS ST ls' '�/ GREENFIELD, MA 01301 Undersecretary Not v * without signature — Nlassachusetts - Department of Public Safet, J 4� Board of Building Regulations and Standards - Construction Supervisor License License: CS 103635 Restricted. to: 00 PAUL SCHMIDT 24 CHESTNUT ST HATFIELD, MA 01038 z F # ,� L �`"�` - , Expiration: 5/20/2013 t'uoinn i..d,,ne•r Tr#: 103635 .4c4oRr, CERTIFICATE OF LIABILITY INSURANCE 1 �i� E (MMOD` ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). O TACT PRODUCER NAME: Shannon Palazzo James J. Dowd B. Sons Ins % o. Exfl :413 -538 -7444 Imo Na):413 -536 -6020 14 Bobala Road E-MAIL -lolyoke MA 01040 AODRESSSpalazzo@a dowd.com INSURERS) AFFORDING COVERAGE NAIC tI _ INSURER A Safety indemnity Company • INSURED COOP INSURER E :Great American Insurance Companies Co Op Power, Inc. INSURERC:U. S. Liability Insurance Company 324 Wells Street Sreenfield MA 01302 INSURER ID : INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 1050225250 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYJITHSTANDING ANY RECUIREMENT, TERM OR CONDITION CF ANY CONTRACT CR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED CR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED - HEREIN IS SUEJEC7 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR ' INSR WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) GENERAL LIABILITY CL1566148 11/8/2011 11/8/2012 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $100,000 CLAIMS -MADE OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEM_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $2,000,000 POLICY F Q LOC $ AUTOMOBILE LIABILITY COM6212701 3/23/2011 3/23/2012 �MHINtt SINGLB LIMI I (Ea accident) $1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON -OWNED PROPERTY DAMAGE $1,000,000 _ AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE. EXCESS UAB CLAIMS -MADE AGGREGATE $ _ DED RETENTION $ $ WORKERS COMPENSATION I WC STATU- OTH AND EMPLOYERS' LIABIUTY Y f N TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under' DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Directors & Officers Liability EPP111 T583 5/2/2011 5/2/2012 1,000,000 5,000 Deductible )ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 1)1, Additional Remarks Schedule, if more space is required) Vaiver of Subrogation Applies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Road Suite 4, 2nd Floor AUTHORIZED REPRESENTATIVE Canton MA 02021 -1461 /7: ©1888 - 2010 ACORD CORPORATION. All rights reserved. .CORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ,4C RD CERTIFICATE OF LIABILITY INSURANCE DATE DDIYYYY) 11/29/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER {S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy {ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement {s). PRODUCER CONTACT Joseph Judd Blackmer Insurance Agency Inc. +AICNn.FX},: (913) 625 - 5527 FAX No): (413)G25 - 8210 1147 Mohawk Trail ADDRESS: jo @blaclmters . corn ry INSURER(S) AFFORDING COVERAGE NAIC iF Shelburne MA 01370 - 9707 INSuRERA :Twin City Fire Insurance Co 29459 INSURED INSURER B : CO -OP POWER, INC. INSURER C PO BOX 688 INSURER D PC Box 688 INSURER E GREE1rFIELU NA 01302 INSURER F: COVERAGES CERTIFICATE NUMBER:Hast er 11 -12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY 'PERTAIN, THE INSURANCE AFFORDED EY THE POLICIES °DESCRIBED HEREIN IS SUBJECT TO ALL -THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE Of INSURANCE ANSR S POLICY NUMBER IMNWDIIYYYY) (MIWIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMI c occurrence) $ I CLAIMS-MADE n OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE S GEM_ AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG 5 I n PRO- � POLICY ! $ JFr;T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea aint) ANY AUTO BODILY INJURY (Per person) S AL SCHEDU� BODILY INJURY (Per accident) $ HIRED AUTOS AUTOS NON-OWNED (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ A WORKERS COMPENSATION I WC STATU I OTH AND EMPLOYERS' LIABILITY TORY LIMITS ANY PROP RIETOR/PARTNERJEXECUTIVE Y! 1,000,000 N ! A EL. EACH ACCIDENT S (Mandatory NH) EXCLUDED? 0 8WECI,C6B66 11/1/2011 11(1/2012 E.L DISEASE - EA EMPLOYEE S 1, 000 000 If {Mar�atary in NH) , D yes IPTI OFO EL. DISEASE - POLICY LIMIT 5 1, 000, 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (Attach ADDED 1D1,AddltIona1 Remarks Schedule, it more space is required) Operations usual to energy efficiency services- energy audits, air sealing, insulation and solar hot water system installation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Honeywell Utility Solutions 65 Shawmut Rd, Ste 4, 2nd Fir Canton, MA 02021-1461 AUTHORIZED REPRESENTATIVE S Deneault, CISR/BLAJ ,7 ACORD 25 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD CO -OP > , ' /c POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal I, Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co- op Power will remove all waste from the job site located at:_ �YliLti`3'� OpitlAi9 'Z/'3 0T,(( ST • NDV w- 14 -n ' p Owner Name Street Address Town /State/Zip Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our removal service is Waste Management. AV Cat Paul Schmidt Date Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop fl City of Northampton Masachusetts 5 •••=: � . 7; DEPARTMENT OF BUILDING INSPECTIONS y. ,4 1 212 Main Street • Municipal Building J ; A. <` \\ Northampton, MA 01060 S 3i Property Address: 2:2- 'j ('t 04-1,--- Ci , VirV( n-( , r U C 6 (e v Contractor Name: 1. Strhitt t 0 Y- Address: 7Z- l.(it` i T T, City, State: 6 -ytivii 'l eve a 01 3 `D 1 Phone: 3 ) - 2 ebei Property Owner � Name: l 9 V 4 cl EA-t'' Address: 2 _ /LouN_ ST-. City, State: 0 ( (p 0 1, eVIAL CVi LI (contractor) attest and affirm that the building I intend to insulate does not have any open air knob and to e) wiring in the spaces to be insulated and that I have provided the property owner with - cos of this .ffidavit. Contractor signature 49,7- T�• Date // r 1 ,. CI z SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Paul Schmidt Name of License Holder : 24 Chestnut St. Al A( Hatfield, MA 01038 s 'ea �S # 103635 U Address(' 1F2-- Exp. 5/20/2013 Sign eleph 13- 772 -8898 ne Home Improvement Contractor: 9. Registered Home Improvement Contractor: Co-op Power Inc. / Paul Schmidt 324 Wells St. Com'ana Greenfield, MA 01301 Aff 4165217 xp. 1/21/ 01 Addre. �� 413- 772 -8898 r� •aul @cooppower.coop SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(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 buildi permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption 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 Alteration(s) Roofing n Or Doors (] Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Descriptio of Propo d Work: et ilkn G / 1 (; ii,vw 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 existing housing, complete the following: 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 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 wetlands? 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 . 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, Cfrl fw' r ` � -- s frX/?t- —✓ as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work thorized by this building permit application. Signature of Owner Date I, h9y�,/ , f 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 perj y. Print Nam • ter Signature of Owner /Agent 4 ' 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 qy Building Department '" ,y ,(5�, b .S `�" 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 er been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Reg' ry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and /or Document #' B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO ! r -.. IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exca ion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © N O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only i - City of Northampton Status of Permit: ' � .. B iIding Departm Curb Cut/Driveway Permit 12 Main Street Sewer /Septic Availability 2 20 Room 100 L Water/Well Availability'' a Two Sets of Structural Plans car No hampton, MA 01060 °FBU' 13 87 -1240 Fax 413- 587 -1272 Plot/Site Plans NoRTHA.4F • . • i A07060 Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 7,7,q P -5-r- Map a‘..- - Lot 100 Unit 0106,D Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: �^ i'� a" fi�l/11 2 Sw 7 Pd vt-Ytfj1 ,0-., Name (Print) k (�� Current Maling Address: V-3‘ � ,[� 2 '� i 1 l � i Telephon`f`j. J 'TI Signature 2.2 Authorized Agent: Pp c 4 _ L 3 ' z q w -' i Sr r r ' - z-' 4 073 61 Name (Print) " Current Mailing dress: Signature �' Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building r3-1-3- i 12 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 1: • Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -1158 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 228 BRIDGE ST MAP 25C PARCEL 106 001 ZONE URB(101)/ % 6 ( THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST 9 E NCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 4 3>& S_S 6° o ' P.' R' Building Permit Filled out 011 i v Fe Paid r -e ftl Typeof Construction: insulation I New Construction ( J /I Non Structural interior renovations t l� Addition to Existing - e.? Accessory Structure Building Plans Included: Owner/ Statement or License 103635 3 sets of Plans / Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ro PRESENTED: Approved 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 . emo,/ , . ■S 6 1)7 Si: a - o 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. 228 BRIDGE ST BP- 2012 -1158 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 106 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2012 -1158 Project # JS- 2012- 001981 Est. Cost: $1373.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 11412.72 Owner: EDWARD ARLEY Zoning: URB(101)/ Applicant: PAUL SCHMIDT AT: 228 BRIDGE ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 - 5739 HATFIELDMA01038 ISSUED ON:6/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: 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 6/25/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner