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38D-019
OWNER AUTHORIZATION FORM Auk (04wes time) owner of the property located at `C2 - tr�b,,7!& - �u- J irX,J gh p ) hereby authortze `b 1._, ani (8_ubm-- ) an auttwrized VJbcontrWw for RISE BVhumft,toad on my behalf to obtain a building permit and to peftm work on my property. r Owner's Signature Date ,JpN � 6 2p15 City of Northampton '��1�`__= S�5-•• ='---sic Massachusetts �� : :•<<G EWARMNMW or suxzj)2 G ZRSPSCTICN3 t+ 212 Main Street t* dpalBuilding M 6 oy NAY 3��~�ca Property Address: �T Contractor Name: ►-- (Ji't`,tff?1'Y� h�' 1.1L? C �`� r . Address: � '- �,� hc.A;. S4e.C-* City, State: CAA Mf4 C)tCkt: Phone: '41,1 )- Property Owner ]� Name: In Address: V-�-•-e-`� City, State: �'` ul C:)C-C 0 i (contractor)attest and affirm that the building I intend to insulate does 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 The Commonwealth of Massachusetts Deparfinent oflndustrid Accidents Office of Invmfigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Businessnvmization/lndividual): cs_-rune, Address: .A± 1-'-e e,+ City/State/Zip: �4aV'�cb Mtn tit b3K Phone.#: g1- 3- a y'7_ ,739 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a to with 4. [] I am a general contractor and I P y er * have hired the sub-contractors 6. ❑New construction employees(full and/or p -time). 2.❑ lam a sole proprietor or partner- listed on the attached sheet. 7. [❑Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in any capaci tY- employees and have workers' t 9. E]Building addition [No workers'comp.insurance comp•insurance. required.] - 5.[] We are a corporation and its 1011 Electrical repairs or additions 3_❑ I am a homeowner doing all work officers have exercised their 1 I.Q Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.n Roof repairs insurance requhrdj t c.152,§1(4),and we have no employees.(No workers' 13.[�Other jcr�'pn comp.instn mee required) 'Any appGcunt that checks box#I must dw fill out the section balow showing their workers'compensation policy infornntion. t Homebwaers who submit this affidavit indicating they act:doing ahl work and then hire outside contractors must submits new affidavit indicating such. tConbactors that check this box must auached an additional sheet showing the nwm of the sub-eontractars and state whether or not those entities have employees. if the sub-cordactots have employees,they mst p ovide their wotkcas'comp.policy number. lam an employer that isproviding workers'compensation hmmncefor my employees. Below is thepoUcy and job site information. . Insurance Company Name: Q Z Q it RD f c� i✓ Policy#or Self-ins.Lic.M. !� "1 D q-~ © ' , Expiration Date: Job Site Address: '\0�.2 r�t �" City/StattMp: X 4,` tm Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire on I Failure to secure coverage as required under Section 25A of MGL c. 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 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 cert r tfie pains enalties of perjury that ilie information provided above is true and correct Si ature• GPi Date: / Phone#: Offu ial use only. Do not write in this area,to be completed by crty or town ofjiciat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction%pervisor. Not Applicable ❑ Name of License Holder: tense Num er 0, DI C)5�r Addres Expiration Date Si nature Telephone 9.Renistered Horne Imorovernent Contractor: Not Applicable ❑ Company Name Registration Number els �;t J-7 A ds s } l Expiration Date Telepho� 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 building ermit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exem don The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 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 Arkin #of Parking Spaces - Fill: (volume&Location A. Has a Special Permit/Variance/Finding,/Over been issued for/on the site? NO 0 DON"r KNOW YES Q IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW CJ YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO CK 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(-) ED Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[o) r[ Brief Des iption of Pro d Work: /) q / rl �f bl S3 Alteration of existing ledroom 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 n construction. Dimensions e. Number of stories? f. Method of heating Fireplaces or Woodstoves Number of each g. Energy Cons ation Compliance. Masscheck Energy Compliance form attached? h. Type of c struction i. Is co truction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. D 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 AG NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, - as Owner of the subject pro —T hereby authorize + -e V to a t on my behalf, in-all matters r ative to wo au on ed by this building permit application. See, c -/7r 1 S� Signature of Owner Date as Owner/Authorized Agent hereby declare that the statements an information on the foregoing applic4tion are true and accurate,to the best of my knowledge and belief. Signe nder the pains and penalties of perjury. Pau i ej�ff,—A Print me Signature of Owner/Age Date LEfectric, _� Department use only of Northampton Status of Permit:9 2015 Iding Department Curb Cut/Driveway Permit 12 Main Street Sewer/Septic Availability g&Gas Insp io Room 100 Water/Well Availability ton,MA 01060 0'rt mpton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Proaerty Address: This section to be completed by office Map Lot Unit Zone Overlay District Elm St.District CB,District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner f Record: Na innt) Currqpt aili dd Tel6ph6ne Signatu e 2.2 Authorized A ent: Name ) Current Ma Address: a-4 ilin V-6 Signa ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building (a)Building Permit Fee 2. Electn 1 (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) 40 , a 5 Check Number 3 This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0807 APPLICANT/CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739 PROPERTY LOCATION 2 REED ST MAP 38D PARCEL 019 001 ZONE SC(68)/URB(32) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 7 75 Fee Paid kpeof Construction: INSTALL WALL 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 INFOR NATION 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 sPermit DPW Storm Water Management it' a ,OPO g� Signature of B it ng 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. 2 REED ST BP-2015-0807 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D-019 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-2015-0807 Project# JS-2015-001569 Est. Cost: $5676.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 21257.28 Owner: STEWART IAN F&MARILYN E SILBERGLIED Zoning: SC(68)/URB(32)/ Applicant. PAUL SCHMIDT AT. 2 REED ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247-5739 WC HATFIELDMA01038 ISSUED ON:212012015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WALL 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 OccuRancy Signature: FeeType: Date Paid: Amount: Building 2/20/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner