30A-016 fsUa►fl
4wm- 13 Permit Authorization "3
/ e
mass save' Form
—av etrerory CONTRACTOR
TIC T
Site ID: S0005013BS41 Customer: NANCY KIRK
I, NANCY KIRK ,owner of the property located at:
(Owner's Name,printed)
350 Florence Rd FLORENCE
(Property street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my prope
Owner's Signature:
Date: ,
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
af�o
a
For Office Use Only
conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800.480.7472
Rev.062015
City of Northamp too
�ssachusetts
ce�
212 Naft Street . Hmiaipa MWA4ng
Noctbmwtm, aw 010 'Ci
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Name:
Address: .
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Name: LLn 0 0 r
Address: —F-k rn-L n C_lL__'2'o a�
Cdr, state: (D— n LL , L:-A 0 t o Ll Z-
(cxnrador)attest and a#nm that the buddtg i MW4 to
mull a does not hamanyqm ak&wb anal Wn)wiring inftspamsto be insulated and that i have
provided Ow pr ay owner wN a copy of thft affidavit.
co*acwswwtLwe
dz
Date
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:
Are y an employer?Check the appropriate box: Type of project(required):
1.Q9 I am an employer with 4.0 I am a general contractor and I 6.0 New construction
employees(full and/or par ime).* have hired the sub-contractors 7.0 Remodeling
2.01 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' 9.0 Building addition
[No workers'comp.insurance comp.insurance.
required] 5.0We 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.O RoArep7:��W
employees. [no workers' 13.E Other
comp.insurance required.]
`Any applicant that checks box#1 most also fill out 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.
$Contactors that check this box most 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 provid71(-`6�ocv ers'compensado 'nsurance for my emplo ees.Below is the policy and job site
information.
Insurance Company Name:
Polic y#or Self-ins.Lic.#: r_T ��TP o(� 0.�_ Expiration Date:
City/State/Zip:
t e2—rA y t�O
f L Job Site Address: A. i4--
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
DIA for coverage verification.
1 do herby certify under the pains d penalties of perjury that the information provided above is true and correct.
Si nature: / t Date: dt a
Print,Vame ALL l , /y1 tCL`� Phone 4: 1L'�j " p� 6 73 9
Official use only Do not write in this area to be completed by city or town official
City or Town: Permitllicense#:
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#:
8.1 Licensed Construction Su or: Not Applicable s�ue❑ "
Name of License Holder: /"I1d r I 0 -) (-.P,3�J
License Number
44a+wrc-L 01
Address E)Orafion Date
ignature Telephone
Not Applicable ❑
Commv Name Registration Number
Addr'ess� Expiration Date
m14 0t O 3� Telephon��3 ay7 5739
.L.c.45z§.2W
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-occuc►ied Dwelliaas 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 788. Sixth Edition Section 108.3.5.1.
Defmition 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 buRdine 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 S-DESCRIPTION OF PROPOSED WORK(heck all
Now House ❑ Addition ❑ Replacement Windows Alterations) [] Roofing ❑
Or Doors ❑
Accessory Bidg. ❑ Demolition ❑ New Signs [n] Decks [M Siding JIM) Other[025'��
`v
Brief Description of Pr
Work: ►r S e�c (r'n
AS
Alteration of existing bedroom Yes No Adding new bedroom Yes No
es
Attached Narrative Renovating unfinished basement Y _ No
Plans Attached Roll -Sheet
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 Hands? Yes No. Is construction within 100 yr. fioodplain Yes No
j. Depth of basement or r 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 7s-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AC,ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize k ::r,,
to act on my behalf, in all matters relative to wo zed by this building permit application.
S' 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.
Print Name
of Ag 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 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/Findlnover been issued forton the site?
NO 0 DON7 KNOW YES 0
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW 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,:j 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 on,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO le
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
R GEw�D
Bu k" Depammnt
212 Main Street
Room 100
oHS N tthampton, MA 01060
587-1240 Fax 413-587-1272
��ppAP�
APPLICATfON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
g �r
1.1 Property Address
OL
SEMX `2
2.1 Owner of Record:
��� �Z inn �
�
Name nnt)
D n C _ Telephone YY
Signature , i
2.2 Audmfked Agent: ����C CL�2.�PrZ73 e(V1 CY" —
I rvi -f- a� C'hp�,j-
Name(Print) Current Mailing Address:
SignatureV Telephone
d .- z
Item Estimated Cost(Dollars)to be (3fr =fl'
compleW by perrrfd a icant
1. Buildiarg vc� (a) '`Fee
r7 00
2. Electrical
3. Plumbing
4, Mechanical(WAC)
5.Fire Protection
0
6. Total=(1 +2+3+4+5)
fss€ted:..
She:
File#BP-2016-0939
APPLICANT/CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD01038(413)247-5739
PROPERTY LOCATION 350 FLORENCE RD
MAP 30A PARCEL 016 001 ZONE URA(100)/WSP 100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction INSTALL WALL INSULATION&840 SQ CLAPBOARD WALLS
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:
roved 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
Demo ' ion De
Signatu Bui ding O ficlal 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.
350 FLORENCE RD BP-2016-0939
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-016 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0939
Project# JS-2016-001592
Est. Cost: $2700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 39508.92 Owner: KIRK NANCY
Zoning: URA(100)/WSP(100)/ Applicant: PAUL SCHMIDT
AT. 350 FLORENCE RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247-5739 WC
HATFIELDMA01038 ISSUED ON.112712016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL WALL INSULATION & 840 SQ
CLAPBOARD WALLS
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 1/27/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner