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13-099 (2) 96 Ca BP- 2010 -0913 GIs #: COMMONWEALTH OF MASSACHUSETTS Mg` • `' k:13 - 099 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- 2010 -0913 Project # JS- 2010- 001350 Est. Cost: $30200.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BASK POWER LLC 103862 Lot Size(ssy. ft.): 80411.76 Owner: CHAFFEE RUFUS J & JOAN L Zoning: RR(53) /SR(47) //RI/WP Applicant: BASK POWER LLC AT: 96 COLES MEADOW RD Applicant Address: Phone: Insurance: 73 METACOMET ST (888) 611 -2275 WC BELCH ERTOWNMA01007 ISSUED ON. 4/20/2010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL SOLAR PV & HOT WATER 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 4/20/2010 0:00:00 $100.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0913 APPLICANT /CONTACT PERSON BASK POWER LLC ADDRESS/PHONE 73 METACOMET ST BELCHERTOWN (888) 611 -2275 PROPERTY LOCATION 96 COLES MEADOW RD MAP 13 PARCEL 099 001 ZONE RR(53)/SR(47)//RI/WP 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 SOLAR PV & HOT WATER New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/ Statement or License 103862 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION 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 Demolition Delay veL.- '� f zo /, Signature of 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. -0 () �t��i� F� The Commonwealth of Massachusetts Board of Building `Regulations and Standards FOR Massachusetts State- Alding Code, 780 CMR, 7"` edition MUNICIPALITY USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January One- or Two - Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers 96 coles meadow road I .la Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner' of Record: Rufus nffep� 96 cotes meadow road N ( 'nt) Address for Service: (413) 587 -3197 Sign u Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner- Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of U ni t s I Other l$( Specify Renewable Energy Syste Brief Description of Proposed Work 2: Installation of Solar PV and H ot Water SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑ Total Project Cost (Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6. Total Project Cost: $30,200 ❑ Paid in Full ❑ Outstanding Balance Due: BASK Power LLC 73 Metacomet Street, Belchertown, MA 01007 PH. 888 - 611- BASK(2275) FX. 413 -460 -0190 baskpower.com guoteftaskpowercom w t " SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) u2 �� 6 fir Af �,h. /G{�y License Number Explrat4 Date Name of CSL- PoWer List CSL Type (see below) 23 q7d4o-* 7 .ff � 7ou/ T Description Address Unrestricted (up to 35,000 Cu. Ft.) Restricted 1 &2 Famil Dwellin Signature M Mason Onl L1 J � RC Residential Roofing Coverin Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regi me Improvement Contractor (HIC) 157584 BASK Power LLG HIC Compony Namc r HIC Registrant Name Registration Number 73 Ietaco t Street Belch ertown, MA 10/18/11 Address 888- 611 -2275 Expiration Date Signature Telephone SECTION 6: 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 permit. Signed Affidavit Attached? Yes .......... X No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Rufus Chaffee as Owner of the subject property hereby authorize BASK Power LLC to act on my behalf, in all matters relative to work authorized har this building permit application. l o Si na re f Owner Date SEC N 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I BASK Power LLC as Owner or Authorized Agent hereby declare that the statements and informat n on the foregoing application are true and accurate, to the best of my knowledge and behalf. Thom Wrig If Print Name Aw Wednesday, October 7, 200 Signature of Owner or Authorize Agcnt Date (Signed under the pains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" BASK Power LLC 73 Metacomet Street, Belchertown, MA 01007 PH. 888-611 -BASK(2275) FX.413- 460 -0190 baskpower.com guoteCbaskpower.com V 91te - Commowwea" Office of Consumer Affairs and Regulation f_ F 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 157584 Type: Ltd Liability Corporation Expiration: 10118/201 t Tr! 289138 BASK POWER LLC. THOMAS WRIGHT _ 73 METACOMET ST BELCHERTOWN, MA 01007 Update Address and return card Mark reason for change. Address Renewal I Employment Lost Card DP-I;-CAI a %*A- 04:04- G10121e „\ .'�it!,.r {�:ramtrx+..e4rllli �� s7�r,uarva t)ffrce of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. It found return to: C ()R Registration: 157584 ice of Consumer Affairs and Business Regulation Expiration: 10/1812011 Tr# 289138 10 Park Plaza - Suite 5170 ' Type: Ltd Liability Corporation Boston, MA 02116 BASK POWER LLC, THOMAS WRIGHT 73 METACOMET ST SELCHERTOWN, MA 01007 Undersecretary Not lid bout signature il:t..:tehu.ettS - Departinrttt fit Public sa(vt" Board of Buildim- Nrgulationr and Standards Construction Superv License License: CS 103882 f Restricted to: W THOMAS WRIGHT 73 METACOMET ST BELCHERTOWN, MA 01007 Expiration: 10r"13 t +irtr» €+wit, r Tr#: 103882 BASK Power LLC 73 Metacomet Street, Belchertown, MA 01007 PH. 888 - 611- BASK(2275) FX. 413 - 460 -0190 baskpowercom quotefbaskpowercom Y II AGORIZ DATE (MMIDDYWY) CERTIFICATE OF LIABILITY NSURANCE 01/28/2010 PRODUCER 413) 323 -9611 FAX (413) 323 -6117 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bell & Hudson Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 19 North Main St. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 669 A LTER THE COVERAGE AFFORDED BY THE POLICIE Belchertown, MA 01007 INSURERS AFFORDING COVERAGE NAIL # INSURED Ba P ovier, LLC INSURERA: The Hartford ins. C o. 73 Metacomet Street INSURERS: Associated Employers Ins. Co. Belchertown, MA 01007 INSURER C: INSURER 0: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 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 BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE POLICY NUMBER POLICY EFFEC7NE EXPIRATION LIMITS GSNmW. LIABILITY 08SBAVZ0829 10/24/2009 10/24/2010 EACH OCCURRENCE S 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO 1 300 00 CLAIMS MADE FX OCCUR MED EXP (Any em perm+) S 10.00 A X PERSONAL l ADV INJURY 1 1 GENERAL AGGREGATE 1 2, 000 ,= GENL AGGREGATE LSET APPLIES PER PRODUCTS - COMP/OP AGO 1 Z,000 POLICY J LOC A UTOM OBI LE ILIABLITY ( C E OMSSINGLE OMIT S ALL OWNED AUTOS BODILY INJURY 1 SCHEDULED AUTOS (PorPercn) HIRED AUTOS BODILY INJURY 1 NON -OWNED AUTOS (Par etdCerfl) PROPERTYDAMAGE 1 (Per scatler) GARAGE AUTO ONLY - EA ACCIDENT i ANY AUTO R OTHER THAN EA ACC 1 AUTO ONLY. AGG $ rRmVtAReRELLA LJAMUTY 03SBAVZ0829 10/24/2:009 10/24/2010 EACH OCCURRENCE s 1, 000,00 0 , 000 00 X OCCUR F__j CLAIMS MADE AGGR 1 A X : DEDUCTOLE 1 X RETENTION S 10 1 WORKERS COMPENSATION AND WCC5008667012009 10/27/2009 10/27/2010 sTATU• H- EMPLOYERS LIABfl.ITY B ANY PROPRIETORIPARTNER"ECUTIVE E.L EACH ACCIDENT S _ S00 O EXCLUDED? E.L DISEASE - EA EMPLOYE 1 S00 ' 0 0( IAL PROVISIONS 69l°a E.I. DISEASE - POLICY MIT 1 500,00 OTHER PTKIN COI' 1 I»stal d I VEHICLES I EXCLUMNS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS So ar Pane General Liability applies on a primary & non - contributory basis & includes Massachusetts Clean Energy Technology Center, the System Owner, & as applicable the Host Customer as additional insured. General Liability & Umbrella policies include coverage for the independent & subcontractors & Residential work only while being performed on behalf of the insured. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, e"G INSURER WRL ENDEAVOR TO MAIL Massachusetts Clean Energy Technology Center 10 DNIYSWRI MNOTIC TOTHECER IMAENTATUM ER NAMED TO THE L EFT, S S Summer Street BUT FAIW T� MAIL SUCH TKI SMALL RIPOSIGATION OR LIABILITY 9th Floor OF ANY N R, 178 AGENTS OR Boston, MA 02110 E ACORD 25 (2001108) CIACORD CORPORATION 1988 BASK Power LLC 73 Metacomet Street, Belchertown, MA 01007 PH. 888 - 611- BASK(2275) FX. 413 -460 -0190 baskgowercom Woteft sk ow rc m ASK RENEWABLE ENERGY SOLUTIONS POWER .k CONSULTATION - SYSTEM DESIGN - INSTALLATION - RESEARCH PERMIT PACK The information contained in this document and any attachments is privileged, confidential, and intended only for the use of the individual or entity it was originally sent to. ADDRESS SITE LAYOUT NAME Rufus Chaffee COMPANY ADDRESS 1 96 cotes meadow road ADDRESS 2 CITY Northampton STATE 1 MASSACHUSETTS ZIP 01060 COUNTY NOTES SITE INFORMATION STATION 1 MA Worcester ROOF TYPE SHINGLE SOLAR RADIATION M ROOF CONDITION NEW ARRAY TILT y , ; : a; ROOF LENGTH FT 20 MAGNETIC DECLINATION 15 WEST ROOF WIDTH FT 20 UTILITY National Grid ROOF AREA SOFT }s k '4 BUILDING TYPE 1 RESIDENTIAL ROOF PITCH 45 # PEOPLE 2 N -S ORIENTATION 165 BUILDING SOFT 2500 PERCENT SHADING 90% Rf)OMS 8 FURNACE TYPE Oil FUEL USAGE N/A HOT WATER TYPE Gas AVE WIND SPEED MPH N/A OTHER HEATING Wood WATER HEAD FT N/A OTHER COOLING - WATER FLOW GPM N/A HVAC DISTRIBUTION 1 Forced Air HVAC DISTRIBUTION 2 Radiant BASK Power LLC Z Z A'1.D/ A/ &V /4' 73 Metacomet Street, Belchertown, MA 01007 PH. 888 - 611- BASK(2275) FX. 413- 460 -0190 baskpowercom quotefbaskpowercom x BASK Power LLC 73 Metacomet Street, Belchertown, MA 01007 PH. 888 - 611- BASK(2275) FX. 413 - 460 -0190 basWower.com auoteCbaskaower.com File # BP- 2010 -0917 APPLICANT /CONTACT PERSON CHARLES SEDER ADDRESS /PHONE 117 MOUNT WARNER RD HADLEY (413) 315 -0045 PROPERTY LOCATION 15 FAIR ST MAP 25C PARCEL 257 001 ZONE SC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Ji Fee Paid Typeof Construction: INSTALL INSULATION /DRYWALL CEILINGS & WALLS New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 94375 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition Delay I q ) z"I C) 14 64-1- ko _ Signature of 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. r ' Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /SepticAvailability Room 100 WaterMell Availability Northampton, 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 Property Address This section to be completed by office Map Lot Uni 15 FAIR STREET - NORTHAMPTON, MA Zone Overlay District Elm St. District Cg District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record STEVE FOUNDS 15 FAIR STREET - NORTHAMPTON,MA Name Print) Current Mailing Address: 413- 315 -00 Telephone Signature 2.2 Authorized Agent: CHARLES SEDER (DBA SEDER & SON) CHARLES SEDER (DBA SEDER & SON) Name (Print) ,r Current Mailing Address: 413- 315 -0045 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 5,000 (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) 5,000 1 Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Comm issionedlnspector of Buildings 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 p arking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever 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 Registry of Deeds? NO 0 DON'T KNOW U YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW e YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all awlicable New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing ❑ Or Doors ❑ Accessory Bldg. 0 Demolition Ne Si ns [O] Deck Siding [0] Other [0] dy2 0 Z - I � A Z J .0 - --r2 Brief Description of Proposed "30 "�- C t- Work: INSULATE AND DRYWALL BUILDING Alteration of existing bedroom Yes XX No Adding new bedroom Yes XX No Attached Narrative Renovating unfinished basement Yes xx No Plans Attached Roll - Sheet sa. If New house and or addition to existina housing, complete the following: a. Use of building : One Family Two Family Other XX b. Number of rooms in each family unit: Number of Bathrooms I c. Is there a garage attached? NO d. Proposed Square footage of new construction. Dimensions e. Number of stories. I f. Method of heating? BB ELECTRIC Fireplaces or Woodstoves NONE . Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction WOO FRAME i. Is construction within 100 ft. of wetlands? Yes XX 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 STEVE FOUNDS as Owner of the subject property hereby aut y CHARLES SEDER to act on�ny half, n attars relative to work authorized by this building permit application. r 04/16/2010 Signature of Owner Date CHARLES SEDER 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. S; Print Name 04/16/2010 Signature wn gent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder CHARLES SEDER 94375 License Number 117 OUNT WARNER ROAD 08/18/2011 A Expiration Date 413- 315 -0045 Sig ure Telephone 9. Reaistered Home Improvement Contractor. Not Applicable ❑ SEDER & SON 151088 Company Name Registration Number 117 M UNT WARNER ROAD 05/16/2010 Address / Expiration Date Telephone 413 - 315 -0045 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 permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ ON FILE FOR THIS ADDRESS WITH TOWN OF NORTHAMPTON 11. - Home Owner ExemDti ©n 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 buildinlz 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 ACORD CERTIFICATE OF LIABILITY INSURANCE 02%14/10 D[YY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFES NO Chase /Clarke /Stewart & Fontana HOLDER. THIS CERT F CA E DOES NOT AMEND, EXT OR 101 State Street - PO BOX 9031 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Springfield Ma 01 102 INSURERS AFFORDING COVERAGE INSURED INSURER A: Travelers Insurance Comp Charles Seder DBA Seder & Son Contract Sery INSURER B, 117 Mount Warner Road INSURER C, Hadley, MA 01035 INSURER D, I NSURER E, COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 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 BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1 ✓ COMMERCIAL GENERAL LIABILITY NC540865 03/23/10 03/23/11 FIRE DAMAGE (Any one fire) $ 50000 A CLAIMS MADE E_; OCCUR MED EXP (Any one person) $ 5000 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000 7,/ policy u project j Ioc AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA A CC $ AUTO ONLY: A GG $ EXCESS LIABILITY EACH OCCURRENCE $ 1 ODUUUU OCCUR L CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND ❑� T WC S TATU_ LIMITS LIMIT ER EMPLOYERS' LIABILITY E.L. EA ACCIDENT $ 1 A UB- 3329M432 05/10/09 05/10/10 E.L. DISEASE - EA EMPLOYEE $ 100.000 E.L. DISEASE - POLICY LIMIT 1 $ 500 OTHER DESCRIPTION OF OPERATION SILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY END RSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION FILE COPY DATE THEREOF, THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Lisa M. Clewes AUTHORIZED REPRESENTATIVE ACORD 25 -S (7/97) (DACORD CORPORATION 1988 F-1 << 94375 .. > m : \. CHARLES E SEDER 2 y ^ !!7%T WARNER RD \ HADkEf y4 01035 . .... . . . >« 2520 The Commonwealth of Massachusetts - Department of Industrial Accidents r;- it Office of Investigations ' 600 Washington Street t' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Q Please Print Legibly Name ( Business /Organization /Individual): Address: (? City /State /Zip: le i M4 o 10 S Phone #: !f f3 - 3lS— ao q S Are you an employer? Check the appropriate box: Type of project (required): 1 I am a employer with _ 4. E] I am a general contractor and I ` 6. F1 New construction employees (full and /or part- time). * have hired the sub - contractors 2. ❑ I am 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 capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors 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 the policy and job site information. Insurance Company Name: ret va4,e ✓S Policy # or Self -ins. Lic. #: V - 3 3 7 -2 M V z —4 -.. Expiration Date: ��f o Job Site Address: J< _ f v r City /State /Zip: AJfJ &Ao.ufJ2 A 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 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 Gerd er the pains aud4wvalties of perjury that the information provided above is true and correct Si ature: Date: - Z 7 1 11 10 Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or perniit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877- NIASSAFE Fax # 617 - 7277749 Revised 4 -24 -07 www,mass.govfdia