38B-161 The Commonwealth of Massachusetts
Department of Industrial Accidents
• Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plum.
Applicant Information Please Print Legibhr
Name ( CO OF Po Gfl ^ ' �
Address: 31 °,S' /l jr - 51
Cit /State/Zip: & j r/g mA • 6 051 Phone #: '— 1 1 Is- 77 6 G
Are you an employer? Check the appropriate box: Type of Project (required): lam an employer with 3 4. _ I am a general for and I 6. New Conshtion
Employees (full and/or part-time)* have hired the sub - contractors
ng
2. _ I am a sole proprietor or partner- listed on the attached sheet. i ?- _Remodeli
Ship and have no employees These have 8_ Demolilion
Working for me in any city. workers' comp. insurance. 9. — Building Addition
[No workers' comp. insurance 5. We are a corporation and its 10. _ Electrical repairs or additions
required.] officers have exercised their 11. — Ply repairs or adclilions
3. I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. C. 152, ' 1(4), and we have no I2 Roof repairs t
insurance required.] employees. [No workers' 13. aOther 3(Jc(i)1
comp. insurance required.] A . Pbeb
* Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
*Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors muse submit a new affidavit indicating such
*Contractors that check this box must attach an additional sheet showing the name of the sub - contractors and their wworkess'
I am an employer that is providing workers' coerpensaiion insurance for my employees. Below is use policy and job site infonnation.
Insurance Company Name` e j y9CK /V1 64 Sit
Policy # or Self -ins. Lic. #: 4 03 W EOL C 614 Expiration Date: VII Q J 1.4 1 D
Job Site Address: Forisr •c City/SiatelZip: 1 oft — (
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
to ire 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 imprisonmett, as wen 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 ofthis stateanent may be forwarded to the Office of Investigations ofthe DIA fur
insurance overage verification.
I do hereby cettifr anderthe ' ,' , of perjury that the information prattled aboveis brie and correct.
Signature: 1°2 / '' Date J . 4 . O,
� 2 — ��f
Phone #: 1 `7 13
O,Q`icial ace only. Do not kilns' area, m. be comipleted by cit oftawn offidaL
City or Town: PermitLi rose #:
Issuing Authority (cir cle one)
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
- (413) 625-6527 FAX: (413) 625 -8210 - THIS CERTIFICATE S I AS A MATTER OF INFORMATION
al so t4 — u" Insurance I - ONLY AND CONFERS NO RIGHTS UPON THE CERTWICATE
1000 'frail HOLDER. TIES CERTIRCATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLE BELOW. •
1
Shelburne Mt 01370 -9737 - DISURERS AFFORDING COVERAGE i NAI: 8
DOMED. a s uR e m landmark. American Ins !
Co-op - Power , Inc - . . Ret w at Eartford insnrafl, Croup 1 -
324 Wells St - Ass m
PO Box 688 e0
Greenfield MA 01301 INSURER E 1 -
COVERAGES
THE POLKA OF INSURANCE USED BREW HAVE BEEPS ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD IPWTED
ANY REQUIREMENT, TERM OR CONBiAN OF ANY CONTRACT OR OlwEit Docul1ENT mini RESPECT TO WHICH TIM OENDFIC&TE MAY BE ISSUED OR
MAY PSI.TAWJ THE INSURAKCEAFIVRDED SYTHE POLICES DESCRIBED HEREIN IS SUBECTTO ALL 1} E MBA EXCI ONS AND COMMONS OFSUCH -
POLICES. AGGREGATE L1M75SHOWNMAYHAVEB EEN REDUCED BY PAID tom.
R M TYPE OF AinemeE 1 - poutriseerea j 1 iI� i �jrA )
CMS
FOAMY EACH OCCURRENCE $ . 1,000,000
. sEe umanv - �I $ 100,000
A X CLAMS WOE r occult 5599600 11/8/2009 11/8/2010 NEOWWlairoaesema S - 5,000
PEiSONN.6AOYKAAY S 1,000,000
t,TasEIILAGGREGNIE $ 2,000,000
h eAGGRPBIfrEMiTTAPPUESPEit PRODUCTS- CO�IOPAB6 s 2,000,000
X POUCY n roc
/Nr MDMI EUAENRY 1
SINGIELMT $ 1,000,000
,aLOMED os
9riAUrOS s
A HIRECI urns
. x NONOMEO AUTOS 11/8/2009 11/08/2010 :
• 3
Ci��
6ARASELMea1rY Mrroo ar- EiIACCO9rr $
_. ANYAUra Om1erTHAa1- OLACC $
AUWOE9.Y: AGO 3 -
a>LT11111ti111111B/Ath WY EACROCCURRENCE { $
OCCUR ❑ CLAMS MIME - AGGRBNCE s
$ _
rsavi r■IE s
- REUMMUN $ $
B laninestsameimemei i 1� ,►l s1 I Fit
ANY PROPREIONPAINNERIENECUME n lam! 0a 1$$6
1$ 11/01/2009 11/01/2010 EL.EACIIPCOCENT s 500000
p 9 r �
9yrr ieNM r�aSlAaSyt EL 0 -MIEINI0YE£ $ 500000
SP PROV SI Wee _ EL OISEASE-1 S 500000
OTHER
o PTIOKOFOPERA ocrous tveectsstE ADDED OVE DD ILISVE IALPROVISIONS - -
Certificats issued subject to the terns, conditions, esoelnrioas, and endorsements attaebed thereto. operations asusal
to alternative solar energy• _ Western !lass aI otri . CO is added as additional is d. - -
. CERTIR ATE HOLDER CANCELLATION
- SHOULD ANYWAIN EOE POuCIES BECANC811$HEFOtETHEEXpRA710N
Western Mass _ Electric Company OA7ETFIHEOF,THE mums emsizer um. Ep t7+o NAM- 10 . DAYS YROrrnnt
Customer Service Center INSTICE'f0 TIE comic= Hou ma HAM83lflTHEIEFTAUTPAIMETODOSOMAL I_
P O Boa 2010 -
+ =ter= a *{, 01090-2010
DOSE MO OR ummur r OFAMY ROM UPON sE>ws�. rte AGENTS OR
RA7HAE.
AQit ppgREMITU M
ACORN 26 (2009101) O 1088-21109 ACORD CORPORATION. AI rights reserved.
INS025 (200901) The ACORD name turd Logo We registered stad s of ACORD
gge
'i° = Office of Consumer Affairs and B usiness Regulation
= ° = =,, 10 Park Plaza - Suite 5170
' - ,,°. Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165217
Type: Corporation
Expiration: 1/21/2012 Tr# 292798
CO -OP POWER, INC.
PAUL SCHMIDT
324 WELLS ST — _ - -- —
GREENFIELD, MA 01301 — — — - - --
Update Address and return card. Mark reason for change.
7 Address 7 Renewal '7. Employment j_ J Lost Card
DPS -CA1 eJ 50M -04104- G101216
.... -, License or registration valid for individul use only
Office of Consumer Affairs & Business Regulatio before the expiration date. If found return to:
1 - - -ii HOME IMPROVEMENT CONTRACTOR
4. °,_ .. Office of Consumer Affairs and Business Regulation
_ . Registration: 165217 10 Park Plaza - Suite 5170
y _rt Expiration: 1/21/2012 Tr# 292798
-,,,,,,__,-„,,,5-7 Boston, MA 02116
Type: Corporation
CO -OP POWER, INC.
PAUL SCHMIDT
324 WELLS ST�_— .""'---
GREENFIELD, MA 01301 Undersecretary Not v without signature
liassachusetts - Department of Public Safety
4 r i l Board of Building Regulations and Standards
,/ Construction Supervisor License
License: CS 103635
Restricted to: 00
PAUL SCHMIDT
24 CHESTNUT ST
HATFIELD, MA 01038
–' ---.• �` Expiration: 5/20/2013
('unmiissioner Tr#: 103635
\ /
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 01 Salm 1 !03 6 3 5
License Number
� fevt,-ei, 51 -w ) �3
Address J Expira ion Date
t r 7 s'
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Gv —OP POr,o 6r 1.6 S - 147
Company Name Registration Nu ber
3z� w ,g )If 1)21 Z�>
Address Expira on Dat
Telephone 1 v lI
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 ❑
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 El Replacement Windows Alteration(s) igi Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [0]
Brief of Proposed 7 . N rA . A ,,�Ji C idA t , S'A f jU ] ArD )
Alteration of existing bedroom Yes 6 6 No Adding new bedroom Yes a 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, A b ( L / /1 Yl , as Owner of the subject
property ( A l 0
hereby authorize CO—OP POLO #r' (Pi9 J M // to act on my behalf, in all matters relative to work aunzed by this building it application.
AtIgask • ' tiA0- s7 11 - 14)1,
Signature of Owner Date
I, 'flu) J d m fr. L , 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 an a ins and penalties of perjury.
4 ce-14 l
Print Name L' / p
Signature o r /Age 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 /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NOA DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained ® , Date Issued:
C. Do any signs exist on the property? YES NO j(
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO o
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 ® NO `)
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well 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 `
1.1 Property Address: „u1 J
This section to be completed by office
M Map Lot Unit
z /oAT sr
Zone Overlay District
Eim St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Ar 6 (4A1A- - DO/1A/CC > K2121 sr ,&f il iogeoisvo A L N A
Name (Print)) Current Mailing A /drrees 7/ / j� — �, / � qc
P i' Telephone (�
Signature
2.2 Authorized Agent:
Au) .1G jq c o . -or powir) 3 Wg7.1 sT (rr( /dgA9
Narfie (Print Current Mailing Address:
1 /)3 "272- - 4797
Sign re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Tc noV (f (a) Building Permit Fee
T /
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) Check Number 055
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: •
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1054
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 12 FORT ST
MAP 38B PARCEL 161 001 ZONE URB(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 /s7 e5 5
Typeof Construction: INSTALL ATTIC,WALL & BASEMENT 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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Signature Building Offic al 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.
1 , BP- 2010 -1054
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -1054
Project # JS- 2010- 001552
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 5575.68 Owner: DOLINGER ABIGAIL M
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 12 FORT ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:5/25/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC,WALL & BASEMENT
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 5/25/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo