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29-040 • ' 4io ® CERTIFICATE OF LIABILITY INSURANCE DATE {MMDDIYYYY) 11/23/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY DR 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 Jeanne Deneault, CISR NAME: Blackmer Insurance Agency Inc. PHONE Ex(): (413) 625 -6527 (v, No, {a1B)625 -8210 1147 Mohawk Trail ADDRESS: J eanne @blackeners. com PRODUCER 00003817 rusroME8J0 #: Shelburne MA 01370-9707 INSURER(S) AFFORDING COVERAGE NAIC INSURED INSURER A :Landmark American Ins Co INSURER B :Commerce Insurance Co Co-op Power, Inc INSURER C:Mar Specialty Insurance 324 Wells St INSURER D : Twin City Fire Insurance Co 29959 PO Box 688 INSURER E : Greenfield MA 01301 INSURER F COVERAGES CERTIFICATE NUMBER:CL10112300749 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. 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A IN R S WVD I POLICY NUMBER (MM DDNYYY) I (MMIDDY EXP LTR TYPE OF INSURANCE /YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO ETE X COMMERCIAL GENERAL LIABILITY PREMISES (E a o $ 100,000 A CLAIMS -MADE X I OCCUR X 1,52%.086972 00 11/8/2010 11/8/2011 MED EXP (Any one person) I $ 5,000 PERSONAL 8ADVINJURY 1 $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /O° AGG $ 2,000,000 X POLICY )ERGOT I I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMITT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ B ALL OWNED AUTOS P5752 3/23/2010 3!23/2011 BODILY INJURY (Per accident) $ X SCHEDULED AUTOS E PROPERTY DAMAGE X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ X UMBRELLA LIAR X I OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAE CLAIMS - MADE AGGREGATE 1$ 1,000,000 DEDUCTIBLE 1$ C - RETENTION $ MAX113100056487 6/2/2010 6/2/2011 I D WORKERS COMPENSATION I TORY LIMITS X O R AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N NH) (Mandatory in NH) I E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER N EXCLUDED? 08WECLC6866 11/1/2010 11/1/2011 E.L. DISEASE - Flt EMPLOYE $ 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Operations usual to energy efficiency services - energy audits, air sealing, insulation, and solar hot water system installation. Certificate issued subject to the terms, conditions, exclusions, and endorsements attached thereto. 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. Center for Ecologic Technology 112 Elm St. Pittsfield, MA 01201 AUTHORIZED REPRESENTATIVE I - 40 ACORD 25 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (2009091 The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.aov!dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): � - op 7r)i),)er / L_LrC Address: - 3 2 lJJQ 7 . City /State /Zip: ��7l1�1�,1� �� (� t l Phone # ( - 7 - 1 a — os - q Are you an employer? Cheek tI}.�,appropriate box: Type of project (required): 1. /� 1 am an employer with ZC 4. I am a general contractor and I 6. New Construction "employees (full and /or part- time)* have hired the sub - contractors Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub - contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. _Building Addition [No workers' comp. insurance comp. insurance. 10. _ Electrical repairs or additions required.] 5. We area corporation and its 11. Plumbing repairs or additions 3. 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per IvIGL 12. _ Roof re insurance required.]-1 C. 152, ' 1(4), and we have no 13. 'K-.Other_�� employees. [No workers' comp. insurance required.] * Any applicant that checks box 1 must also Fill out the section below showing their workers' compensation policy information. H Homeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit a new affidavit indicating such. I Contractors that check this box must attach an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. [f 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: ; ~ ahcl (Y etyq K' 4 hr ercCtern SnS, C c. Policy # or Self-ins. Lic. #: C (41 r - 1 - - C- e / - 6 4 ' (c Expiration Date: t ` 2-0 1 Job Site Address: 4 Pt � t.%ee y ti 4Y Y�,g S'f Ci ty /State /Zip: r �drr"tiCC 'M ( CC 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 NIG L 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 5250.00 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 certi - nder the pain and penalties of perjury that the information provided above is true and correct. 7 10 Date: j xr 13 .001( Si „nature: II 11 2,�.�_ � Phone #: Official use only. Do not write in this area, to be completed by city of town of 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 #: •,----4 s... -69, . Office of Consumer Affairs and usiness Regulation J 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 - -- - GRE €NFIEL D MA 01301 _ Update Address and return card. Mark reason for change.. _� 0 Address 7 Renewal In Employment 0 Lost Card 1 Co 50M- 04104 - (( 6 11 2 1 _ 66 /�/ �,� ����/ d.4 ✓ e V 111/11Z!✓711Zf Q+GC/r /Wo ad! License or registration valid for individul use only Orrice ofCunsamer Affairs & Business R y. HOME IMPROVEMENT CONTRACTOR before the expiration date_ If found return to: _ Office of Consumer Affairs and Business Regulation `' Registration:,:, ,165217 10 Park Plaza - Suite 5170 Expiration 1!21/2912 Tr# 292798 Boston, MA 02116 Type:. - :• oporatitm;. -_ __ ;O-OP POWER JNG`: - J'__' L CAUL SCHMIDT": �'`� ( f 124 WELLS ST �a -�'°' c:Y ;REENFIELD, MA 61 Undersecretary Not valid without signature s =• . NIassachusetts - Department of Public Safety II'; Board of Building Regulations and Standards CoristructiCn Supervisor License License: CS 1 03635 u t IV, f , Restricted to: 00 S. r .1 PAUL SCHMIDT i a 24 CHESTNUT ST t:, ' r- HATFIELD, MA 01038 J� ; .g." � Expiration: 5120!2013 ('onunissioner Ti#: 103635 S ECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Superv' + ( - Not Applicable El 3 4 Name of License Holder : Sc% 1 C7 f 103 4 C g� f License Number 2 Addres r Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ^1 C6-0 P W�'"2 1/11c- t42 2 Company Name / Registration Number 32}.( (AA* 5-(-- 6 'NA 6 13 ( t - - "— Address 7 Expiration Date ' Telephone !-7Z'i 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 t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) leg, Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [D Siding [El] Other [ f] Brief Description of Proposed 114j„ 66 6671 S � o {^ KLItt I .. ( 6 , 4 G , 1 „. / L /__ ((� Work: / T„ 1 C7Gt Ce -389 Q2 — (ci) 6R 3 �0 VC.-;-vii Alteration of existing bedroom Yes No Adding new bedrooZn 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, ]" / 1 t C x16\6 ill ,fit 1 f ,f it 4 (2 , as Owner of the subject property hereby authorize C 0- 0 (7 Powc- L . to act on my behalf, in all matters relative to work authorized by this building permit application. 2 -J t- ' ,-/ 2 5 /t Signature of Owner Date I, Tam. ( Sc 1`I (CK , 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 pe jury. Palk( 5��I IC( Print Name it ., Signature of Owner /Agent Date l 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 /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW O YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained l Obtained O , Date Issued: C. Do any signs exist on the property? YES ® NO o IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , - '41), Department use only ANO C of Northampton S tatus of Permit: ;S;. Bui • ing Department Curb Cut/Driveway Permit �O`\ 2 • Main Street Sewer /Septic Availability `�(�►� ' • •m 100 Water/Well Availability ,y ampton, MA 01060 Two Sets of Structural Plans co / - - 587 -1240 Fax 413 587 - 1272 Plot/Site Plans Other Specify A' (CATION 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 wee h 0 ( IS S-t Map Lot Unit Zone Overlay District 1 J6-yvv c n t o 492., Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: M 1c C1 ae4- -/ f Vtit1- h - a t `7 /1 o „r-t• Fiev -e � � � /13 Name (Print) Currer�y,�qaiv g Addrss: `n ey I U ( Z ��l - Telepjh",ne (� Signature ( � , r 3C/ y 2.2 Authorized Agent: Co-o Pare -l-vic P ( Cc/mirk 3 wek f ;r�c�. i c�fl ,130 Name (Print) Current Mailing Address: ,,. 4(3-1 4 rci 3" Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 t ‘`-'' (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) l 6 Check Number `43 7 05 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0702 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 67 PIONEER KNLS MAP 29 PARCEL 040 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Al -� Fee Paid Tvpeof Construction: INSTALL ATTIC & KNEEWALL 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 F 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 Airr iliamsaggt11112 3/2/p 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. 67 PIONEER KNLS BP-2011-0702 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 040 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- 2011 -0702 Project # JS-2011-001153 Est. Cost: $1650.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 11 979.00 Owner: MAHAR MICHAEL J JR & ALICE L Zoning: URA(100) / /WSP Applicant: PAUL SCHMIDT AT: 67 PIONEER KNLS Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:3/2/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & KNEEWALL 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 3/2/2011 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner