Loading...
23A-120 (4) co - OP � v POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal I, Paul Schmidt Energy Efficiency Program Director of Co -op Power certify that Co- op Power will remove all waste from the job site located at: !" ) i N14- t> A bo &t - f = v c 1''' o I 0 6, -2- Owner Name Street Address Town /State/Zip Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our removal service is Waste Management. / t:17 2-7 2 - Paul Schmidt Date • Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop H� . City of Northampton ` a 'p ,, y5 S Massachusetts A. *� lec ,I. • W • w ; ' r 4 \ DEPARTMENT OF BUILDING INSPECTIONS y ; r' 212 Main Street • Municipal Building � ' s C a ~ r � . .�. h. Nort MA 01060 1 ' 4 V •;i Property Address: ��l c �' ►�) �= St {'1, iwt�v(it / 1t't ri v 1 G t Z Contractor Name: (fevtt (.46 .44 c 07- - Address: 71-( wFG c S Cr City, State: C--1 {?ir`Yr' (`j c `t, ✓�� 44 II 0 / '3 0 / Phone: r 2 " t`7 Property Owner Name: I` {Pit 0I ,, „,J A' Address: $ 1vA.t rF✓,?1/t; -CT City, State: 'VW' 1./C- � kit / a l D t Z I, [ .2. (contractor) attest and affirm that the building I intend to insulat 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 cop ` of the affidavit. "i 1 2 Contractor signature /� //i Date / 7 2 . CO-OP ■I POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY City Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 April 13, 2012 RE: Building Permit for Insulation Work at 8 and 8b Middle Street in Florence We are submitting these applications to obtain permitting for insulation work at the properties of Nora Kalina. Enclosed please find: 1. building permit applications 2. debris disposal affidavits 3. copies of CSL and HIC licenses 4. certificates of Workers Compensation 5. certificates of liability 6. stamped return address envelopes 7. check numbers 3208 and 3209 in the amount of $55.00 each. Kindly return the authorized Building Permit to Co -op Power in the enclosed envelope. Thank you. Sincerely, / --) l Kaihe n ol Energy Efficiency Ad inistrator katherinep @cooppo er.coop Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop a• SECTION 8 - CONSTRUCTION SERVICES Licensed Construction Supervisor: — 8.1 Licensed Construction Supervisor: Paul Schmidt Name of License Holder : 24 Chestnut St. Hatfield, MA 01038 Alf CS # 103635 U Address ; Exp. 5/20/2013 413- 772 -8898 Signat r f Telephone Home Improvement Contractor: Co -op Power Inc. / Paul Schmidt — 9. Registered Home Improvement Contractor: 324 Wells St. Greenfield, MA 01301 Company Name 4 165217 Exp. 1/21 /2.4) Address 413- 772 -8898 Jr T paul @cooppower.coop • 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 C2 No ❑ 11. - Home Owner Exemption 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 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 I I Addition I 1 Replacement Windows Alteration(s) I Roofing I I Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed Work: 3 . 5 [ N }vt 1 t v F41 u114-04 t ( ft ✓l "' y r/ 7 Alteration of existing bedroom 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 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, NM_ t WALK , as Owner of the subject property hereby authorize ` o / / (/L " j'`/ t (24,7& J 1 , ( to act on my behalf, i II matters relative to work authorized by phis building permit application. Signat o caner — Date I, PlA.0 (9K' , as Owner /Authorized Ageni 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. M4/1 Print Na e a ew ti 2 Signature of Own:V nt 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 . r. Building Department t � Lot Size 1 1 ( 1 Frontage 1 1 11 ( Setbacks Front 1 1 ( 1 I 1 Side L:1 1 R:1 L:I R:1 1 1 1 1 Rear 1 1 1 1 1 Building Height ( 1 ( 1 1 1 Bldg. Square Footage 1 1 1 1 % 1 ( 1 1 1 1 Open Space Footage 1 1 % 1 1 1 (Lot area minus bldg & paved parking) # of Parking Spaces 1 1 1 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding er been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis of Deeds? NO 0 DON'T KNOW YES 0 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 Q" YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: f C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excav ton, 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. ,4 Department use only 1 z .J City of Northampton Status of Permit: � Building Department Curb Cutlt)riveway Permit 212 Main Street Sewer /SepticAvallability [APR 1 S 2012 1 Room 100 Water/Well Availability , Northampton, MA 01060 Two Sets of Structura Mans DE phdne 13- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other ,pecify °, 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 ^ S ry2�( t�� {' 04 l oat- Map Lot Unit i Zone Overlay District Elm St. District CB District • SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: tiro VZ..A -t,i.ik 2 (vLt,oc u Sk- lo ,c. 1 ,A,1 0 tC Name (Print) 77 Curr4 Mailing A1re� V i i P Telephone Signa 1k 51 . 91--- 2.2 Authorized Agent: o!I 1- • .iii t 7' 5 )- t-' 4 Si ico ;� i0; ! f- o I' ?-0 j Name (Print / Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building " (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) 2. (46 ') ? 9 • c 0 Check Number 3o2O9 '5.5s This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0904 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 8 MIDDLE ST MAP 23A PARCEL 120 001 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 CJ ? 06 6- Fee Paid Typeof Construction: WALL INSULATION & VINYL SIDING 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 INFQRMATION 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 /1 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. 8 MIDDLE ST BP- 2012 -0904 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 120 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- 2012 -0904 Project # JS- 2012- 001591 Est. Cost: $2639.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 11499.84 Owner: ROESSLER JO R & NORA R KALINA CIO TIMOTHY S COTTON Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT: 8 MIDDLE ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATF ISSUED ON:4/30/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:WALL INSULATION & VINYL SIDING 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 4/30/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton ( f. .. "' t Massachusetts ` ' * e I � 1 I, m , !' " DEPARTMENT OF BUILDING INSPECTIONS Y !r � Y 212 Main Street • Municipal Building b y s , [1 ,,,ii) ~ Northampton, MA 01060 "4 ad' Property Address: (/ M" ?Ur S'r rtwr f r 4- 't" 1 A li (Z 6 2 Contractor , Name: t cL ` ✓''1 � • Address: 2 fj 14.A t. c . '-r City, State: i el.,? r /A 4 0 /;,4)/ l Phone: 1 49 3 "7 - i- Property Owner Name: N 4; y.' 4 K All r f ,4 Address: i f , a ci City, State: 6-D/712\ r,?';v'G-t' f / 0/ r 6 2 I, prxi, fct4 t7i' (contractor) attest and affirm that the building I intend to insultite 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. I ) /1 Contractor signature Ld (,/ , Date / j Vcil 2 co -OP J1v 1 L /S POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal 1, Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co- op Power will remove all waste from the job site located at: Via' C r / i g I V l - h am + ✓ PM D ( VI-- Owner Name Street Address Town /State/Zip Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our removal service is Waste Management. 0/4;771 Q 3 I Paul Schmidt Date Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop lite / - 0 for 0 / 4 g. =_ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 M - , Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21 /2014 Tr# 220702 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Update Address and return card. Mark reason for change. 0 Address Renewal 0 Employment 0 Lost Card DPS -CA1 sr 50M- 04104- G101216 fie t onto 4 Leoeala ,i` laddafAu°etI° License or registration valid for individul use only Office of Consumer Affairs & Business Regulation g y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 165217 Type: Office of Consumer Affairs and Business Regulation Expiration: 1121/2014 Corporation 10 Park Plaza - Suite 5170 Boston, MA 02116 CO -VP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Undersecretary N ot v w ithout signature Massachusetts - Department of Public Satoh 7 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 C ommisiunrr Tr#: 103635 • The Commonwealth of Massachusetts Department of Industrial Accidents ._ ; , ; i, �` Office of Investigations 600 Washington Street ±" Boston, MA 02111 t r` wwwanass.govldia Workers' Compensation insurance Affidavit: Builders / Contractors /Electricians/Plumbers Aanlicant Information Please Print Legibly Name (Bu sinessiorgani7ntion llndividuai): C 6 re _. s� C Address: 3 f{ (,J&( S " City /State /Zip: Phone #: `` ( 3 1 - - ' Are ou an employer? Check the appr riate lox: Type of project (required): 1. Nl am a employer with (0 4. 0 I am a general contractor and I employees (full and/or part-time).4 have hired the sub - contractors 6. ]Nevi construction 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub- contractors have 8. 0 Demolition working for me in capacity. employees and have workers' g any 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 10.0 Electrical repairs or additions 5. 0 We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. Other .-f- (rl� fig 0. �"IUYv 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. t Homeowners 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. ram an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t W fr C i Fli - l"'Y∎S i " Policy # or Self -ins. Lic. #: O ` (D6 O Expiration Date: f4 - [ ^ di Job Site Address: City /State /Zip: 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 ofMGL c. 152 can lead to the imposition of criminal penalties ofa 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 he forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cer under the nd p hies of perjury that the information provided ab e is true and correct. Signature: - -* Date: _Z .,,z* Phone #: g 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 1. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: AC °R» CERTIFICATE OF LIABILITY INSURANCE �i; 2 i ') THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 CCOONNTACT Joseph Judd NA Blackmer Insurance Agency Inc. BONE Nn. Fan: 625 -6527 FAX 4413)E25 -6210 PHONE tAIC. No): 1147 Mohawk Trail App Ess: joe@hlackmers.com INSURERS) AFFORDING COVERAGE NAIC Shelburne MA 01370 -9707 INSURERA;Twin City Fire Insurance Co 29459 INSURED INSURER B : CO —OP POWER, INC. INSURER C PO BOX 688 INSURER DI PO BOX 688 INSURER E : GREENFIELD MA 01302 INSURER F COVERAGES CERTIFICATE NUMBER.÷Master 11 -12 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 ISSUER FOR AIIA'Y THE INSURANCE'AFFDRDED BY THE POLICIES DESCRIBED HEREIN IS - SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 LTR TYPE OF INSURANCE ANSR SUBR POLICY NUMBER (Mr°ruDD/YYYNi IMM/DDM'YYt UMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS -MADE I OCCUR MED EXP (Any ale person) $ PERSONAL & ADV INJURY S _ GENERAL AGGREGATE 5 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGO S POLICY n IF a n LOC $ AUTOMOBILE LIABILITY C e SINGLE LIMIT 3 _ ANY AUTO BODILY INJURY (Per person) S — AL OS /NED _ SCHEDULED BODILY INJURY (Per accident) 5 AUTOS _ HIRED AUTOS _ AUTO -0WNED PROPERTY a DAMAGE accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION TORY 1 A M U- 1 1 O FR AND EMPLOYERS' LI&BILnY ANY PROPRIETOR/PARTNERfE)CECUTIVE Yf N E.L. EACH ACCIDENT $ 1,000,000 OFF/MR/MEMBER EXCLUDED? I I N 1 a 11/1/2011 11/1 /2012 (Mandatory in NH) 08WECLC6866 EL DISEASE - EA EMPLOYEE s 1,000,000 11 yes. describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 7117, Additional Remariat Schedule, If more space Is required) Operations usual to energy efficiency services - energy audits, air sealing, insulation and solar hot water system installation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Rd, Ste 4, 2nd Flr Canton, MA 02021 -1461 ALrtHORISED REPRESENTATIVE J Deneault, CISR /BLAJ ACORD 25 (2010105) 01988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD ,4c D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �..�/ 11/22/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 NAME: Palazzo James J. Dowd & Sons Ins I No. Ext1:413- 538 -7444 FAX Ne1:413- 536 -6020 14 Bobala Road Holyoke MA 01040 ADDRESS s paIazzQ dowd.com INSURER(S) AFFORDING COVERAGE NAIL ti INSURER A • . - Indemnity Company INSURED COOP INSURER B :Great American Insurance Companies Co Op Power, Inc. INSURERC:U S Liability Insurance Comaanv 324 Welis Street Greenfield MA 01302 INSURER D INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 1050225280 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC INDICATED. NOTWITHSTANDING ANY RECUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W-1ICH 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP w LIMITS LTR INSR VD POLICY NUMBER (MM/DD(YYYY) (MMIDD/YYYY) C GENERALLIABIITY CL1566148 11/8/2011 11/8/2012 EACHOCCURRENCE $1,000,000 MAGE TO X COMMERCIAL GENERAL LIABILITY PREM SES (Ea RENTED $100,000 CLAIMS -MADE OCCUR MED EXP (My one person) 55,000 PERSONAL & ADV INJURY $1,000,000 _ GENERAL AGGREGATE 52,000,000 _ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 — 1 POLICY PFCT X LOC $ A AUTOMOBILE LIABILITY COM6212701 3/23/2011 1/23/2012 COMBIN SINGLE LIMIT (Eeaccid $1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED x SCHEDULED BODILY INJURY (Per accident) $ _AUTOS AUTOS ON-O �� PROPERTY DAMAGE — 51,000,000 X HIRED AUTOS X AUTOS (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE $ _ DED RETENTION $ • $ WORKERS COMPENSATION 1 WC STATU- OTH- AND EMPLOYERS' UABILRY Y / N I TORY 1 !NITS ER ANY PROPRIETOR/PARTNERtEXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1411 A (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ ffyes, sib undar DESCR OF OPERATIONS Wlav E.L. DISEASE - POLICY LIMIT $ - B Dicers & Officers Liability EPP1117553 32/2011 5/22012 1,000,000 5,000 Deductible DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD IDI, Additional Remarks Schedule, it more space is required) Waiver of Subrogation Applies. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Road • Suite 4, 2nd Floor AUTHORIZED REPRESENTATIVE Canton MA 02021 -1451 /7: rsfr 019B8 -201D ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SECTION 8 - CONSTRUCTION SERVICES , icensed Construction Supervisor: 8.1 Licensed Construction Supervisor: 'aul Schmidt Name of License Holder : !4 Chestnut St. iatfield, MA 01038 - 2S # 103635 U Address ?xp 5/20/2013 113- 772 -8898 Signat ,re Telephone -Tome Improvement Contractor: 1.'o-op Power Inc. / Paul Schmidt 9. Registered Home Improvement Contractor: 324 Wells St. Jreenfield, MA 01301 Company Name 1165217 • Exp. 1/21/'2d,q Address 113- 772 -8898 )aul @cooppower.coop / 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 buildin 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 - vear 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 n Addition n Replacement Windows Alteration(s) Fr Roofing n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [EA Decks [E] Siding [O] Other [O] Brief Description of Proposed Work: tt ".bic. 'k n^ - 3. S " 1N vt.4 -14- (V;Nyt- S,o Alteration of existing bedroom 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 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 1, Nora- VA, ( 1 Gl , as Owner of the subject property hereby authorize r '- c57 " i J f (i - e hg� 'T ( to act on behalf, ters )ve to work authorized by this b i�V lding per application. Signature of Owner Date I, I L ,.�(i( to , as Owner /Authorized Agen 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. P e T t ,f ' WV Prin Nam i ir Signature 05wniert• gent Dat 647/6.2_ 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 b Building Department . Lot Size 1 11 I 1 Frontage 1 11 1 I Setbacks Front 1 1 1 1 1 1 Side L:1 1 R:1 1 L:1 1 R:1 1 1 1 1 Rear 1 1 1 1 1 Building Height 1 ( I Bldg. Square Footage 1 1 1 1 % 1 1 1 1 I Open Space Footage (Lot area minus bldg & paved 1 1 I I 1 1 I I I parking) # of Parking Spaces 1 1 1 1 1 1 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ev r 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 O DON'T KNOW ler YES O 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 O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO ©- ---- IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO '. IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only ii :',.. „ City of Northampton Status of Permit: F________ — Building Building Department Curb Cut/Driveway Permit APR 212 Main Street Sewer /epticAvoiiability 1 9 20!? Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT. .onTH aFSU ,;;.# n i_ry � ,y n P .,- - , +413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans,. N _._.. _ Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Addres`s: This section to be completed by office "f) M t f 0t '' ri- ' Map Lot Unit r n r .. lac- i^” A d (0 C C i�1'I Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name ( int) Currepl ng Ass: /al `1i [ r �Y Telepho e Signs ure 2.2 Authorized Agent: 119 x' Sz v (i'('z sr C- t zr✓4t- / ,/1 o/J Name (Print) ,/, i Current Mailing Address: /1 67/1) 9 — P Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (Z 2 G (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) , 7-7- C . %') Check Number ,teap S ✓ This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0905 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 8 MIDDLE ST MAP 23A PARCEL 120 001 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 Typeof Construction: WALL INSULATION & VINYL SIDING UNIT B 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 INF9RMATION PRESENTED: V 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 - Peunit DPW Storm Water Management Demolition Delay (Zi I Z- Signature of Building Official Date g g 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. 8 MIDDLE ST BP- 2012 -0905 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A -120 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- 2012 -0905 Project # JS- 2012 - 001591 Est. Cost: $1225.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 11499.84 Owner: ROESSLER JO R & NORA R KALINA C/O TIMOTHY S COTTON Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT: 8 MIDDLE ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:4/30/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:WALL INSULATION & VINYL SIDING UNIT B 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 4/30/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner