Loading...
49-038 Ark mass save COIMUICTOIN PERMIT AUTHORIZATION FORM I , //4//45 #.4N LL Y , owner of the property located at: (Owner's Name, printed) 62i-( / vac. f-L02 Crt/ C_ Pia , (Property Street Address) / (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and /or weatherization work on my property. " Ow - Signature / Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 0 .O ?WEP> 10/1q//,), Participating Contractor Date Rev. 12132011 Y p ., City of Northampton / Massachusetts 4, - * C, ' DEPARTMENT OF BUILDING INSPECTIONS y i i „ i t i 212 Main Street • Municipal Building � � Northampton, MA 01060 S 1 Property Address: / 2) PAM< f/LL �D/-b "LQr c.L J Contractor C O -Q P `� ' F Name: /C� vV Address: 15A 1,4/ T City, State: WEST t14TF1E Lb / NA OIQ n C) Phone: 6 / f�� - f 1 Property Owner j Name: JANET 4ANLEy Address: 7c2 1 7/xi< HILL Rai City, State: FINE Il 'E kt4 0 000 I, TP,4c'J'L S(' H44 /D (contractor) attest and affirm that the building I intend to insulate 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. / .....------ Contractor signature j / Date 10 ( r A CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DDNYYY) ■� 10/16/2012 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 Shannon Palazzo - ____ James J. Dowd & Sons Ins (a/cC, ONE Ext1:413- 538 -7444 FAX No):413- 536 -6020 14 Bobala Road E -MAIL Holyoke MA 01040 ADORESs_sPalazzo adowd. INSURER(S) AFFORDING COVERAGE NAIC d INSURER A : Safety Indemnity Company__ INSURED COOP INSURER B _Great American Insurance Companies 1 Co Op Power, Inc. INSURER C:U S. Liability Insurance Company 324 Wells Street Greenfield MA 01302 iNSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 462479872 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRI I POLICY EFF T POLICY EXP r -__- -_ - -- - - --- - - - - -- - - - LTR TYPE OF INSURANCE I INSR' WVD • POLICY NUMBER I (MM /DD/YYYY) (MM /DD/YYYY) LIMITS C I GENERAL LIABILITY ! I ! , ICL1566148 11/8/2011 11/8/2012 i EACH OCCUR_ RENCE 51,000,000 1 DAMAGE TO RENTED CLAIMS -MADE OCCUR 1 1_PREMISESLa occurrence)_ $100,000 _ r -- ! CLAIMS- GENERAL L MED EXP (Any one person) ! 55,000 CO — IC ! PERSONAL & ADV INJURY I $1,000,000 _ _... - _.. - _ - - GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG J $2,000,000 POLICY LOC $ - PRO- X !! ! . � .IECT ' ' 3/23/2012 6/23/2013 COMBINED SINGLE LIMI 1 A , AUTO AUTOMOBILE AUTO . ABILITY ! COM6212701 (Ea accident_ $1000000 I 1 1 BODILY INJURY (Per person) S ALL OWNED r - - _ -- - -- _ -- - - _ AUTOS X SCHEDULED !AUTOS �! ! BODILY INJURY (Per accident) $ NON -OWNED ! HIRED AUTOS X AUTOS PROPERTY DAMAGE • I __(Peracciden>< _ I Comprehensiv Collision deductible $500 C X 1 UMBRELLA LIAB CUP1550265 1 12/23/2011 12/23/2012 _ U- - AGGREGATE i $1,000 000 $1,000,000 E XCESS LIAB OCCUR, E ACH OCCURRENCE - _ — I i CLAIMS MADE 1 DED IX RETENTION$0 S I WORKERS COMPENSATION I I I WC STATU- I OTH AND EMPLOYERS' LIABILITY YIN BILITY !1 _LTORY LIMITS ER ' ANY PROPRIETOR /PARTNER /EXECUTIVE ! ! ! I E.L. EACH ACCIDENT • $ OFFICER/MEMBER EXCLUDED? ' N / A I , . (Mandatory in NH) ! I L E.L.DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below 1. I [ E.L. DISEASE - POLICY LIMIT 1 1 $ B Directors & Officers Liability EPP1117563 6/2/2012 /2/2013 11,000,000 5,000 Deductible 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CET, National Grid, The Berkshire Gas Compnay and their respective officers, agents and employees are inlcuded as additional insureds with respect to general liability. Waiver of Subrogation applicable to CET in respect to General and Auto to waive all rights of recovery against Center for EcoTechnology or any of its affiliates for any loss or damage covered by said policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Center for EcoTechnology (CET) ACCORDANCE WITH THE POLICY PROVISIONS. 112 Elm Street Pittsfield MA 01201 AUTHORIZED REPRESENTATIVE r ow; ,,,,, © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts _ Department of Industrial Accidents ph =RV ` Office of Investigations Washington Street l Boston, MA 02111 ~ '-a, ,s www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /individual): Co - op Power Address: 15A West Street City /State /Zip: West Hatfield, MA 01088 Phone #: (413) 772 -8898 Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 10 4. ❑ l am a general contractor and 1 employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in it employees and have workers' g any capacity. y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.111 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] ` c. 152, § 1(4), and we have no employees. [No workers' 13.2] Other Insulation comp. insurance required.] *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 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: Twin City Fire Insurance Co. /The Hartford Policy # or Self -ins. Lic. #: 08WECLC6866 Expiration Date: 11/01/2012 Job Site Address: 721 Park Hill Road city /state /zip: Florence, MA 01062 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 10/19/2012 Phone #: (413) 772 -8898 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Paul Schmidt 103635 License Number 24 Chestnut Street, Hatfield, MA 01038 05/20/2013 Address Expiration Date (413) 772 -8898 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Co -op Power 165217 Company Name Registration Number 15A West Street, West Hatfield, MA 01088 01/21/2014 Address Expiration Date Telephone (413) 772 -8898 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 (I) 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 n Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [IL) Siding [O] Other [O] Brief Description of Propo ed work: Insu 7 sq tt of attic floor with 4" open blow cellulose and 72 sq ft with 6" open blow cellulose Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x 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, Janet Hanley , as Owner of the subject property hereby authorize Co -op Power to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ENCLOSED AUTHORIZATION FORM Signature of Owner Date Paul Schmidt , 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. Paul Schmidt Print Name 10/19/2012 Signature of Owner /Agent 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 he tilled in by Building Department Lot Size Frontage Setbacks Front Side L:a 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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO C DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. FCE --- Department use only I >l of Northampton Status of Permit: �CT B ilding Department Curb Cut/Driveway Permit 2? y,�2 f 212 Main Street Sewer /Septic Availability � t Room 100 Water/Well Availability L F G .j Nohhampton MA 01060 Two Sets of Structural Plans NORrygMpT M ' t or , 41 - 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 721 Park Hill Road Map Lot Unit Florence, MA 01062 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Janet Hanley 721 Park Hill Road, Florence, MA 01062 Name (Print) Current Mailing Address: (413) 587 -2656 SEE ENCLOSED AUTHORIZATION FORM Telephone Signature 2.2 Authorized Agent: Co -op Power 15A West St, West Hatfield, MA 01088 Name (Print) Current Mailing Address: (413) 772 -8898 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $1,148.00 (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) $1,148.00 Check Number 0 21f 9 tj 05 This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0475 APPLICANT /CONTACT PERSON CO -OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413) 772 -8898 Q PROPERTY LOCATION 721 PARK HILL RD MAP 49 PARCEL 038 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out O C�� Fee Paid CY d `I `' - T ypeof Construction: INSTALL ATTIC 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 D - �s o;; on Delay ; / .0 0.° : igiee 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. 721 PARK HILL RD BP- 2013 -0475 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 49 - 038 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- 2013 -0475 Project # JS- 2013- 000759 Est. Cost: $1148.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO -OP POWER INC 103635 Lot Size(sq. ft.): 108812.88 Owner: HANLEY THOMAS B & JANICE D Zoning: Applicant: CO -OP POWER INC AT: 721 PARK HILL RD Applicant Address: Phone: Insurance: 15A WEST ST (413) 772 -8898 () WC WEST HATFIELDMA01088 ISSUED ON:10/25/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 10/25/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner