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42-058 CO-OP 1 [ POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY PERMIT AUTHORIZATION FORM I, Ke v %� y u3IG d , owner of the property located at: (Owner's Name) 64'6 lames 11, 1, Pi ce A (Property Street Address) (City /Town) hereby authorize Co .0 ' i (Contfactor) to act on m behal btain a building permit and to perform insulation and /or weather' i work' o my grope i -, (Owner's Signature) SkJ IC r 2-01' (Date) Co -op Power 15A West Street, West Hatfield, MA 01088 phone: 413.772.8898 or 877.266.7543, fax: 413.517.0300 Email: info @cooppower.coop Website: www.cooppower.coop DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE �.� 11/12/2012 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 JAMES J DOWD & SONS INS AGCY INC CONTACT NAME: 14 BOBALA RD HOLYOKE, MA 010411900 PHONE (A/c. No, Ext): (413) 538 -7444 Fax (A/c, No): (413) 536-6020 E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Liberty Mutual Insurance INSURED INSURER B : CO OP POWER INC 15 A WEST STREET INSURERC: WEST HATFIELD MA 01088 INSURERD: INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 14687992 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS FED 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR wvn POLICY NUMBER (MM/DDIYYYY) (MM/DDYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DA MAG MI ET R E TO ( RENTED ) G o $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY JEC7 LOC $ AUTOMOBILE LIABILITY COMBINED acccideD) SINGLE LIMIT $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED r SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION WC5 -31 S- 388245 -012 11/2/2012 11/2/2013 � / TORY L M TS °R - AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 100000 OFFICER /MEMBER EXCLUDED? N N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HONEYWELL UTILITY SOLUTIONS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 65 SHAWMUT ROAD, SUITE 4, FLOOR 2 ACCORDANCE WITH THE POLICY PROVISIONS. CANTON MA 02021 AUTHORIZED REPRESENTATIVE . � -Q G4 Jeff Eldridge © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CERT NO.: 14687992 Tara McLaughlin 11/12/2012 10:07:14 AM Page 1 of 1 This certificate cancels and supersedes ALL previously issued certificates. The Commonwealth of Massachusetts Department of Industrial Accidents .— z' � Office of Investigations ' 600 Washington Street t .414 Boston, MA 02111 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. ❑ I am a general contractor and I 6. D 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 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 11. ❑ 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 employees. [No workers' 13.® Other Insulation 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Co. Policy # or Self -ins. Lic. #: WC5 -31S- 388245 -012 Expiration Date: 11/02/2013 Job Site Address: 686 Westhampton 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: ����" �` =K- Date: 01/22/2014 Phone #: ( 3) 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. ReciiStered Hor nprovement Contractor Not Applicable ❑ Co -op Power 165217 Company Name Registration Number 15A West Street, West Hatfield, MA 01088 01/21/2014 Address Expiration Date 4972 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 XI No ❑ ; Homvowner Exenip ivn The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (l) 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 ❑ Replacement Windows Alteration(s) ❑ Roofing IT Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [5]] Insulation Brief Description of Proposed Work: Insulate clapboard -sided wall with 4" dense pack cellulose, 983ft Alteration of existing bedroom X Yes 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, Kevin Russell , 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 01/16/2013 Signature of Owner Date I, 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 Nam, ��±i 1 y,.. 01/22/2013 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 be filled in by Building Department Lot Size Frontage Setbacks Front Side 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 DONT KNOW 0 YES IF YES, date issued IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT 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 0 DONT KNOW 0 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 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. _ -- �at tetIt tie oy City of Northampton SMtus of Pence Building Department ur�f/fn Peru i 212 Main Street Sewer /SepttcA °- ° JAN 2 3 2 (313 I Room 100 ii Weir/ Avaaylilty DAFT of BUi: Northampt MA 01060 two o f Structur Ia , NORTHAPAFTON ' ' f " u e 413- 587 -1240 Fax 413- 587 -127 P IQt/Stte Plans _'' S ,, .................. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 686 Westhampton Road Map Lot Unit Florence, MA 01062 zone _ Overlay District Elm St. Distric CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Kevin Russell 686 Westhampton Road, Florence, MA 01062 Name (Print) Current Mailing Address: (413) 586 -4994 See Enclosed Authorization Form Telephone Signature 2.2 Authorized Agent: Paul Schmidt / Co -op Power West Street, West Hatfield, MA 01088 + �' Name (Print) Current Mailing Address: _ y� (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 $2035 (a) Building Permit Fee 2. Electrical (b) Estimated tal of — — Construction To from Cost (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) $2035 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0713 APPLICANT /CONTACT PERSON CO -OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413) 772 -8898 0 PROPERTY LOCATION 686 WESTHAMPTON RD MAP 42 PARCEL 058 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid e� Building Permit Filled out .0.06 1Ff 3 Fee Paid Typeof Construction: INSULATE CLAPBOARD SIDE WALL 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 WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 .;'_• - lay ..4111111111 Signature of Bui ding 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. 686 WESTHAMPTON RD BP- 2013 -0713 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42 - 058 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 -0713 Project # JS- 2013- 001192 Est. Cost: $2035.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO -OP POWER INC 103635 Lot Size(sq. ft.): 286189.20 Owner: RUSSELL KEVIN A & JUDITH FIONA RUSSELL Zoning: Applicant: CO -OP POWER INC AT: 686 WESTHAMPTON RD Applicant Address: Phone: Insurance: 15A WEST ST (413) 772 -8898 0 WC WEST HATFIELDMA01088 ISSUED ON:1/28/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE CLAPBOARD SIDE WALL 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 1/28/2013 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner