17C-245 (2) r \ Office of"t�o mer airs : I u's " sRegu License or registration valid for individul use only
*=— HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
i Registration: 153287 Type: Office of Consumer Affairs and Business Regulation
'° — Expiration: , 11/14(2012 DBA 10 Park Plaza - Suite 5170
� Boston, MA 02116
T' NERGY SPECIALISTS
MIKE GRENWOO[? ‘
55 CIRCLE VIEW DRIVE ,,,_„_«���—
H
A l' 411.
AMPDEN, MA 01036 Undersecretary Not valid w' out signature
1
NLISSachu - Department of Public Safer,
Board of Building Regulations and Standards
Construction Supervisor Specialty License
License: CS Si. 99381
Restricted to: WS,IC .
1 IAE _ GREENWOOD „,
CIRCLE =W DRIVE
:'i 1%.7A 01036
J "" — ' y � � Expiration: 3/9/2012
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800) 876 -2765 NCCI NO 40959
POLICY NO. WCC 5009547012011
PRIOR NO. WCC 5009547012010
ITEM
1. The insured Michael Greenwood dba The Energy Specialists
Mail Address: 55 Circle View Drive Hampden MA 01036
Street No. Town or City County State Zip Code
FEIN xxxxx4364
Individual ❑Partnership ['Corporation ['Joint Venture DAssociation ['Other
Other workplaces not shown above:
2. The policy period is from 10/16/2011 to 10/16/2012 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per $100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 842600
SEE EXTENSION OF INFORMATICN PAGE
•
Minimum premium $ 500.00 Total Estimated Annual Premium $ 13,350.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 3,531.00
❑ Annually ❑ Semi Annually ❑ Quarterly ® Monthly
MA Assessment Chg.
$13,124.16 x 5.9000% $774.00
This policy, including all endorsements, is hereby countersigned by 08/16/2011
Authorized Signature Date
GOV GOV KIND PLACING CLAIM NAME SAFETY Richard R Green Insurance
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP 11 Allen Street
MA 5645 8 507 Hampden, MA 01036
WC 00 00 01 A(7 -11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
FW •
'THE PATRONS GROUP Glastonbury, Connecticut 06033
® Patrons Mutual Insurance Company of CT ❑ Litchfield Mutual Fire Insurance Company Date of Issue
0 Provision State Insurance Company ❑ Patrons Fire Insurance Company of RI AV 09/08/2011 1
COMMERCIAL UMBRELLA /EXCESS LIABILITY POLICY DECLARATIONS
COMMON POLICY DECLARATIONS POLICY NUMBER CEX 1001324
NAMED INSURED Michael Greenwood
and P.O. Address 55 Circle View Drive
(Number, Street, Town, State & Zip) Hampden, MA 01036
POLICY PERIOD: From 10/14/11 To 10/14/12 12:01 A.M. Standard Time at your Mailing Address above
AGENT Richard R Green Insurance Agency Inc, Agency Code
"11 Allen Street - - -- _ - 7680._ _
Hampden, MA 01036 -9789
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS
STATED IN THIS POLICY.
FORM OF BUSINESS: I ❑ Corporation ❑ LLC I ❑ Partnership L ❑ Joint Venture ® Individual I ❑ Other
LIMITS OF INSURANCE
EACH OCCURRENCE/GENERAL AGGREGATE LIMIT $ 1,000,000/1,000,000
PRODUCTS - COMPLETED OPERATIONS AGGREGATE LIMIT $ 1,000,000
• RETAINED LIMIT: $10,000
SCHEDULE OF UNDERLYING INSURANCE
Insurer Policy Number I Policy Period COVERAGES LIMITS OF INSURANCE
Commerce 10mmbbj27 01/05/11 -12 AUTOMOBILE LIABILITY EACH PERSON EACH ACCIDENT
Insurance Bodily Injury Liability $ $
Property Damage liability $
Bodily Injury and Property
Damage liability Combined
❑ Hired ❑ Non Owned $ 1,000,000 CSL
Pstrons Insurance CTR 0011514 10/14/11 - GENERAL LIABILITY EACH OCCURRENCE UMIT GENERAL AGGREGATE LIMIT
PREMISES /OPS $ 1,000,000 $ 2,000,000
PRODUCTS COMP /OPS PRODUCTS AGGREGATE
$ 2,000,000
Hartford 650UB- 10/16/11 -12 EMPLOYER'S LIABILITY -- EACH ACCIDENT - -- -DISEASE- H EMPLOYEE
9955.97A - 09 - . $ 100,000 $ 500,000
DISEASE - POLICY LIMIT
$ 100,000
OTHER EACH OCCURRENCE LIMIT AGGREGATE
$ $
$ $
- $ $
MINIMUM PREMIUM $ 500 TOTAL ADVANCE PREMIUM $ 500
Forms and endorsements made a part of this policy at time of issue: Terrorism Certified UM 0755 01 08 Premium $ 0
UM 0200 04 00 CL 5999 08 01 UM 0202 04 02 UM 0277 04 00 UM 0278 04 00 PG 5601 06 03
UM 2776 06 06 PG CUPN 07 03 TDN NR 01 08 UM 0272 04 00 UM 0206 01 08 UM 0201 04 07 UM 02 03 04 02
UM 02 05 04 02
These Declarations together with the Common Policy Conditions, Coverage Part Declarations, Conditions, Forms and Endorsements; if any,
issued to form a part thereof, complete the above numbered policy.
Countersigned By
Date Authorized Representative
IN WITNESS WHEREOF the Company has caused this policy to be signed by its president and secretary. But, this policy shall not be valid unless
countersigned on this Declarations page by a duly authorized representative of the Company.
The Commonwealth of Massachusetts
�--- Department of Industrial Accidents
Office of Investigations
emax. tr. - -~ 600 Washington Street
- Boston, MA 02111
V. 4111.11•10
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information / Please Print Legibly
Name ( Business /Organi7ation/Individual): 7% L ,v �-,-.�, y s get '9 tit 3/5
S
Address: $ C irc/ >� 4 / /
City /State /Zip: . , ��� 0 Phone #: y/3 5-6 i - Are you an employer? Ch ck the appropriate box: Type of project (required):
lgt am a employer with 6 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' . com p right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no 13 ❑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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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: X 5,,5 0 c ' Cr)
Policy # or Self -ins. Lic. #: f C Sbo 9s /o /9 Expiration Date:
�� /C, - / 6 - oZo /.4
Job Site Address: b'7 �U / � / City/State /Zip: /l tr -1. ,,,rref 0 %
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 certi, he pains ' ' pen s of perju that the information provided above is true and correct
Signature: Date:
Phone #: 5'47- 5
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 S "14,/ pervisor: Not Applicable ❑
Name of License Holder : i/ , p.. ��,i!�G / C J .35-/
AA License Number
1)--11 4 - 5 /' , . , eseS' /If 0 %.,3 3
Addr Expiration Date
//I se 4-. 4.) 5` -
Sign:tur " Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name `f � Registration Number
5 S / t CJr�r doar, �,�0� ✓' l/ /� /v '
Address Expiration Date
Telephone ��,1 - St C $
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing 1 1
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [0 Siding [O] Other [pr
Brief Descripti n of Proposed / /
Work: /�,/ l'rf i s, /'� y 1/ PSI t.H.�,... r/3 1 / t'c er /l 3• fi4 �C
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, J /coa , as Owner of the subject
property
hereby authorize 74 t��' yy 5 y /,
to act on my behalf, in all matters relativework authorized by this building permit application.
Ajetpe 41'3 //
igna ore of Owner Date
I, 7.4- , as Owner /Authorized
Agent hereby declare that state ents and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains an. •enalties of perjury.
trii Arti� i afiel,
Si. - ur-•'nt 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 tilled 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 Q DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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 Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
9 1 � ity of Northampton Status of Permit: Department use only
o oe„ ° Building Department Curb Cut /Driveway Permit
do 212 Main Street Sewer /Septic Availability
e e
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 Property Address: This section to be completed by office
1 " 7 t? ' J/ /11.L 5/ Map Lot Unit
,i , i _.c e; /i.-1 o% Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
s ,, s-5-
N.
e (Print) Current Mailing Address:
3- ®CGS
TAIL _ , i_ Telephone
gnature
2.2 Authorized Agent: /
- I.%/ 5 42/0‹ //ter f ' , 4.4 l � r 614:4:
Name P Current Mailing Address:
Si ( 1 -�' 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
4)/4( Construction from (6)
3. Plumbing j Building Permit Fee
4. Mechanical (HVAC) ,t
5. Fire Protection �y /rT
6. Total = (1 + 2 + 3 + 4 + 5) SO <XI Check Number 57
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date