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37-004 A c CERTIFICATE OF LABILITY INSURANCE DATE(MMIDD /YYYY) L...- 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 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 Jeanne Denaault, CISR NAME: Blackmer Insurance Agency Inc. jA ,Ext) (413 625 -6527 ( No): (413) 625 -8210 1147 Mohawk Trail ADD E -MAIL RESS: eanne @blackeners. com PRODUCER 00003617 CUSTOMERJOJL 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 Max Specialty Insurance 324 Wells St INSURERD:TW1n City Fire Insurance Co 29459 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID Y PAID CLAIMS. irisR TYPE OF INSURANCE INSR WVD I POLICY NUMBER (MMIDDIIYYYY) I (MM D I D/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE X COMMERCIAL GENERAL LIABILITY PR M SES occurrence) $ 100,000 A CLAIMS -MADE X OCCUR X LBA086$72 00 11/8/2010 11/8/2011 MED EXP (Anyone person) $ 5,000 PERSONAL S. ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENII_ AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 X POLICY PRO JECT - LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO B ALLDWNEGAUTOS 25752 3/23/2010 3/23/2011 BODILY INJURY (Per erson) $ BODILY INJURY (Per accident) $ X SCHEDULED AUTOS 1 PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON -OWNED AUTOS $ $ X I UMBRELLA LIAR X OCCUR EACH OCCURRENCE 1$ 1,000,000 EXCESS LIAR CLAIMS•MADE AGGREGATE $ 1,000,000 DEDUCTIBLE $ - C RETENTION $ 113100056487 6/2/2010 6/2/2011 $ D WORKERS COMPENSATION 1 WC STATU- X IIOTH- AND EMPLOYERS' LIABILITY TORY LIMITS l ER Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE N I A E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 11/1/2010 11/1/2011 (Mandatory in NH) 08WECLC6866 E.L. DISEASE • EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H 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 Center for Ecologic Technology ACCORDANCE WITH THE POLICY PROVISIONS. 112 Elm St. Pittsfield, MA 01201 AUTHORIZED REPRESENTATIVE i I ACORD 25 (2009109) ©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.m ass.2ov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): Address: - 3 2 ...q City /State /Zip: G r` \Wk Phone # 13- a --ogq Are you an employer? Check tlappropriate box: Type of project (required): I I am an employer with 4. 1 am a general contractor and I 6. New Construction employees (full and /or part - time)* have hired the sub - contractors Remodeling 7. 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 nie in any capacity. employees and have workers' 9. Building Addition [No workers' comp. insurance comp. insurance. 10. Electrical repairs or additions required.] 5. We are a corporation and its 1 1. Plumbing repairs or additions 3. 1 ani a homeowner doing all work officers have exercised their myself. No workers' comp. right of exemption per NIGL 12. Roof repairs insurance required.]t C. 152, ' 1(4), and we have no 13. /Other la isw employees. [No workers' . comp. insurance required.] Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. H Homeowners who submit this affidavit indicating they are doing all 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. 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. �..a ncl ?flair K A hiercC s C. , Insurance Company Name: ��qq II Policy # or Self-ins. Lic. #: V IAJ L C 1 -e- ( (V 410 Expiration Date: 6 _ ( 2 0 1 Job Site Address: 1 I-- ( orth C 1 ` City/State /Zip: l` 0 4 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 ofMGL 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 nder the pain and penalties of perjury that the information provided above is true and correct. ) , S � 3,aOl( Signature: c • Date C��S1 Phone #: LAG Official use only. Do not write in this area, to be completed by city of 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 #: ..,....,, gi -62,,,, 0,/d,,,„:,,,,,,,,A,..a Office of Consumer Affairs and Business Regulation . l r � 1 0 Park Plaza - Suite 5170 = � Boston, Massachusetts 02116 - Home Improvement Contractor Registration -- - . Registration 165217 _- -- - - - Type: Corporation 7_,--..,. = Expiration: 1/2112012 Tr# 292798 CO -OP POWER, INC. _ PAUL SCHMIDT - = - -- 324 WELLS ST _ _ -, - GREENFIELD MA 01301 = - Update Address and return card. Mark reason for change.. v Address 7 Renewal T i Employment Li Lost Card 1 ea 50M- 04/04- G1D1216 __ flee - eoliviiiogursecrili of i rmacizeidet °- License or registration valid for individul nse only Office of Consumer Affairs & tininess Regulation before the expiration date. If found return to: y HOME IMPROVEMENT CONTRACTOR it,, Office of Consumer Affairs and Business Regulation - Registration::, : :155217 10 Park Plaza - Suite 5170 Expiration: Tr# 292798 Roston, MA 02116 Type :; = = CeaFpbiafion . _ ;O-0P POWERDIN 'AUL SCHMIDT (7a 324 WELLS ST _ - ��Eia vti. �. .. 3REENFIEL-D, MA 0130 IIndersecretary Nut valid without signature 1 --T- , iMa_ssachusetts - Department of Public Safety I/_ ' Bo ard of Building Regulations and Standards Construction tion Supervisor License License: CS 103635 { Restricted to: 00' x tr PAUL SCHMIDT a iMi a 24 CHESTNUT ST i HATFIELD, MA 01038 - t„-.: f. �. - - !�'__ Expiration: 5120/2013 Commissioner Tr #: i 5 • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ?M 3 & ' 5' " t ` 1 J 43 Number License Nu 2 4 ( c L-b t Si- �} ak f i -(c. o (d3 s Nu r 3 Addr sp Expiration Date o,, �! 4(3 62 q Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Na Registration Number z�{ k S Grn .io(d i (3e> Address y /} 2 Expiration Date - F' 4 3 . _ 111- � � 0 Tee a �� O 7 3 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 - 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 ❑ Or Doors 1] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [IV C�� - ' L11� Brief Descriptipn gf p d'w ( I 4 " e€ s (G-s YrS r (hn Giis F L y kss 4, 2.55 7/ Work: W �^'CuN� J Alteration of existing bedroom Yes No Adding new bedroom Yes No 4 t0 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 I , as Owner of the subject property hereby authorize CU P' lative PC) 1 n 1-El� to act on my behalf, in all matters ( tQwork authorized by this building permit application. g Arl,a(A.- Signature of Owner Date r� �,,� QA (� t r^^^" S G brut t Q ` , 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 and penalties of perjury. c sc td ' Print Name Z 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 L: R: L: '• Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Sp. ~s Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 -' — -� — -` 1 ctr e :,, _, ; c , ,_. c;k eGe\ Department use only i • f Northampton St atus of Permit: ild 1g Department Curb Cut/Driveway Permit 12 ain Street Sewer /Septic Availability - OOm 100 Water/Well Availability ofeSsitcs orthampton, MA 01060 Two Sets of Structural Plans • one 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 5 7 0 ( ork I Map Lot Unit . 04-e. r l C, / NA r1 o b Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: n1 1'l Pv w'er S Telephone /3 5, 001(� Signature 04/A/t,� fry) / 7..ue 2.2 Authorized Agent: 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) f Z 04 1 1 O -1 Check Number tc01 ■/ This Section For Official Use Only � Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0794 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 579 FLORENCE RD MAP 37 PARCEL 004 001 ZONE SR(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ��7 035 Fee Paid Typeof Construction: INSTALL WALL 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F 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 ems lit' on Delay nature of tuilding Of icial 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. 579 FLORENCE RD • BP- 2011 -0794 COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 004 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 -0794 Project # JS- 2011- 001308 Est. Cost: $2048.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 30056.40 Owner: DELUE ANNA M AKA ANNA M POWERS Zoning: SR(100)/ Applicant: PAUL SCHMIDT AT: 579 FLORENCE RD Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:4/6/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 4/6/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner