38A-018 The Commonwealth ofMassachusetls
Department of Industrial Accidents
t * EI °' Office of Investigations
-i- =ate' - 600 Washington Street
Ar
!= 5 Boston, MA 02111
� www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information y Please Print Legibly
� Name ( Business /Organization/individual): CO Or1 t/t) ev ---• _
Address: 3 Z L i W (. )fl sr
Cit /State/Zip: �J',�'(,Z' j � Phone #: "/ `'77
Are you an employer? Check the appropriate boa: of ect
1 I am a employer with ID 4. E I am a general contractor and I project (required):
employees (full and/or part-time).* have hired the sub - contractors 6. ID New 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 g. ❑ Demolition
working for me m any capacity. employees and have workers'
# 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
requite.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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
employees. [No workers' l f Other L '+ / )0
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 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 aneinployer that is provkiing workers' compensation insurance for my employees. Below is the policy and job site
information.
Name:
In n) /4 er is J
Insurance Company /�1 F, �' ` t ,
Policy # or Self -ins. Lic. #: O? W t L c) C ICI' Expiration Date: I ) ) ti l Z Y 1
Job Site Address: l tC 0 1 -,-- A Cit A/0 p � MA
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirat 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 ' 4 k Gr5— and penalties ofperjwy that the information provided above is true and correct. Date: Z I? 2 Lf I ) )
Phone #: 1 % ) 3 ( f7 — 5_7 31
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PITTSFIELD Permit/License #
Issuing Authority: Building Department
Contact Person: Phone #: (413) 499 -9440
,NCO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�...� 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 Deneault, CISR
Blackmer Insurance Agency Inc.
PHONE . (413) 625 -6527 Nor (413) 62s =6210
1147 Mohawk Trail
E-MAIL em Jeanne @blackmers.com
VI
PRODUCER ID S . 00003817
Shelburne MA 01370 -9707 INSURER(S) AFFORDING COVERAGE NAIL€
INSURED INSURER A:La'di' ark American Ins Co
INSURER B :Commerce Insurance Co
Co -op Power, Inc INSURER C Max Specialty Insurance
324 Wells St INSURER D :Twin 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 CLAIMS.
INSR ADDL SUBRI POLICY EFF POLICY EXP
LTR - TYPE OF INSURANCE INS WWI POLICY NUMBER - IMMIDDIYYYY) (MMIDDIYYYY) UNITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LABILITY PREMSES (Ea occurrence) S 100,000
A I CLAIMS -MADE J X OCCUR X LBA086972 00 11/8/2010 11/8/2011 1,ED Exp (My one n) $ 5,000
PERSONAL&ADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GE? rL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
X POLICY n JC- ! j n LOC $
AUTOMOBILE UABIUTY COMBINED SINGLE LIST
(Es ) 1, 000,000
ANY AUTO
B ALL OWNED AUTOS LP5752 3/23/2010 3/23/2011 BODILY INJURY(Pwpetson) $
X ALL OW
tJ31 AUTOS BODILY INJURY (Per acddent) $
X HIRED AUTOS t DAMAGE $ )
X NON-OWNED AUTOS $
X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS UAB CLAIMS -MADE AGGREGATE $ 1,000,000
DEDUCTIBLE — $
C RETENTION $ MaX113100056487 6/2/2010 6/2/2011 $
D WORKERS COMPENSATION RJ + I TORY i X I ER
AND EMPLOYERS' LIABTY
ANY PROPRIETORIPARTNERADIECUTIVE N 1 A EL EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? 08GrECLC6866 11 /1 /2010 11/1/2011
(Mandatory in NH) EL DISEASE - EA EMPLOYEE $ 1,000,000
K describe under
DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If 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
ACORD 25 (2009109) 01988.2009 ACORD CORPORATION. All rights reserved.
1NS025 (20090 91 The ACORD name and logo are registered marks of ACORD
IfWflfl
Master Electrician
A 15246
9 DEN "I'ON STREET PO BOX 52
LAKE PLEASANT. MA 01347
(413) 3(7 -9278
October 18, 2010
My company has eradicated all knob and tube wiring in the residence of David Paine at
#13 Rust Avenue, Northampton, MA. All circuitry was replaced with new NM -B wire.
inspector, and approved.
Sincerely,
(c.
Richard A. Adams
„TA/de go,,,,, oty,,
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I
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston., Massachusetts 02116 '
_.
—.-
Home Improvement Contractor Registration ,
1---z---, ,----- Registration: 165217
• r_z_.:- .z__.. ---:,_,...- __- _ ,--
-, -- .. -- -_-_,---, .,--.,:a -- Type: Corporation
Expiration: 112112012 Tr* 292798
CO-OP POWER, INC. .',--_: tz--_- -__,?-- --_--_-:,--• - __
PAUL SCHMIDT - _ _
324 WELLS ST _
.
- ' - - ---7-----*-- ..—
'Update Address and return card. Mark reason for change..
----- --- 0 Address 0 Renewal fl Employment 0 Lost Card
41 0 50M-0404-6101216 _
9.4 e goo n a ma, t i € v a aa le,itetridadsadeata
Office of Consumer Affairs &
License or registration valid for individul use only
Nosiness Regulation
HOME IMPROVEMENT CONTRACTOR before the expiration dote. If found return to
Office of Consumer Affairs and Business Regulation
r-_-- -- - Registratiorx 1 ,165217
, , „ 10 Park Plaza - Suite 5170
Expiration.--:::4112112012 Tr* 292798
•=;.- Boston, MA 02116
Type: - ; ROOTPOir*fl-- - - -- .
CO-OP POWEK1NW --- -_ --- - _
PAUL SCHMIDT - - : 7 --..._ -,-;,--
324 WELLS ST -: 44-e-----ptabg._—_ •
GREENFIELD. MA 01301 - Undersecretary Not valid without signature
Massachusetts - Department of Public Safety
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
Commissioner Tilit 103635
.1
� r
SECTION 8 - CONSTRUCTION SERVICES I
i !
;II Licensed Construction Supervisor: ivu4 Applicable U
Name of License Holder : / V/ J c,/ p /�� J ,() 3 -6 3
License Number
01 GJ' .JT)c ` \5T ✓ f ie("4 s z6 )3
Address Expiration Date
i —
0)3 X 7 -- 3 - 73
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Co Po w nr SA/ / -
Company Name Registration Number
orf
Address J Expirati Date
Telephone
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 Gl? No ❑
11. - Home Owner Exemption
i ne current exemption tor '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 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: 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 DONT KNOW ✓ ) YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O 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 O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex .vation, 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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) _Jlll Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding [D] O her ••- �,
,U
Brief Description of Proposed ,. � -� ,/��
Work: -i-J1 /.Alt LAJ/ (Xr(G,i•?V r'
Alteration of existing bedroom Yes }c No Adding new bedroom Yes }.Z 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, �.,I JX i 2 / -- i IV , as Owner of the subject
property
hereby authorize J 4 V �f . �� )1 ��/J `-ee /
to act on my behalf, in all mattes relative to work authorized byihis building permit a [[ ��plication.
(V (
Si of Owner Date
I , ) IJ .1'G )im ie (6o-or r,, t , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing appli tion are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Na e
Signa ure of Owner /Agent Date
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
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
TV Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: is it ()Jr ,
pAvo Name (Print) Curren ai . , g Addr
Telephone
Signature
2. uthorized Agent:
)99i Sc. 11 2 q Sr, ! L4 j in gt d)07y
Name (P '' r Current Mailing Address:
qi 7— 777, r kriff
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building c (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) Z S Z? Check Number /602a 4:5:cr`'
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0499
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 13 RUST AVE
MAP 38A PARCEL 018 001 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
Tvpeof 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Demolition Delay
•
)1)3-6) ro
Signs e of Building • f cial 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.
a R,
BP- 2011 -0499
GIS #: <& COMMONWEALTH OF MASSACHUSETTS
:# CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0499
Project # JS- 2011- 000814
Est. Cost: $2300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 8319.96 Owner: PAINE DAVID A
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 13 RUST AVE
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:12/1/2010 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 12/1/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner