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25C-127 (2)
Property Address: ? -2-7 -7- E! 1 Z "' i l A Contractor Name: (/ 0.--op �d `T" TivC CPAAL -C e-14 M -' Address: P ( ? LS S City, State: 1T' ( At ' C,442 y 4 Phone: 1/ 7L- V X . Property Owner t7 Z C 4 NI' V N Name: Li: r L e4I ..*�!� "ir ,1 / . Address: �i� — - 2- Z to / 1 A 6' -«bi sr City, State: NO J J/y) m I, fiq1/ i jGhi )'dj ) (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 ow -r with a copy of this affidavit. Contractor signature / Date . 10 _ - --- -/------*----iosr E il:•11 *1°41 ,c possomis"VAiss .s17-00-s.s•sto 1......„..0004_,_______:.../-100001.11 * WOO 1110 ;ova orosi 1 ,-. ,-- „poi 4001°Orav .,-----"---Of-ti I -Pi 1•0°."-.$.‘14.6P ___Ilo,-•••••glii woos moo 0,10.zooryry-- 000, -000 400101 40001.112,00111.1..04014;11 1.11111"11 se 00111011° MISO • S VieSt°11841.3.1" infoodesa ...0,e19 I; 4 "cnossa*MPa 0000 0101 o t ,,," s'. deck 4e:o'ctloivt--. , - . .. a.° sort 00::::::•70.0.000000010.0001 10111/4.41°111.1.1.1g.s.r. trast4ta .1.°.°r44;1 vs-11011. ..111110." 11.. -` 0100.1.10:1;400001114; ., 0400 -Ct .10010,400ilar_lt ----.5 40103,8,00,0011100 --' -' t +041 °1 y R � mow" 10,7",issocr it -1:00:01740"--..0000asii , . f 1.4170.41 vi. 0000041..". °S41 21' We' Ilitts 0 0 0 .110 OP *all 014.111.1.°. .*: ' CERTIFICATE OF LIABILITY INSURANCE /2 2i " 2 '""° 0� 1 PRODUCER (413) 625 -6527 FAX: (413) 625 -8210 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Blackmer Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1000 Mohawk ' HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Shelburne MA 01370 -9737 INSURERS AFFORDING COVERAGE RAC # 1NSUEED INSURER A T.anelaa r c American Ins Co Co -op Power, Inc awasm Hartford Insurance Group 324 Wells St INSURER o I PO Box 688 I NSUrrex Er Greenfield MA 01301 Ire COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDTTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO AMINE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR I: TIMEOFUMMUCF POLICY NU I1 ..,, ,I I LINTS GENERALUANUTY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL UABifY OAMAISEPREMISES t RENTED ) S 100,000 A X I CLAMS MADE I I OCCUR 16A0559960 11/8/2009 11/8/2010 I,EmoCP(Aryra,eo +) 5 5,000 PERSONAL a ADV INJURY S 1,000,000 GENBMI.AGGREGATE $ 2,000, GENt AGGREGATE MKT APPLES PM PRODUCTS- COMPAPAGG i 2,000,000 X 1POLICY n El AUTOMOBILELUBIUTY P SINGL.EI.BIT i 1,000.000 ANYAUiD AU. OWNED AUTOS BODILY wUR — S SCHEDULED AUTOS A — HIRED AUTOS X NOW-OWNED L05599600 11/8/2009 11/08/2010 I $ � V I I S GARAGE UABIUTY AUTO ONLY -EA ACCIDENT S _ ANY AUTO OTTtEAN EA ACC $ ALITOONLY: A . AGG S EXCESS! UMBRELLA mustily tiTY EACH OCCURRENCE S OCCUR 0 C AMNS MADE AGGREGATE S _ S DEOUCTELE S RETENTION S SCATU- OTH- S B EMPLOYERS* UAWUIY jJnRYE CWT 41 I ER ANY © INIRCT.C6866 11/01/2009 11/01/2010 EL EACH mama* S 500000 (Mandatory IeNH) EL. DISEASE - EAL3WWLOYEE i 500000 m EL- DISEASE - PaJCYWAFT S 500000 OTHER DESCRIPTION OP OPERAf]ONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMEtai SPECIAL PROVISIONS Certificate issued subject to the teals, conditions, exclusions, and endorsements attached thereto. Operations ususal to alternative solar energy resources. Western Mass Zle^*ric Co is added as additional-insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF7HE MOVE DESCRIBED POLICIES BECAIIC8.L BEFORE THE EXPIRATION Western Mass . Electric Company DATE THEREOF. THE ISSUING INSURER NIL ENDEAVOR TO MAW. 10 DAYS WRITTEN Customer Service Center NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, FALURE TO DO SO SHALL P O Box 2010 IMPOSE Springfield, MA 01090 -2010 IMPOSE NO OBIJBATION OR wisa. nr OF ANY END UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTOO O R TATWE ACORD 25(2009/01) ®1988.2009 ACORD CORPORATION. All rights reserved. INS025 (200901) The ACORD name and logo are registered marks of ACORD t . Massachusetts - Department of a bi Safety Board of Building Regulations and Standards +... I Construction Supervisor License License: CS 103635 • Restricted to: 00 . PAUL SCHNICT 24 CHESTNUT ST -,- , . HATFIELD, MA 01038 . , Expiragon: 50012013 - : Tot 103 coronievkas - • . gge eCtriMiOlgaleatleg ( e tAtesdasmsea. ,.. !, . f! , Jar, . Office of Consumer Affairs and usiness Regulation . =-. ; r; .;-• --. ., 0. 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 . Home Improvement ntractor Registration Regishadon: 165217 --" ----_-: . . - .:?..-.-.-. Fri-- .•••:-7_, - - - -. :-.t: --: . ---.- .,..-.:: -.... -.. -- Type: Corporation .:-/ : Exph 12112012 Tilt 292798 CO—OP POWER, INC _ . PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 - ........ : . ... _ . . - . ,-- -.-....-. s . -... _. . Update Address and return card. Mark reasondor change. - . . 0 Address 0 Renewal 0 Employment 0 Lost Card • OPS-CAI ci 50140464431012111 -- g2e esassenruseaal of, Kessianinsea4 Lic" ease or registration valid for intlividtd use only - 0Uiee or Consesser Affairs dr Rosiness Revdatioa before the expiration date. If found return isz HOME IMPROVEMENT CONTRACTOR Office of CORSUllier Affairs and Business Regulation - fl ' Reflistnitiotz 165217 10 Park Plaza - Suite 5170 ' _ ... Expiratiorc , 1/2141012 Tr/ 292798 . Boston, MA 02116 Typo:- Ceipotalion CO-OP POWER,INC: PAUL SCHMICIT 324 WELLS ST •' - --1 - - d GREEW1ElD, MA 01301 ' Undersecretary Not v without signature ... SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y�, Not Applicable ❑ f 'E .'/c 1 / Name of License Holder : t J (� (','l/ �,��' 163 63,5 License Number 1—t4 C I L?s��¢ c Address J Q Expiration Date Sign re Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ DP a r', j Fr-- 1 g 5 Z Company Name Regi ation Number 3 Z� ce+ ei f G-f�- ,�itj(�'ti)gyH 4 -, b z l Address Expiration Date Telephone / 7 rY — 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 Zig 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 [J Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks ED Siding [D] Other [d] w Bri o e rk f Description of Proposed' graft t VAMPS G.A C I Wei Z �f)!/f 4 c PV V41 CO N 6114 - Ill J �JI 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, Q ci5 �C� : W `� _ ►�� — as Owner of the subject prop v, (� hereby authorize R —6F ) 1/'1 L fi�rr,, � . x�(y �1Z 6Afi )17) to act on my be' - , in all matters relative to work authorized by this building permit a•plication Signature of Owner Date I, /J/ cJ 6/1)''10 v , as Owner /Authorized Agent h by 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. firri v1 m 0 -2 7 -) Print Name tr Signature of r /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: 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 ,14'4 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® YES 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 O NO A) IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO ■ r 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit • 212 Main Street Sewer /Septic Availability i Room 100 Water/Well Availability_ i ' Northa pton, MA 01060 Two Sets of Structural Plans cJ� 010 phone 41587-1\240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify AP 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 2;2- j A 6F � ,C/ Map Lot Unit H r i p d" » Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZE.D AGENT 2.1 Owner of Record: 1 14 Name Print #10 Current Mailing V Sri ys �/� ■ .�i - -�� Telephone Sig ure 2.2 Authorized Agent: Name not Current Mailing Address: 1 - Y13 2 17 - ., 73q 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) ) Check Number Li-1 ✓ This Section For Official Use Only Permit Number: Date Building Issued: -..111.41/111 Signature ll/ // Building Commissioner /inspector of Buildings Date j. 22 ELIZABETH ST BP- 2011 -0278 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C -127 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 -0278 Project # JS- 2011- 000463 Est. Cost: $5200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 5183.64 Owner: NIEDZWIEC KENNTH A Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT: 22 ELIZABETH ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:9/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL CELLULOSE INSULATION IN ATT & WALLS 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 9/27/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner