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30B-108 (2)
ACQ ®• DATE (MMIDD/YYYY) ,I,,C O CERTIFICATE OF LIABILITY INSURANCE 1l22/2010 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 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1000 Mohawk Trail ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Shelburne MA 01370 -9737 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Landmark .American Ins Co I Co -op Power, Inc - INSURERB:Hartford Insurance Group I 324 Wells St INSURER C: PO Box 688 INSURER D: Greenfield MA 01301 INSURER E: 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 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR INSRD TYPE OF INSURANCF I POLICY NUMBER I DAT IM EFFECTIVE ID I DATE (MM I) I UNITS GENERAL LIABILITY EACH OCCURRENCE 1$ 1,000,000 DAMAGE TO RENTED I COMMERCIAL GENERAL LIABILITY PREMISES (Ea oeeunence) I $ 100,000 A X CLAIMS MADE I OCCUR 05599600 11/8/2009 11/8/2010 MEDEXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2,000,000 X I POLICY I I J I I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY _ SCHEDULED AUTOS ( pew) ) a A HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS 1,5A05599600 11/8/2009 11/08/2010 (Per accident) PROPERTY DAMAGE $ (Per accident) G ARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG I $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ I OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION I WC STATU- I 10TH - AND EMPLOYERS' UABWTY TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE L d.._ 8WECLC6866 11/01/2009 11/01/2010 EL. EACH ACCIDENT $ 500000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE - FA EMPLOYEE $ 500000 I describe under SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS !VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate issued subject to the terms, conditions, exclusions, and endorsements attached thereto. Operations ususal to alternative solar energy resources. National. Grid is listed as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION National Grid DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN P 0 Box 960 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Northborough, MA 01532 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009101) © 1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (zoom) The ACORD name and logo are registered marks of ACORD a i .,...L.... ..v... .. �2' =': iid ,� �f _ a Offs a' a fiees ti iows • _ 600 Washb Rion Street - - Boston MA 02111 "' _ www.nzass.govAlio A Worker Insurance Affidavit: BuildersiContracforstElee r s A i • {� W . ll Info f F_ l 4 please ' s 1, :.a Name - - A i -- Of blLw , /re _ . Address: _ _ 3a - Lilt us - Oct - / , �� ` �t,� ° ° j 03 Anion as etalIageft Checklist a ppavp bled - - Type of pct treed): 1_ lam aenpbyerwith 7 : 4 0 Image:weal vontrador and 6 o New consfru n . sumployces MB an3Awpart4ame.* have hired thesah -off ❑ 2. ❑ I atn a sokproptk or arparoner- Based on the attached sheet. t . 7. map and have no caspbytei - have - S. [❑ Donation working forme in any capacity. - vankene coop_ . 9 ❑ Bi addition - - - w math& L - 5_ El We me a unwed= and - ion isiec or additions 3 *Sunk have e efltea um . - 3. ❑ I ass. a homeowner doingau w_ odc sight of a nanptio' npertelL 11.0 Pinabing repairs Qradditons - xysol [No work acs* comp. - to 152. ilea andwolawem . 12.[] Resole:paits - ] - - 'a1)lO ees.-1Nowarkes -1 :LW .i'U)/ V . comp. insurance mune(' d . *Aayapptieasontri nftbotatanatelsofiUuptThcw w ladoir *wile the wage eaaepeaeado : - t Hameeaeea yip stsbnittio Theyaedaaog dlwatzed tbes lie outside exttaclawnwetatannt mew a asack 'Cosby:ton diattheckThisbox mut ithalfld ewes/ratoaal AIM iaoite emirs edie sobvnigaidaiseed laeireaaloaef cal* Par ilinE4011- J am en Will*Fer OW isprovillingivirkere +ompeaa ow a asformy excloyees. itetow ie tke pally ondlob site info - insurance Z of yName: J4fl s hi S, Po #or scl. Lic #: 03iAlE6 (-43 44 Expiatka Dot= tl 1 i I -z6i Job Site Ad#reas: 7 "1 - - ! ) i A) s _ jl O rFN ci &A Attach a copy of the worker compensation policy dcc1 ration page (showingthepolicy number and =pine= date). Fall= to scaac s age as required under Section 25A of MGL c. 152 canlead to theimposhint ofes l penalties; of a - fine up to $1,500.00 andfor one -year iznprisoament as via as civil penalties it the fora of a STOP Wig ORDER and a fine of up to $250.00 a day against ibciiolamr. Be advised that a copy oftltis statement maybe fort a rdeel to the Office of invcstigaaitian oftheDIA forte cove rage vedfication. - • - .I do frdreiy 1-• a dpenakies sfJiD3ury that the inibrwatoo provided elbow *hue and correct. :Y.. Ap_IL: r - 1 it - pgz_Zil.4.20_LP Phone #: / V)3 — 7 X- . O use Do not Write in this a aa, to be coinpieted lry dty or tow officiaL - . City or Tom - Permit/License # - issuing Authority (circle one): - 1_ Board ofHezith 2- BusiclingDepartment 3_ C ltyffown Clerk 4.>lectric&Inspector 5- Phua egISpector 6.Other _ (� Contact /imps: . Phone #: 1 - _ I Massachusetts - Department of Public Saf'et� ',. , Board of Building; Regulations and Standards 1 %...41 Co:^struction Supervisor License License: CS 103635 Restricted to: 00 PAUL SCHMIDT 24 CHESTNUT ST =,, HATFIELD, MA 01038 ��- - _ y _ Expiration: 5/20/2013 ('ummisiuner Tr#: 103635 Jlte - 6 , „ „„ , 1.' — J .:: f Office of Consumer Affairs and usiness Regulation — _ " 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2012 Tr# 292798 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST -- - - -- GREENFIELD, MA 01301 -- — — _____ Update Address and return card. Mark reason for change. - Address TI Renewal _? Employment r- Lost Card DPS -CA1 it 50M- 04/04- G101216�� ,, J�ie ehorrumonu/e/zia a /•. adJaclic a License or registration valid for individul use only Office of Consumer Affairs & Business Regulation before the expiration date. If found return to: � ` HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation >__. __4 Registration: 165217 10 Park Plaza - Suite 5170 = % Expiration: 292798 1/21/2012 Tr# 29 \� P Boston, MA 02116 Type: Corporation CO -OP POWER, INC. PAUL SCHMIDT ,, 324 WELLS ST 1:) GREENFIELD, MA 01301 Undersecretary Not vale e without signature SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �-#. Not Applicable ❑ Name of License Holder : T4 U 1 1 ) a.,,?,163„ License Number Address Expirati Date " ■•.1. 1 1)3 - 2)/7-5-7731 )84 Signs ure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 324 l4 Oil 6-re ft/ )6' )41, 4, d)3° t /) t) 120) L Address Expira on Date Telephone f g '77 v f 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 (k No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied DwellinSS 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 buildine 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 Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained , Date Issued: C. Do any signs exist on the property? YES ® 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 O 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 ® NO Q 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 [J Addition ❑ Replacement Windows Alteration(s) 0 Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks ED Siding [0] Other [0] Brief Description of Proposed 'r � / ^/ / y. p Work: install attic insulation , 9 inches of cellulose, r3l) and install ridge vent Z N \ � Ark 141 , n G flivioSE 3 Alteration of existing bedroom Yes xxx No Adding new bedroom Yes xxx No / Attached Narrative Renovating unfinished basement Yes xxx 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 / r A/1/ 6-A,n) , as Owner of the subject property ,- (Co ? l hereby a rize 1/ I LI �t'��1 -o pe J to act .y beh ; in al matt r lative to wor authoriz ( by this building per applic on. . 7 - D CCU Signs re owner Da e I, PIIA U 1 J r b' , 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. 4V/L � 157 Print Name 'I - m) 1 ) Signature o • er/ gent Date . Department use only • City of Northampton Status of Permit BuilOng Department Curb Cut/Driveway Permit r J. ? 21 ,Main Street Sewer /Septic Availability V oom 100 Water/Well Availability , rthampton, 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 7 ( e-r Map Lot Unit 7 L i / 1 �! Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Own f l ord: Patric a Man n `� 74 Milton Street, Florence MA ::: rint) f iling Address: 413 - 303 - 9858 / � � r 2.2 Au ized Agent: FAA jc, 14 m 4 ...-azcz=raf *, V C HiSTN UT sr tric Name (Print) Current Mailing Address: j-i AT �j, i O J M Ll, . o a o . � �20 413 247 - 5739 1 (' 1 Q J J Signat Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building iz - 4.—,) (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of r- Construction from (6) , J O 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) / 95-e- �1 Check Number / 4*5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0166 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 74 MILTON ST MAP 30B PARCEL 108 001 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 rfi Typeof Construction: INSTALL RIDGE VENT & ATTIC INSULATION (CELLULOSE R31) 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 F OWING 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 Pen 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 ■40, //, i , - 411111 Jir , -°' Air Y -/v Sigma a of Building 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. s 4 BP- 2011 -0166 GIB #: COMMONWEALTH OF MASSACHUSETTS ¢ (41 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 -0166 Project # JS- 2011- 000271 Est. Cost: $1500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 13503.60 Owner: MANGAN PATRICIA Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT: 74 MILTON ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 - 5739 WC HATFIELDMA01038 ISSUED ON :8/2 7/2 01 0 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL RIDGE VENT & ATTIC INSULATION (RELLULOSE R31) 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 8/27/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner