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32A-079 05/03/2011 13:58 FAX 4135871272 n f ��� ,✓ X001 Property Address: j Q l (- c) VES No!1 0 Contractor Name: Address: 37 -( 1 k ¶ City, State: .._ 6r C-1A � ( C Yvvr Phone: 4( — �l `1 9 Property Owner Name: L CLSl GN'v1 Address: 3 ( t3 6rFWES e City, State: NC L 1 S CLAt J'f (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 owner with a copy of this affidavit. G=am a Contractor signature Dated ( I 1(..i - S ( C Iff ',,......,, l® DATE (MM /DD/YY`YY) ° ACORN CERTIFICATE OF LIABILITY-INSURANCE 6/9/2011 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, ANUTHE CERTIFICATE HOLDER. j 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). CONTACT PRODUCER NAME: Shannon Palazzo James J. Dowd & Sons Ins PHONE FAX WC. No. Ext):42.3 - 5"38 -7444 (mc,No):413- 536 -6020 14 Bobala Road E -MAIL Holyoke MA 01040 ADDRESS:spalazzo ®dowd.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Safe.t.y Tndemni ty Company INSURED COOP INSURERB:Great American Insurance Companies Co Op Power, Inc. INSURER C : 324 Wells Street INSURERD: Greenfield MA 01302 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1944936959 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PR LOC $ JFCT A AUTOMOBILE LIABILITY COM6212701 3/23/2011 3/23/2012 COMBINED SINGLE LIMIT (Ea accident) _$1000000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $1000000 $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- 0TH - AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER ANY PROPRIETOR/PARTNER /EXECUTIVE N / A E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Directors & Officers Liability EPP1117563 6/2/2011 5/2/2012 1,000,000 5,000 Deductible DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 701, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Center for Ecological Technology ACCORDANCE WITH THE POLICY PROVISIONS. 113 Elm Street Pittsfield MA 01201 AUTHORIZED REPRESENTATIVE © 1988 -201 ACORD COR O RATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD _ I . 4 • AC6 D CERTIFICATE OF LIABILITY INSURANCE 6/22/201rc1 ) 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 1SSU1NG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) 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 NAME: Blackmer Insurance Agency Inc. P A ONNn.Fxtl: (413) 625 -6527 FAX NoY (413)625 -6220 1147 Mohawk Trail eanne @blackmers.com ADnRF __— INSURER(S) AFFORDING COVERAGE NA1C tI Shelburne MA 01370 -9707 INSURER A :Landmark American Ins Co INSURED INSURER B Max Specialty Insurance Co -op Power, Inc INSURERC:Twin City Fire Insurance Co 29459 324 Wells St INSURER D : PO Box 688 INSURERE: Greenfield MA 01301 INSURER F : COVERAGES CERTIFICATE NUMBER:CL1162200869 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 L TYPE OF INSURANCE ADD SUER POLICY EFF POLICY EXP LIMITS LTR INs WvD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,000 A CLAIMS -MADE XI OCCUR X LSA086972 00 11/8/2010 11/8/2011 MED EXP (Any one person} $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 , 000 ,000 PRO- - X - 1 POLICY LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE HIRED AUTOS ! AUTOS (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS - MADE AGGREGATE $ 1,000,000 DED I RETENTION $ RENEWAL MAX113100056487 6/2/2011 6/2/2012 $ C WORKERS COMPENSATION X WT I% I FR I WC TORY STATU- fOTH- AND EMPLOYERS' LIABILITY Y (N ANY PROPRIETOR/PARTNER /EXECUTIVE H.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N NIA O SWECLC6866 11/1/2010 11/1/2011 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS (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. Center for Ecological Technology is listed as an additional insured. Co -op Power acknowledges that they have contractually waived (as allowed by the ISO CG0001 10/01 policy) all rights of recovery against CET or National Grid or Western Massachusetts Electric Company or Berkshire Gas Company or any of their affiliates for any loss or damage covered by said policy. 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 Ecological Technology ACCORDANCE WITH THE POLICY PROVISIONS. 112 Elm St. Pittsfield, MA 01201 AUTHORIZED r A7� J Ju.., Acct xe . L ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. IMSrl96 Al TI... nrnon ..............i L...................a......a .....rl.....t nrnan • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : VS-4A( S LLjf ( 6 3 `e S License Number Lafiuct fE/mil C (03s- s -,2,6 - I Addr Expiration Date Si Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ C c -or pexi -,' �►�G/ I� ( S' v..,„ t I (� s---7,( �- Company Name r Registration Number Adc;ss Expiration Date // Telephone 7 7 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 l i Or Doors El Accessory Bldg. ❑ Demolition I I New Signs [O] Decks [Q Siding [O] Qther [ N Brief Description of proposed b eh OW t (� 1020 le--50 EEi .,(t�s� t Work: lr� W 235" 0 12l et 4- turf 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 C 4' , S (E S - t-t h , as Owner of the subject property hereby authorize C® C''( powe- -," to ( et on my behalf, in - 'atterp relative to work authorized by this building permit application. y �.. . 1∎ Sigma Owner Date I &uA ( ¶ G fl L k Q as Owner/ uthorized Agent reby declare that the statements and information on the foregoing application are true and accurate, to the best of m5r1 letSge elief. Signedr the pains and penalties of perjury. Print Name Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Propose d Required by Zoning This column to be filled in by Building Department E • 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 0 DON'T 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 O 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 O NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. (e 1 CTO ' 5b Department use only RECEIVED' i ity of Northampton Status of Permit: .:ullding Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability 2 ( i011 Room 100 Water /Well Availability No hampton, MA 01060 Two Sets of Structural Plans DEPT.OF , M A 01060 TON $1- 13 .87 -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 / SO B G-rcwE S --111/(": Map 1 ) Lot 1 Unit 11 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: CaS16 S hVifJ 3 C ray s A -v Name (Print) Current II/ Address: 3 2 0 / a / Telephone Signat 2.2 Author' ed Agent: / a aid% K. (4 efj Name P • '' 7 Current Mailing Address: ( i 4 3- T77-- r 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 d /733 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0111 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 30B GRAVES AVE MAP 32A PARCEL 079 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid d j /�(/ N 5 X5: Typeof Construction: INSULATE ATTIC FLOOR 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 INFO TION PRESENTED: pproved 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 ignature of Building Of icia 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. 30B GRAVES AVE BP- 2012 -0111 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 079 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- 2012 -0111 Project # JS- 2012 - 000167 Est. Cost: $1600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): Owner: SMITH CASIE Zoning: URC Applicant: PAUL SCHMIDT AT: 30B GRAVES AVE Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:8/1/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATE ATTIC FLOOR 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 8/1/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner