32C-123 (2) •
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Lela'bly
Name ( CO or $ f ' �
Address: Zz Gu fS 5fi
Cit /State/Zip: _ �' J v ) mA C iS6 Phone #: '- / )3 77 g— 888
Are you an employer? Check the appropriate box: Type of Plaice Oulith red)-
1 Cam an M y
employer with 9 4. _ I am a metal contractor and I 6. New Construction
Employees (full and/or part time)# have hired the sub - contractors T _Remodeling
2. _ I am a sole proprietor or partner listed on the attached stmt. I
Ship and have no employees These sub-contractors have g- Drarmlituon
Working for ate in any capacity. workers' comp. insurance. 9. Building Addition
[No workers' comp. insurance 5. We are a corporation and its 10. Electrical repairs or additions
required.] officers have exercised their 11. _ Plumbing repairs or additions
3. , I am a homeowner doing all work right of exemption per
myself [No workers' comp. C. 152, ' 1(4), and we have no 12. _ Roof repairs
insurance required.] employees. [No workers' 13. t Other u&1
comp. insimmce required.] ATIDeD
* Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information
*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 attach an additional sheet showing the name of the subcontractorss and their workers'
I am an employer that &providing workers' compensation insnrancefor my employers. Below is the policy and job site information.
Insurance Company Name: e f J 1cI
Policy # or Self -ins. Lic. #: W 601 -C ` ( 6 ` S Expiration Date: ti I 1 ° 1 { t I T •
Job Site Address: �� U a sr - — f lT 1 4A ft r
Attach a copy of the workers' compensation policy declaration page (showing the policy number acrd expiration 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 ofthis statemest may be forwarded to the Office of Investigations of the DIA for
insurance coverage verification.
I do hereby certifr alderthe ' penalties ofperjury that the information proviried above is true and correct
Signature: e Date: 101 I J
Phone #: 1— L )3 t '37
(Weird use only. Do not write in this area, to be conspkted by city of town o,
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 #:
MOW (413) 625 -6527 FAX: (413) 625 -8210 - THM CERTIRCATE IS ISSUED AS A MATTER OF INFORMATION
R1 AAnn/RT Insurance A _ - ONLY AND CONFERS NO RIGHTS WON THE CEI;iiFlCATE
1000 Trail - HOLDER. THIS ATE DOES No OR
ALTER TIE COVERAGE AFFORDED BY TIE POUCIES BELOW.
i
Shelbl3rne MA 01370 -9737 - INSURERS AFFORDBJG COVERAGE = NA1C P
mum im Landmark. American RUB CO
Co -op Powwer, Inc eR9t1RER& ord Insurance Croup f -
324 Wells St c
PO Box 688 INSURER De
, Greseaffistld MA. 01301 SOURER e .
COVERAGES
THE POUCTS OF WSURANCE USTED 8E N HAVE BEEN ISSUED TO THE DIMMED MAIM) ABOVE F-OR1FE POLICY PERIOD MIMED. NorwriliSTANDING '
ANY REQuiRENENr. Mai O R COPD7i10N O F ANY CONTRACT OR OMER DOCUDIENT w a i R E S P E C T TO MEM THIS Ci3UWICATE MAY BE ISSUED OR
MAY PERTANit. TFE INSURANCEAFFORDED BYTE POLICIES DESCRIBED HEREIN IS SUB.ECT TO ALL THE IERIM EXCLUSIONS ANO coNomoNs OF SUCH
POLICES. AGGREGAIE LNA75 SHOWN AIRY HPNEIEE3tR BY MID tUM& -
TYPE eEanemet I POIXTM I nw T aa00tw � r m 1 W. l MRS
GEHERALUAIN TY I EACH oCCUs - 1,000,000
n PEWEES esememed $ 100,000
A % nill CLANS MADE Ei occtR SIBB5599600 11/8 /2009 11/8/2010 Mt7a'RAateependl , t 5,000
IIIII PERSONAL aim MIRY $ 1, 000 , 000
III - GENERAL seommano $ 2,000,000
GEM AOR EtaiiAPPLESP6t PRODUCTS- COSEOPeG6 $ 2,000,000
S ruicv 1 i jE ! t LOC
I 8 $ 1,000,000 COMBIREOMNSIE MT
SWAM
ALL OrY►1� iums -
sCHE ARBD�anoS -
$
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— 1 OCCUR D WAX MOE A GREOSIE $
$ _
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-
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B WORKERS °0 ''SS""ON - 1, I 11
NW PROPREIORMONMSBOXIXNE Y t j 0eaa L
$866 11/01/2009 11/01/2010 Er Acc1013f S 500000
!fTrs, Is L EL SE ER EMPW E S 500000
PROVISIONSbabw - EL.DISELSE- POUCYtnir S 500000
OTHER -
_E TIONOF °MASONS / WORM= MENICLE5/ EXCLUSIONS MOOD sr tt rNa loNS - - -
Certificate issued subject to the terms, conditi.oars, aselnsions, and endorsements attached tito. OErsatiaes asasa1
to alternative solar energy - - Western !leas B1ectei= Ca Is added as additional insured. -
CERTFICATE HOLDER CANCELLATION
SpaBAlaraFliEAewEOescasED MUMS eECANCacEDeE[OaER1EE W5Ai1OH
W e s t e r n Mass- Electric r c C o m p a n y OY►TE THE F, THE mums aarlass: mat mamas TO MAT. 10 DAYS MWTTEN
Customer Service Center - NOLICET011ECE RTFICKTEHOL ,DEitNRYED'iOTHELEFT,HUTFARD El00o 50MALL
P 0 Boar: 2010
- aa►OSE EEO (11I OR USSR= OF KIND I r THE aaaIRBI, WS AMITS O R
Springfield, MA 0109D - 20] 0
HEPRESEInsasea
PAITHDREINRonesEsuram
ACORD 25 (2009101) 019n-2009 ACORD CORPORATION. All riffs reserved
tNS025 ammo The ACORD name mid logo as reed Earns of ACORD
sow --670,;onowtoected e c���
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.
1 Address Renewal Employment TI Lost Card
UPS -CAl sa 50M- 04/04- G101216
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
a Office of Consumer Affairs and Business Regulation
J � Registration: 165217 10 Park Plaza - Suite 5170
Expiration: 1/21/2012 Tr# 292798 Boston, MA 02116
Type: Corporation
CO-OP POWER, INC_
PAUL SCHMIDT
324 WELLS ST - >6_ -- ""
GREENFIELD, MA 01301 Undersecretary Not valt without signature
Massachusetts - Department of Public Safeh
A , } Board of Building Regulations and Standards
Construction Supervisor License
License: CS 103635
Restricted to: 00
PAUL SCHMIDT
24 CHESTNUT ST
HATFIELD, MA 01038
° - �--G - � - y '`t Expiration: 5/202013
•
( u mntissioner Tr#: 103635
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �+ Not Applicable ❑
Name of License Holder : p p (J l J 1. ��) f 03 (7 C
License Number
z- iricrivr Sr / 7 Ff>R l s Z
) 6 l zD)3
Address / , / Expiration Date
Si ture Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
c,o - how c 16
Company Name Registr tion umber
�j 2.,i( GI> Ws si z1 ZO)7—
Addr€ss Expira ion Date
6 7 -6 /414 . /6 1 , 1 NA Telephone 1 -113-1 71-1797
-
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 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E7 Siding [0] Other
Brief Description of Proposed .r !24 t n
Work: it I 4,14, Pt/or
Alteration of existing bedroom Yes No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes ,X 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
TM G gi l / 0 04 E , as Owner of the subject
property
hereby authorize PA GY'y )q (o ^Op to act on my behalf, in all m- relative to work aorized by this building permit application.
.S l? (v
Sig ature of Owner • Da e
PO SL H,/VVi , as Owner /Authorized
Agent here declare that the statements d 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.
Print ame
zo)D
Signature o Owne • ge Date
Section 4. ZONING AU 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 IA YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 `�
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
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 Q NO 9
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Department use only
Cit of Northampton Status of Permit
Bui ding Department Curb Cut/Driveway Permit
2 2 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
North: mpton, MA 01060 Two Sets of Structural Plans
phone 413 -5 =7 -1240 Fax 413 -587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRU T, 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
� �
M2� L Lot Unit
t� 7
-1.1 � V Zone Overlay District
Efts .St. District CB District
SECTION 2 - PROPERTY OWNERSHI • /AUTHORIZED AGENT
2.1 Owner of Record:
rint) �� Current M it dyes J
Name (P ���
Telephone
���� `� ��
Signature
2.2 Authorized Agent:
Ply vl rq ib- . co-op Off) 3L`t Loa Si" CsregvreRmA.
Name (Print) /6, i Current Mailing Address:
1 113 ' ?7
Signatur Telephone
SECTION 3 - ESTIMATED CONSTRU r TION COSTS
Item : stimated Cost (Dollars) to be Official Use Only
..mpleted by permit applicant
1. Building 4110 (a) Building Permit Fee
2. Electrical V (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 /51 $55
This Section For Official Use Only
Building Permit Number:
Date
g Issued:
Signature:
Building Commissicner /Inspector of Buildings Date
File # BP- 2010 -1053
APPLICANT /CONTACT PERS OWN PAUL SCHMIDT
ADDRESS/PHONE 24 CHES T ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 28 FR SIT ST
MAP 32C PARCEL 123 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,�/ ff'
Fee Paid /J W �'
Typeof Construction: INSTALL . TTIC INSULATION
New Construction
Non Structural interior rend vations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or Licen.e 103635
3 sets of Plans / Plot Plan
T HE OLLOWING ACTION AS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTE I :
A pproved Additional permits required (see below)
PLANNING BOARD PE ' IT 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 PER IT REQUIRED UNDER: §
Finding .pecial Permit Variance*
Received & Rec • rded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DP Water Availability Sewer Availability
Septic Approval B oard of Health Well Water Potability Board of Health
Permit from Cons: rvation Commission Permit from CB Architecture Committee
Permit from Elm 'treet Commission Permit DPW Storm Water Management
Demolition Delay
- 2 v ( 0
Signature of Building Official Date
Note: Issuance of a Zoning per 't does not relieve a applicant's burden to comply with all zoning
requirements and obtain all req fired permits from Board of Health, Conservation Commission, Department
of public works and other appli able permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for mor information.
vz
BP- 2010 -1053
GS #: COMMONWEALTH OF MASSACHUSETTS
} 2 - 123 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- 2010 -1053
Project # JS- 2010- 001551
Est. Cost: $3400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 5401.44 Owner: DOHERTY MICHAEL J
Zoning: URC(100)/ Applicant: PAUL SCHMIDT
AT: 28 FRUIT ST
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:5/25/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 5/25/2010 0:00:00 $55.00
•
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo