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38B-223 RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/22/2011 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, 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 NAME: Shannon Palazzo James J. Dowd & Sons Ins ( PHONE . Exti :413 -538 -7444 (AC.No):413 536 -6020 14 Bobala Road E -MAIL Holyoke MA 01040 ADDRESS:spalazzo @dowd.com INSURER(S) AFFORDING COVERAGE NAIC i! INSURER A:Safety Indemnity Com a{anny INSURED COOP INSURER B :Great American Insurance Companies Co Op Power, Inc. INSURERC:U. S. Liability Insurance Company 324 Wells Street Greenfield MA 01302 INSURER D: INSURER E : INSURER E COVERAGES CERTIFICATE NUMBER: 1050225280 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 CR 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 I S TYPE OF INSURANCE ADDUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) C GENERAL LIABILITY CL1566148 11/8/2011 11/8/2012 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $100,000 CLAIMS -MADE OCCUR MED EXP (Any one person) 35,000 PERSONAL & ADV INJURY 31,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP /OP AGG $2,000,000 POLICY IF X LOC $ A AUTOMOBILE LIABILITY COM6212701 3/23/2011 3/23/2012 COMBINED SINGLE LIMA (Ea accident) J1 000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS N-O PROPERTY DAMAGE 31,000,000 X HIRED AUTOS (Per accident) X NUN -OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ —; EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU OTH AND EMPLOYERS' LIABILITY Y! N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 11 yes. de5Dnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ B Directors & Officers Liability EPP1117553 3/2/2011 52/2012 1,000,000 5,000 Deductible DESCRIPTION OF OPERATIONS 7 LOCATIONS / VEHICLES (Attach ACDRD 101, Additional Remarks Schedule, it more space is required) Waiver of Subrogation Applies. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Road Suite 4, 2nd Floor AUTHORIZEDREPRESENTATNE Canton MA 02021 -1461 r fr © 1988 -2010 ACORD CORPORATION. All rights reserved. • ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ,r _ L..q7te - 16 . 041142t0 6 ,2 0 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2014 Tr# 220702 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Update Address and return card. Mark reason for change. ❑ Address Renewal Employment Ell Lost Card DFS -CAi a.w 5CM- 04/C4- G1C1216 ✓fte - wea �✓ULacoa a . Office of Consumer Affairs & Bu Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: i 1 Registration: 165217 Type: Office of Consumer Affairs and Business Regulation Expiration: 1/21/2014 Corporation 10 Park Plaza - Suite 5170 Boston, MA 02116 CO P POWER IIC PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Undersecretary ' Not v without signature Massachusetts - Department of Public Safe 4 Board of Building Regulations and Standard Construction Supervisor License License: CS 103635 Restricted to: 00 PAUL SCHMIDT 24 CHESTNUT ST HATFIELD, :MA 01038 >a _. '/ Ri Expiration: 5/202013 C'umtriksi.iner Tr#: 103635 The Commonwealth of Massachusetts r.:,a n .Department of Industrial Accidents # Office of Investigations - = t7 Washington Street Boston, ALI 02111 '' ` * • w1414). mass.govldic Worker O'anipenstiaan Insurance Affidavit. BuildersiCaritractors'. ,1ectriciansiP(umhers Aprllicani Information. Please. Print Le&ily 3'axne as rgtniz tiora'Individua]): t C �•- P e�.� c Ad tress: tirktrzstEirtrift /5}3 M374 rr `lip ?tD j l - Old U U City /Sta Z : 4 1'"' •0 i d ' e: Phone 4 : ( 3 1 7 ` Z t- 7 y- Art 79.1 an employer? Check th¢ app .+ ?late hex: . I T, e of prom (required ): r 4. i� 1 asp, a general contractor a rd 1 I i . ` I am employer -with O. ,i l N evi eorstrlaclicr, i employe s (fall; 2mti �,r paw- -iinie).a i;Gve laireC the salt - contractors 2.0 1 2779 a sole proprietor or partner- 'listed an file attached sheep. : �. D ;R emodeible i ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' y n 9. [ Building addition [No workers' comp. insurance comp. insurance $ 1 p Electrical repairs or additions required.] 5. 0 �� e are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o workers' comp. right of exealption per MGI� � p 12.0 Roof repairs _ insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13 .51t. Other .k- ( CA, (Go76-lr 'v comp. insurance required.] *Any applicant that checks boy. (11 must also iill 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. TContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. Mho sub - contractors have employees, they must provide their workets' comp. policy number. I am art employer that is providing workers' corrrpensag insurance for my employees. Below is the policy aad job site irlformatlort: .-- �. E k I n s u r a n c e Company N a m e : ( W ill C i F [ r 6 - — 'r`.SLVY` GCS. e-- C n ` Policy # or Self-ins. Lie. #: C) R"` kJ E �.L C (0 g cp cp Expiration Date. -` i 2.-� C-1 ` ---- /� Job Site Acidness: 37 FAIR V )fW A VEALU E. Cit ,thQ ► /-/Axpro))4i n - d /0 l0 O' Bch a copy of the workers' compensation policy declaration page (showing the police number and expiration ation ate }. Failure to secure coverage as required under Sedan 25A of IE {GL c. 152 caa lead to the imposition of criminal penalties ofa fine up to S [,50Q.42D nor one••Srear impprisannnn.ent, as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to S250.OD a day against the violator. Be advised that a copy of this statetneat may be forwarded to the Office of lnct€gations of the DIA for insurance coverage verification. f do hereby car , under the , : ' , .nd p - • of petittry that the information provided abo a is true and correct. Signature: ----- ° Date: / . i/ / Phone #: '4( 2, - 2 g Official use only. Do not write in this area, to he completed by city or town official , : City or Town: Permit/License # Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. C €tyfTown Clerk 4. Electrical Inspector S. Plumbing Inspector • 6. Other • Contact Person(: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Paul Schmidt 103635 License Number 24 Chestnut Street, Hatfield, MA 01038 05/20/2013 Addre: Expiration Date (413) 772 -8898 Sign. ure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Co -op Power 165217 Company Name Registration Number 15A West Street, West Hatfield, MA 01088 01/21/2014 Addre s Expiration Date Telephone (413) 772 -8898 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 [1; 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 I I Replacement Windows Alteration(s) ( 1 Roofing Or Doors El Accessory Bldg. I I Demolition 1 1 New Signs [D] Decks [0 Siding [D] Other [D] Insulation Brief Description of Proposed , ► _ i s 1 Work: AU et q le'11 IV6IGUnnral i 1Is i%1 - (© — 1000 54, �. Alteration of existing bedroom Yes No Adding new bedroom Yes G 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 OrAlt 84 k �, � , as Owner of the subject property l hereby authorize Co -o. P.wer to act on • behalf, in 1��.,;- •- iative to wo ,r horize.r' thi building permit application. //f,507 10 /02 /2012 ' . M i Signature o .wn-� �; Date I, te2Egraltda, 4. Pra641 5CJfY1.,GG , 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. Paul Schmidt Print Name 10/02/2012 Sign ure of Owner /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 tilled in b■ 13uilding Department Lot Size Frontage Setbacks Front Side L: R: L:, _ R:i, .. _ _ ., Rear _ , Building Height Bldg. Square Footage % j Open Space Footage _ __ , % ,, .__. _, (Lot area minus bldg & paved I I ' . ._ .,, z parking) # of Parking Spaces , _ Fill: l (volume & Location) __ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DON'T KNOW 0 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 i Paget t and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 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 0 NO 0 1 1 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO 0 IF YES, describe size, type and location: i i G 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only ti C ity of Northampton Status of Permit: 1 5 2012 uilding Department Curb Cut /Driveway Permit 212 M ain St ree t Sewer /Septic Availability r Gz o� \ Room 1 00 Water/ Well Availability, B 0 14, Mp 01p60 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 39 Fairview Avenue Map Lot Unit Northampton, MA 01060 Zone — Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Dorothy Baker 39 Fairview Avenue, Northampton, MA 01060 Name (Print) Current Mailing Address (413) 586-6096 Telephone Signature 2.2 Authorized Agent: Paul Schmidt/Co -op Power 15A West Street, West Hatfield, MA 01088 Name (Print) Current Mailing Address: (413) 772-8898 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7 5 0 () (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) it,), S0 0 Check Number • , j This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0452 APPLICANT /CONTACT PERSON CO -OP POWER INC ADDRESS/PHONE P 0 BOX 688 GREENFIELD (413) 772 -8898 Q PROPERTY LOCATION 39 FAIRVIEW AVE MAP 38B PARCEL 223 001 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 3 X76' Typeof Construction:_ADD ATTIC 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 INFO 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 -lay /o Signa' o f Building fficial 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. 39 FAIRVIEW AVE BP- 2013 -0452 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 223 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- 2013 -0452 Project # JS- 2013- 000721 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO -OP POWER INC 103635 Lot Size(sq. ft.): 5532.12 Owner: BURROWS MEADE & DOROTHY BAKER Zoning: URB(100)/ Applicant: CO -OP POWER INC AT: 39 FAIRVIEW AVE Applicant Address: Phone: Insurance: 15A WEST ST (413) 772 -8898 0 WC WEST HATFIELDMA01088 ISSUED ON:10/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD 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 10/24/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner