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The Commonwealth of Massachusetts
Department of Industrial Accidents
=I VOINIONNON
Office of Investigations
=B 600 Washington Street
".r.-7777/1 ..7 Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization /Individual): Co -op Power
Address: 15A West Street
City /State /Zip: West Hatfield, MA 01088 Phone #: (413) 772 - 8898
Are you an employer? Check the appropriate box: Type of project (required):
1. ® 1 am a employer with 10 4. ❑ 1 am a general contractor and 1
employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working aci employees and have workers'
g for me in any capacity. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.® Other Insulation
comp. insurance required.]
*Any applicant that checks box 14 1 must also till 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.
:Contractors 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. If the sub- contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual Insurance Co.
Policy # or Self - ins. Lic. #: WC5 - 388245 - 012 Expiration Date: 11/02/2013
Job Site Address: 57 Redford Drive City /State /Zip: Florence, MA 01062
Attach a copy of the workers' compensation policy declaration page (showing the policy number and 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 of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 97 01 Date:
Phone #: ( 3) 772 -8898
Official use only. Do not write in this area, to be completed by city or town official.
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Thomas Rossmassler 092540
License Number
100 Main Street, Hatfield, MA 01038 09/02/2013
Addres Expiration Date
(413) 322 -3111
i ature Telephone
9. Registered Horne Improvement Contractor: Not Applicable ❑
Energia, LLC 165169
Company Name Registration Number
242 Suffolk Street, Holyoke, MA 01040 01/11/2014
Address Expiration Date
Ar Telephone
(413) 322 -3111
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 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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed
Work: Improve attic floor insulation from 3" to 12" with R -30 cellulose (1173ft install basement wall insulation
Alteration of existing bedroom Yes No Adding new bedroom Yes No (511ft2)
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. If New house and or addition to existing housing, complete the foiiowing:
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 '
Paul Barry , as Owner of the subject
property
hereby authorize Co -op Power /Energia, LLC
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Thomas Rossmassler of Energia, LLC , 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.
Thomas Rossmassler
Print Name
Si a ure of Owner /Agent ate
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: _ I,: 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 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
� / i .a -1 ,, i �'
ent ire
-------r---' `. — - City of Northampton to r fPer t i t
s 3 Building Department Curb Cu ri y it
\ ------
? 2t‘ 212 Main Street Sewer /Sep1icA�a a Iflt' f
\ o s Room 100 fiater±Uyei Av
�,0 -o Northampton, MA 01060 Two, Sets e3f fre Pns , , ' ,
`
V---- ' .phone 413 - 587 -1240 Fax 413- 587 -1272 Pi iSltea tan :'`
" Other SpeQify . ,
- ... �. < _ ��a
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
57 Redford Drive Map Lot Un
Florence, MA 01062 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Paul Barry 57 Redford Drive, Florence, MA 01062
Name (Print) Current Mailing Address:
D , (413) 330 -4329
Jf 0 D ," �''/)—'--‘ Telephone
Signature
2.2 Authorized Agent:
Co -op Power /Energia, LLC 15A West Street, West Hatfield, MA 01088
Name rin 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 2,618 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Btai tiiny Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 2,618 Check Number /yp�
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
File # BP- 2013 -0853
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 57 REDFORD DR
MAP 36 PARCEL 054 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �
Fee Paid
Typeof Construction: INSTALL BASEMENT WALL & ATTIC FLOOR INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 92540
3 sets of Plans / Plot Plan
THE FO OWING 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
r : •� � el ay
"or,
Y --2'7 1
Signature of Buil. i g 0 icial 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.
57 REDFORD DR BP- 2013 -0853
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 054 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 -0853
Project # JS- 2013- 001460
Est. Cost: $2618.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 12501 .72 Owner: BARRY PAUL
Zoning: Applicant: ENERGIA LLC
AT: 57 REDFORD DR
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:3/25/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL BASEMENT WALL & ATTIC FLOOR
INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Numbing 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 3/25/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner