30A-003 (2) CO-OP ,
POWER
BUILDING COMMUNITY-OWNED SUSTAINABLE ENERGY
PERMIT AUTHORIZATION FORM
I, Atitcipda . G 130'1,owner of the property located at:
(Owner's Name)
a g o R i;vvl c. . (Aral e MA 0 I U(e L
(Property Street Address) (City/Town)
hereby authorize C, � r2 U1 CA U- �i'vi Les
(Contractor)
to act on my behalf to obtain a building permit and to perform insulation and/or
weatheriz•tion work/on my property.
• OM
(0 er's ignature)
\-1
(Date)
Co-op Power
15A West Street,West Hatfield,MA 01088
phone:413.772.8898 or 877.266.7543,fax:413.517.0300
Email:info @cooppower.coop Website:www.cooppower.COOp
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Sat _ „Jo 600 Washington Street
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.® I am a employer with 10 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I 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 for me in any capacity. employees and have workers'
g P h 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I 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.❑ 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#1 must also fill 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.#: WC5-31S-388245-012 Expiration Date: 11/02/2013
Job Site Address: 280 Florence Road _ 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 certifyu��nder the pains and penalties of perjury that the information provided above is true and correct.
Signature: �.!��' 4_ Date: 09/24/2013
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: Shawn Gallagher CS-095430
License Number
15A West St, West Hatfield, MA 01088 04/29/2014
Addr- /AO Date
-door
(508) 317-0041
Sig Or P Telephone
9,_iitgionitiimmhasmaymisgan Not Applicable ❑
Co-op Power 165217
Company Name Registration Number
15A West St, West Hatfield, MA 01088 01/21/2014 _
Address 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 X No ❑
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 El
Accessory Bldg. ❑ Demolition ❑ New Signs [o]Insulaii67 s [D Siding[0] Other[El]
Brief Description of Proposed
Work:12311ft2 of R-119 cellulose in attic; 181W of rim foist fiberglass; 160W of cellulose in interior walls
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
es If New house and addition to existing homing, com fowin+g':
a. Use of building : One Family Two Family _ Other_ _-
b. Number of rooms in each family unit: Number of Bathio^m:';_��
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 i City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Amanda Anderson ,as Owner of the subject
property
hereby authorize Shawn Gallagher/Co-op Power
to act on my behalf, in all matters relative to work authorized by this building permit application.
See enclosed authorization form 09/24/2013
Signature of Owner Date
I, Shawn Gallagher ,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.
Shawn Gallagher
Print Name
09/24/2013
Signature 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 filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
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 DON'T KNOW 0 YES
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 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained I 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 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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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q. . 6 2013 i City of Northampton S�u�s ;#_ Vi , µ ; '
J �M Building Department curb ` ' " "
_ ---- 212 Main Street �r� � �� �� r a � �,
�pections Room 100 eI
r ,.... 1 1 ':10 W e,rM(s�'+�A �411,i ' " S*�a''x� ''t� a 4 ,'.
i Northampton, MA 01060 Tw � ' ,
phone 413-587-1240 Fax 413-587-1272 � � 7., r
I
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
280 Florence Road iota Unit
Florence, MA 01062 zone Overlay District
Elm St.District �.._ C8 District
'
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Amanda Anderson 280 Florence Rd, Florence, MA 01062
Name(Print) Current Mailing Address: (413) 320-8300
See enclosed authorization form Telephone
Signature
2.2 Authorized Agent:
Shawn Gallagher/Co-op Power 15A West St, West Hatfield, MA 01088
Name(Printt',Air Current Mailing Address:
lic. (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 $2105 (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 ,ij-
6. Total=(1 +2+3+4+5) $2105 Check Number 5- 4#4.? S'
This Section For Official Use Only
Building Permit Number: Date
9 Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0384
APPLICANT/CONTACT PERSON CO-OP POWER INC
ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413)772-8898 Q
PROPERTY LOCATION 280 FLORENCE RD
MAP 30A PARCEL 003 001 ZONE URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 561/ 55
Fee Paid / yLy
Typeof Construction: INSTALL ATTIC&WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 095430
3 sets of Plans/Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO 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
• itio I Delay
/d--/-/s
Signature of Building Of 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.
280 FLORENCE RD BP-2014-0384
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-003 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-2014-0384
Project# JS-2014-000667
Est. Cost: $2105.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CO-OP POWER INC 095430
Lot Size(sq. ft.): 24611.40 Owner: ANDERSEN AMANDA
Zoning: URA(100)/WSP(100)/ Applicant: CO-OP POWER INC
AT: 280 FLORENCE RD
Applicant Address: Phone: Insurance:
15A WEST ST (413) 772-8898 O WC
WEST HATFIELDMA01088 ISSUED ON:10/2/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & WALL 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 10/2/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner