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31B-120 (3) The Commonwealth of Massachusetts Department of Industrial Accidents Am= Office of Investigations . 1 mom 'V iit� 600 Washington Street 9 Boston,MA 02111 'rites"219; 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. ❑ 1 am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y P n' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* 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#I 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: 9 Edwards Square city/state/zip: Northampton, MA 01060 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: 972 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#: DATE(MM/DD ACCORD CERTIFICATE OF LIABILITY INSURANCE /YYYY) 11/12/2012 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 JAMES J DOWD & SONS INS AGCY INC CONTACT NAME: K , MA A 010411900 HOLYOKE, PHONE(A/C,No,Ext): (413)538-7444 FAX(A/C,No): (413)536-6020 - E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Libe M -11n r-n= _ INSURED INSURER B_ CO OP POWER INC 15 A WEST STREET INSURER C: WEST HATFIELD MA 01088 INSURER D: INSURER E: _._.-.. INSURER F: COVERAGES CERTIFICATE NUMBER: 14687992 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 —�-- -- -ADDLISUBKI----------- - ----�POLICY EFFTPOLICY EEXP ---- — -"-----' LTR. TYPE OF INSURANCE I INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE __ $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY j i PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ _ RO- POLICY jECT LOC I$ AUTOMOBILE LIABILITY 1 Yi COMBINED SINGLE LIMIT Ea accident ANY AUTO ( BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ HIRED AUTOS NON-OWNED I PROPERTY DAMAGE AUTOS (Per accident) $ _ $ — UMBRELLA LIAR I $ I OCCUR 4 LEACH OCCURRENCE $ EXCESS LIAB I CLAIMS-MADE I AGGREGATE $ DED I RETENTION$ $ $ A WORKERS COMPENSATION WC5-31S-388245-012 r 11/2/2012 11/2/2013 I we sTATU- oar l- $ AND EMPLOYERS'LIABILITY Y/N � TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? N I NIA — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under i DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT I$ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers compensation insurance coveraoe applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HONEYWELL UTILITY SOLUTIONS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 65 SHAWMUT ROAD, SUITE 4, FLOOR 2 ACCORDANCE WITH THE POLICY PROVISIONS. CANTON MA 02021 AUTHORIZED REPRESENTATIVE 0t- -4 Jeff Eldridge O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 'EST NO.. 14687992 Tara McLaughlin 11/12/2012 10:07:14 AM Page 1 of 1 AC RO°® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L._., 11/13/2012 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 NAMEACT Debbie MacNeal James J. Dowd&Sons Ins /acc.No.Ext):413-538-7444 FAX No):413 536 6020 14 yo la Road H olyoke MA 01 040 E-MAIL SS:dmacneal dowd.com INSURER(S)AFFORDING COVERAGE NAIC It INSURER A:S fety Indemnity Company INSURED COOP INSURER B:Great American Insurance Companies Co Op Power, Inc. INSURER C:U. S. Liability Insurance Company 324 Wells Street INSURER D Greenfield MA 01302 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1237597439 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 I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER .(MMIDD!YYYY) (MM/DD!YYYY) LIMITS C GENERAL LIABILITY CL1566148 '11/8/2012 11/8/2013 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO X LOC $ JECT A AUTOMOBILE LIABILITY COM6212701 Si/2 2l3 012 3/23/2013 COMBINED-SINGLE LIMIT 1,000,000 (Ea accident) ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ T S PROPERTY $HIRED AUTOS X AOS ED (Per accident) _ Comprehensiv Collision I deductible $500 C X UMBRELLA LIAB _ OCCUR CUP1550265 111/8/2012 11/8/2013 EACH OCCURRENCE $1,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION$0 $ WORKERS COMPENSATION WC STATU- OTH- 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 612/2012 3/2/2013 11,000,000 5,000 Deductible I DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Workers'Compensation Certificate of Insurance to follow separately from the carrier. 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 AUTHORIZED REPRESENTATIVE Canton MA 02021-1461 ro on.I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD fF_., `y fZe WO/in4rbOW/atea 't/f't . ,/' '4if l Office of Consumer Affairs and Business Regulation ` 10 Park Plaza- Suite 5170 yy Boston, Massachusetts 02116 Home Improvement Coltractor Registration Registration: 165217 Type: Corporation Expiration: 1121/2014 Tr# 220702 CO-OP POWER, INC. SHAWN GALLAGHER 324 WELLS ST _ _._ -_ .. GREENFIELD, MA 01301 ..........._ Update Address and return card.Mark reason for change. r;I Address fl Renewal (l Employment 0 Lost Card SCA 1 t, 20M-06/11 (92e Warit,M.0724AECtidt a"C 1fa atAudeal S \ Office of C e uiatr Affairs&Busiatss Rtguletior a ieei,C or Yegibiinii'i011 J1tue f t irisKviiliii ust only ;y— •ME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: "'a ;egistratlon: 165217 Type: Office of Consumer Affairs and Business Regulation 4 10 Park Plaza-Suite 5170 ` zpiratints _:.1/2'll�fl1�4; Corporation ;;; :=.,. g ,.:;:;_ Boston,MA 02116 CO-OP POWER,INGr .-.a' SHAWN GALLAGHER-. "'f Y Y s f � 324 WELLS ST ..---- / GREENFIELD,MA 01301 � Undersecretary N.�� ' lid without signature j Massachusetts - Department of Public Safety / Board of Bu iding Regulations and Standards Cirn trrzrtic;n SuperF'iaar 3 License: CS-095430 re" SHAWN GALL:4ti -fER . - 14 BELTRAN STAP'f ` t Malden MA 0215$ ' ,- ,.!. . 'l , 954- _�J Expiration Commis sioner 04129120/4 CO-OPT J imi POWER BUILDING COMMUNITY-OWNED SUSTAINABLE ENERGY PERMIT AUTHORIZATION FORM i, "Jü ?t-/ owner of the property located at: (Owner's Name) c7 Er)vmeiD5 5-6wAeE AlaireilkOMAf/' /IP (210C'0 (Property Street Address) `- (City/Town) hereby authorize co -0-1N /� J` W /c (Contractor) to act o beha • •• •in a • ilding permit and to perform insulation and/or weath ri •tion i ork o, •• • o•-rty. __ APIP 0 1. I I - 's Signature (Dat ) 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 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 Addres /! Expiration Date 'r (508) 317-0041 Sign Ar, Telephone 9.Reo steredl-Ho e Imoiovintenteontractor 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 i No ❑ 11-4,:r. flame whet' xemotion 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 El Replacement Windows I Alteration(s) ❑ Roofing f1r Doors E j Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding[0] Other Bill Insulation Brief Description of Proposed Work:800ft2 of 3.5" cellulose under vinyl siding Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.it New house'antoraddition 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. _Y Dimensions I 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 Joseph Defazio as Owner of the subject property hereby authorize Co-op Power/Shawn Gallagher to act on my behalf, in all matters relative to work authorized by this building permit application. See authorization form enclosed 09/24/2013 Signature of Owner Date 1, 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 Nam- / r 09/24/2013 Signatures/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 L: R:.. Rear Building Height Bldg. Square Footage Open Space Footage � `%0� (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 YES IF YES, date issued: YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 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 Obtained Date issued: C. Do any signs exist on the property? YES NO C) 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 i NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. - ' ',-.•:,..,,..!!!:‘,";.:.•,,,,,,!14 -,,44.iit.'t 14.P.77.41', ''' ,. _,,„,, '-.54f,'"t*-'1-4,,,X atc^$%iti;%"141.4:::7,: ficin,,,:;.44-r,,," •-' , teg,,,,,,,,,,,;;,›Pfit: •,• ,.:: ,'-,x•, .!,,,:,!•=4.4‘•;":.;,,-.?riz ,,,,,....4— A'10';';!:'%,„..:;:i;t . ‘ 1 r Pik A.-," diatornfilw-,%,,V,4 4.1 ife2:4", :'1•1•''' ',,,,,,,,,,, ' ' ",, ' - ,. , 1 1 f Northampton %Al"' '7 •''''':'',A.'" ':,,,-;12-,,,,,r.i.0.2k:+%,,,,,:,:5',„,.q0„,7,„,—,,' ' :4' .,, .,!.717. -, '',' ', -..,..e1T.''''''`,.,<., ,,,,•..,;",,,, •••1,'"" ' • -.;,- ' Building Main--. 4" Room 100 ,,,,°,.,,,.,- teto ,i7y41:4,,;,As44 'f,' "' --' '''`''----"Si:' ,'Vtit;', ectIcsCs PSatilremeet Department <,,..-4,, i.?'-' ,.,ei.,:ifkitt,,,,;;1;1 _ „,-,-,T,, ,4.74,!:,',.. ;•4.,, ,1 ,,,,,,,,,,, q DWELLING Gas 1,11g0 Northampton A,A,,, FMaAx 0411036_5087-1272 —lops 0 I .__,-,87-1z-tu OR TWO FAMILY - phone 413 0 by Office fa be completed APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE _,,,ort,...., unit , This section , - SECTION 1 -SITE INFORMATION LOt 1 property , zMoanpe Coveria' ' y cargatriet Address: plstrict 1c; Edwards SquaAr ni060 Dist.dcf......._ — Northampton, M' u . Elm St. Northa : SECTION 2-PROPERTY n-" E—RSHIP/AU—TliORI—ZED AGENT 9 Edwards Address: • 5 11) 86-6161 Record: t Mailing Addr (413)— r of Rec Curren ro i 2.1 Owner Defazio Joseph Telephone H Ards Square, Northampton, MA 01060 Name(Print) . ,4 MA 01088 See authorization form enclosed ,A, t Hatfield,15A West St, "es Signature Authorized Agent: 2.2 Autho , _...n Gallagher Power/Shawn - Co-op r Telephone (Print) 011 hone (Current 4 13)Mailing 7 7 2-8A8dcl9re8ss. ■■■•■•A-t:- ---- Official Use Only Signature p je t.0 be ESTIMATED CONSTRUECsTtfimOaNteCdOCSoTsSt( (a) Building completed (Dollars)Item 1. Building $1400 Building 2. Electrical (b) Fc_sotnims.atrtuecd.cioTo from(6) 3. Plumbing Check 4. Mechanical (HVAC) Use Fire Protection 5. . .•- . , +4+5/ This 6. Total=(1 +2-1-a \ $1400 ding PermittFaleCeosSt of ' Section For Official U 0 I Building Permit Number: ______ Dlsastueed: _ Signature: Commis Building sio ne r/Inspector of Buildings Dais File#BP-2014-0386 APPLICANT/CONTACT PERSON CO-OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413)772-8898 0 PROPERTY LOCATION 9 EDWARDS SQ MAP 31B PARCEL 120 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled outO W Fee Paid Typeof Construction: INSTALL INSULATION UNDER SIDING 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION 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 Delay dr, Si. afore of Building Official 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. 9 EDWARDS SQ BP-2014-0386 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B- 120 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-2014-0386 Project# JS-2014-000669 Est. Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO-OP POWER INC 095430 Lot Size(sq. ft.): 3920.40 Owner: DEFAZIO JOSEPH J Zoning: URC(100)/ Applicant: CO-OP POWER INC AT: 9 EDWARDS SQ 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 INSULATION UNDER SIDING 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