23C-102 (8) ENERGY EFFICIENCY SERVICES
C 0-0 P CUSTOMER CONTRACT
— Co-op Power, 15A West Street, West Hatfield, MA 01088
OWER www.cooppower.e:coop,
413 772-88 oppower.coop
Phone: 413-772-8898
Toll-Free: 877-266-7543
BUILDING COMMUNITY-OWNED Home Improvement Contractor Registration# 165217
Shawn Gallagher, Director of Energy Efficiency Programs,
SUSTAINABLE ENERGY Contractor Supervisor License#CS-095430
Federal Tax ID 20-2201642
PURCHASER'S NAME TELEPHONE DATE
Heidi Sawicki (413)586-1425 5/5/14
BILLING ADDRESS JOB LOCATION
565 Riverside Dr same
CITY,STATE,ZIP CITY,STATE,ZIP
Florence,MA 01062 same
Statement of Work/ Scope of Work to be completed: WEATHERIZATION AND AIR SEALING
ALL WORK DONE IN A PROFESSIONAL MANNER,
NOTICE TO THE BUYER- PLEASE READ CAREFULLY TERMS:
1. You are entitled to a copy of this agreement at the time you Total Homeowner Contribution: $ 437
sign it. Deposit with Contract `,)EP0571_ pAb $ 109.25
2. YOU MAY CANCEL THIS AGREEMENT by ordinary mail Balance Due Immediately Upon Completion $ 327.75
posted, by telegram sent, or by delivery, not later than mid- 1. In the event legal action is necessary to collect monies due the
night of the third business day following the signing of this contractor,the customer will pay all costs incurred including
agreement. YOU MAY CANCEL THIS TRANSACTION attorney's fees and court costs.
WITHOUT PENALTY OR OBLIGATION WITHIN THREE 2• Any unpaid balance after 15 calendar days of work completion will
BUSINESS DAYS FROM THE ABOVE DATE. be subject to 1.5%interest charge per month.(ANNUAL
3. This contract price is valid when signed and returned with PERCENTAGE RATE 18%).
your deposit within 30 days. 3. 1 have read this entire agreement and received a copy.I agree to the
terms and conditions,INCLUDING THE ATTACHED SCOPE OF
l WORK AND THE TERMS AND CONDITIONS ON THE REVERSE
Contractor Signature ` ""�" pate 5/5/14 SIDE of this agreement.
Contractor Staff Name If Jonathan Smith DO NOT SIGN THIS CONTRACT IF THERE ARE ANY
Operations Support BLANK SPACES.
Contractor Staff Title Customer Signature-)&c,-i% 5 .�/;, 7cd( Date 5-7-)l
Contractor Staff Phone: 413-772-8898 Customer Signature Date
Arbitration: The contractor and the Customer hereby mutually agree in advance that in the event that the contractor has a
dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been
approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such
arbitration as provided 4 —
Contractor Signature ate 515114 Customer Signature�uiL 6 (i
.! LACa Date
Customer Signature Date
NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated
by the contractor. The Customer may initiate alternative dispute resolution even where this section is not signed separately by
the parties."
WORKMEN'S COMPENSATION AND PUBLIC LIABILITY INSURANCE PROVIDED ON ALL WORK.
PLEASE READ TERMS AND CONDITIONS ON REVERSE SIDE.
All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617) 973-8700
Permit Notice: It is the obligation of the contractor to obtain any and all necessary construction-related permits.
Customers who secure their own construction-related permits or deal with unregistered contractors shall be excluded from
access to the Guarantee Fund.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a I Congress Street, Suite 100
Boston,MA 02114-2017
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
employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ 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 1310-1 OtherLq' F `Z
employees. [No workers'
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.
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. 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 Company
Policy#or Self-ins. Lic. #:WC5-31 S-388245-013 Expiration Date:11/02/14
Job Site Address: 'Z) �o'5- ��,t d- s i de Drl City/State/Zip:
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:ture: Ze—W1 7 , Date:
Phone 7 7 aZ tC�
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 Constructiioon(Swervisor: ( Not Applicable ❑
Name of License Holder: �,7Y \Q�/� 61 ����} % C4 1' `7 Li �(�
_ —�— License Number
�Z29 /I
Address Expiration Date
S' ature Telephone
9. Registered Home Improvement Contractor:` Not Applicable ❑
(s) - aoje I G 15-a( -7
Company Name Registration Number
' w( O�t (d o I IA I Al
Address Expiration Date
�—
Telephone
�1� 77�2� q
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) 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[0] Other[k
Brief Des ription of Proposed
Work: j t' !�;-'P)t7�T T S,T Ch I U t�
c
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to'existina`housin6, comalete 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
1 ,Zt( `C�vy C L as Owner of the subject
property
hereby authorize
to act on my behalf, in all matthrs rela ive to work authorized by this building permit application.
Signature of Owner Date
1 A c E t� as Owner/Authorized
Agent hereby declare that the'sta1eftieds 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.
Pri
S atu of Owner/Agent Da e
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 t
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
#of Parking Spaces
A. Has a Special Permit/Variance/Finding been issued for/on the site?
NO K J DONTKNOYY K�O YES K ]
[�----------| '
IF YES, date issued.[_ _
IF YES: Was the permit recorded at the of Deeds?
NO DON7 KNOW YES
|pYE5' enter Bonk | | Page | and/or Document#[----- - - -|
' L__-_____] [ |
B. Does the site contain a brook, body of water orwetlands? NO 0 DONT KNOW 11�� YES x~�
IF YES, has a permit been or need tube obtained from the Conservation Commission?
Needs to be obtained �~� Obtained »�� Date Issued: [-------- --1
�-� �~/ ' ' L__-
C. Do any signs exist on the property? YES NO
IF YES, describe size' type and location: �
------'-------------- ------ /
D. Are there any proposed changes to or additions of signs intended for the property? YES ���-`� NO
IF YES, describe size, type and location: | ����--------------------'--------'
E. Will the construction activity disturb(clearing,grading n,or filling)over 1 acre or is it port of common plan
that will disturb over 1acre? YEGK��� NO ��)
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
An
FV(
„ Department use only
(( � �� —�;-p City of Northampton §6M of Permit ��;
�-- =-�� ��
Building Department� g p Curb Ctat/Driveway Permit
`<I
i 212 Main Street Sewerl5epticAvailabitity
L JUN � � 2014 Room 100 WaterNVellAvailabluty
r
Northampton, MA 01060 T bets of Strtactural Plans OA,-'
E ctric, Piu
mn ng&Gps it ne 13-587-1240 Fax 413-587-1272 a Ixtans � ”
Ncrthamnto a ions Q
MA 01060
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
,t
6(P -;' j?-\Ue-CSk0(! P(`. Map �( � Lot /y �— Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�1� 1zq ��w i c �L i �CQ �� V-0 c
Name(Print) I Current Mailing Address:
� '\VV � Telephone
Signature
2.2 Authorized Accent:
Name(Print) Current Mailing Address:
• ?, -7 72,
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2- ';5C)-7 (a)Building Permit Fee
r
2. Electrical (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
This Section For Official Use Only
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2014-1334
APPLICANT/CONTACT PERSON CO-OP POWER INC
ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413)772-8898 Q
PROPERTY LOCATION 565 RIVERSIDE DR
MAP 23C PARCEL 102 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,,Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL
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 ATION 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
Demolition D ay
Si re of Buildin J"'J
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.
565 RIVERSIDE DR BP-2014-1334
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C- 102 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,gory: INSULATION BUILDING PERMIT
Permit# BP-2014-1334
Project# JS-2014-002233
Est. Cost: $2507.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group. POWER INC 095430
Lot Size(sq. ft.): 16465.68 Owner: SAWICKI STANLEY J JR&HEIDI S
Zoning: URB(100)/ Applicant: CO-OP POWER INC
AT. 565 RIVERSIDE DR
Applicant Address: Phone: Insurance:
15A WEST ST (413) 772-8898 O WC
WEST HATFIELDMA01088 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEAL
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 6/12/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner