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23B-065 (2) G3 lI1 of3MaSSkh12sem A fffx xwe C W"y Gas Account# Audit Request# N 12 PRI PRELIMINARY AGREEMENT READ THIS AGREEMENT AND MAKE SURE YOU UNDERSTAND IT BEFORE SIGNING. MAKE SURE ALL BLANKS ARE COMPLETED AND ALL PROVISIONS THAT DO NOT APPLY ARE CROSSED OUT. THIS AGREEMENT HAS LEGAL FORCE AND EFFECT AND BINDS THOSE WHO SIGN. ( This Agreement is made on between Honeywell of 65 Shawmut Rd, Suite 4, 2"d floor,Canton, Massachusetts 02021,(800-2474112)hereafter called"Administrative Contractor"or"Honeywell"and Eh2- 4.0 A W of �5t't'�.2 f�trr t CYr^�c C (Customer) (Address) (Address cont.) — (Telephone ^-4 't' �� �e � mea�es Hereinafter called"Customer."The Customer is the Owne Tenant of the above-mentioned Premises. DESCRIPTION OF WORK TO BE PERFORMED In consideration of the Administrative Contractor's agreement to select a qualified Installation Contractor to perform in a good workmanlike manner all work("the Work")set forth in the attached Home Energy Audit Report(s),the Customer agrees to the terms and conditions of this Agreement. No Work may be performed without the written consent of Owner. Customer understands that calculated energy savings are estimates only and are not guarantee PRICE For field technician use on/v: For the Work described in the Home Energy Audit Report(s) COMMENTS: the Total Estimated Cost is$ ❑ SEE HEALTH AND SAFETY FORM ❑ OTHER The Total Due at the time of Installation from $ the Customer for the Work to be performed is: If the Installation Contractor determines that the Work cannot be providbjor Tne rrice quorew avove, will have the right to terminate this Agreement Price quoted is valid for 90 days. • Owner of the Premises agrees to pay,prior to the commencement of the Work,and Administrative Contractor accepts, in full satisfaction for the Work the Price set forth above. • Tenant agrees to pay, prior to the commencement of the Work, and Administrative Contractor accepts, in full satisfaction for the Work the Price set forth above. RIGHT TO CANCEL THE CUSTOMER MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED AT A PLACE OTHER THAN AN ADDRESS OF THE ADMINISTRATIVE CONTRACTOR, WHICH MAY BE ITS MAIN OFFICE OR BRANCH THEREOF PROVIDED THAT THE CUSTOMER NOTIFIES THE ADMINISTRATIVE CONTRACTOR IN WRITING AT ITS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED,OR BY DELIVERY,NO LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. IMPORTANT:ADDITIONAL TERMS AND CONDITIONS ARE ON THE REVERSE SIDE By signing below you,the Customer,represents that(1)You read and understood both sides of this Agreement before you signed it;(2)You agree to be bound by the terms and conditions set forth on the front and back of this Agreement;(3)The Administrative Contractor(directly or indirectly)has made no representations or warranties regarding the Work,other than those contained in this Agreement;(4)That at the time you signed the Agreement,it has been signed by the Administrative Contractor or its administrative representative,there were no blanks that had not been completed and that the Work you requested was properly d cribed above. oncywcll Signature 0 Da e O er' Signature te� Tenant's S' Date MAIL THE SIGNED AGREEMENT TO: HONEYWELL 65 SHAWMUT RD,SUITE 4,2 No FLOOR CANTON,MA 02021 Honeywell-White Installation Contractor-Yellow Customer-Pink Revised 10/2013 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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, MAO 1088 Phone#:(413) 772-8898 Are you an employer? Check the appropriate box: Type of project(required): 1.X 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. ❑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.t required.] 5. ❑ We are a corporation and its 10.[:J Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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' ]3.❑ Other ,��t 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 Company Policy#or Self-ins. Lie. #:WC5-31S-388245-013 Expiration Date:11/02/14 Job Site Address: I _T_e.(-race City/State/Zip: r uQ n( e i oM m(�) 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 D1A for insurance coverage verification. I do hereby certify under the pains and penalties, perjury that the information provided above is true and correct' Si nature: ? Date: Phone#• � C; — 7 7 2 V�9 Q 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: S V1 n `q I'a ��'`�' t I (..) License Number Address Expiration Date H [ - 7 7 2 S (K 15� Signatyffe Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Lo � (P �7a( .7 Company Name Registration Number Address , �7 Expiration ate C Telephone "1 J l 3 -772— 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....... �r 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [ice] Decks [Q Siding [O] Other[( !J Brief De cription of Proposed Work: i�t' � A,1tr`� `T r�S�J10.f v� -ti7 boo v\LL 4+-f 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 existing housing, complete the #ollowina: 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, 01-L-00& \ as Owner of the subject property hereby authorize �-° !�P FO`^x'r to act on my behalf, in all matters relative to work authorized by this building permit application. 'See g-�taOY\ed f�v'\, Signature of Owner Date I, ,S�N a 1JJ rN 6-7A I �0, e 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. Print Name Signature of wner/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 T Frontage I I Setbacks Front Side L:; R:1 LJ R:( Rear ! Building Height I 3 Bldg. Square Footage 1_ % ! _. Open Space Footage % }} (Lot area minus bldg&paved pat-king) #of Parking Spaces Fill: volume&Location); A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW ® YES Q IF YES, date issued:i IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW YES IF YES: enter Book i Pagel and/or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW © 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 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. Depa rt men#use only. ter% City of Northampton status nfiPerrr►it E uilding Department Curb C" nveway Permit �Q�p, 212 Main Street ewe�/Septic gva►lab►I►ty' ��,o� Room 100 V1/a#etNVell Availability \ 4 �6v hampton, MA 01060 Twa Sets of Structural Plans V GU. r 413-587-1240 Fax 413-587-1272 Piot�Site Plans thsr Specify � �P r ATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Prooerty Address: This section to be completed by office I eILSh r-e Te,�—rgce Map Lot Unit l 0 C Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: E b -2 e- Name(Print) � Current Mailing Address: S gt) - 7c,110 Telephone Signature 2.2 Authorized Agent: S ha Cs 01 cis .�— `7 Sf S�, lnl a r(off , Nam (Prin Current Mailing Address: i C)c / —7 72-2'K 2 7�ignato Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building , A (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 6. Total=0 +2+3+4+ 5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0234 APPLICANT/CONTACT PERSON CO-OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413)772-8898 Q PROPERTY LOCATION 9 BERKSHIRE TER MAP 23B PARCEL 065 001 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 Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin Plans Included: Owner/Statement or License 095430 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolitio Dela Signature of Building Of cial 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 BERKSHIRE TER BP-2015-0234 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B-065 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-2015-0234 Project# JS-2015-000440 Est.Cost: $1812.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO-OP POWER INC 095430 Lot Size(sq. ft.): 13939.20 Owner: HARLOW ELIZABETH Zoning. URB(100)/ Applicant: CO-OP POWER INC AT. 9 BERKSHIRE TER Applicant Address: Phone: Insurance: 15A WEST ST (413) 772-8898 O Liability WEST HATFIELDMA01088 ISSUED ON:91212014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 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 9/2/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner