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23A-178 (3) og'ci+?u�PTO Crzt� of wort4aillptarr Z �858RC}�IiStttS - M, DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building S , Northampton, MA 01060 FAX TRANSMITTAL DATE FAX TO TELEPHONE NUMBER 411 ` o,3 6b TO _tea Dp Y FROM RE: vv PAGES INCLUDING THIS SHEET 3 8 � r Linda LaPointe Secretary i City Building Department 212 Main Street, Rm 100 587-1240 Northampton,MA 01060-3189 Fax 587-1272 0 tswly 4rA �► 41011'C0-O P ENERGY EFFICIENCY SERVICES ++� �► p pQ � CUSTOMER CONTRACT , BUILDING COMMUNITY-OWNED CONTR" TI�I ��AC .R SUSTAINABLE ENERGY Co-op Power Ma Albert 15A West Street Hatfield,MA 01088:Toll-Free:877-28&7543 tY MM cooaoower,c000.infoacooppower.coop 24 Pine St Shawn Gallagher,Director of Energy Efficiency Programs Florence,MA 01062-1925 Contractor Supervisor License#CS-095430 Horne Improvement Contractor Registration#185217 Site ID:SOOM225011 Federal Tax ID 20-2201842 Project ID:P00000230411 t4soricers'Compensation&Public Liability Insurance,provided an all Customer ID:C00000235077 Contract ID:20140430 WORK 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform the following work on these`Premises"in a professional manner and in accordance with the terms of this Contract, including the attached recommendationstwork order describing the work in detail(the'Work")which are incorporated herein by reference: Description tluar tr Location Attic FI=Open Blow Ceilufose 9' __. _ _ .._ _ ._ _._.._672.___.. _!��_Space_ .___ _ $1,021.44 Hatch:Thennai Baniet.Pottylso 2 inch_( ).._ , ._ ._ j_ !g Sam., _._._ SM-09 Bab Total: $1,059.53 Udlky kncsntive Steam $794.65 Customer Contribution $254.66 Printed:4=2014 Paps 2 of 2 11 PAYMENT Customer agrees to a Contractor for the work,the Customer Share of the Contract Price as follows: Payment#1:$ as a Deposit payable to Co-op Power upon signing the Contract(1 14 of of total customer payment). Final Payment:$ as the final payment for the Watt shah be due and payable to Co-op Power upon satiBf ion of the Work. Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ The Utility incentive Share Is dependent upon the package purchased and/or prior kx;enilve uhhzation.Changes to individual kne items snWor previous incentives may increase or decrease the site of the Utility incentive Share. You may cancel this agreement ff x has been signed by a party there to at a piece other then an address of the seller,which may be his maim oftsCe or a branch thereof,provided you notify the seller in rutting at his main office or branch by ordinsny mad posted by telegram sent or by dekvery,not later then midnight of third business day fodowlny the signing of this agreement, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. — _� Customer Signature Date op Power Representative Signature Date PLEASE READ TOM AND CONDITIONS ON REVERSE ME. 1 � �`�s ttlerar rt4r ♦ c�, 0 ENERGY EFFICIENCY SERVICES � POWER CUSTOMER CONTRACT PMCN%%G BUILDING COMMUNITY-OWNED COttiitACM SUSTAINABLE ENERGY Co-op Power Ma �� 15A West Street Hatfield,MA 01088;Too--Free:877-266-7543 Mary WWWrCoopppftr,cop .infoacooppDwer.cooP 24 Pine St Shawn Gallagher,Director of Energy Efficiency Programs € Florence,MA 01062-1925 Contractor Supervisor License 8 CS-095430 Home Improvement Contractor Registration*165217 Site ID:500602225011 Federal Tax ID 20-2201642 Project ID:P00000230411 WortrorsI C oWnsetion d Public t WI y Insurance provided on all Customer ID:000000235077 Contract @:20140430 ASFAL I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract, including the attached recommendationstwork order describing the work in detail(the"Work')which are incorporated herein by reference: Deeerlpt!on Quanft Location Perform Air Seating at Estimated 62.5 CFMW Per Hour _ _. 8 t _ _. .__ ____..__. $618_QO_.. _ sub Total: $616.00 WIlty Mcerove Share $616.00 Custionw CorAdbutton $0.00 Printed:41"14 Peas 1 of 2 II PAYMENT Customer agrees to pay Contractor for the Work.the Customer Share of the Contract Price as follows: Payment i1:$ f as a Deposit payable to Co-op Power upon signing the Contract(114 of of total customer payment). Final Payment:$ as the final payment for the Work shall be due and payable to Co-op Power upon satisfactory completion of the Work. Customer understands that hetshe w�not be required to pay the utility incentive Share of the Contract price In the amount of$f r� n 4� The Utility Incentive Share is dependent upon the package purchased and/or prior incentive utilization.Changes to individual tine items andlor previous Incentives may increase or decrease the size of the Utility Incentive Share. You may come/this agreemer4 if 4 has been&Vmd by a party there to of a place other than an address of the seller,which nisy be his main office or a branch thereof,provided you rwttfy the seNer In writing at his main office or branch by ordinary mat✓posted,by telegram sent or by delivery,not later theca midnight of third deafness day following the signing of this aflreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. "`��--r Customer Signature Date C#P Power Representative Signature 4Dte Pe EASE READ TERMS AND CONDITIONS ON REVERSE SIDE. C ` ("lit sir r,/rrr!t'{r/V { /4r 616, rrj�r -_ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2016 Tr# 247991 CO-OP POWER, INC. SHAWN GALLAGHER 12A WEST ST WEST HATFIELD, MA 01088 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 C. 2010.0511 Office of Consumer Affairs&Business Regulation License or registration valid for indietu use only j .N before the expiration date. If found return n to: .NOME IMPROVEMENT CONTRACTOR Type: Office of Consumer Affairs and Business Regulation V',�Reqistration: 165217 expiration: 1/21/2016 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 rtf- CO-OP POWER,INC. SHAWN GALLAGHER 12A WEST ST .} �__ _ WEST HATFIELD,MA 01088 Undersecretary o valid without signature * Massachusetts -Department of Public Safety Board of Building Regulations and Standards ( umtru.ii,�n Suprrt�+nr µ,Vi License: CS-095430 S11AWN GALLAgUER.s 14 BELTRAN ST.9 IF Malden MA 0214$ Ik}b �,•G... .�1F- ,r ,,, Expiration 04/2912016 Commissioner The Commonwealth of Massachusetts fu 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/Contra ctors/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 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 g. ❑ Demolition working or me in an capacity. employees and have workers' g Y P tY• 9. E] Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.❑ 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 13A Other Wect`w)e(I Zr�ca„ 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. *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. Lic. #:WC5-31 S-388245-013 Expiration Date:11/02/14 Job Site Address: P.� F r,Q (�, 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 perjury that the information provided above is true and correct. � f Si nature: Date: Phone#: 7 7 17Z —1� � 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#: ACC>RV CERTIFICATE OF LIABILITY INSURANCE DADD/YYYY) 3/14 4/2/20 014 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). CONT CT PRODUCER NAME: Debbie MacNeal James J. Dowd & Sons Iris PHONE FAX 14 Bobala Road A/c No Ext:413-S3 8-7444 - E-MAIL Holyoke MA 01040 ADDRESS: dmacneal @dowd.com PRODUCER CUSTOMER ID#:COOP INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA:Mount Vernon Fire Insurance Company Co-op Power, Inc. 15A West Street INSURERB:Safety Indemnity Company 133618 West Hatfield MA 01088 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:400481920 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR IN SR WV POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY CL1566148A 11/8/2013 11/8/2014 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea.'r,.nce $ CLAIMS-MADE El OCCUR MED EXP(Any one person) $S,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY PRO X LOC $ B AUTOMOBILE LIABILITY 6212701 3/23/2014 3/23/2015 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULEDAUTOS PROPERTY DAMAGE $ • HIREDAUTOS (Per accident) • NON-OWNED AUTOS deductible $500 Comprehensiv $ A X UMBRELLA LIAB OCCUR CUP1550265A 11/8/2013 11/8/2014 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ X RETENTION $0 $ WORKERS COMPENSATION VVC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T RY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers' Compensation Certificate of Insurance to follow separately from the carrier. RCS Network,Conservation Services Group, National Grid, NSTAR, Boston Gas Co., Colonial Gas Company and Essex Gas Co. are named as additional insureds per written contract in regard to general liability only. 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 ACCORDANCE WITH THE POLICY PROVISIONS. Conservation Services Group 40 Washington Street Westborough MA 01581 AUTHORIZED REPRESENTATIVE @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 11/7/20'13 11:56:13 AM PST (GMT-8) FROM: 100005-TO: 14135170300 Page: 5 of 6 ACC>R°® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD1YYYY) 44. _ 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: 14 BOBALA RD PHONE tAtC No Exti, FAX AIC No: HOLYOKE, MA 01040 E-MAIL ADDRESS: INSURER($)AFFORDING COVERAGE NAIC# INSURER A INSURED INSURERS: CO OP POWER INC 15 A WEST STREET INSURERC: WEST HATFIELD MA 01088 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 18307643 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WV POLICY NUMBER MMIDDIWYY MMIDDfYYYY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPlOPAGG $ POLICY PRO- L 0 C $ AUTOMOBILE LIABILITY Ea aBBINEDt)IN L LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS AUTOS $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS ( eraccitlent) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LJAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-388245-013 11/2/2013 11!212014 WC STATU- OERI- AND EMPLOYERS'LIABILITY YIN ✓ TORV LIMITS ANY PROPRIETOR/PARTNERIEXECVTNIE -NIA E.L.EACH ACCIDENT $ 1000000 D? OFFICERIMEMBER EXCLUDE (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space is required) Workers compensation ins ranee cov r li es only to theworkers rn ensa n laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CONSERVATION SERVICES GROUP THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 40 WASHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS. WESTBOROUGH MA 01581 AUTHORIZED REPRESENTATIVE r (! Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD C P3' NC.: 1530 593 Oidi ❑an as 11/7!2913 11:52:00 AM Page 1 of,l TEhis certificate cancegls and supersedes ALL previously issued certificates. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: i Not Applicable ❑ Name of License Holder: C�C CA w✓\ ��� 0 G C r' r) c I -- S 0 License Number Address Expiration Date ignatu Telephone 9,Roulstered,Home h mCrvartlernt Contracks Not Applicable`❑ Company Name Registration Number ",5: (-\ totoc,4 5-t . Ai; t\ a+1 e yw Uios / /';� ! / 1 �� Address Di � Expiration e Telephone tI �3-7 F��J(k 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 axe np ' D 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) ET_] Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding[❑] Other Al Brief De cription of_Proposed Work:�SQ9, \ y2 � ACS �>✓1 �i✓'Q 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 housing, complete the foilowina: 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 rAk%Z J PLg tZT as Owner of the subject property hereby authorize Lto "o P F0 W I t2 to act on my behalf, in all matters relative to work authorized by this building permit application. Sec P%ttaChed (—'Of'rV\ Signature of Owner Date as Owner/Authorized Agent hereby declare that the stat&nents 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 &ALLAbH EK Print Name ignat 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 L: _. R: L: ! R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved Arkin #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW W YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document#. 0 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , 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 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,exc vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Depkftent t only - � Qi of Northampton Stattis cat'Permit= B ding Department s ��12 Main Street Sev r' ticAvsllabloty - - . 0 Q Room 100 Watr ± �l A llu N j mpton, MA 01060 res of structural Plans 1 - -1240 Fax 413 587- ets 1272 Plotltlef#a Eiectrlc, hurr` h 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: 5 Q e at+tq C�eol CTJ ^'� Telep ne Signature 2.2 Authorized Agent: We Name(Print) Current Mailing Address: btgnatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building /_ -7,S (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=(1 +2+3+4+5) ( � (� �j Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0235 APPLICANT/CONTACT PERSON CO-OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD (413)772-8898 PROPERTY LOCATION 24 PINE ST MAP 23A PARCEL 178 001 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 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 INFORMATION PRESENTED: Z,,<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 o itio e y Signat Building fi ial 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.