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38C-052 (5) DocuSign Envelope ID:F4C7204C-2287-4F13-A875-557BA2E23B66 www.cooppower.coop CO-OP CO-OP Power POWER Home Performance Contractor 15A West Street,West Hatfield,MA 01088 CONTRACT 413-772-8898 FAX 413-517-0300 Page 2 PROGRAM CMA-HPC CUSTOMER PHONE DATE CLIENT# WORK ORDER David Narkewicz (413)531-6794 04/15/2015 415780 00001 SERVICE STREET BILLING STREET 31 South Park Terrace 31 South Park Terrace SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Northampton,MA 01060 Northampton,MA 01060 JOB DESCRIPTION Total: $3,564.19 Program Incentive: $2,680.00 Customer Total: $884.19 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Eight Hundred Eighty-Four&19/100 Dollars $884.19 DocuSigned by: DocuSigned by: le�laa8t�-.co-oP Power RF60R6ANBE... 4/19/2015 NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE DAYS. DocuSign Envelope ID:F4C7204C-2287-4F13-A875-557BA2E23B66 www.cooppower.coop CO-OP CO-OP Power PGWER Home Performance Contractor 15A West Street,West Hatfield,MA 01088 CONTRACT 413-772-8898 FAX 413-517-0300 Page 1 PROGRAM CMA-HPC CUSTOMER PHONE DATE CLIENT# WORK ORDER David Narkewicz (413)531-6794 04/15/2015 415780 00001 SERVICE STREET BILLING STREET 31 South Park Terrace 31 South Park Terrace SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Northampton,MA 01060 Northampton,MA 01060 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) (8)working hours. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $680.00 ATTIC FLAT:Provide labor and materials to install a 9"layer of R-32 Class 1 Cellulose added to(890)square feet of open attic space. $1,272.70 KNEEWALLS:Provide labor and materials to install 3.5"R-13 faced fiberglass batt insulation to(60)square feet of kneewall area. $79.20 KNEEWALLS:Provide labor and materials to install 6.25'R-19 faced fiberglass batt insulation to(257)square feet of kneewall area. $377.79 KNEEWALLS:Provide labor and materials to install 2" FSK faced semi-rigid fiberglass board insulation to(202)square feet of kneewall area. $707.00 ATTIC ACCESS:Provide labor and materials to install(3) new,finished plywood,kneewall space access hatch.The hatch will be insulated with code compliant 2"rigid Thermax board,weather-stripped,and held closed by eye hooks. (Wood surfaces will be unfinished. Prime coat and/or paint is not included.) $360.00 BASEMENT CEILING:Provide labor and materials to install(50)linear feet of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $87.50 The Commonwealth of Massachusetts Department of Industrial Accidents a Office of Investigations W ' d 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 Lep-ibly Na1710 (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): 1.9 I am a employer with 20 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 8, ❑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.❑ 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.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no 0 ■❑ Othe employees. [No workers' 13. r L 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 _ Policy#or Self-ins. Lic. #:WC5-31 S-388245-0pp13 Expiration Date:11/02/2015 V1 Job Site Address: �! ��I� ��l l✓K 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: Date: Phone#: 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#: t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y Not Applicable O Name of License Holder � � (� Lt I J V License Number qL 4�,••- t `1 12-1 Address V Expiralich Date Signature Telephone P.Realstered Home Improvement Contractor:,;- Not Applicable O ( 1 Company Nam b biz-h Registration Number Address , � � Expira i�on DaRe Telephone, SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) 7 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 bu'Iding 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 nerson who constructs_more 01aLa 2ne home in a hvo-vicar period shall nat be considered a honteowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that lie/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 [__J Replacement Windows Alteration(s) E] Roofing ❑ Or Doors ❑ I. Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other Brief Descrip iop f ro osed Work: fu l o Alteration of existing bedroom Yes No Adding new bedroom Yes 1J No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If Now house and or adgition to xis in h2uslinitti' comolete the followin 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 YV ' -Z- as Owner of the subject property hereby authorize' to act on my behalf,in all matters relative to Work authorized by this building permit application. v I � r ,, Signature of Owner Date VW 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 OwnertAgent Q to 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 °lo Open Space Footage (Lot area minus bldg&paved p ; )arkin ) #ot'Parking Spaces Fill: (vplumc&t.ocalion) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW Q YES O IF YES, date issued t IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW t) YES O IF YES: enter Book Page and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES © NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. •, pspartmsnt use on \ City of Northampton StowsO Permits Building Department Cu cut 0rlveway�errn,t � E s 212 Main Street ���q, vAllAb pfity ' ► 4 Room 100 1y , vailifty'° Northampton, MA 01060 + � e 'o f�S trtur�llei" 6 „ phone 413-587-1240 Fax 413-587-1272 �St �gng 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 rw I Map Lot Unit Zane Overlay District" Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ S otA _Perk T Err Name( nnt) Current Mailing dress, -L_ (�_ Telephone Signature 2.2 Authorized Ac ent: tJ Y{5 ffgq y/` o t 1 1 Name(Print) ` t Current Mailing Address: A Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (-A (a) Buildirg Permit Fee i 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) 4�- G Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-1048 APPLICANT/CONTACT PERSON CO-OP POWER INC ADDRESS/PHONE 15A WEST ST WEST HATFIELD01088(413)772-8898 Q PROPERTY LOCATION 31 SOUTH PARK TER MAP 38C PARCEL 052 001 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 CYZZ 1J Fee Paid Typeof Construction: INSTALL INSULATION, WEATHERIZATION&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 107864 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOYXATION 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 m clay Signature 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. 31 SOUTH PARK TER BP-2015-1048 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C-052 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate ory: INSULATION BUILDING PERMIT Permit# BP-2015-1048 Project# JS-2015-001996 Est. Cost: $3564.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CO-OP POWER INC 107864 Lot Size(sq. ft.): 7187.40 Owner: NARKEWICZ DAVID J&YELENA MIKICH Zoning: (100)/ Applicant: CO-OP POWER INC AT. 31 SOUTH PARK TER Applicant Address: Phone: Insurance: 15A WEST ST (413) 772-8898 O WC WEST HATFIELDMA01088 ISSUED ON.51512015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL INSULATION, WEATHERIZATION &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 5/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner