35-218 t..
ik tt
P ARTICIPATING
mass save CONTRACTOR
S.w,w ttrowh enemy oNick•ncy
PERMIT AUTHORIZATION FORM
! � i.- , owner of the property located at:
(O er ai•e, a r1 e.
MA 0
2 ,72 ' _,.. --
P' o'"e f FS re'aied tens ( Cit y /Town )
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor fisted below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
er S graa Left
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above, referenced project:
Participating Contractor Date
Rev. 12132011
j
`1,4%..1., huv•11. Ilrlt.0 ttucttl ..I I'uhltt ' 1.
Ku.trtl •.I (iutltltn. Rc•.ut.1tt.ut..11111'1.11111.11 .1.
Construction Supervisor License
THOMAS 8 ROSSMASSLER
100 MAIN STREET
HATFIELD MA 01038
i
i i
(mice o onsamer.i atn u toe. c:u el.uo License ut 1c t.IraUun N a ltd for tndtsttful ux unl\
• HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: e9 165169 Type Office of < on.umer Affairs and Business Regulation
Expiration: 1/;1,'2014 IU f'ar{. Place - tiuue �I'0
Boston. NI N 1)21 Ib
ENERGiA __C
• HOMA;-; RCSSMASSLER l
242 SUFFOLK STREET k ✓ `� ..,
- 1OLYOKE MA 01040
1 n( -r.c. .ft41, \ut t alttt A ithout signature
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
=''1 a Office of Investigations
— _ 1 / 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Ener• ia, LLC.
Address: 242 Suffolk Street
City /State /Zip: Holyoke, MA 01040 Phone #: 413- 322 -3111
Are you an employer? Check the appropriate box: Type of project (required):
1. ® 1 am a employer with 10 4. ❑ 1 am a general contractor and I
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
p 8. E] Demolition
working for me in any capacity. employees and have workers'
9. E] Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. El I 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 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no 13.® Other Insulation
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: Guard Insurance Group
Policy # or Self -ins. Lic. #: ENWC319433 Expiration Date: 2/16/13
Job Site Address: 2 -2 Z20/2 � �/' City /State /Zip ‘ gd/e/jet , ///, d, '2
Attach a copy of the work 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 cery under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: /,2 `12 _
Phone #: 413- 322 -3111
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 : 1 Vl d .S O ��2 f 2 s k{ D
License umber
-2- Stc k S ' - 4 - OV ot , �f14 dl04o 2 1 3
Address . Expiration ate
y(3' 322 - 31 1
Sig ure Telephone
9. Renistered Home Improvement Contractor: Not Applicable ❑
11 Pf /c) IC-PCIC,q
Company Name Registration Number
242 S4 '0(k SA- . 4-a 0(Le , AM- I << iu
Address Expiration Cate
/ Telephone 4(g - 32z--: 1 I 1
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)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [
Brief Description of Proposed " J ` u 'Z–
Work: ��'l,� dlt —
Alteration of existing bedroom Yes /// 2L /
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 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
, as Owner of the subject
property
hereby authorize L_E; /a�
to act on my behalf, in all mat to work authorized by this building permit application.
,eco7/64 r ot- 6ate4 • /2-2/,-/2
Signature of Owner Date
1, b t91 (A, S ( R asS rna-SS 2 r , as Owner /Authorized
Agent h reby 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 a • penalties of perjury.
'1 . S a S5
Print N- -
/
Signature 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
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 0 YES 0
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 #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
R -CE VED
Department use only
DEC ? 7 City of Northampton Status ofPetmit:
r Building Department C urb° u tfD way Permit
—I 212 Main Street Sewer/SepticAvai bi r,
A SFECTIONS
+ AMFTON, MA 01060 �.. Room 1 OO Water/Well Avatlabil
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 587 - 1240 Fax 413 587 - 1272 Plot/Site Plans
Other Specify
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
22 LQ S / /Q/1er Z/7 . Map Lot Unit
// �i,ce, /11(/1 � �D ( Zone Overlay District
��QQ Elm St. District_ CB District _ _
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 1
2.1 Owner of Record: ji
414_ /( Irper 2 - 2 /-a# S/ er ill. .fDre/7ce
Name (Print) Curren Mail in ss.
5ee ` 1 -r t�i 1 AA 4eCtkL Telephone � ���`�
Signature
2.2 Authorized Agent: Q0 /o5Sana1 2y2 . fo ( />
VornAS
r t) Current Mailing Address:
y/3. 322 - a li/
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 5�o • o 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 = (1 + 2 + 3 + 4 + 5) 2, �O • 06 Check Number / q 5 St65
This Section For Official Use Only
Building Permit Number: Date
�/ Issued:
Signature: �/ � /� .- ��
Building Commissioner /Inspector of Buildings Date
22 LADYSLIPPER LN BP- 2013 -0678
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 218 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- 2013 -0678
Project # JS- 2013- 001126
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 48787.20 Owner: HARPER MALCOLM M & KARA KRITIS - HARPER
Zoning: Applicant: ENERGIA LLC
AT: 22 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:1/3/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSULATE ATTIC
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 1/3/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner