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29-294 (3) AC40REP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/19/2014 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 CONTACT Kari Reeves NAME: FIAI/Cross Insurance P"°"E (603)669-3218 No):(603)645-4331 1100 Elm Street ADDRES :kreeves @crossagency.com INSURERS AFFORDING COVERAGE NAIC# Manchester NH 03101 INSURERAVest American Insurance Co. INSURED INSURER B:Ohio Security Insurance Company ESE Insulation, Inc. INSURERC:Ohio Casualty Ins Co Energy Saver Enablers INSURER D;American Alternative Insurance 52 Fitzgerald Drive INSURER E: ,Jaffrey NH 03452 INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 All lines 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE Fx_1 OCCUR BKW55684497 /31/2014 7/31/2015 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 ril POLICY PRO- LOC $ AUTOMOBILE LIABILITY Ea a.,d.DtSINGLE LIMIT 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED S55684497 /31/2014 7/31/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,00 US055684497 /31/2014 /31/2015 $ 1 WC D WORKERS COMPENSATION 2A2WC0000371-02 X ORSTATIT ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN (3a.) NH S MA E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? "/A 11 of included /8/2014 3/8/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below FE L.DISEASE-POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Refer to policy for exclusionary endorsements and special provisions. 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. City of Northampton, MA 212 Main Street Northampton, MA 01060 AUTHORIZED REPRESENTATIVE Laura Perrin/JSC •^- ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS07517Mnn51 M Tha ARnon nnma nnrl Innn nra ro icfararl mnArc of arnon III, r r. ass save I:itPl{Rtit:t lift PERMIT AUTHORIZATION FORM I, Don Shiels ,owner of the property located at: (Owner's Name,printed) 37 Pencasel Dr Florence (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. �l. Owner's Signature Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: � ( fZ� is Participating Contractor Date [ME] [oil 01 - Rev. 12132011 W CENTER FOR CONTRACTOR WORK ORDER U I oTechnology- we make green make sense- nationalgrid Printed: 2/4/2015 Work Order Id: S01635P09849C332 Contractor Information , Customer/site retails ESE Don Shiels Phone(Eve): 413-586-5412 52 Fitzgerald Dr 37 Pencasel Dr Phone(Day): 413-586-5412 Jaffrey,NH 03452 Florence, MA 01062-3530 Site ID: S00002301635 Total,Installed Measures Location Description Quantity Unit$ Total$ Door Sweep 2 $23.18 $46.36 Living Space Perform Air Sealing at Estimated 62.5 CFM50 6 $84.32 $505.92 Exterior Door Weather Stripping 2 $27.59 $55.18 Living Space Hatch:Thermal Barrier Polyiso 2 inch(Attic) 1 $41.71 $41.71 Damming 18 $2.19 $39.42 Attic Propavent 2'or 4' 45 $3.83 $172.35 Living Space Attic Floor Open Blow Cellulose 5" 750 $1.40 $1,050.00 Installed Measures Total $1,910.94 WorkOrder Notes -Initial Combustion Safety Test recorded a CO level in excess of 44 ppm. If high CO levels persist, recommend to the homeowner to have their system serviced. -Make sure customer has installed CO detector prior to beginning work Payments Incentive Payments Air Sealing Incentive $607.46 Weatherization Incentive $977.61 Total Incentive Payments $1,585.07 Customer Share Total Customer Share $325.87 Less Deposit Of $108.62 Customer Share Balance(Due Contractor) $217.25 Center for EcoTechnology, Inc. - 112 Elm Street - Pittsfield, MA 01201 ---� City of Northampton ``-,1. Massachusetts 1 DEPARTMENT OF BUILDING INSPECTIONS S, 212 Main Street • Municipal Building J�;rrt rt<�q Northampton, MA 01060 h Property Address: 3 -7 10 o C co.J -b d rz 0 Gz— Contractor // fA Name: C�+-e- Y A60 Address: City, State: 1 Phone: b� � Z ' la. Property Owner Name: n ShG�/s Address: Pen 6erso-,( b r City, State: 00 l Gl,�eh N�113 (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature `��_..Date 11 2((ZI LS- City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: —3 7 Pe-c\ �c�..S� L r 06 Ke0 COL A The debris will be transported by: U5 The debris will be received by: r2 W !S �4 Building permit number: Name of Permit Applicant Lc,I��O1lna 111141< Date Signature of Permit Applicant The Commonwealth ref:19assetcTtusett.� — _ Department of lndustriat.-t ccidents Office of tivestigations -, I Congress Street, Suite 100 Boston, MA 02114-2017 wtvw.tit asr.govldia '"'orkers' Compensation Insurance Affidavit: Builders/('ontr actors/Electricians/Plumbers Applicant Information Please Print I-e(ibl% Nc9PT1C tRu,ine. (.h'±tuntiaCtcrr )ndntduall: ESE Inc. Addfess: 52 Fitzgerald Dr City State`Zip: Jaffrey, NH 03452 Phony 603-532-6346 Are Non an ernployer:' Check the appropriate box: T'Npe of project (required) i 1. ) aril a et» layer cctth 5 4 ❑ 1 '1117 a get?eral connactur and i t p — ( r ❑ Nei con,tructton employees (full and'or part-tunic).* hacr hired the wh-cimtractc7r ! 2.❑ I an) a sole proprietor or partner_ listed on the attached sheet ❑ 12ennodchnc ship and hay e no employeesI hear sub-cttntracton ha,,c ti ❑ t)emohtion t%orkinL for me in any capacno_ cmpluvices and haw c%orkcrs` Iiudtftn±�addition { ('\o c%orkern* trump. insurance romp untaanct s �'+'c are a CAI[1101",111011 and it, 1 tt ❑ )~.Ieitnctl tep.urs cn .tdtittittm reyuirc ti j ❑ Z ❑ I am a honlcowner doting all work olttecr, haA1 cwt-ciNcd theft ( 1 1.❑ Plan NIW R:13alr, tit Alt liven' nnysclf No c>-orkcr,' comp n� ht of c�empttcnt per \161. ( 1 -❑ )Zvot r;_pair, insurance required.I 1(4M. and tvc hays no I I Insulation emplowcs. 1.\o v%orkc•r, i�.� Oth r tromp Insurance rcqun-ed i A11y aprl](ant Ihat cheeti>ho"`l moil ai,o tit!out tits utuon hciott .huttut dice;uwrkcl, ,an?pc'n..uwn p,dwy aau„1n?.i=.unr ihn?te inner.ah„,uhmlt the,aifitiat i(111dw:umk tile,, arc dollly afi vNwl,and th.n hu-e,n t';I;C t„rtrae.o,1 'id,nut .i1il r,.a n11UI..rIM, t'ontract,rr-.ihat cht-ck:his i,oy mua an a,hed an ad,fuiunal.hrct�IwAklnv the name orthe nuF-ronu;lcu011.+nti.i;nc ,I 11„0 :ho.c cmpi„Aeca I tihe.uh-e,An tractnr.hatv ell p!oecc>'Itc, nma motile thctr ltor{cl� i,amp n.+h.. nunti''; I ant an empliger that is providing workers'compensation it►.cttruttce•for mr emphl,ve•es. Below is the perlict'and joh site it►f ortnation. I11,urance (.onnpanN Name American Alternative Insurance Company Polk`, rr All Srlt=in, Ltc. ;: W2A2WC0000371-02 L.tpiritvt Uatc 3/8'2015 Job Site Addres,: _ 77---Pe �1a�1"(lL b✓ _ -- --- - (its stare !i) Oflj/2 t alp .Attach a copy of the workers' compensation police declaration page Ishovsing the polic} number and expiration date). f allure to secure coverage as required under Section 25A of'MOL c- 152' can lead to the "'Irw 111on of crunnnai of a tine up to S1.500.00 and'ur one-year impri,onment. .is kwil as ci?it penaiue, ill the lorin tit .t tilt 11' Ott)kh ()RDt'R and ,i line of u)) to S2 50,00 a ciay agaunst the %101,1101. Be ad%i,ed that a copy of tilts,taterttetrt mac he lof v"trded to the )I!ICC W Imestwatnons oftlhe DIA tur Insurance co%cragc ceriticatton. I do hereby certtIfj•read th d p to/ties of perjury that the information provided above is r tic a►td orrcc t. Plnatne 603-532-6346 Of use oni y. loo not write ire this area, to he completed bi'cite or town oflicietl. 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: C�� b License Number Address Expiration Date Signature a Telephone 9 Renistered Home Improvement Contractor: Not Applicable ❑ Company Name /�/� Registration Number Address j 2 / Expiration Date Telephone 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....... Jk 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 108.3.51 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [lam] Decks [M Siding[O] Other� Brief Description of Pr posed ii Work: a I Y15'wlau at, f cx4 4 e- eLg J P t v ,�g Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housina, 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 'J�� 5 (� �s as Owner of the subject property hereby authorize to act on my behalf,in all atters relative to work authorized by this building permit application. Signature of Owner Date LO-12 b A 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 �� ,���.. 2(r 2•�r sr 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 ® DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only �. y of Northampton status of Permit: ilding Department Curb Cut/Driveway Permit FEB 1 8 2015 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric, Plumbing&Gas Inspeq4q6R ampton, MA 01060 Two Sets of Structural Plans Northampton,MA 01060 - 87-1240 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 This section to be completed by office 1.1 Property Address: Map Lot Unit Zone Overlay District f(a fe h c, , 94 A Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Y" Shid��s ��A1 �.zttGczS�� ►� —�6Y�ne,L, CUBA Name(Print) Current Mailing Add ess- ��� Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: bas -<�Z- � Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building � (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of l Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) /O Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0806 APPLICANT/CONTACT PERSON ESE INC ADDRESS/PHONE 52 FITGERALD DR JAFFREY03452(603)532-6346 PROPERTY LOCATION 37 PENCASAL DR MAP 29 PARCEL 294 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina 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 072316 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOgWMATION 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 mQlitdoa Delay Si atur o uildi g O ficial 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. 37 PENCASAL DR BP-2015-0806 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-294 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-2015-0806 Project# JS-2015-001565 Est.Cost: $1910.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ESE INC 072316 Lot Size(sq.ft.): 12196.80 Owner: SHIELS DONALD F& SUSAN E zonine: Applicant: ESE INC AT. 37 PENCASAL DR Applicant Address: Phone: Insurance: 52 FITGERALD DR (603) 532-6346 WC JAFFREYNH03452 ISSUED ON:211912015 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 2/19/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner