23A-256 www.victoryenergysolutions.com
Victory Energy Solutions WHPC
Home Performance Contractor
1 Hartford Square,New Britain,CT 06053 CONTRACT
860-357-5590 FAX 401-123-1234
Page 1
PROGRAM
CMA-HPC
CUSTOMER PHONE DATE CLIENT# WORK ORDER
Theresa Naumowiez (413)582-0513 02/17/2015 409662 00001
SERVICE STREET BILLING STREET
15 Maple Street 15 Maple Street
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP
Florence,MA 01062 Florence,MA 01062
JOB DESCRIPTION
AIR SEALING:Provide labor and materials to seal areas ofyour 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,weatherstripping 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.
$600.00
ATTIC FLAT:Provide labor and materials to install a 6"layer of R-21 Class 1 Cellulose added to(345)square feet of floored attic
space.
$448.50
WALLS:Provide labor and materials to install blown in Class I Cellulose to(1264)square feet of exterior walls through a surface
drill and plug method. Plugs will be spackled and left with a rough finish.Finish sanding and touch-up priming/painting will be the
customer's responsibility.Subsequent to your payment,as an added service,RISE Engineering will return when weather permits to
check for any voids with an infrared scanner. Any major voids that may be found will be filled at no additional cost.
$2,338.40
Total: $3,386.90
Program Incentive: $2,690.18
Customer Total: $696.73
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Six Hundred Ninety-Six&73/100 Dollars $696.73
ory Energy o u io
NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE
DAYS.
The Commonwealth of Massachusetts
Department of In dustrial Accidents
Office of Investigations
k9 600 Washington Street
Boston,Mass. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naive (Business/Organization/Individual): O( S e
Address: "SQ
City/State/Zip: r1�Q 1P1 .G`T OCo( Z Phone#: S)J_' • 30&- `� Ll
Are you an employer?Check the appropriate box: Type of project(required):
1. �/I am an employer with_3o — 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp.insurance.$
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
myself (No workers'comp. right of exemption perm MGL 11. ❑Plumbing repairs or additions
insurance required]t c. 152, § 1(4),and we have no 12. ❑Roof repairs
employees.[no workers'
comp.insurance required.] 13. OtherZv�S�
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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 isproviding workers'compensation insurance for my employees.Below is thepolicy and job site
information.
Insurance Company Name: I Jft " 0 Q., �SU i'a1^1 [` 2. r co 3,P
Is
Policy#or Self-ins.Lic.#:_ 14a,405M,5 I Expiration Date: y to 0 S'
Job Site Address: 15 Marie 4r ed City/State/Zip:.fl0,f_,i1 C e, JMJ+ 0]O(o Z
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: Z S kJ ^
Print Name: Q"-\eQt Pa �t n rcD�pu,to 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
r ,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ' 1� G (G4 r 1�Q 1 ® s -9- 1
License Number
5 N ► c�ial y� . lit 1c fiPr �� . ,� (P 1 a o 1 ►
Address �— Expiration Date
Signatu� Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
i CTo r�A 'IP(CA 14 �� I (-,- 2d--I-
Company Narhe J _J Registration Number
kAoc fd so �J-eJ, ) TrAAAV\ .r--ro (mooS2 I1�s � 1rp
AA!dress Expiration Date
Telephone'S11-2b6 'tt'�i g_)
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
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 buildog 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
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[
Brief Dipscription of Proposed
Work:��1A\CA 1 C Cjafi (ti;cell S
Alteration of existing bedroom Yes__IZ"No Adding new bedroom Yes— -'I- No
Attached Narrative Renovating unfinished basement Yes w' 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
I, 1 1 K res Q. IV CIL UKII O W r C 2— as Owner of the subject
property
hereby authorize hi I 1 r k Mo
to act on m behalf, in all matte relative to work authorized by this building permit application.
s a5
Signature of Owner Date
l `)(1�.�(c 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.
l rn i Mo
Print Name
Sign a of O en 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 NO
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Srt Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was th permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 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 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,e tion, 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.
i
I
City of Northampton status of Permit: Department use only
11 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailability
_3 �� Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
Ctric, Plumbing a,Gas as t. ne 13-587-1240 Fax 413-587-1272 Plot/Site Plans
ampton, MA oFO 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
15 tc' �1re�� Map Lot Unit
f wY�e�C �i Zone Overlay District
2� � YY11a U 1 a�`Z
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l m&40 lc- S-�ree , �(o,r�►��P_
Name(P'nt) Current Mailing A dress:
�//3 - 5Y2 - QS-/3
Telephone
Sign e
2.2 Authorized Agent:
I kE_ (Sion Tr 1 0 M c&L_5 Ayie , wez-Aer l ys) z_
Name(Print) Current Mailing Address:
Signa 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
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
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0838
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q
PROPERTY LOCATION 15 MAPLE ST
MAP 23A PARCEL 256 001 ZONE URB000)/
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&WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108212
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
ignature of it ng ff al 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.
15 MAPLE ST BP-2015-0838
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-256 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-2015-0838
Project# JS-2015-001622
Est. Cost: $3387.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 108212
Lot Size(sq ft.): 5140.08 Owner: NAUMOWICZ THERESA M&TIMOTHY
Zoning. URB(100)/ Applicant. VICTORY ENERGY SOLUTIONS LLC
AT. 15 MAPLE ST
Applicant Address: Phone: Insurance:
I HARTFORD SQ SUITE 206 (877) 306-4483 O WC
NEW BRITAINCT06052 ISSUED ON:31412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & WALL 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:
FeeTvpe: Date Paid: Amount:
Building 3/4/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner