38B-086 (3) 11l
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 167827
Type: LLC
Expiration: 11/5/2016 Tr# 258839
VICTORY ENERGY SOLUTIONS LLC.
RAQUEL KENNEDY
1 HARTFORD SQUARE SUITE 206
NEW BRITAIN, CT 06052 -
Update Address and return card.Hark reason for change.
Address Renewal Employment Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 167827 Type: Office of Consumer Affairs and Business Regulation
Expiration: 11/5/2016 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
CRY ENERGY SOLUTIONS LLC.
JEL KENNEDY f
RTFORD SQUARE SUITE 206
BRITAIN. CT 06052
Undersecretary l\ot valid without signature
A
CS-108212
MICHAEL GIONFR I IDDO AM
15 NICHOLS AVENUE APTI
Watertown MA 02472
0612012018
Unrestricted -Buildings ofany use group which
contain less than 45,000 cubic feet(99 1 m')of
enclosed space
Fai lure to possess a cur-rent edition of the Massachusetts
State Building Code is cause for revocation of this license
www.Mass.Gov/D?S
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k9 600 Washington Street
Boston,Mass. OZlll
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization��//InIndividuai): Or' S
� F
Address: � r - CO C-J .5Q
City/State/Zip:tk,l,�P-)r't�,}oiY .C--T O&C62— Phone#:
Are on an employer?Check the appropriate box: Type of project(required):
1. 71 am an employer with_s. c) 4. ❑ I am a general contractor and I 6. 0 New construction
employees(full and/or part time)." have hired the sub-contractors
7. 0 Remodeling
2. 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. 0 Demolition
kworking for me in any capacity. employees and have workers' 9. 0 Building addition j
[No workers'comp.insurance comp.insurance. I
required] 5. We are a corporation and its 10. 0 Electrical repairs or additions
' 3 I am a homeowner doing all work officers have exercised their r
myself [No workers'comp. right of exemption perm MGL
1 t. f_i Plumbing repairs or additions
insurance required]t c. 152,§ 1(4),and we have no + 12. 0 Roof repairs
employees.[no workers' 13.> Other�T+., tai rrt t �n
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
`Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContactors 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 is providing workers'compensation insurance for my employees.Below is the policy and job site
information.
Insurance Company Name: rNs^ y_QU n C P CC) P -
Policy#or Self-ins.Lie.#: 13 tp 6 i Expiration Date:
Job Site Address_6 V__C 1 City/State/Zip: , f Cua,,Q y1,
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 S)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
5250.00 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 of perjury that the information provided above is true and correct.
Sivnanire: Date: (t 3 t l
Prin(:Name: Phone#: $')271c:)22—Si KS
{ Official use only Do not write in this area to he completed by city or town official
City, or Town: Permitflicense#:
Issuing Authority(circle one):
i I.Board of Heath 2. Building Department 3.City/To�w•n Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
i
Contact person: Phone#:
� i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Le — I Q 8 2 ' 2----
License Number
Address Expiration Date
Telephone
9. Re istered Home Improvement Contractor: Not Applicable ❑
((o �' --
Companv Nom4 Registration Number
Address\\ Expiration Date
JlN �2rl �� L� ��G��-�2— Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi 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 O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[o] Other
Brief Descript'on f,Proposed `
Work: CcesS S a t o ���ti t ate-C e""��^�
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yeso
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
Si4►- en ac)-k— as Owner of the subject
property
hereby authorize l 1 (Aci�c>
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, M t �� ( �'j 1 t -1 1 as Owner/Authorized
Agent hereby declare at 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.
1 1 1 t e-, Cl'Ly✓i <Ac�
PrT�Name
3 lS
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: 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 Speci ermit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO (/)
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`
IF YES, describe size, type and location: w
E. Will the construction activity disturb(clearing,grading,excav 'on,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
r= ! City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
APR 2 I .
212 Main Street Sewer/Septic Availability
Electric,Plumbing&Gas Inspectioil5
Room 100 Water/Well Availability.
Northampton,�A 01060
one 413-587-1240 Fax 413-587-1272 Plot/Site sPlans� ural Plans 30 rthampton, MA 01060 Two
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
LLr-�c��� Qd. Map Lot Unit
�I;,r rrL,c.w�p1 tr'X(-t '0\0W0 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
. L
1re.AaAf is Let Lr 'n eA
Name(Print) 1' Current Ma g Address:
A/1 �,�r� �p�Q�`L'A Telephone
Sig a ure
2.2 Authorized Agent:
Name(Print) - Current Mailing Address:
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Z (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 'l[(g®
5. Fire Protection 7
6. Total=(1 +2+3+4+5) 2 Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1021
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q
PROPERTY LOCATION 39 LYMAN RD
MAP 38B PARCEL 086 001 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/BASEMENT 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
Qe i ' n Delay
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.
39 LYMAN RD BP-2015-1021
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-086 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-2015-1021
Project# JS-2015-001945
Est. Cost: $3792.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 108212
Lot Size(sq. ft.): 6141.96 Owner: SUPRENANT RHIANA
Zoning: URB(100)/ Applicant: VICTORY ENERGY SOLUTIONS LLC
AT. 39 LYMAN RD
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 306-4483 O WC
NEW BRITAINCT06052 ISSUED ON:412712015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC/BASEMENT 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 Sip_nature:
FeeType: Date Paid: Amount:
Building 4/27/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner