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37-043 (2) ;� nCERTIFICATE F LIABILITY INSURANCE �,5s : THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.T141S 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 CON TRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ? REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION 15 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 NAI FACT Brian GaUagher BNC z?1StLBT!Ce agency, Inc- MC NE (914)937-1230 Fle,N,.(914)937-1124 111 South Ridge Street E-IAu .bga11agher @bnaagency.com ADDRESS INSURERS AFFORDING COVERAGE NAIC 0 Rye Brook NRY 10573 INSURERA:Se1Gctj-Va TnS ranC9 CO Of S-C. 19259 INSURED INSURERB:StaSNet Insurance DoMany 40045 Energy Prz LLC INsuRER c-landmark American Ins Co- 33138 DBA: The Energy Store INSURER D: 31 Old Route 7 INSURER E. Brookfz eid CT 06804 INSURER F: COVERAGES CERTIFICATE NUMBED CI.1542465662 REVISION 14UMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING 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 TYPEOFINSURANCE POLICY PO EXP uEUrs L POLICY N111ASE t MIJUDD 6 GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 O I; CM.AMERCIAL GENERAL LIABILI iY DAMAGE TOR PR 100 000 PREMISES Ea octaurett S � A { CLAWSMADE MOCCUR 2s35e2 /27/2015 127/2016 UEDEXP(Arty one n) S 5,000 PERSONAL EADVINJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 NGS 'LAGGREGATSUMrrAPPUESr S r PRODUCTS-COMPIOPAGG S 2,000,000 i POLICY X PRO LOC S AUTOMOBILE LIABILITY COMBINED SINGLE UMIT Eaaceidentl S_ 1,000,000 A -X{ANY MIT. BODILY INJURY(Perper=) S ` ALL OVIN,01 SCHEDULED 2153542 /2712015 127/2026 eDDILY INJURY(Peraccident) 3 AUTOS AUTOS PROPERTY DAMAGE HIRED AUTOS AUTOS Were dam) S S X UPABRELLA UAB Y OCCUR EACH OCCURRENCE S 5,000,000 A EXCESS(JAS CLAIAIS.MADE AGGREGATE _ S 5,000,000 DED RETENTIONS s2153542 /2712015 /27/2016 S B WORKERS COTAPENSATION X 11 STATU OTH- AND EMPLOYERS LIABILITY YIN PIT ANY PRO?RIETORIPARTNEP.tt_XECUIN'c a EL sACH acCIDENr s 1,000,000 ER OFFIGERRfErdBER EXCLUDED? f.1lA (Mandatory in Nit) -CD131379 4/15/2015 /15/2016 EL O)SEASE-EA 0APLOYEE S 1,000,000 M describe under RIPTION OF OPERATIONS bNow E.L.DISEASE-POLICY 1 S 1 000,00 { C Professional Liabilitv LHR75044 1 /27/2015 /27/2016 LIMIT 2,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE IMLL BE DELIVERED IN ((( ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE I �-t I o Colabella/BGALL ACORD 26',(2010105) ©-1988-2010 ACORD CORPORATION.All rights reserved. IN5025 nrrtnnm n Tha annpn nama anri Innn=rn ranie+amrl marlre of A r1!?1Z �taeror� • � Ir SWWW ovotch WWO"de rcir is enh z d a IP b lAa A oB�'#'4.9 i .. ...+...... i .rr r . w rar.r.a...:"b i 3 i.,ii i i A 220 Rocky Hill Rd NORTHAMPTON 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 X 1 C-> /IS-/�S WSW Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contr=Lor to the above referenced project: r Participating Contractor Date IkMMPA 3T t bamrtsaAt Rev. 12132011 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: ;-20 IZclv Pill J The debris will be transported by: do Debris The debris will be received by: Building permit number: Name of Permit Applicant avlc Date Signature of Permit Applicant r_ The Conunonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass 02111 www mass.gov/dia Workers' Compensation insurance Affidavit: Builders!Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address:_, Old city/sty/zip: 1311njj P CT (12uQL4 . Phone#: '(LJQ —&(pL4 Ar you an employer?Check the appropriate box: Type of project(required): 1. _, 1 am an employer with 4. i l I am a general contractor and I 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling 2. 0 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_�:j We are a corporation and its 10. _l Electrical repairs or additions 3. i_ I am a homeowner doing all work officers have exercised their 11 D plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]; c. 152,§ 1(4),and we have no 12_ 1 oof repairs employees. [no workers' 13. ther i r PtL comp. insurance required.] AG *Any applicant that checks box#1 must also 511 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 an:arc employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: R V(C T_ 14i I aiffi rp c N Policy#or Self-ins.Lic.#: Rw U W C_� l.3 � ��q Expiration Date: 2 dI�Q Job Site Address: City/State/Zip: (2 10 19 2 Attach a copy of the workers' com ensation 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 ce der Z_tns and penalties of perjury that the information provided above is true and correct St nature: Date: 2 Print Name: L!�rJcJoi)Jq_4r Phone#: 1-G U Official use only Do not write in this area to be completer)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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction u ervisor: ^ Not Applicable Name of License Holder: /L�,('t O to License Number Fn &x 191 MA of 2 -fi r Ad Expiration Date t( 2U Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ re off S 2 Company Name of Registration Number , 1 Dl�i 1 &elA 06KN mo ll ic Address yy��// Expiration Dat TelephoneM O--"j4 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 buil ' g 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 [o] Decks [C] Siding[lam] Other(o] Brief Description of Proposed / Work: Air to 5" O C flw[U e C• Alteration of existing bedroom Yes 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 I, l bet OCT ucli d) �'f—+-u Kct65 as Owner of the subject property � � a4sos hereby authorize 1S to act on my behalf,in all matters relative td work authorized by this building permit application. L SAC a-R c ht� 1 1( 1 25 I Signature of Owner Date 1, i(��r.lclavx Cd'&' s ,as Owner/Authorized Agent hereby declare that the statementd 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. Print Name 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 ininus bldg&paved parking) of Parking Spaces Fill: volume&Location) A. Has a Special Permit/Variance/Findi ever been issued for/on the site? NO O DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Re stry of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES O 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,e cavation,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. Department use only ,*r�. City of Northampton Status of Permit: �L—"f ilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availabili 'WOW 2 ty 201 N rthampton, MA 01060 Two Sets of Structural Plans phon 41 -587-1240 Fax 413-587-1272 Plot/Site Plans dsn cronrg Other Specify fFl APPLICATION TO CO TRUCT,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: 2 Map Lot Unit �� �dC�� � ' I I � I(�• Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ?&f Y'okk05 2a k 'J. Name(Print) /� (1 n\ Current Mailing Address: l;gee cAotckid / Telephone �v�11 Signature "� J (/ 2.2 Authorized A ent: Po Box W PA Name(Print) Current Mailing Address. 01125-7 4 75 204-45SfS 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 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 +2+3+4+5) Ll. to 2 Check Number This Section For Official Use Only Date Building Permit Number: Issued. Signature: Building Commissioner/Inspector of Buildings Date File 4 BP-2016-0746 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888) 840-6641 PROPERTY LOCATION 220 ROCKY HILL RD MAP 37 PARCEL 043 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid BuildingO 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 106024 3 sets of Plans/ Plot Plan THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN O 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 De if Si�O nature of Building Of ici 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 Plannin�& Development for more information. 220 ROCKY HILL RD BP-2016-0746 GIS 4: COMMONWEALTH OF MASSACHUSETTS n L,h Block: 37 - 043 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0746 I'mi ct 4- JS-2016-001247 I.SL. Cost: 53185.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq. ft.): 44866.80 Owner: KAKOS PETER J&LINDA L "l_onilwy: Applicant: THE ENERGY STORE AT: 220 ROCKY HILL RD Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON:121212015 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 12/2/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner