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22B-048 (4) 15 RYAN RD BP-2016-1165 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22B -048 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-1165 Project# JS-2016-002009 Est. Cost: $1092.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq.ft.): 12980.88 Owner: BAYLISS ROBERT Zoning: WP(99)/WSP(99)/URA(66 /GI(32)/ Applicant: THE ENERGY STORE AT. 15 RYAN RD Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON:4/6/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL BASEMENT INSULATION - basement ISO must meet ignition barrier requirements 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 4/6/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1165 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804 (888)840-6641 PROPERTY LOCATION 15 RYAN RD MAP 22B PARCEL 048 001 ZONE WP(99)/WSP(99)/URA(66)/GI(32)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING CLOSED REQUIRED DATE ONING FORM FILLED OUT Fee Paid 6W Building Permit Filled out 1 Fee Paid P' K111V Typeof Construction: INSTALL BASEMENT INSULATION New Construction 1(/ ice dr Non Structural interior renovations Addition to Existing Accessoa Structure Buildin-, Plans Included: Owner/Statement or License 106024 t or 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: pproved 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 moli 'on D y / 001 Signa ure of Buil mg 5fficiar 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. .. \ CP- -7� � Department use only 206 City of Northampton Status of Permit: A Building Department Curb Cut/Driveway Permit 212 Main Street 5ewet^/SepfcAvai#ability Room 100 Water/WellAvailabi#ity pE NpP�NPt� 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 i Map Lot Unit O�►'1 �fC 11 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 7 2.1 Owner of Record: �be.(-+ &q 1',ss I Qy0/y� ion cp-. MA 6)1062 Name(Print) f J Current Mailing Address: ! / "eL C*CL(-—e d) Telephone Signature 2.2 Authorized Agent: L--6s poxM8 of 2� Name( ) 7 Current Address:r J r!G [15 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) OCI 2. v 22 Check Number This Section F Official Use Only Building Permit Number: Date issued: Signature: Building Commissioner/Inspector of Buildings 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/Findin ever been issued for/on the site? NO 0 DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Re istry of Deeds? NO ® DONT KNOW YES IF YES: enter Book Page and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW d YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained ® , Date Issued: C. Do any signs exist on the property? YES Q NO d IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO d IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,�vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO ��:IJ1 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) El Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[O] Brief Desc�r�igtion of Propo ed n do Work: W t✓Yl,. F-v -fn, s � cvu b0.�2(Y e i+ waA - Alteration of existing bedroom Yes o 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 Lcomolete 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 �Df 7�(� (�.V I I S as Owner of the subject property \� hereby authorize (/^ l\r,, I op l� CG S —�- DS - he F rpy ore, to act on my behalf, in all matters relativ6 to work authorized by this building permit application. (See QANac_hPr�� Signature of Owner Date C1, ` ,SSP as Owner/Authorized Agent hereby declare that-he statemerks 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. v CSOS Print Name 0-46L 0 1 (v Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: 1- Not iApplicable ❑ Name of License Holder: r STC�J 1Q( Cr,+so� (0(0y2 License Number MA 2 6/111 VA, Ad s Expiration Date 77 Ll -?S - 209 - _ ' Signature Telephone 9.Renistered Home Improvement Contractor: Not Applicable ❑ -7-ke- �--- nerd v S-1 r-�cam- i ) k Sq 2- Company Name Registration Number IF), (ale C- G�F3G(! Ll //(;'U& & Address Expiration Dam Telephone R NC)--LL,-LL( SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affida must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the buil ng permit. Signed Affidavit Attached Yes.......1z 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 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: The debris will be transported by: dc) D�r-'- S The debris will be received by: If Building permit number: Name of Permit Applicants© -- 7k, e nk c Or- Date Signature of Permit Applicant ACC]IRO CERTIFICATE OF LIABILITY INSURANCEDATE(M?NDDNYYY) 11� 1 5/5/2015 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 pofioy(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 C NTACT Brian Gallagher X (914)937-1124 A:AIC. !BNC insurance Agency, Inc. PHONE (914)937-1230 1 PAX (91-0)937-1124 1111 South Ridge StreetE- Alt .bgallagher@bncagency.com INSURER(S)AFFORDING COVERAGE NAIC# .Rye Brook NY 10573 INSU1RERA:SeleCti.VG Insurance Co of S.C. 19259 iNSUR50 IN$URERS.StarNet Insurance Company 40045 Energy Prz LLC INSURER c.Landmark American Ins Co. 33138 DBA; The Energy Store INtURER 0: Old Route 7 �Brookfield CT 06804 IN$URER F: COVERAGES; CERTIFICATE NUMiER:CL3.5424 65 662 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- NOTINITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VvATH 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 1 LTR I TYPE OF INSURANCE POLICY EFF -POLICY EXP GENERAL LIABILITY INSR wVD POLICY NUMBER IMMD[YYYYLIMITS I EACH OCCURRENCE 000,000 X COMMERDAL ri r-rqERAL LIABLITY OAMAGE TO RENTEE 100,000 - — 3/2712015 /2712016 PREMISES(Ea A CLAIMS-MADE Lil OCCUR 1 2153542 3rAEO EXP(Any one pemon) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 2,000,000 7 POLfCYFX7,PF�C,_ 17 LOC AUTOhiOSILS LIABILITY COMBINED—SINGLE LIMIT (Ea accident) S 1,000,000 A ANYAUTO SCHEDULED F BODILY INJURY(Per Person) S ALL OWNED 2153542 3/27/2015 13/2712016 BODILY INJURY(Per amdent) S A U T 0 S ALIT S NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS fPer accident) UMBRELLA LIAE3X OCCUR L EACH OCCURRENCE- is 5,000,000 I EXCESS LiA5 I AGGREGATE 5 $,000,000 I RE DED 1 RETENTIONS �2153542 3/27/2015 3/27/2016 V40RKERS COMPENSATIONST, YIN AND EMPLOYERS'LIABILITY AY_w ANY PROPRIETCRIPARTMERIEXECUfNE 1------I OFF,CERIMPPABER EXCLUDED? N/Al E-L EACH ACCIDENT — S 1,000,000 (Mandatory in NH) 0131379 4/15/2015 4/15/2016 EL DISEASE-EA EMPLOYE 4 S 1,000,000 i 3f yep, , , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 000 000 C �Professional Liability MZ7S0441 /27/2016 LIMIT 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS)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 WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT14ORIZED REPRFSENTAMVIE 0 Colabella/BGALL ACORD 25(2010105) (D1988-2010 ACORD CORPORATION. All rights reserved. IN.1025 oninn_,i m Tha Af'nPr)n=ma nnri Innn era r rticfororl rnnr1,-c of A(r)Pr) The Commonwealth of Massachusetts Department of Industrial Accidents AM Office of Investigations 1 Congress Street Suite 100�VV A, Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: �j- ��d f-�) —L City/State/Zi C� Olo D Phone#: BLJD — (p(p Are ou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ 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.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ oof repairs insurance required.] t c. 152, §1(4),and we have no V� iz��oN employees. [No workers' 13. Other 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: rClrlCs✓ pXlL �G-- Policy#or Self-ins. Lic. #: ¢j N'A U W C.6, 1 !2-7 9 Expiration Date: t Job Site Address: City/State/Zip:T5_ ,n(L' , Mtl- 0 062- Attach a copy of the workers' co pensation 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. 1 do hereby ce uer the pains n penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: L4 5 2 C,Ll- 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#• City of Northampton Massachusetts `..�A h DEPAR7WNT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 I Property Address: 15 Contractor Name: ��r'IS41chfC (2Ak� o rf� Address: City, State: ��� � 1 I...I' d 12-5 Phone: L `7S Property Owner Name: Address: City, State: t-) I, ac; , r ( a-Lc�c' (contractor) attest and affirm that the building I intend to insulate does nof 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 RISE60 Shawmut Road,Unit 2 1 Canton,MA 020211339-502-6335 ENGINEERING www.PJSEengineering.com _•; OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: (Property Ad ss) ri���t 41.a h (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. j c Owner's Signature pr Date l�1 H i i u'i