Loading...
29-019 (4) 30 BIRCH HILL RD BP-2016-1218 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-019 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-2016-1218 Project# JS-2016-002099 Est. Cost: $4762.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq. ft.): 17816.04 Owner: DADMUN DQNALD C&BARBARA K zoningL Applicant: THE ENERGY STORE AT. 30 BIRCH HILI. RD Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON:4/21/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL KNEEWALL 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 Siunature: FeeType: Date Paid: Amount: Building 4/21/2016 0:00:00 $65.00 212 Main Street,Phone(413).587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1218 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888)840-6641 PROPERTY LOCATION 30 BIRCH HILL RD MAP 29 PARCEL 019 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 0 (p Building Permit Filled out Fee Paid Typeof Construction: INSTALL KNEEWALL 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: LAf roved 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 Demoli ' n ay Signature of Building Of 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. - Department use only City of Northampton status of Permit, r Building Department Curb Cut/C)riv®way Permit 212 Main Street Sewer/SOptic Availability Room 100 WaterNVell Avallabiiity ,Y Northampton, MA 01060 Tres Sets of Structural Plans r � phorne_4-13-587-1240 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 j `� I I ' Qj Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: nn Jhona << ridrnu��. h 4� Iov (P M 4 Name(Print) Current Mailing Address: ( See J1kc� Ll 84- ��,0 101oto2 Telephone Signature 2.2 Authorized Agent: P-r>4 181 the ell M_ _ 000 Nam n Current Mailing Address: W7S oL1--9 S8 S 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) 1-1-7 to 9_ Check Number 6 This Section For!Official Use Only Building Permit Number: Gate 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/Finding ever been issued for/on the site? NO Q DON'T KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW © YES i 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 ® 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 ® NO O 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all an 'licable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[O] Other[a Brief Description of Proposed Work: (Ar k �m IS", L10 wt. ak W Tkwy"a* . Alteration of existing bedroom Yes__L 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 j omalete 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 as Owner of the subject property hereby authorize C_V�f i5AC C4SOS to act on my behalf,in all matters relative to ork authorized by this building permit application. G�'�I y I 15 I I b Signature of Owner Date I, C�n -�O>>c C c� oS 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 me Ll 15A le Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:. tir i� r 7ys I &02H License Number PC) &x 1��Shi�- ; M25-� 8 b l IF) A s Expiration batel 9-6 209—L�5 ignature Telephone 9 Registered Home Improvement Contractor Not Applicable ❑ The, 11 LM Z Company Name J Registrationumb r /'2)1 D18 R--T- 7 - Address Expiration Date C 71=\It�l C,—T O&Bc 1 Telephone 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....... V 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►fable 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: Ej-rr-� The debris will be transported by: br, S The debris will be received by: Building permit number: Name of Permit Applicant CC()s H 15 Date Signature of Permit Applicant City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y. 212 Main Street • Municipal Building bks Northampton, MA 01060 5� �1 Property Address: JC Z-Irch +-'1 A Contractor L Name: y 14 so S Address: PC 'Ecx ! &I City, State: I" 7V 0125-7 Phone: Property Owner r Name: Do-a1'1 wvt,-, Address: �� ',( C� Llw� zj City, State: ��G r ,ry�� 1 Tj, U(p 2 I, C1r (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 / .----Date L RISE60 Shawmut Road,Unit 21 Canton,MA 02021 339-502.6335 ENGINEERING' www•RISEengineering.com OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at: � •b� (Property Add ss) (Props 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. Owner's Signature Date ' { i The Commonwealth of Massachusetts Department of Industrial Accidents -, Office of Investigations = , I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: 'j ! old City/State/ZiL7 QlO Phone#: 808> &Ll0— & Are ou an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time), have hired the sub-contractors b. F1 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' g F1Building 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 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ oaf repairs insurance required.] ; c. 152, §1(4),and we have no V� }71� R17710N 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. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: rCln(.J1i Policy#or Self-ins. Lic. #: ?jN U- Vq�t� ln�13—7 9 Expiration Date: q I`� 17 Job Site Address:_ © -«xu N I) 1L� City/State/Zip: MA U 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 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. I do hereby ey rder the airs and penalties of perjury that the information provided above is true and correct. Si nature: / Date: L4 15 Phone#: . H�5 Z09- 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 5.Other Contact Person: Phone#: AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 4/12/2016 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 NAMEACT Brian Gallagher BNC Insurance Agency, Inc. _--- PHONE (91�Q 937-1230 FAX --- (AIC.No.Ext): ) _�1q/C Not:(914)937-1124 111 South Ridge Street AIL DDDDRESS:bgallagher@bncagency.com INSURERS)AFFORDING COVERAGE NAIC# Rye Brook NY 10573 — INSURERA:Selective Ins Co of South Carolina 119259 INSURED -- -- ----- - INSURERB:StarNet Insurance Company 140045 ENERGY PRZ LLC INSURER c:Landmark American Insurance Co. 33138 dba THE ENERGY STORE INSURER D: 31 OLD ROUTE 7 INSURER-E: BROOKFIELD CT 06804-1711 1 INSURERF: COVERAGES CERTIFICATE NUMBER-.CL1641170511 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-1 TYPE OF INSURANCE ADDLi§UBR-- _-- - 1 POLICY EFF POLICY EXP LTR POLICY NUMBER MM/OD/YYYY) (MM/I YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _�$ 1,000,000 DAMAGE T O y ENTpED - - y - - A �CLAIMS-MADE X -OCCUR PREMISE�Eaoccunence�_ ' $ _ 100,000 X Contractual Liability S2153542 3/27/2016 3/27/2017 MED EXP An one person) 5,000 - - --. _.. ,.. PERSONAL&ADV INJURY $. 1,000,000 PRO- _ S PER: j AL AGGREGATE GENERAL $ POLICY 2,000, 00 0 GE_N'LAGGREGAT JECT APPLIES _-- --- --- __-- X LOC PRODUCTS COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 000,000 LEa acc dents-- _-. _ A X ANY AUTO 'i BODILY INJURY(Per person) $ ALL OWNED I SCHEDULED - — - AUTOS AUTOS S2153542 3/27/2016 3/27/2017 BODILY INJURY(Per accident) $ - NON-OWNED PROPERTY DAMAGE ! --- --- --- 1 - HIRED AUTOS AUTOS - - _ Per accidenQ $ _.. 111 _ - - $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE ---� ---- t._.- -_-- !� -_ - 'AGGREGATE __ +$ 5,_000,00.0 DED i 11 RETENTION$ 152153542 3/27/2016 3/27/2017 j $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE jER ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT 11000,0Q0 QQ�00 OFFICER/MEMBER EXCLUDED? _-.l N I A I _ - - _ B (Mandatory in NH) BNUWC0131379 4/15/2016 4/15/2017 E.L.DISEASE-EA EMPLOYE i$ 1,000 000 If yes,describe under - - --- -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 C Professional Liability LRR756563 3/27/2016 3/27/2017 LIMIT 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O Colabella/BGALL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 M14nn