23A-212 (3) 66 BEACON ST BP-2016-1507
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-212 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 ft BP-2016-1507
Protect ft JS-2016-002573
Est. Cost: 52706.00
Fee:565.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo: THE ENERGY STORE 106024
Lot Size(sq. ft.): 43734.24 Owner: MCCARTHY-LENZ JUSTINE S
Zoning: LiRB(100)/ Applicant: THE ENERGY STORE
AT: 66 BEACON ST
Applicant Address: Phone: Insurance:
31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC
BROOKFI ELDCT06804 ISSUED ON:6/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEALING, INSTALL R-19 TO RIMJOIST
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Slcter:
Footings:
Rough: Rough: I louse# 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 6/16/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck.—Building Commissioner
File#BP-2016-1507
APPLICANT/CONTACT PERSON THE ENERGY STORE
ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD (888)840-6641
PROPERTY LOCATION 66 BEACON ST
MAP 23A PARCEL 212 001 ZONE URB(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Cp466'
Building Permit Filled out
Fee Paid
Tvpeof Construction:_AIR SEALING,INSTALL R-19 TO RIMJOIST
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
FOLLOWINGTHE^^,,,� ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9R% 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
Demo T2;t7
v?' aN *( At
Si re 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.
Department use only
City of Northampton slaws dPemal'aill
Building Department crab Cutl ivsw yPemaI1 212 Main StreetSewedS$IC Avaiebiily
Room 100 Wale/Neil Availability
orthampton, MA 01060 Two Seb afSbuctumplarie
pEFNore ,ne."s�e�,°Ns • 3-587-1240 Fax 413-587-1272 Plot/Site Plans
rill
0.TtiPft Other ems.
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
662 eBe&co n
c Map Lot Unit
Zone Overlay District
Fl ore ri cc_ 1 MP- v�`, } 0 Cc 2 Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�us-�-Ine, 111ccar+hj (o& 3Pci_cpn S* 1-lo{-en
Ce, MA
Name(Pnnt) Current Mailing Address:
(Se€ at ) ( IGdo2
Telephone
Signature y13 (09S - KI )2
2.2 Authorized Anent:
yrs+/-Cher C- F0 no f" xx Igl € �� ozc1
Nam P n Current Mailing Address: y
czyy
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 J l
6. Total=(1 +2+3+4+5) 210& . ip Check Number S J (€9
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature:Signature:
Building Cammissionedlnspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column robe filled in by
Building Department ,,+:t
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 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0 NO 0
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) Roofing ❑
Or Doors 0
Accessory Bldg. 0 Demolition El New Signs to] Decks (p Siding]D] Other(C1]
Brief Desgqri�pion of P((posed + n
Q.-
Work: ft,r 0.1,/10. Si)5401 1cl +0 rimy s •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Nanative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Self New house and or addition to existing housinai 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 W oodstoves Number of each
g. Energy Conservation Compliance. Messcheck 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
I, J/ Pe 1
V ,✓1� I ' [(,(n✓� f1v as Owner of the subject
property
r/rAI t
hereby authorize (Alit$ O )W �5
to act on my behalf,in all mfaLttters' rela11tive to work authorized by this building permit application.
Signature of rnmer Date
I. l
(/`ill,cl-f C S ,as Owner/Authorized
Agent hereby declare that the state nts and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pins and penalties of perjury.
i rlc ( u;
Print
__� (Pi,ct
Signature of Owner/Agent _ Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensedd C nstruction Su( rvisor: (/� Not Applicable 0
Name of License Helder: L.GIjc JO 0 0 2
YYY License Number
PCF)())( 181 Sh9F1A 1 M-IF- 0/257 K ! I I
Ad ss ) Expiration Date
"i`6./ t— 7 3 204- LIS g5
ignatu Telephone
9.Renistered Home Improvement Contractor[ Not Applicable 0
the EnercA 1-185`1Z_
Company Name Registration Number
S) (Aar 9) l01)e�
Address (� � CT py Expiration Dat
l(1)0k-"C—
I�)� p_l \ U &�U � Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(6))
Workers Compensation Insurance affid t must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the buying permit.
Signed Affidavit Attached Yes No 0
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
Massachusetts 4
,ii �t F DEPARTMENT OF BUILDING INSPECTIONS i f'
A v¢ 212 Main Street a Municipal Building � JC
\` lJ Northampton, U. 01060 rah �^
+Cont / n
Property Address: 3 arr n S-1-
Contractor
ractor �
Name: (�r1 %A- &r C2 k )S
Address: PC) X72)0)‹ IN
City, State: C--)'h2q7F1A v ViAnG12FD7
Phone: (-1 is— 2.0LI– L 5g5
Property Owner
Name: J './1-I',>1L V I c x f i
/
Address: l 0(o T�eO C on
City,Coate: lc✓ 2r CP, )�Iy.. � O 1 O CO 2
I, l Alof CGLSes (contractor)attest and affirm that the building I intend to
insulate does not h ve 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
Contractor signature l
L/iYs, .
-
Date
I,
RISE60 Shawmut Road,Unit 21 Canton,MA 02021 )3395026335
ENGINEERING' www.RlSEenngineering.com
=..u.enC Enc,c ac .
OWNER AUTHORIZATION FORM
t
I, k) ;1-1 eAe. 1\1\c,C 't'L y ,
(Owner's Name)
owner of the property located at:
bc, %-&cci Ci"
(Property Address)
l0(�� �..-- MAC (/�
J a a _ , to
(Property Address) D t L t= i v L,c.
hereby authorize .' JUN - 8 2016 D
(Subcontractor) I
an authorized subcontractor for RISE Engineering,to act on my behalf tc obtain a building
permit and to perforin work on my property.This form is only^lyvalid with a signed contract.
O er' Signature
Date
The Commonwealth of Massachusetts
w— Department ofIndustrialAccidents
1a_`— G
S='''I�=r Office of Investigations
la
is E:110.= ; 1 Congress Street, Suite 100
—I�=�—_ Boston,MA 02114-2017
�,,m www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): he_- an ,( ) /J,re-
Address: ' f DJ( 'PA- 7
City/State/Zip: -Hro0L IEL ) Li O(p ✓ok- Phone#: 88K 8`10— lalo4 I
Are ou an employer? Check the appropriate box: Type of project(required):l
1. I am a employer with 4. ❑ I am a general contractor and I
employees (hill and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. 9 Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.] 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 109 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.9 PI bing repairs or additions
myself. [No workers' comp. right of exemption per MGL
1249 oof minim
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13. Other 'J 1Jpaj+2-e 17GJ i0r1
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 anached 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
Insurance Company Name: )NC --cn S11ran c Ai-Cr
Cr C/ t ----NJ �—'
Policy#or Self-ins. LLi��6oe. #: a 14 L \VC l?\ 2,1 Expiration Date: (o/I c J i t
Job Site Address: U/
.Deacon 5± City/State/Zip: f0(ell Ce. A4-6 oiG(oZ
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.
do hereby ce .fy a e/the p 'yand penalties of perjury that the information provided above is( true and correct.
Signature: Date: (a 1 l 51)1Q
Phone#: 1—17S 2oLi* kSS
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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: Ep0.t
The debris will be transported by: N i) Dc kv ;
The debris will be received by: —'
Building permit number:
Name of Permit Applicant A riS 0 le( TSQS
51) am,vi
Date Signature of Permit Applicant
A�De CERTIFICATE OF LIABILITY INSURANCE MATE
�s"
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 4NAMEpOi Brian Gallagher
SNC Insurance Agency, Inc. P"^"'F (914)937-1239 DAX t014)017-G24
LtttC.NR.4Bti__ _ . LAK NaY..__.._
111 South Ridge Street -Dp1) bgallagher@bncagency.cen
IXSJRERIS)AFFORDING COVERAGE XAICi
Rye Brook NY 10573 IxsuRERA:9alactive Ina Co of South Carolina ' 19259
INSURED IxsURERa StazNet inauxance Company _:80045
ENERGY PRE LW xaUREFC Landmark American Insurance Co. :33138
dba THE ENERGY STORE INSURER O:
31 OLD ROUTE 7
INSURER E: - _ _._
RROOEFISLD CT 06804-1711 INSURER F:
COVERAGES CERTIFICATE NUMBER:C11641170511 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. NOPNITHSTANDING 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.
Binh! -ACDLSUSRI ..._. _. ___ Po�ICY EPF PoLIC'/El(O.'
OR; TYPE OF INSURANCE 11NSL) aY01 POLICY RUMMER IMY@p1YYYY1'IYWDOIYYPY)' Leers
X COMMERCIAL GENERAL UAEDLRY EACH 1,400,090t
ACLAMS-MADE'- — CLAMS-MADEXOCCUR I P EMMS2108 NSC LET ) $ 100,000
I X Contractual Liability 52153542 3/27/2016 13/27/2011 MED EXP(Ay one person) $ 5,000
_ 1,000,000L
GENL AGGREGATE LIMIT APPLIES PER. -GENERAL AGGREGATE $ 2,000,000
Bat( X k LGC 1 ;PRODUCTS.C_OMMONAGO;$ 2,000,000
OTHER $
AUTOMOBILE LIABILITY •
I 'COMBINED SINGLE LIMIT $ 1,000,000
. ILx idenU _____________
__.... _ y
A IX IPNYAUTO BODILY INJURY(Per person) 5
PLL OWNED SCHEDULED 52253542 3/27/2016 , 3/27/2037 BODILY NJURY(Per aDJANNI $
'AUTO$ _AUTOS
- . i weIEO - RTY DAMAGE
h
1 RED AUTOS 1 - j S
•
X UMBRELLA LIAB X
_I OCCUR EACH OCCURRENCE S 5000,000
•A
EXCESS LIAB CLAIMS-MADE! ! I AGGREGATE 5 5,000,000
- ..-
'DEO RETENTION 32153542 3/27/2016 3/21/2017 t
WORKERS CONPEFISATAX X I PEE
AMO EYPI.OY1ORIP TI11TT _ .. .
ANT ROMEIMBERIEXCLUDEIEX[CUTIVE •INI LEL EACH ACCIDENT $ 1,00�00p
CADGER/MEMBER ryMRE%CwpEP7 x/A'
B (Myaess.s to NH) Jwider . ENONC01313]9 4/15/2016 4/15/201] IELDISEASE,EA EMPLOYERS 1,000 000
ft I DESCRIPTION OF OPERATIONS Cekm I EL DISEASE-POLICY LIMIT•
$ 1,000,000
C Professional Liability 11118756563 3/27(2016 13/27/2017 Her 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddIIMNl Remarks&NBXNx,may be FMCMd if more space Is maiM)
Proof of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PROOF OF INSURANCE I THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTXORiEc REPRESENTATIVE
0 Coiabelia/BGALL 1 .-�'�"y,e.'` /—��'
O(' 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The AGGRO name and logo are registered marks of ACORD
INSD25nmwn