24C-113 (6) 5 FIFTH AVE BP-2017-0318
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 113 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-2017-0318
Project JS-2017-000523
Est. Cost: $400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group ENERGIA LLC 92540
Lot Size(sq.f): 5749.92 Owner: Kathleen Becker
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 5 FIFTH AVE
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:9/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION - RIM JOIST WITH 2" THERMAL
BARRIER POLY
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:
FeeTvpe: Date Paid: Amount:
Building 9/16/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0318
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 5 FIFTH AVE
MAP 24C PARCEL 113 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid CfC *N.) 7 y 'z0 6,6-
Building Permit Filled out
Fee Paid
Typeof Construction: INSULATION-RIM JOIST WITH 2 THERMAL BARRIER POLY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 92540
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Signature of Building Officio 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.
To: Northampton Building Dept Page 2 of 3 2016-09-09 15:24:37(GMT) 14133223155 From Tom Rossgsmassler
9 I a PRE-WEATNERIZATION BARRIER INCENTIVE ( I jfhrty &Ityk
WkaSS save CONTRACTOR EVALUATION REPORT
Eligibility information and completion instructions on back
Ru.. .e ,re Kathleen Reeler sso lc _
c wsctsr3
r g dde�s(itdlera) 5511IAve � j.�Do o.olerU
w, r _. -nm 5/4/16 -...
errlr Nodhanpton sue MA _01060
_ �nwe. .__ ._. Emu; W Hanley
ENERGY SPECIALIST EVALUATION
�K/NOB&TUBE WIRING
Y' Con tractor is to evaluate the seectod locations below where weethebration recommendationhave been made to determine it there is any
active knob&tube wiring.
O Attic U All Sopes U Attic Wells Up Walk U Trier,Via I Area LI -exter co.Walls ',1 Over mg U (mom Coding $ -ocoment
MECHANICAL SYSTEM,HIGH CARBON MONOXIDE EVALUATION
s Contractor is to evaluate the selected mechanical system(s)below and provide service,f possible,to reduce nigh carbon monoxide levels as
nesureJ to lee undiluted flue gas to below Ten ppm;
U Hearing bystc PI Ll .'TA Muter°Ystrn U C U .. ._
DRYER VENT EVALUATION
U Contractor is to evaluate the dryer veil:and provide service to properly exhaust the vent to the exterior.
ELECTRICIAN EVALUATION(Completed by Electrical Contractor,as needed)
Upon rl tion of rim torSpectton I have found that there is no active nob&t b wiring the O checked fibUAt: Atte h.pes AlApt We Wails Lnee WAal AscJr Exterior ] cyem:rp ]
�3r rC lirg �M (
.ry? ELECTRICAL CONTRACTOR INFORMATION
r:vivo vName /#e,vlek E(errT:e Pae.
htomtriusiols Na 7;A.c14Y_lh / 4cra,r4 cense is . 0318-FJ
6044 :rem,and mgrec tothe burns&Conditions ochePraWeat,e at B lel lure twit.
Electric .q tor —�.: .^�— ._.. Date:... '/i /i
MECHANICAL EVALUATION(Completed by Contractor,as needed)
MECHANICAL SYSTEM,HIGH CARBON MONOXIDE EVALUATION
The selected mechanic&system has been evaluated e,dshrvicieJ, &Meu tomtits of cat wFl monoxide in the undiluted rave gas. e os lc lows
U N :ngSete ; CC) J (Ar , _. `Opnm ❑ I lot Wa ./4^m COpom
U (duos copun
CONTRACTOR INFORMATION
Company Nemo
Contract() N..5ex
lin we rend all(wren t..Mit ler nis&Ccadaior to 3 los nU Veatic outrun..trier Incentive.
Ccnlracter Signa:ure' __ _ Dde.
DRYER VENT EVALUATION(Completed by Contractor,as needed)
DRYER VENT EVALUATION
O The dryer Vent has been exhamted to the exterior
CONTRACTOR INFORMATION
Company Name
ControttorNama.. LcenseYr
LI have recto,mid "ree lo-the Te- &Conditions tl e\'eaNf l rho: Imrntive
t
Co muni- __._. Dos: _
SUBMISSION INSTRUCTIONS: Please submit completed copies of the dated and itemized contractor invoice
and this Contractor Evaluation Report to:
Email:CustomerSupport@cetonlineorq or
Mari: Pre-Wx Barrier Incentive, C/O CET, 320 Riverside Drive-1A, Florence, MA 01062
kheEIVE Department use only
City of Northampton status of Permit:
ONyE`� Building Department Curb Cut/Driveway Permit
■* 212 Main Street Sewer/Septic Availability
Room 100 WatertWell Availabiety
J13roFsudrnNcelsracnOnaortham ton, MA 01060 Two Sets of Structural Plans
Noxrrw,mfoN ma mono ,�j) P
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 Proverb/Address: This section to be completed by office
J� S111 Map Lot Unit-
�p(-m A,MS:ricO 1 t NAY" OI o(Do Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
3.1 Owner of Record:
MM r-at - Seen Bec,ar 5 5T^ Wive . Noc-mC�..mp- on ti+1'1.
I Name(Print) Current Mallin Address: 01 Otoo
SE: - Pe t 7 A't•T o -raerk Telephone Ilz sas4oe
Signature
$.2 Authorized Anent:
ener9ia — ?HoAAS gdsst4AssZ k-2 SU44niK s-t • - HONOI(4 Nh19
Name(Pratt) ,.. Current Mailing Address: 01040
LIS 3111
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1, Building q} `•'1 I I o O Cao (a)Building Permit Fee
2 Electrical U, (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4, Mechanical(HVAC)
5,Fire Protection — ^-
6. Totals-CI +2+3+4+5) 4400 - Ua Check Number Zy/,,e) y if Ld"+J
This Section For Official Use Only
Building Permit Number: Date
ated:
Signature:
Building Commissioner/Inspector of Buildings Date
Ca/reg /?13
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)
it of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O 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 O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 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 O NO O
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 Q Replacement Windows Alteration(s) n Roofing
Or Doors G7 _ /
Accessory Bldg. ❑ Demolition ❑ New Signs (MI Decks IO Si�tlJPa[Dal O [lye
...Brief Description of Proposed ....... YIN)
lC t �
work:LYlSUtten hint - Vim tDtSt Lorin 2" Tecrrnat Mary' ev 17011
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house and or addition to ' ing 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?
t Method of heating? Fireplaces or Woodstcves 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 to•OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORTAPPLIES FOR BUILDING PERMIT
ktirth 1L C ri CJC C ILL.r ,as Owner of the subject
property
hereby authorize Thomas pt,SSYnaSsu r
to act on my behalf, in all matters relative to work authorized by this building permit application.
C4tfin rt AU'YhO CLCA_non -form Fist itLe
ora of Owner 9rL�,t Date
_1320,111126 n%
s(trla c U. r ,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.
ThOmOS hoSmasst2r
Print Name
( (B
Signature of Owner g Date
SECTION 8-CONSTRUCTION SERVICES
§.1 Licensed Construction Supervisor: Not Applicable C
Name or Lkanse Hcider_�, hm(i
- s C;y]OSSYYtekSS1Cr g2sq j}
License Number
Min • • s1 I , Ili IOUO 9 / 2117_
Address Expiration Date
vor U - 222—Si.i.J
Signatu : Telephone
9,Registered Nome Improvement Contractor. Not Applicable 0
Cntrala Ito 5i (s9
Company Name Registration Number
Str€*olC &i - tip 1.0t A nntl nioct _ k HUI &
Address Expiration Date
Telephone 41 A-32 2-3l I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAI.c.152.§25C(8))
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 building pe
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 1084.$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 he
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, 554, 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: Lill ?IOSC S"t • Cprtne flcldi M19
The debris will be transported by: ftl I I ed WQSte
The debris will be received by: fAlt t tL WaSte
Building permit number:
Name of Permit Applicant 'Mom AS Z oss
;� • /A
Date Signature of aermit Applicant
The Commonwealth of Massachusetts
'—r== I
Department of Industrial Accidents
v
= lf1,=; Office of Investigations
=::S : 600 Washington Street
i`I= - Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Energia, LLC.
Address: 242 Suffolk Street
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer?Check the appropriate box: Type of project(required):
I.12 I am a employer with 24 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
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'
. insurance.:
9. ❑ Building addition
cpm
[No workers' comp. insurance P
required.] 5. ❑ We are a corporation and its 10.111 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.111 Plumbing repairs or additions
myself. [No workers' right of exemption per MGL
Y comp. 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.® Other Insulation
comp. insurance required]
'Any applicant that checks box 141 must also fill out the section below showing their workers'compensation policy information.
s 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 subcontractors 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: HDI - Gerling America Insurance Company
Policy#or Self-ins.Lie.#: EWGCR000186816 Expiration Date: 7/1/2017
Job Site Address: 5 61n 1a‘kIP City/State/Zip: t\)OCCY1CavvS n M19
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). O 1 Otpo
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 certify unde the pains and penalties of perjury that the information provided a..ye is t ue and correct.
Si. ature: 4 A Date: •
Phone#: - -
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#:
DATE
Ae ROS CERTIFICATE OF LIABILITY INSURANCE 9/5/2016OTYYYI
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 pollcypes) 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 endorsementls).
PRODUCER LUN!AL I
NAME: Mary Conroy
James J. Dowd and Sone Insurance Agency Inc. PHONE o.Eels 9T 3-STB-7949 (AX Ns:19 Hobala Road .MAIL
Holyoke MA 01090 ADDRESS: mcOnrO idawd.COM
CUSTOMER ID S: ENERLLC-01
INSURER(S)AFFORDING COVERAGE NAICM
INSURED INSURER A:HD I-Gerling America Insurance Comps
Ener]ia, LLC INSURER B:Tort1R National In9'urance Company 25996
292 Suffolk Street
Holyoke MA 01090 INSURER E:
INSURERO:
INSURERE:
INSURERF:
COVERAGES CERTIFICATE NUMBER:2039052479 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 CERTIICATE 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 IAOOL MAR POLICY EFF POLICY EXP
VTR TYPE OF INSURANCE INSR MVO POLICY NUMBER IMM/DDMITYI (MMIWrfYVYI LIMITS
A GENERAL LIABILITY Y Y E(YtCR000186B16 7/1/2016 7/1/2017 EACH OCCURRENCE 81,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occltrrnce) $100.000
CLAIMS-MADE X OCCUR MED EXP(My one person) S
PERSONAL ADV INJURY 8LD00.000
GENERAL AGGREGATE 182.000,000
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS,COMPOP AGG 52,000,000
1POUCY171 & Lac
A AUTOMOBILE UABIUTY Y Y EXGCR000106816 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per perste) S
_ALL OWNED AUTOS
BODILY INJURY(Ref accident) S
X SCHEDULED AUTOS
PROPERTY DAMAGE
X HIRED AUTOS (Per accident)
X NONOWNED AUTOS
S
H
x UMBRELLA LIAB OCCUR Y Y 55391M50ALI 7/1/2016 7/1/2017 EACH OCCURRENCE $1.000,000
EIICE88LIAB CLAIMS-MADE AGGREGATE 51.000,D00
DEDUCTIBLE S
X RETENTION SIC,000 5
A WORKERS COMPENSATOR Y EamoR000166816 7/1/2015 7/1/2017 X WL]IAIU OIH-
AMJEMPLOYERS'LIABILITY YIN TORY LIMITS E0.
ANY OFFICER/MEMBER ExCLUOEDSEUITIVE r�I N!A E1.EACH ACCIDENT SL0'J0,000
IMeditory In WI El DISEASE-EA EMPLOYEE)81,C00,000
ir yet cescr,De anger
DESCRIPTION OF OPERATIONS Mow El DISEASE-POLICY LIMIT )51,000,000
DESCRIPTION OF OPERATORS!LOCATIONS I VEMCLES (Attach ACORD IM,Additional Remarks Schedule,If more space Ie required)
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE /b (J
®1888-2009 ACORD CORPORATION. All rights reserved.
ACORD 25)2009109) The ACORD name and logo are registered marks of ACORD
r97r .irila.uar/,mrm
Office of Consumer Allain&Business RegulaIoa License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 165169 Type: Office of Consumer Affairs and Business Regulation •
Expiration: 1/11/2018 LLC 10 Park Plaza-Suite 5170
+� Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET Ac.ix
HOLYOKE.MA 01040 Undenecretary Not valid without signature
, Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-092540
Construction Supervisor
THOMAS B ROSSMASSI:ER
100 MAIN STREET
HATFIELD MA 0504
Expiration:
Commissioner 09/02/2017
Ift
Permit Authorization �'
mass save Form P, ,AnRG
yMasoe uy V7 CONTRACTOR
Site ID: 500050189564 Customer: KATHLEEN BECKER
I, KATHLEEN BECKER ,owner of the property located at:
(Owner's Name,printed)
5 5th Ave NORTHAMPTON
IPropeny Street Address) laty)
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 weatherization
work on my property.
i
Owner's Signature: 1� ,4/ /6'
Date: _5 -9 _ ,/k
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating .
Contractor to the above referenced project: ,
L—Vte2/A
Participating Contractor Date
1
For Once Use Only
Conservation Services Group • 50 Washington Street Suite 3000 • Westborough,MA 01581 • 1800-480-7072
Rev.062015