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29-573 180 OVERLOOK DR BP-2017-0723 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-573 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-2017-0723 Project# SS-2017-001194 Est.Cost: $1600.00 Fee:S65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: _ ENERG1A LLC 92540 Lot Size(sq. ft.): 26658.72 Owner: HARNESS JEFFREY J&BETH K ELLIS HARNESS Zoning: Applicant: ENERG1A LLC AT: 180 OVERLOOK DR Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:11/29/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL A 9"CELLULOSE TO OPEN ATTIC FLAT 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: FeeT •i e: Date Paid: Amount: Building 11/29/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0723 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 180 OVERLOOK DR MAP 29 PARCEL 573 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL A 9" ELLU SE TO OPEN ATTIC FLAT 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 INFORMATION 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 e of Building •fficial 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 NOV 2 8 2016 City of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability DEPT.OFBu:L.";G INSr`ECnONS NORTHAMPTON, 01063 Room 100 Water/Well Availability 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 C ,p CO \)t Map Lot Unit ` tn Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -:Yn *k0.x o.oec\c)c)K_ or . A- 1(Y en Le t APN Name(Print) Current Mailing ss ddre :_ _ - Gl: P �,t7 ♦�1 k—C <1 Telephoned ` ��1c� Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: () OLA Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Ic:^i.' (a)Building Permit Fee , UU 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �C� 6. Total=(1 +2+3+4 +5) l ! Lg 00 Check Number -11L/g5. (� This Section For Official Use Only 7 Building Permit Number: Date Issued: Signature: Building Commissioner/nspector 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 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q 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. r SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other On Brief Descri.i.n of Proposed A Work: I. It II liw l -to o9-en -ft c L* Alteration of existing bedroom Yes No Adding new bedroom Yes 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 I. 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, V2;e,'tf� �l'},�y\(SS ,as Owner of the subject property ins hereby authorize -MD r rtn O Yv1 IbUSS f 1 la.SS 1 Y to act on my behalf,in all matters relative to work authorized by this building permit application. P6,2-ru (% it.C7k9 Signature of Owner Date 7 i^ � 12)° n`1 §S rt' ,as Owner/Authorized Agent hereby declare t at the statements and in ormation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ii0 AI t _ S 1�I. Print Name / G Signature o Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y� Not Applicable 0 _- q ( Name of License Holder: �� ��Y } r \'e a 5 `�0 License Number • fit 6 -2C Y.-C $1\A q/ 2.1 I 1 Address Expiration CL13-3DiD-31 Signat e Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 e N E 11.4 S 1 (o I Company Name Registration Number 3 Sul--€01K_ AVA\ -e _Pt11./' / i 8 Address Expiration Date Telephone t�" LL'3aa -31`% 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 building permit. Signed Affidavit Attached Yes 00 No 0 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellinus 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 buildinu 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: 15e1 O J !J i OO K. p r . The debris will be transported by: /I-( ( I -Cl{ IA)6S-k-C The debris will be received by: l N-fd. aks-k-e Building permit number: Name of Permit Applicant 12")/4 S (20,..CS AArA£SGGit I/ Date Signature a of Permit Applicant g pP OWNER AUTHORIZATION FORM 1, 14I -5 S (Owner's Name) owner of the property located at 1 C6b Com . (Property Address) a 13tU � (Property Address) hereby authorize (Subcontractor) MAY I02016 ' an authorized subcontractor for RISE Engineering,to ad on my behalf to ob adding permit and to perform work on my property. Owner's Signature 1-V Date (J ACORD CERTIFICATE OF LIABILITY INSURANCE DATE;MMIDD.YYYY, 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 cer lficate holder is an ADDITIONAL INSURED, the policy(les) 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 CON FACT NAME: Mary- Conroy James J. Dowd and Sons Insurance Agency Inc. PHONE FAX 14 Bobala Road Alc ,Ext):413-538-7444 I (An,No): Holyoke MA 01040 ADDRnoESS: mconroy@dowd,com PRODUCER CUSTOMER ID at:ENERLLC-01 INSURERS)AFFORDING COVERAGE NAICfI INSURED NSURERA:HDI-Gerling America Insurance Compa Energia, LLC NSURER B:Torus National Ins•.irance Company 25496 242 Suffolk Street Holycke MA 01040 iNSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2034052479 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BE_OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQJIREMENT,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 REDJCED BY PAID CLAIMS. INSR PADDL SUER POLICY EFF POLICY EXP LIR TYPE OF INSURANCE 'INSR WVO POLICY NUMBER IMMIDDIYYYY) IMM!DDIYYYY) UMITS A GENERAL LIABILITY Y Y EGGCR000136316 7/1/20:S 7/1/2017 EACH OCCURRENCE j$1.000,000 E COMMERCIAL GENERAL LIABILITY PREM.Iit I( a occurrence) i rr $100,000 PREMISES(Ea occurrence) $ CLAIMS•MADE X OCCUR MED EXP(Any one person) $ PERSONAL 8ADV INJURY $1,000,000 GENERA.L AGGREGATE $2,000,000 GEM AGGREGATE LIMIT AP PLIES PER: PRODUCTS•COMPIOP AGG $2,000,000 7 POLICY;X JECT Ifl LOC $ A AUTOMOBILE UABIUTY Y Y EAGCR000186816 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT $1,000,000 I (Ea accident; ANY AUTO BODILY INJURY(Per person) $ _ ALLOWNEDAUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS X PROPERTY DAMAGE HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ 3 X UMBRELLA LIAB OCCUR Y Y 85393N150AL1 7/1/2016 7/1/2017 EACH OCCURRENCE $1,000,000 EXCESSLIAB CLAIMS.MADE AGGREGATE $1,000,000 DEDUCTIBLE $ •. RETEN'ICN $1C,COO $ A WORKERS COMPENSATION Y EWGCR000136816 7/1/2016 '711/2017 'X TORiSLIMITS 1 10ER AND EMPLOYERS'UABILITY Y IN ANY?ROPRIETORIPARTNER/EXECU TIVE —^ E.L.EACH ACCIDENT $1,000,000 CFFICERrt4EMBEREXCLUDED', N/A ' (Mandatory in NH) '— E.L.DISEASE-EA EMPLOYEE $1,000,DDO ryes.aescrPeunaer DESCRIP-ION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,COO,000 I DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (Attach ACORD 101,Additlonal'Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAN CE'..LED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE GV4:, X y I 1 i ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD . i 1: • r/icr*wit hI,npry,Lrr/r/c r/r',fZ jirrr/ujc//J '-^-- Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ;721--;--T;i174. OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: rill 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 HOLYOKE,MA 01040 Undersecretary Not valid without signature Massachusetts Department of Public Safety V. Board of Building Regulations and Standards License: CS-092540 Construction Supervisor THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELD MA 0.103: Expiration: Commissioner 09/02/2017 V�\ L'AC \.vlrcr•wrc rvcfa cc s vJ AYI WNw►11socsw Department of Industrial Accidents _,�li`�!�� Office of Investigations : _ -4, __ 600 Washington Street 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): 1.IM I am a employer with 24 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp.insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.1E Other Insulation 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 employees. Below is the policy and job site information. Insurance Company Name: HDI - Gerling America Insurance Company Policy#or Self-ins.Lic.#: EWGCR000186816 Expiration Date: 7/1/2017 Job Site Address: 180 Ch),°.if 10 L Dr - City/State/Zip: ,Q 'e n(.e t M I9 0 i m(p 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 certify under t pains and penalties of perjury that the information provided above is true and correct. Signature: Date: h(7.2.---?(," Phone#: 413-3 2-3111 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#: