13-020 20 ROCKLAND HEIGHTS RD BP-2017-1405
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 13 -020 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-1405
Project# JS-2017-002340
Est.Cost: $1050.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS99381
Lot Size(sq.R): 42993.72 Owner: ROCHE NORMA
Zoninv: Applicant: THE ENERGY SPECIALISTS
AT: 20 ROCKLAND HEIGHTS RD
Applicant Address: Phone: Insurance:
212 AMES RD (413) 566-1058 WC
HAMPDENMA01036 ISSUED ON:6/2/2017 0:00:00
TO PERFORM THE FOLLOWING WORK ADD R-19 FIBERGLASS INSULATION AND 2
INCH THERMAX TO CRAWLSPACE CEILING
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 6/2/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1405
APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS
ADDRESS/PHONE 212 AMES RD HAMPDEN (413)566-1058
PROPERTY LOCATION 20 ROCKLAND HEIGHTS RD
MAP 13 PARCEL 020 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
/J ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT f
Fee Paid t, 1
Building Permit Filled out
Fee Paid
Typeof Construction: ADD R-19 FIBERGLASS INSULATION AND 2 INCH THERMAX TO CRAWLSPACE
CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99381
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
%.:\c"
V. 0 . m.selay
Si . . ur- afficia 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.
/
�
244 \
Department use only
.--------2-Building
2 City of Northampton status of PenPent*:Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
\ 4i
/ Room 100 WaterNVell 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 Pro a AdAddress: LThis section to be completed by office
ate, oc4 /4-/a /4�•j41s r .! Map /J Lot OaO Unit
Asc..14c..y{a-7 41 4 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nor' Mt Ad, do noc/4am1 WiS11S cel
N y.P, ) Current Mailing Address
(r///"(f 1 //�� f 64- v3G S�
6 �( {� f.[�c TelepM1one
Signature
2.2 Authorized Agent:
%1r 4"..r- %d/J du A.+., ,j 4.." r/.- ..• A o/JC
Name(Print) Current Mailing Address.
t 6 G-/(o Y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Budding Permit Fee
/o Sc.. cs
2. Electrical (b)Estimated Total Cost of
.o /.9 Construction from(6)
3. Plumbing ...,14Building Permit Fee
4. Mechanical (HVAC) /
5. Fire Protection ......44q( y
6. Total =(1 +2 + 3+4 +5) 10ro,o` Check Number I�l[/err`moi
This Section For Official Use Only
Building Permit Number: Date
Issued
Signature:
Building Commissioner/inspector of Buildings Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be tilled in by
Building Depamment
Lot Size
Frontage
Setbacks Front
Side L. R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage ,o
HOT area mow bldg&posed
purkincl
#of Parking Spaces
Fill:
volume&I.(sawn)
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO reff DON'T 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 O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NOE
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
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) In Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks CI Siding[0] Other[DI
Brief Descn�2/f Prop9sed
Work: /'-/9 /Q , •All f.A.J.,/ {,"c . f 2 " /..7e.'Ism 4
fhm/9.rr
Cr,'/. j
Alteration of existing bedroom Yes X No Adding new bedroom Yes .. No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family 1...------ 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. , °,m9 /try le ,as Owner of the subject
property
hereby authorize �Ai , -r-/y caret/4/11:11.1
to 9n my behalf, in all m 's relatifl 15 worlauthorized by this building permit application.
a
Sign of Owner / Date
I, 7:4 Ste.,..//yy j//rcrc A.Vi ,as Owner/Authorized
Agent hereby declare that the Stdtements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and .enalties of .erjury
//rti/��
Print e
L •/• /7
Signet a of Owner •gent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: j Not Applicable ❑
Name of License Holder / 'pr, ,4 car/ t r.. ca ao / 9$Jfr/
License Number
A / /e �,/ �i9 0,� sL 3t
Addr- - ExpirationnDate natee
SGC- /r(o y
Signat . Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
^
Eiy/ ;Vet. 4 /S /CJAJ7
Company Name � Registration Number
d/.0 Ag-es r / �7s/•�, ANA Expiration
/05 i //-/J - /
Address Expiration Date
Telephone f(C-hie 'r
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 buildin permit.
Signed Affidavit Attached Yes yY No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dy chinas of one(I) 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 he 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 Codc,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: cid. /ceOO /4
e/ _ ! /Act its r I'
The debris will be transported by: j,(, c-;..,.JJ 7.c o/i/s
The debris will be received by:
Building permit number:
Name of Permit Applicant j, 6.-e / bit!L-t'/7
/
Date Signature of Permit Applicant
- City of Northampton
4 Massachusetts ¢t, '` `e41 '.
r ,pnd DEPARTMENT OF BUILDING INSPECTIONS S m
•prop`s:* 212 Main Street • Municipal Building aCI'
\,r' Northampton, MA 01060 'h"P 3b‘
Property Address: ,e0 /�e /4, / /0 -J/1S I'
Contractor
Name: 7% EAAE. t. 3.dPc.'c /. j/s
Address: ,2/2 //.Yr3 r /
City, State: //c„70/t7 m,4
Phone: S GG • /,) o Y
Property Owner ��/
Name: Adorn. few/e //4.'
/
Address: I 4e,h. /� /frs//CI/ S
City, State: nn a 7c.c. 1/ c -L,_/._�
I, 7% 11.-.._,, .Sec, /,•J/J (contractor) attest and affirm that the building I intend to
insulate does nth 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 affidavit.
Contractor signat e
Date
G-/-/7
'.-C‘. The Commonwealth of Massachusetts
, . �7t Department of Industrial Accidents
'47 7 1* Office of Investigations
Ire g
�'� =Nis(�/ 1 Congress Street, Suite 100
�� Boston, MA 02114-2017
. _Jr, ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businc,sstOrganization'Individual); The Energy Specialists
Address: 212 Ames Road
City/State/Zip:Hampden, MA 01036 Phone#:413-566-1058
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I and a employer with 2 4. ❑ I am a general contractor and I h. ❑ New construction
employees (full and/or pan-time).` have hired the sub-contractors
2.❑ I am a sole proprietor or partner- list d on the attached sheet. 7. ❑ Remodeling
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. inwmncc.t
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their I1.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL
12.5 Roof repairs
insurance required.]- c. 152.F 1(4),and we have no Insulation
employees. [No workers' 13.❑� Other
comp. insurance required.]
'Any applicant that checks hoe FI mutt also fill out the section below showing their workers compensation policy Information.
rt Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
kkontractors that check this box must attached an additional sheet showing the name ofthe subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their markers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below a the policy and job site
information.
Insurance Company Name:Associated Employers Group
Policy 4 or Self-ins. Lie. WCC5009547012014 8. Expiration Date: 10 6
. -16-2017
Job Site Address: ai¢ /ba&. Je._ .1 l4et 445 r I City/State/Zip: No /�< A_
--_- Y , 11 it
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
line up to 51,500.00 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 insuranc overs 1rification.
Ido hereby ter '- n 'r the r ns allies tined ury that the information provided above is true and correct.
Signature: - Date: e, t-f7
Phone e: 4135661058
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#:
��. a DATE tMwoo�.'..�I
CERTIFICATE OF LIABILITY INSURANCE 10'19/201E
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
GELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT'. 11 the certificate bottler Is an ADDITIONAL INSURED,the policylies)must have ADDITIONAL INSURED previsions or be e,dersed.
Y SUBROGATION IS WAIVED.subject to the terms and Conditions of the policy.certain policies may require an endorsement. A slatement on
MIS ceriderele does not cooler rights to the certificate holler in lieu of such ondorsomont19).
EM'E 6t
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Hampden MA010HE enoaiss. cdavanpetWrrcharefgreemnsurance corn
INSURFNNS COVERAGE ono
imuREp MUTUAL INS PATRONS MUTUAL CO OF CT 14922
he. t1 t IG ee. e. 1w CITATION INS CC 40274
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E boson Sec>aSsts lmSURE A located Employers IDSUEETCD sons ars A023C
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IOPT Orr PAA 010 INSURER
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',OVERAGES CERTIFICATE NUMBER', REVISION NUMBER:
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i 11Of INSURANCE JESTED¢CLOW HMC PLEBE ISSUES,'TO THE INSURED NAMED ABOVE F nR THE POLICY TCPIU
Ir II t TEHL.',1 I`I CIN E IN/ RE.C UIHEMENT TERM EONDILAAN CF ANY CONTRACT OR OTHER DOCUMENT WITH NF SOFCT To'WILT THIS
AT ell S f R MAY PC(STAIN. THE INSL I RAN.A IU FORDED PS THE PLL LOLLS DESCRIBED HEREIN IS SUBTLE CT TO EU THE 'TERMS.
N r N TT T IONAOH SUCH POI II.:IF.S LNAITS SHOWN MAY IIAVE BEEN REDUCED By PAID CLAIMS
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.. .Perron I r. :Icy id Auto 1.11.1b1111j pOlicre$when reouesled by written contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AaOVE DESCRIBED POLICIES OE CANCELLED SECURE
I Loeler SrncIAL615 THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN
I'Arrieb Yid ACCORDANCE WITH THE POLICY PROVISIONS.
Haipder.MA 01035
MIT A iZFo REn#eLMNTATIVt
91988-2015 ACORD CORPORATION. All rights reserved.
ACORD 2512016/03) The ACORD name and logo are registered marcs of ACORD
Crib. isomaaoruo«e¢s 07041es:1 ette
Office of ConsumerWaits t Business Regulation
- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
Type: InOMdu before the expiration dale. If found return to:
Reaistra0on Expiration Office of Consumer Affairs and Business Regulation
PBZ 11/13/2018 10 Park Plaza-Suite5170
Roston,MA 02116
The Energy SpeciaGsl
Mice Grenwood
212 Ames Rd. - -
Hampden,MA 01o3e
Undersecretary Not valid without signature
Massachusetts Department of PublSafety
Board of Building Regulations and Standards
License: OSSL-099381
Construction Supervisor Specialty
MICHAEL E GREENWOOD
212 AMES ROAD
HAMPDEN MA 01036
MExpiration
Commissioner 03/09/2018