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29-324 (5) 341 ACREBROOK DR BP-2019-0399 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-324 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-2019-0399 Project# JS-2019-000641 Est.Cost: $2811.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RICHARD ABTS 74666 Lot Size(sq. ft.): 25439.04 Owner: RITCHESON GARY A&LAURA E Zoning: Applicant: RICHARD ABTS AT. 341 ACREBROOK DR Applicant Address: Phone: Insurance: 132 PROSPECT ST (860) 306-7275 WC EAST LONGMEADOWMA01028 ISSUED ON.101212018 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR WITH 4" BLOWN CELLULOSE & INSULATE ATTIC HATCH 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 10/2/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner lI ECEI V ED —, /V�V Department use only OCT – 1 204( of Northampton Status of Permit: Buildin De artment Curb Cut/Driveway Permit f ain Street Sewer/Septic Availability . BUILDING INSPFCTIQl� M4AMPT0N.PAAoto6 00n1 00 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 zp—j 9-- 1< q 1.1 Property Address: This section to be completed by office Map Lot Unit 3'f I AGvrzbvaoK� 1)v'ive, No v'+k(kr0'}-OIA j /'Ll Zone Overlay District VA R Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: G—wv'S/ t2ic(tesov► 341 Ary & bvnok Do— Alam-A a-mornN M4 Name(Print) Current Mailing Address: 689 0 4J�A Qd` a,lA F'wOM x,0.'4 j eft Telephone ,J t��ti Jc-3 3 Signature �(" J T It 2.2 Authorized Agent: _R�c11c,y`c� 1�k IO�s 13 z. {�y'oc�eec-f st , Eb„s+ l..oa3u�la�ow /14/4 Name(Print) Current Mailing Address: Of 402- -t"wa� $ Co O — 3 06 — 7-z 7s- 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 CJ Building Permit Fee Q 4. Mechanical (HVAC) 5. Fire Protection Q 6. Total =(1 +2 +3+4+5) Z ( ( Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signatur . " � /0zb Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 0 0 0 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 XV DON'T KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q) DON'T KNOW © YES 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 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 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 9 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding [❑] Other[of �P.atkev�zw+ioy Brief Description of Proposed Work: -Cris%A1c.{e s.tiC 400r pJ,+-1A *"blowlk Ce-16clohe T4t, (.,4e QAic kotc-(4 Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes XNo 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 1. 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, See AIy%ABV CLLt ("6Vi as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, �;C.�II.�U►�� A io+ as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m`yR ol�Iv Ige a`P Mlief. Signed under the pains and penalties of perjury. LAtlJ4a) A,14♦5 Tint Name Signature of Owner/Agent Dat 0 0 0 SECTION 8-CONSTRUCTION SERVICES 6.1 Licensed Construction Supervisor: A t_ Not Applicable El Name of License Holder: *tc.� aAt A 6+5 C CJ- O7µ(ft 4 4 License Number 132- TOO 6Pec+ 6ttee+. Gn s+Lo k4 iAtea.Jaw AAA, O 10 2 T 2/5- / Z.o ZG Address Expir ion Dale 114an OA):;* %&6-W(e-r2.76f Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ L.ax+-P-V K E7Wr- Sj j LL C 17 7 3 $y Company Name Registration Number 33 k);sc_ok.siy� Ayc, Rloywick CT 6(a3&6 12/1 / 19 Address Expiration D to Telephone 2"G 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....... x No...... ❑ C O O City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS O's 212 Main Street • Municipal Building Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: /C eA.+(,per.;Z&+i o q A rl.�{a�'i o It Est. Cost: Address of Work: 3JL( Acte- h OOK DJ -, A/n y*4-,a a►0 ftt% IKA Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: /�"� _ Q a,�x I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Q i City of Northampton ' � �� sus•-� '��c ' b Massachusetts 1 w. ( DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building �0 D Northampton, MA 01060 rs1 �10C Debris 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. The debris from construction work being performed at: 341 Acar- 6"o k -Dv,we (Please print house number and street name) Is to be disposed of at: II y-wti- I NN4 C'K, KC, -- (vT&Ptk A�4- (Ple6se print name and ocation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. 0 0 0 Permit Authorization imss save Form SV"Q% —My.ff-«,n Site ID: 3457912 Customer: Gary Ritcheson I, 640 ry R4a-le� ,owner of the property located at: (Owner's Name,printed) 341 Acrebrook Dr Northampton, MA 01062 (Property Street Address) (city) 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. Owner's Signature: Ga.>"y Rutrl�e�owv Date: 09/06/18 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 1, tetrk C Lt P-ev.- Lir_ 9 .? Ztv Participating Contractor Date Date Name: CLEAResult Phone: 800-480-7472 Email: For Office Use Only Rev.102015 0 �� o to -- City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS yJ 212 Main Street • Municipal Building Qs Northampton, MA 01060 Property Address: 3 Ac Ne to wOok D v,;Ve Contractor _ iP Name: L_4.VIieJK t YL& cv , L-L.0 Address: 33 w i sc aw 6 i h. Ave- City, State: No w w ,'c.k. . GT O 6 3(o0 Phone: V 77- $7c6 - 300(0 Property Owner Name: 6'Q.u'y 1�; GkeSo1� Address: 31+ 1 ALcweby%oaK 17V-;v e, City, State: &10 V`f- k a.wL n+o A . MA I, i C.L.a,VCL A6+S (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date ?/2q /zOlcd, I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 10 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1_4L(A+e.V`v. FVI9,N,GY a --�••G Address: 33 U),5c0fS ivk AVeKCAP, ; City/State/Zip: A/o y w;C k GT 0&3(p 0 Phone #: g'7T— K 7$ — 300(p Are you an employer?Check the appropriate box: Type of project(required): I� 1. I am a employer with 30 4. ❑ I 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. Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working forme in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] I employees. [No workers' 13.9 Other WP.a►.'t'kL'V';2G-E&oVt< comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C tit n IoVeytS M u+UO l C O S u ail+v COM 1n Policy#or Self-ins.Lie. #: H $/ O Z$ Expiration Date: 11/31 /101s Job Site Address: 3µ( A C.V'-IQ y-anV, -DN i V o- City/State/Zip: Alb tit+ t�ofo�- /uq 01062- Attach l0(oZAttach 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 Mnder the pains and penalties of perjury that the information provided above is true and correct. Signature: ��� Date: CI/ x Cf I! g Phone#: D 3 O — 7 2.?S Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense# 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#: 0 0 0 IDDfr ACC)O® CERTIFICATE OF LIABILITY INSURANCE °ATE(MM3/20 8 01/03/2018 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 3ELOW. 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 have ADDITIONAL INSURED provisions or 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 CONTACT NAME: Sheri King, CIC Byrnes Agency, Inc. - Norwich 6 Consumers Avenue IA'CExtie (860) 886-5498 FAX No:(860) 859-5075 E-MAIL Norwich CT 06360-7521 ADDRESS: sking@byrnesagency.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:EMCASCO Insurance Company 21407 INSURED INSURER B:Employers Mutual Casualty Comp 21415 Lantern Energy, LLC & Lantern Electrical, LLC INSURER C: 33 Wisconsin Ave. INSURER D: Norwich CT 06360-1550 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:Cert ID 18955 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY B X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 ENTEO CLAIMS-MADE l X I OCCUR 5D81028 12/31/2017 12/31/2016 PREMISES DAMAGE TEaoccurrrence $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑X PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY AUTO SES1028 12/31/2017 12/31/2018 BODILY INJURY IF rperson) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ B X UMBRELLA LAB X OCCUR SJ81028 12/31/2017 12/31/2018 EACH OCCURRENCE $ 5,000,000 EXCESS L1AB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 1 $ WORKERS COMPENSATIONPER OTH- B AND EMPLOYERS'LIABILITY YIN SH81028 12/31/2017 12/31/2018 X STATUTE I I ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? I yl N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 C C O Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Supplement Card LRegistration: 177389 LANTERN ENERGY LLC. 33 WISCONSIN AVE Expiration: 12/01/2019 NORWICH,CT 06360 Update Address and Return Card. SCA 1 O 20M-05/17 / �-'Fx''(r N/INRI�rnPll�/� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:SuDDIement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs d Business Regulation 177389 12/01i2019 10 Park Plaza-Suite 5170 LANTERN ENERGY LLC. Boston,MA 02116 RICHARD ABTS 33 WISCONSIN AVE NORWICH,cr 06360 N Undersecretary Vali without signature 0 0 0 ® Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-074666 4pires: 02/05/2020 RICHARD L ABTS 132 PROSPECT STREET EAST LONGMEADOW MA 01028 Commissioner C G C