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35-050 (8) 966 RYAN RD BP-2019-0410 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 35-050 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:INSULATION BUILDING PERMIT Permit# BP-2019-0410 Project# JS-2019-000654 Fest 2600. 0 77.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq.ft.): 14897.52 Qwner: JONES MICHAEL h&MEGAN E zoningApplicant: ENERGIA LLC AT.- 966 RYAN RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.101512018 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATION-VAPOR BARRIER, ATTIC FLOOR OPEN BLOWN CELLULOSE 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 N Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire I)enartnment Fireplace/Chimney: Rough: Oil: Insulation: Final: Sm,ake Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupangy §ignat9re: Fee aRe: Date Paid: Amount: t3uilding 10/5/2018 0:00:00 $77,00 212 Main Street,Phone(413)5871240,Fax:(413)5871272 Louis Hasbrouck--Building Commissioner Department use only City of Northampton Status of Pernk Building Department Curb cutiort"way-Permit 212 Main Street Soarer/SepticAvrat+4ebility Room 100 v�iotorlWeAvelaittry Northampton, MA 01060 Tw' SbtsofS icturalPfono phone 413-587-1240 Fax 413-587-1272 Plo"o Pfans Specif+�,.... APPLICATION TO CONSTRUCT,ALT OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION OCT — 2 2018 1.1 Property Address: This section to be completed by office /�s-, RYA /A ( �'� DEPT. R BUILDING MA Oio6tNS Lot (J �/� Unit y y /V '\ NORTHAMPTON,MA 01066 W612 / R A a P Td Zone Overlay District 1C Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) ,Ci�nt�M�aiI �A�ddg�s- lT' A(klti& lNlepfi6nk �3�b Signature 2.2 Authorized Agent: worn ]=Vm1eY S - iu-u Name(Print) Current Mailing Address: k'4 Signature zz&' ��elepho& SECTIO16-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 7 ,� (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee kf7t7 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 2 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: J b Building Commissioner/Inspector of Buildings �,- Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 _..__. .., _._, r ................ __.__ Frontage Setbacks Front ^" Side L+-__e_.... R.`,_.-..., _ L:1.-....... R:.. Rear Building Height Bldg.Square Footage t._ ... .., OX 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 Q YES Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: 3 D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 Q 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) ff7Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [ - Siding[p] Other[ q icon Brief Description of Proposed Work:— .-\kXDnV' -t - A�Yxs� vra o�- LA own �ov�n �� ,C Alteration ot`t;xisting bedroom Yes��No Adding new bedroom Yes / No Attached Narrative -Renovating unfinished basement Yes –��—No Plans Attached Roll -Sheet 6a.If New house and or addition to exLsfina housina, complete the followin : 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 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 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. Yrn oh c r(y-\ 91 Signature of O er Date _ as Owner/Authorized At hereby declare that the statements and information on the foregoing application are tFbe and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print rvan- Ila Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: (NNoot�Applicable ❑ Name of License Holder: ` � � © l ) �'L,1 �. p(MLAO License Number Address Expiration Date L_ \ Sig aturei elephofie 9.Reaistered Home improvement Contractor: Not Applicable ❑ EX-ItKWa 1 16x1 Company Na a Registra ion Number Address Expiration Date Telephon 1 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....... No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 ...••• 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: quo ��Cl �1 (Please print hoAe number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: iglu 1c��k. S-� ,©mN (Company Name and Addr ss) Signatu 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 DATE(MWODrYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 8/2/2018 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 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 NA . Ma Conroy The Dowd Agencies, LLC PHONE FAX 14 Bobala Road EXt,v 413-538-7444 ac Nol: Holyoke MA 01040 E-MAILADDRESS: PROD ER ENELL INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A:Evanston Insurance Company 35378 Energia, LLC 242 Suffolk Street INSURER B:Commerce Insurance Company 34754 Holyoke MA 01040 INSURER C:StarStone National Insurance Company 25496 INSURER D:Guard Insurance Group 8281 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1131630225 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 SU POLICY NUMBER POLIO POLICY EXP LIMITS LTR A GENERAL LIABILITY 2DB4466 7/1/2018 7/1/2019 EACH OCCURRENCE $1,000.000 X COMMERCIAL GENERAL LIABILITY PREMIE Ea occurrence $50,000 CLAIMS-MADE OCCUR MED EXP(Any one person) S1,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 JECT POLICY X PRO- LOC $ B AUTOMOBILE LIABILITY BHQPBJ 7/1/2018 7/1/2019 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ C X UMBRELLA LIAR X OCCUR 7575OH180ALI 7/12018 7/1/2019 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE $ RETENTION $ $ D WORKERS COMPENSATION ENWC952172 7/12018 711/2019 X I WCSTATU- 0 TH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is 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. To Whom It May Concern AUTHORIZED REPRESENTATIVE m 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD ommonwealth of Massachusetts Division of Professional Licensure CBoard f Building Regulations and Standards Construction Supervisor CS-092540 Expires:09/02/2019 THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELID MA 01038 Commissioner Office of Consumer Affairs&Business Regulation License or registration valid for individul use only FIOME IMPROVEMENT CONTRACTOR before the expiration date, if found return to: + Registration: 165169 Type: Office of Consumer Affairs and Business Regulat'io`n Expiration: 1/11/2018 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 ENERGIA LLC �/ _Z D THOMAS ROSSMASSLER 242 SUFFOLK STREET V , HOLYOKE,MA 01040 undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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 St. City/State/Zip: Holyoke, MA 01040 Phone#: 413-322-3111 Are you an employer?Check the appropriate box: Type of project(required): 1.VI am a employer with_meq_ 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in ancapacity. employees and have workers' � y p �• comp. insurance.$ 9. EJ Building addition [No workers comp. insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] 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.❑ Other 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: Guard Insurance Group Policy#or Self-ins.Lic.#: ENWC952172 Expiration Date: 7/01/2019 Job Site Address: 1. , City/State/Zip:1' l-CAin ;t`r�G OIC Attach a copy of the workers' c4pensation 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 f r insurance coverage verification. I do hereby certify and the pains and penalties of perjury that the information provided abo7e is tru ndorrect. Signature: Date: Phone#: 41 -3 -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#: