24C RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Kathleen Mellen
(Owner's Name)
owner of the property located at:
73 Massasoit Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby `^authorize �r1.er' iq L— <�—
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.This form is only valid with a signed contract.
Owner's Signature
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-6335
www.RISEengineering.com
7
Y::j,E,'ergy Special-st's recornmendazions,your unie cw' 1,orn ptogra"-eilg ole insulation and/or air sealing
B(_"Cre rvC),.',tj'o,waru.please f-c-lov.,all ..S*.'_C ('a'r erg,
CUSTOMER INSTRUCTIONS
1. - e a awl,f en.I censea contractor to eval-ate at'alc,
2.:... sw-,ei!anuco-oleteo coues of tinslarm a-c 1y "acto,trIvoce
"Epf'.a
t:e eXCCe,!5 _-U-,Crrer 5 Cc-ray,Y,C,*a^aiiat.
4.
\,a-,. Kathleen Mellenr..(3, S,rp 11) 470480
73 Massasoit Street Northampton "C MA 01060
".&
413 584-6033 Jdkatz127@ ahoo.com
CuStOrTW/HoMeowner Signature: Date:W/J
1089416 W
_.31 Will eV,' vwq areas %-e-et a cl.eass
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Lanu cete,r- _c o-c c t-.:!zvcas below.
On - __CrC!r:
.all -k;At'!cSlor:o
:,D-,no-arms I IV.Car a;t'c e rr.c to s fcr
':--s 5-L State /11 'T' ZIP:
ZC... let- ri
Contractor Signature, Date: c11zK7R
High Carbon MondKLd
Draft Failure:,--,
Existing CO ppm Revised CO ppm sbrg Draft Pa, Revisecl Draft on:
Heating System
Hot Water Heater
Other:
Spillage:co!af�Ctar is to V'.e snl!!ane'-.`f:ve gases it:he selected rnechinical sys:�. V,i5'!t sodl after 60 seconds of operation.
Hen"ng sYste L; i iot Wate, Gthe.
14T.Q C2Q11`J`IILU n1.. "SMIL'lu'l ai::. I'z,' the 1eS r_"'e";
hzivf•roacl alin a9we to the T(,vnr;arm Conditions nn the bark of This
Contractor Name.
cross' City: Stat' zzl-
dame: -ce,s-NLI—hi"
Contractor Signature: Date:
(rage 1 of 2)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
�. 600 Washington Street
Boston, MA 02111
tt' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ati,plicant Information Please Print Legibly
N�Ine(Business/Organization/Individual): Energia, LLC
Address: 242 Suffolk St.
CityJState/Zi : Holyoke, MA 01040 phone#: 413-322-3111
Aretyou an employer?Check the appropriate box: Type of project(required):
i. I am a employer with 1�494. ❑ I am a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.U 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 an capacity. employees and have workers'
� S Y P ty. 9. ❑ Building addition
[No workers' comp.insurance comp. insurance
5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions
required.]
3. I am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
j myself. [No workers'comp. right of exemption per MGL 12.nRoof repairs
insurance required.]t C. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
tContraators 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.
Insuratice Company Name: Guard Insurance Group
I
Policy#or Self-ins.Lia#: ENWC952172 Expiration Date: 7/01/2019
— C�
Job Sit Address: i 1� M�`� Q� ti - City/State/Zip:t, nny
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 to250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the 91A for insurance coverage verification.
I do It ereby cern nder fire pains and penalties of perjury that the information providedab a is t e and correct.
Si atuie: Date:
Phone#, 413-322-3111
Oficial use only. Do not write in this area,to be completed by city or town official
I
City�r Town: Permit/License#
Issui g Authority(circle one):
1.Bo rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S,Plumbing Inspector
6.Ot er
Contact Person: Phone#:
i
i
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-092540 Expires: 09/0212019
THOMAS B ROSSMASSLER A
100 MAIN STREET
HATFIELD MA 01038k- 6
At
Commissioner Cj'
/A r
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ROME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
-
lRegistration- 165169 Type: Office of Consumer Affairs and Business Regulatidn
Expiration: 1/11/2018 LLC 1.0 Park Plaza-Suite 5170
Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE,MA 01040
Xluderseeret;try Not valid without signature
ac"� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
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
REPRE6,ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poilcy(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 C TACT
The Dowd Agencies,LLC PHONE Ma CDnro FAX
14 Bobald Road •413-538-7444 IAjC,No):
E-MAIL
Holyoke MA 01040 s
PRODUCERCUSTOMER 10#- ENELL
INSURER(S) AFFORDING COVERAGE NAIC0
INSURED INSURER A:Evanston Insurance Company 35378
Energia, 41LC
242 Suffolk Street INSURER a.Commerce Insurance Company 34754
Holyoke MA 01040 INSURER c:StarStone National Insurance Company 25496
INSURER D:Guard Insurance Group 8281
i 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.
INSRTYPE OF INSURANCE ADL POLICY EFF POWCY EXP
D. POLICY NUMBER LIMITS
A GENERAL LIABILITY 2DB4466 7/1/2018 71112019 EACH OCCURRENCE S 1,000 000
X —�
COMMERCIAL GENERAL LIABILITY PR I a ccuaanca S 50,000 _
CLAIMS-MADE a OCCUR MED EXP(Any one arson) S1,000
j PERSONAL 8 AOV INJURY S 1.000,000
GENERAL AGGREGATE S2.000,000
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000
POLICY FX PRO Loc
LOC S
B AUTOMOBILE LIA131UTY BHOPBJ 711/2016 7/112019 COMBINED SINGLE LIMIT S 1000.000
AN AUTO (Ea accident)BODILY INJURY(Per person) $
ALL OWNED AUTOS —°—°—°
X SCHEDULED AUTOS BODILY INJURY(Per accident) S
PROPERTY DAMAGE
X HIRED AUTOS (Peraccident} s
X NON-OWNED AUTOS S
S
C JDED�CTJEILE
UMA LIAR X OCCUR 75750HIBOAU 7/1/2018 71112019 EACH OCCURRENCE $1.000,000
EX
LIAR CLAIMS-MADE AGGREGATE $1.000.000
S
E7iNTII S
D WORKER COMPENSATION ENWC952172 71112016 711/2019 X iM1C STATU• OTH-
AND EMP OYERSI LIABILITYIN
ANY PRO RIETORIPARTNERIEXECUTIVE Y❑ N/A E.L.EACH ACCIDENT _$.1,000.000
OFFICER be
EXCLUDED?
{Mrndat 0 In NH} E.L.DISEASE-EA EMPLOYEE $1,000 000
It yyes,des be under
DESCRIP
ON OF OPERATIONS below. E.L.DISEASE-POLICY LIMIT S
000 ODO
DESCRIPTION 00
OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AddlUonal Remarks Schadute,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
i
IN ACCORDANCE WITH THE POLICY PROVISIONS.
To Whom It May Concern AUTHORIZED REPRESENTATIVE
1988»2009 ACORD CORPORATION. All rights reserved.
ACORD 25(?009/09) The ACORD name and logo are registered marks of ACORD
I
I
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS a. 4
212 Main Street a Municipal Building yi>d.• �a�
Northampton, MA 01060 ssp •••a,����
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:
(Please print house number and street name)
Is to be disposed of at:
R_ \Wb Vl(AC- SAL\
( ease print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Sig tdpd'ol Permit Applicant or Ow er D e
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.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
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:'Zec�`)U Est. Cost:
Address of Work::1.2)
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:
I hereby apply for a building permit as the agent of the owner:
![yyVmaUL ler
Date J 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
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Cons cfion Sug)ervisor: Not Applicable 0
'T lc�
Name of License Holder cpk go
License Number
2.LA k 121ffita
Address Expiration Date
tble�0
�arure I h n6'
9.Reallatered Home Improvement Contractor: Not Applicable 0
Company Names Registration Number
Address Expiration bafe
C)\O'--A3 TelephoA �22-- W
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....... )q No...... 1:3
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all agglicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ NUW Signs IO] Docks [Q Siding[[--3] Other[ ]
Brief Descri tion of Propose
Work:Z'n��C�\r�cl
Alteration of existing bedroom Yes No Adding new bedroom Yes ��N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existina 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
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,kftA-_ \e-,e r\ as Owner of the subject
property R
hereby authorize —Vcm
to act on my behalf, in all matters relative to work authorized by this building permit application.
�- (
T ALA Tf to
Signature of Owner Date
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.
Print Name
Signature f Owner/Agent 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 °lo
(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 DON'T KNOW 0 YES 0
IF YES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 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 a NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Depawienf use only
City of Northampton Status of P16(mit
• -'"° Building Department Curb CuVoriveway Permit
212 Main Street SeweNSepticAvailability
•� Room 100 WaterNVeil Availability
Northampton, MA 01060 T $0111119f$$ni4
phone 413-587-1240 Fax 413-587-1272 Plot%Se P1�ns
Other Specify.
APPLICATION
APPLICATION TO CONSTRUCT ALT a R DOLISH A ONE OR TWO FAMILY DWELLING
7
SECTION 1 -SITE INFORMATION old
1.1 Property Address:
This section to be completed by office
�J
Map Lot _Unit
M i DEPT OF r'UILDING INSPECTIONS
NORTHAMrTON,MA 01$Wje Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) CtTnjilin Ad
sec �r MkA N-ft Toy m
teleph
Signature
2.2 Authorized Anent:
TQES:1 2
Name(Print) Current Mailing Address:
LA va) X22-�11
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2(t(`(\ M (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
#jq
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) lCheck Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: L /( ?6 ��
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
73 MASSASOIT ST BP-2019-0610
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24C-096 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-2019-0610
Project# JS-2019-000995
Est.Cost: $2000.00
Fee: $77.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sa. ft.): 14592.60 Owner: MELLEN KATHLEEN
zoning:URB(100)/ Applicant: ENERGIA LLC
AT. 73 MASSASOIT ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:11/26/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:INSU LATION CRAWL SPACE WALL R10 RI DIG
BOARD
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 Deuarlment 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 Shmature:
FeeTy>pe: Date Paid: Amount:
Building 11/26/2018 0:00:00 $77.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner