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DocuSign Envelope ID:4E62FF75-C102-4ABE-A4F0-05FFBFEB16DC RISEwM ENGINEERING OWNER AUTHORIZATION FORM 1, Ben Cuperman (Owner's Name) owner of the property located at: 408 Florence Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize L1V 6"- I (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. Docuftned by: 6W, �YWMPJA, w!9a&k_mature 11/27/2018 1 8:53 PM EST Date RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com The Commonwealth o,f"Massachusetts Department of Industrial Accidents ' Office of Investigations >= .� 600 Washington Street s Boston,MA 02111 ' www.mass.govhlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers At)121icant 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.Q1 am a employer with _ 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers'comp. insurance comp. insurance.$ 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.❑ 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 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box N 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. tContractors 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 rite 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 crud job site information. Insurance Company Name: Guard Insurance Group Policy#or Self-ins. `Lic.#: ENWC952'172 � ` Expiration Date: 7/01/2019 Job Site Address:L1� V\QA e WQ �(, City/State/Zip:_F 01(e )U_ 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 ane-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 un er the pains andpena/ties of perjury that the information provided above is true ndddccorrect. Signature Date: 2, d Phone#: 06-322-3111 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitJLicense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Cleric 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor CS-092540 Expires: 09/02/2019 THOMAS B ROSSMASSLER 100 MAIN STREET HATPIF-1-0 MA 01038 Commissioner Office of Consumer Affairs&Business Regulation License or registration valid for individul use only AOME IMPROVEMENT CONTRACTORbefore the expiration date. If found return to: ftegistration: 165169 Type: Office of Consumer Affairs and Business Regulatidn -Suite 5170 10 Park Plaza Expiration-. 111112018 LLC Boston,MA 02116 ENERVA LLC THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE,MA 01040 ITudersecretRry Not valid without signature 0, DATE(MM/DDIYYYY) AC"RV CERTIFICATE OF LIABILITY INSURANCE F 8/2/2016 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(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endorsements, PRODUCER NAME! Mary Conroy The Dowd Agencies, LLC PHONE 413-538-7444 o✓c Nol: 14 Bobala Road E-MAIL Holyoke MA 01040 DRS PRODu ER ENELL INSURERS AFFORDING COVERAGE NAtC S INSURED INSURER A:Evanston Insurance Company, 35378 Energia, LLC INSURER B-Commerce insurance Company 34754 242 Suffolk Street Holyoke MA 01040 INSURER C:StarStone National Insurance Company 25496 WSURER o: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 ODwyn l S POLICY NUMBER MMI ICY EFFit POLICY YYY XP LIMITS LTRA GENERAL LIABILITY 2084466 7/1/2018 7/112019 EACH OCCURRENCE S 1,000,000 CAMTO RENTED X COMMERCIAL GENERAL LIABILITY PR AI S Q occurrence) S50,000 CLAIMS-MADE a OCCUR MED EXP(Any oneperson) IS1.000 PERSONAL 8 AOV INJURY $1.000.000 GENERAL AGGREGATE S 2.000.ODO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2.000.000 POLICY X PRO• LOC $ 8 AUTOMOBILE LIABILITY 8HQPBJ 7/1/2016 7/1/2019 COMBINED SINGLE LIMIT S 1.000,000 (Es accident) ANY AUTO BODILY INJURY(Per person) j$ ALL OWNED AUTOS "— X BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS 5 S C X UMBRELLA LIABNCLAIMS.MS-MADE CCUR 7575OH180AU 711/2018 7/1/2019 EACH OCCURRENCE $1,000,000 EXCESS UAB AGGREGATE $1,OOQ000 DEDUCTIBLE S RETENTION S S D WORKERS COMPENSATION ENWC952172 7/1/2018 7/112019 X I WC STATU- OTH- AND EMPLOYERS'LIABILITYFR ANY PROPRIETORtPARTNER/EXECUTIVE YN NIA E.L.EACH ACCIDENT 51,000,000 OFFICERIMEMSER EXCLUDED7 `—' (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 701,Additional Remarks Schedule,if more space)a 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 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD City of Northampton JMassachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street oMunicipal 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: Lli OL E I o Venct, V"6 - (Please print house number and street name) Is to be disposed of at: (Please print name and location of facilit ) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) oTPermit Applicant or Owner Plate 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. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Superviso Not( 0 Nam of License Holder:-Vom C A 2-43-�A c) License Number csuf�n\V-NA-5k Oq la-L I Mn AddIres pirat � -J,')T2--? Exion ate X113 1106re' -relephont 9.Registered Home Improvement Contractor: Not Applicable 0 CPU a QLC— &A Company Naro Registration Number 2- -�&- �\�\ Y-P-f M ngo \ 12-07-0 Address ,f Expiration nate Telephone1L%4322--3\\\ SE TION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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....... lrp-- No...... 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:i Rear Building Height Bldg. Square Footage °to 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 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 Q DON'T KNOW Q YES 0 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 © 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 i 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampto it: Building Departme t Curb Cut/D Permit 212 Main Street DEC sus Lability '.L Room 100 Water/Wet wail Ility Northampton, MA 01 60 DEPT UILDIN Stru ural Plans phone 413-587-1240 Fax 4 -587-4 AMPTO , r pact APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION + t' Jrt,� I U 1.1 Property Address: This section to be completed by office Map — Lot 2(L/ Unit LAQf� , V\C)yCvC-:Q, Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Print) C rrent k4a'lin Address: A1C Y �� TVA 1 1 r ephone Signature 2.2 Authorized Aaent: j 142- aA01 Name(Print) Current MailingAddress: Signat Telephone Y SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ` ISM .0<� (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only BuildingPermit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Inr ie— EMAIL ADDRESS (REQUIRED, EITHER HOMEOWNER OR CONTRACTOR) 408 FLORENCE RD BP-2019-0670 GIS#: COMMONWEALTH OF MASSACHUSETTS MW.Block: 30C-014 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-2019-0670 Proi ct# JS-2019-001090 Est.Cost:$1800.00 Fee:$77.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sg.ft.): 54885.60 Owner: MATTESON PAUL D C/O BRUCE T WOOD Zoning: SR(100)1WSP(78) Applicant: ENERGIA LLC AT. 408 FLORENCE RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (4132322-3111 WC HOLYOKEMA01040 ISSUED ON.121512018 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC FLAT - 14" OPEN R-49 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# 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 12/5/2018 0:00:00 $77.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner