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35-181 (3) 4 PINE VALLEY RD BP-2020-0201 GIS#: COMMONWEALTH OF MASSACHUSETTS MW.Block: 35 - 181 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-2020-0201 Proiect# JS-2020-000341 Est.Cost: $1700.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 32103.72 Owner: ORTIZ ANGEL Zoning: Applicant. ENERGIA LLC AT. 4 PINE VALLEY RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.8/16/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-ATTIC FLOOR - 12" OPEN BLOW 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 8/16/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dep f�. City of NjDpar��ie�ntqt amBuilding 21 Rom 1-treAetgUG fo? NSULATION Northampton,it 060 X019 phone 413-587-1240 Fax 4133 72 ONLY J APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY QWELrLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 ProaertV Address: This section to be cod by office Map_ Lot eteUnit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A"QA C1r-V\7 UO►\feu jA_ Nov�hi��r�c�t ,r'1Aor, GZ Name(P' t) �1 (�' !, Curren Mailin ddres W\ t � A \ �Y �� Telephoned � Signature 2.2 Authorized Agent: T o, 2 -12 S� �� ���� M own Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i —�y� O© (a)Building Permit Fee 2. Electrical ��•lJ (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: t�j' �(o'Zol l Building Commissioner/Inspector of Buildings Date Ce EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) .. !"'7�' �:«. �'� — .�ash:.. r_�`, i � .f� �;, '. ...<� �r� :�y� ., ,i • '�� r r.. . .. ..� ..a .. . .��......., w dtP ...� ... i a ,�< .r .. - .,. .. �... �.�r �. � .; -n. _ _ .,. � .. F _ r • ,: .. � . _ w ,. .. ... , . ' � � t -. � t �� . i � � ., �. -' {, „�,. � � _. .... t ._. .. ._. .. .. _. .�.. ,. .. s. _. _. y • _ - � � Ty .�� `. . ._�w ._. ...,_ ..__ _ ._ __ M .. ... _ N --••— .�rt -�-- -- -- - L..�a t ...-, �. d .._,. -9 mer ..�i _.. ..,�. .•.:. C.- _ ;. ._.. ,. '_. ._.. _ _ .�, ._ ,1� ,, ., ', . .. � � , ,. � . .. .� '. .. � -. `{ *fit' i ,, r ... ,.. ..�..� .v _. _ ... _. _ . . . - - - .� . . '. .. ''�7 , , ., .. �'' r y,� ` �i '.�� "'•. Jnr � @,� e r .. r .,. 1F�a of '���� � 1� •w , 5�e � .'�� �1 �` �' i , � t x. .,1^r''�^ a t"'r n ' 1 .. \Y .. SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicaab`le1❑ c,) Name of License Holder: m SIE r OWL ""1 C) License Number Address Expiration Date Sign ur Telep one 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Narqd Registration Number Address J Expiration Date Telephon t-1 - &\ SECTION 5-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....... �K No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY I, -TcAnI��c)r( 5��er 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 I, Nc 1 Q Y-V\L 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. c566 Re&A4-1' t d R b5 0 Signature of Owner Date City of Northampton Massachusetts w ;L DEPARTMENT OF BUILDING INSPECTIONS �. 212 Main Street •Municipal Building Northampton, MA 01060 rsY-.- `hoc 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: ,-1 TMr,\Iw feu '. (Please print house numbe nd street name) Is to be disposed of at: (Please print name and location of facility) -j Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ell r4 Signatu/fPermit Applicant or O ner ate 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 j• .,a. Sys...:�-:..s�� Massachusetts G 1 N: DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Jdf. aOb Northampton, MA 01060 Property Address: L1 V1 eyja�k e�.% 1� Contractor THOMAS ROSSMASSLER-ENERGIA LLC Name: Address: 242 SUFFOLK ST City, State: HOLYOKE, MA 01040 Phone: 413-322-3111 Property Owner Name: ` Address: City, State: 1, THOMAS ROSSMASSLER (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 Dates I�S I ICS ENERLLC-01 CHRISTINE '4`coRo CERTIFICATE OF LIABILITY INSURANCE DATEIYYYY) 6/226/206/2019 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 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 c TncT Christine Sullivan Phillips Insurance Agency,Inc. PHO(A/C,No Ext:(413)594-5984 Arc,No: 413 592-8499 97 Center Street ) Chicopee,MA 01013 affis,christine@phillipsinsurance.com INSURER AFFORDING COVERAGE NAIC# INSURER A:.State Automobile Mutual Ins Co INSURED INSURER g:Guard Insurance Group Energia LLC INSURER C 242 Suffolk Street INSURER D: Holyoke,MA 01040 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILTR NSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR X DAMAGE TO RENTED , PBP2870943 7/1/2019 711!2020wrence100,000 MED EXP(Any oneperson) 5+000 PERSONAL&A V INJURY 1+000+000 ,GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY L_J JJECT EILOC PR DUCTS-COMP/OP A 2,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000 rip X ANY AUTO BAP2477206 7/1/2019 7/1/2020 BODILY INJURY Per erson AUTOS EONS ONLY AUTNOSSWU�L�EED BODILY INJURY Per accident AUTOS ONLY ABIOS ONLOY PAOacc dent AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 1+000,000 EXCESS LIAB CLAIMS-MADE PBP2870943 7/1/2019 7/1/2020 AGGREGATE S 1,000,000 DED I X I RETENTIONS 0 B AND EMPLO COMPENSATION RS'N A T ON PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE TY Y� ENWC989225 711/2019 7/1/2020 STA UTF ER 1,000,000 L EACH ACCIDENT QpFICER rytIn BER F>(CLUDE07 N!A1,000 000 (Mandato NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � .. .... .., +� •gip_(.i {>t� , '�'. 1 1.7, - I �f, 1. . .r t' tt .��!-. a ��, !r :�'i. Ti',! F I i' .z, � :r � • r!: .. i)' . ) :ij � - .. S'. :.rS '�lr . ,_. ,�tq.+ `3;i�i ,ti-.lp :{i� 1 ct� h�' i°. •• t. '.� ...i' 1 i'+.c'l.Fl4`•!"Lt,. i`i. +'' ,... +tltSF , • ,.. .•.,{Or if , • ,. ':'{;� ... ,. 1. , .• � � t.{{ :�., , .: `)' . ' 1 ' i ��,. ,� 'alp -'': �} • ' °' ' DocuSign Envelope ID:AADE0735-2BA2-4B1D-B27D-D998BA8D1017 AmPermit Authorization mass save Form 'rav:nye rrw�dq+-4MPrtT: ... n>r. Site ID: 3857973 Customer: ANGEL ORTIZ Angel Ortiz owner of the property located at: P/ /Q w er's Name,printed) 4 Pint � 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. D�cuS(igned by: Owner's Signature: a 0 mv� Date: $/5/2019 19:23 AM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: �AJG12&14 Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 for Office rise✓nly Rev. 102015