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18C-022 275 HATFIELD ST BP-2020-0376 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-022 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2020-0376 Project# JS-2020-000646 Est. Cost: $1400.00 Fee: $71.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 8145.72 Owner: DRAPER SARA Zoning: SR(100)/WP(93)/ Applicant: ENERGIA LLC AT. 275 HATFIELD ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.9/23/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.INSULATE ATTIC FLAT 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 9/23/2019 0:00:00 $71.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner /"' F // a City of Northampton /`� DePFOR Building Department 212 Main Room Oto et '`'T 2 lyl ULA TION Northampton, MA 0106a phone 413-587-1240 Fax 413-587-1q TON r�'oropFc ONLY MNS APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING Y SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: �se/ction to be completed by office Map v Lot !/O.�" Unit L15Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �0rcl. Dklc-�iL 2 � 4 �a, ��.IdStYeet.►�artham►�ron. ��C Name(Print) ICurrent Mailing Address Cc w ff"0- RUM to(m Telephone 1203�`�2S—y�108 Signature 2.2 Authorized A-gent: 2L12 Name(Print) Current Mailing Address: 3�LD -3M Signatu Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building nco, (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 7/' 't) v 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Numbe : Date Issued: Signature: Building Commissioner/Inspector of Buildings Date yZ L(CE @ 2 nevi/�°c.c�CS • � _ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) k � ;:,..`'�'���» "U'. ):.'�� ..'•' ���ti'�i�.S�_.� t..S. N•..t�.'"�: rr. rr�F;' .=4 `� � t;^'�t.�r�'ai. .'.i.:i.i , �wn.,.....,.+.......-.krM�M.'..MM.+r-+lr'`�ua..nlp:..p..s-, w.. �w ......-...i►+..a...a.r,.....r .w,.+� ..... .._.M.. v1•'p+-.r r� M.w.- ,f.,.ew.�W •rIi-, ,.. .A r.wrr+r...•'��w ." it'i � - ✓t S-:' ,, it , e !?�_ .. ...,,', .. 'i_c',��'fi1��.._1 .�� ...;' _i�f,r f•�'+tom.,' _f ...s,� .,:•�.+. iTc Ls } .. 4. ..;, ._ ,.^.. _- fir•, __ _ f S S 4 ,414.' y Ix ,". �p l `�bS_/'"ii�St e.',1--" .'�{tip b�.-. _(�� Si+r., .,.1!S .,;,^.." ` f'1r#. '�.,.,�_{_t�:r. .7 •,� ' - ��.! .jt� .ZiY.�, r`rfl�`J 17 -'.,�'f r i .,'•r'f' .,, 2'd•. T.• f.i"'��t�'' 3•c��'��' , �i IR' •# Off �� i jr11,7E+7y5S' y` .1 /;'t 14` ~} ti S ai •,,,"k !r('4. '3 '� .. SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not liApplicable ❑ Name of License Holder:JC",) Yl (`)�>,f`(�Gl�1�j�f r 1?Z s:u 0 License Number Zk4l V, oK,e o\ Z if Address Expiratio Date &::� (X11 11 Signa/e Telep one 9.Reaistered Home Improvement Contractor: Not Applicable ❑ rcarG X /COS%�99 Company Nab Registration Number L c, RO\C-)qo 111.112e) Address n Expirati D TelephoneNk]k ,,2 3tirr 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....... No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONL:Y1- fm " x-31 C�IkU\o I, TC�C`C� RCic,�CY�C `�;1F( 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. Thmc c Print Name q 11)20�� JIA— Signature of Vm&fAgent Date I, JO.Y Ck as Owner of the subject property hereby authorize �d�l5�1 MSS _r to act on my behalf, in all matters relative to work authorized by this building permit application. bm i f f r) rYI G Ix 301 Signature of Owner Date i t , K,v +� •"�.�r.> '�! .«. d Lr ti���+� auI �►t.. A Mo' •.w •►- -a'JJc dt City of Northampton Massachusetts ��t,?s' �L `ct� DEPARTMENT OF BUILDING INSPECTIONS — 212 Main Street •Municipgal Buildinyt ,� f z Northampton, MA 01060 �f►jY� j,�O 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: -�kc\d 5-t �'r-,r kVYkMMn m C�1 OCA (Please print house number and street name) Is to be disposed of at: $11sf-'c1 y\1GSif (4" Rom `�-E- `�nr�noc�if l d , "Y\- 0 YYA (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 2,911 `7 Signa r of Permit Applicant or Ow er D# 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 9 fS}i 212 Main Street • Municipal Building O x1�CL ` Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: Z 0100, Contractor Name: TOM Y:g= f t' Address: LU Sk- c 1 y, City, State: y\G\S2�! . 11-IM C> O"C.1 Phone: 32.7 3\�1 Property Owner Name: YC`�; Address: SAyfrA City, State: C\(X)C) I, 10t`dSSS51e (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 p q 2� 1 ®� Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstWtt1Q�j� n,isor CS-092540 THOMAS BASSLER Expires: 09/02/2021 100 MAINSTREET /04) HATFIELD MA 01038 y Commissioner % wOffice of consumergffairs&Business Regulauou ' '�IOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only Registration: 165.169 before the expiration date. If found return to: Expiration: 1/'11/2018 Type Office of Consumer Affairs and Business Regulation laza-Suite 5170 • LLC TO Partt P ENERGIA LLC //l !�+ D Boston,MA 02116 THOMAS ROSSMASSLER f 242 SUFFOLK STREET HOLYOKE. MA 01040 `'`' LL ^ >--• t 1Jndersecretary Not valid without signature . J ENERLLC-01 CHRISTINE ,4`ofzo CERTIFICATE OF LIABILITY INSURANCE DAT D/YYYY) 6//26/22612 019 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 NTACT Christine Sullivan Phillips Insurance Agency,Inc. AIC, o Ext:(413)594-5984 A/c 97 Center Street ,No:(413)592-8499 E-MAIL p p Chicopee,MA 01013 .christine hilli sinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:State Automobile Mutual Ins Co INSURED INSURER B: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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE , CLAIMS-MADE a OCCUR X PBP2870943 7/1/2019 7/1/2020 DAM AGE To RENTED urrence) $ 100,000 MED EXP(Any oneperson) 5,000 PERSONAL&ADV INJURY 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY EK JE 0 E]LOC PRODUCTS-COMP/OP AG 21000000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO BAP2477206 7/1/2D19 7/1/2020 BODILY INJURY Perperson) OWNED SCHEDULED AUTEOS ONLY AUTOSBODILYBRODILY INJURY Per accident AUTOS ONLY AUOTOS ONLDY PPerr OPERcent AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 1,000,000 EXCESS LIAB CLAIMS-MADE PBP2870943 7/1/2019 7/1/2020 AGGREGATE 1,000,000 DEC) I X I RETENTION$ 0 B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YINTATT. ENWC989225 7/1/2019 7/1/2020 E.L.EACH ACCIDENT ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000 000 QFFICER/MEMBEREXCLUDED7 N/A 1,000,000 (Mandatory In IJH) E.L.DISEASE-EA EMPLOYE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kip 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): 1.61I am a employer with 19 4. ❑ I am a general contractor and 1 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 1011 Electrical repairs or additions 3.❑ 1 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 employees. [No workers' 131-1 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.#: ENWC989225 Expiration Date: 7/01/2020 Job Site Address: 2-1� wic ld b{- City/State/Zip:Nol VV)Gmwc)n�M1j-0 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 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. Ido hereby certify u er the pains and penalties of perjury that the information provided above is true andel correct. Si ature: Date: 7 Phone#: 4(3-322-3111 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. 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X it t.( ►fr:, t. ff� �iz'(A' ,ye� � v.t1" 1 1�1� L.i � to ] .f" ;•xy;� S'ir • _ Off, ,g4a W"i AA*'N�i ;, ear t� t ;, :•� 4 RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Sara Draper (Owner's Name) owner of the property located at: 275 Hatfield Street (Roperty Address) northam ton, MA 91060 ( perty Address) hereby authorize �fj6k-C—Z-14 � CC- (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'sS g atu Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 02021 1 339-502-6335 www.RISEengineering.com