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35-136 (3)
28 WESTWOOD TER BP-2021-1370 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35- 136 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-2021-1370 Project# JS-2021-002288 Est.Cost: $3200.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 165169 Lot Size(sq. ft.): 10105.92 Owner: ANSALDO KAREN Zoning: Applicant: ENERGIA LLC AT: 28 WESTWOOD TER Applicant Address: Phone: In.tiurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON: TO PERFORM THE FOLLOWING WORK:INSULATION - WALLS & ATTIC FLOOR 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 PO• ;CATION OF ANY OF ITS RULES AND REGULATIONS. I. ' ; • � ' Certificate of Occupancy Sif4natnre: I FeeType: Date Paid: Amount: Building 5/24/20210:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 c\I c (.- The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR 1 Massachusetts State Building Code, 780 CMR MUNICIPALITY USE •It 1 uileling Permit Application Construct,Repair,Reriavate Or Demolish a - Revised Mar 27711 .. One-or Two-Family Dwelling This Section For Official Use Only Building ermitNumber:ee,202(•(370 A plied: �Z/�ZoV( Ell iL R o,5 j7D)te J� 2y'Z1�Z) Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 28 WESTWOOD TERRACE '— 13 So 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 1 Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: KAREN ANSALDO NORTHAMPTON, MA 01062 Name(Print) City, State,ZIP 28 WESTWOOD TERRACE 413-387-9482 IVELICE@ENERGIAUS.COM No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 'Specify: INSULATION Brief Description of Proposed Work2:WALLS-WOOD SIDED-3" DENSE PACK CELLULOSE ATTIC FLOOR - 7" OPEN BLOW CELLULOSE SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $3,200.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ o 0 Suppression) �o J�' Check No:7115 Check Amount: Cash Amount: 6.Total Project Cost: $3,200.00 110 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 92540 09/02/2021 TOM ROSSMASSLER License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 242 SUFFOLK ST No.and Street Type Description HOLYOKE, MA 01040 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-322-3111 IVELICE@ENERGIAUS.COM I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165169 01/10/2022 ENERGIA LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 242 SUFFOLK ST IVELICE@ENERGIAUS.COM No.and Street Email address HOLYOKE, MA 01040 413-322-3111 City/Town,State,ZIP Telephone SECTION 6: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 LB/ No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize TOM ROSSMASSLER - ENERGIA LLC to act on my behalf in all matters relative to work authorized by this building permit application. SEE PERMIT AUTHORIZATION /'L� Print Owner's Name(Electronic Signature) Die SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in is application is true and accurate to the best of my knowledge and understanding. Print er's or Authorized Agent's Name(Electronic Signature) qt ate NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton O/yS H A MY>'O� 7.? "' S�Gf • Massachusetts ��,?• *�:_ e. DEPARTMENT OF BUILDING INSPECTIONS 7S. \*"C A` 212 Main Street do Municipal Building vj - OD Northampton, MA 01060 sr'W TO‘'‘� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: ROSE ST., SPRINGFIELD, MA The debris will be transported by: Name of Hauler: ALLIED WASTE Signature of Applicant: Date: Z.!' Commonwealth of Massachusetts Dtvisioal of Profess:on-al Licensure Board of Building Regulations and Standards ConStrthttibriStitliervisor CS-022540 Eycpires:0510212021 THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELD MA.0103 _ • r I f f ..,:, i Conn mil ssiartet' y4.4-'4"4--_ 5'7,"/' %Cii/,i/(iil/v//7//i/2 .. . . . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 165169 01/10/2022 1000 Washington Street -Suite 710 ENERGIA LLC Boston,MA 02118 flidfl;THOMAS ROSSMASSLER /) 1 ,, --iis 242 SUFFOLK STREET ,,,,,r-a.r ,(,6,4. q. r t" HOLYOKE,MA 01040 Undersecretary Not valid without signature The Commonwealth of Massachusetts —4 Department of Industrial Accidents !" ►—_ Office of Investigations =13im1= Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 -#"� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ENERGIA LLC Address: 242 SUFFOLK ST. City/State/Zip: HOLYOKE, MA 01040 Phone #: 413-322-3111 Are you an employer? Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 16 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.111 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑■ Other INSULATION *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: GUARD INSURANCE GROUP Insurer's Address: 2' WESrvW/00 0 TE22Ace City/State/Zip: Nd R1 k411ef V1 /ya 0(04 0 Policy#or Self-ins. Lic. # ENWC162970 Expiration Date:7/01/2021 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nder the pains and penalties of perjury that the information provided ove is true and correct Signature: Date: 71241 Phone#: 41 -322-3111 Ext 122 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.0Board of Health 2.1=1 Building Department 3.1=1 City/Town Clerk 4.1:Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia � �—"� ENERLLC-01 CHRISTINE AAC`CP ® DATE IMM)DD/YYYY) �e.� CERTIFICATE OF LIABILITY INSURANCE 6/25/2020 THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Christine Sullivan Phillips Insurance Agency,Inc. PHONE 97 Center Street INC,No,Ext):(413)594-5984 IFax (ac,No):(413)592-8499 Chicopee,MA 01013 a D'E$S:christine@phillipsinsurance.com INSURER(§)AFFORDING COVERAGE NAIC It INSURERA: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. LTR TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS NOD INVD INLft�l/DD/WYYI IMM/DD/YYW) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 1 CLAIMS-MADE FT OCCUR PBP2870943 7/112020 7/1/2021 DAMAGE TO RENTED 100,000 1 L___I PREMISES(Ea occurrence) S MED EXP(Any one person) S 5,000 — _ PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JET L I LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BAP2477206 7/1/2020 7/1/2021 BODILY INJURY(Per person) $ OWNED SCHEDULED — AUTOS ONLY _AUTOS p BODILY INJURYT (Per accident) $ AUTOS ONLY —AUTO ONLY (Per acccttdent}p AMAGE S _ $ A X UMBRELLA UAB X OCCUR 1,000,000 _ ____ EACH OCCURRENCE S EXCESSUAB CLAIMS-MADE PBP2870943 7/1/2020 711/2021 AGGREGATE S 1,000,000 DED X RETENTIONS 0 _ s B WORKERS COMPENSATION X PERTUTE ERH AND EMPLOYERS'LIABILITY ENWC162970 7/1/2020 7/1/2021 1,000,000 OFFICREWMEMBOER PROPRIETOR/PARTNER/EXECUTIVE ECUTIVE I N N/A E.L EACH ACCIDENT S 1000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S ' If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS/LOCATIONS/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, Energia LLC ACCORDANCE WITH THE POLICY PROVISIONS.NOTICE WILL BE DELIVERED IN 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE d ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:0DBD4657-E2C1-4C9A-B406-AF969D87BC13 Permit Authorization mass save Form Sivvngs thro..gn an..y t ,r, Site ID: 4209814 Customer: ANDREW SADOWSKI it Karen Ansal do , owner of the property located at: (Owner's Name,printed) 28 Westwood Terrace 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. DocuSigned by: Owner's Signature: 611t awSatjo L ret,z far,m,Ce'.ee 4/28/2021 Date: •s••••••••••••••••••••••••••••••M •••••••••••••••••••••••••••••••••••- FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: a}62-CIA" Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Orly Rev. 102015