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23A-152 (4)
12 MAPLE ST BP-2021-1372 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 152 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-2021-1372 Project# JS-2021-001492 Est.Cost:$1400.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 165169 Lot Size(sq.ft.): 15420.24 Owner: KAMINS KATHERINE Zoning: URB(100)/ Applicant: ENERGIA LLC AT: 12 MAPLE ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:5/25/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC 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 ' ad2 TI FeeType: Date Paid: Amount: Building 5/25/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner - oast) ,1 -.*-T- 11-FF -rr s' Clukta9 5-VI-Zi i_ I iiwct The Commonwealth of Massachusetts Board of Building Regulations and StandardsFOR , Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011 _ i— „I One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number:(3P-202.1-0 z377� Date Applied: 5(2- 202 /1c:uiDJ / 25S _1/. / 5-25-20 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property APLE ST Address: 1.2 Assessors Map&Parcel Numbers 12.3 A 159-- 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: u1?13(6 Ot7 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided lT 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record:KATHERINE KAMINS Florence, MA 01062 Name(Print) City, State,ZIP 12 MAPLE ST 413-563-2094 IVELICE@ENERGIAUS.COM No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other La' Specify: INSULATION Brief Description of Proposed Work':ATTIC FLAT-14" FLOORED R-49 DENSE CELLULOSE ATTIC FLAT-6" FLOORED R-19 DENSE CELLULOSE SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $1 ,400.00 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 $Suppression) Total All Fees: $ (0�el-) Check No7])l$ Check Amount: Cash Amount: 6.Total Project Cost: $1 400.00 ❑Paid in Full 12 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 U List CSL Type(see below) 242 SUFFOLK ST No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) HOLYOKE. MA 01040 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) ENERGIA LLC 165169 01/10/2022 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 l8 No .❑ 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 _ ((ZI2( Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering m ame 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 understandin . Jv Print O er s or Authorized Agent's Name(Electronic Signature) Date 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 Massachusetts w •'0 .( DEPARTMENT OF BUILDING INSPECTIONS 2 z 212 Main Street • Municipal Building yvj a' Northampton, MA 01060 ..f`SN�Y 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: U 1/V The Commonwealth of Massachusetts i Department of Industrial Accidents metls Office of Investigations fi . M Lafayette City Center Ilia': 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 I am a employer with 16 employees (full and/ 5. 0 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]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑■ Other INSULATION *My 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: 12 M4Pt'e S`r City/State/Zip: Flo kg NG , Ma 011 G Z 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, u er the pains and penalties of perjury that the information provided abov is true and correct. Signature: Date: //2/ Phone#: 413- 2-3111 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): 1ljBoard of Health 2.1=I Building Department 30 City/Town Clerk 4.0 Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia AcC4::::DGE®.. ENERLLC-01 CHRISTINE -- CERTIFICATE OF LIIABLOTY NSURAMCE DAs 25;2o D2 0 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 POUCIES 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 R$34 nEACT Christine Sullivan Phillips Insurance Agency,Inc. PHONE 97 Center Street (NC,No.EXU:(413)594-5984 1FAX No):(413)592-8499 Chicopee,MA 01013 no lss,christine@phillipsinsurance.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. INSR ADM_SUER LTR TYPE OF INSURANCE IMl0DI EFF POLICY EXP _!NM WVD, POLICY (pgM(DD(yYYY1 (MMfODI`�Y1 UMI75 A X COMMERCIAL GENERALLWBIUTY EACH OCCURRENCE g 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/112020 7i1/2021 DAMAGETOEEND n ) S 100,000 I— MED EXP(Any one person) S 5,000 — - PERSONAL&ACV INJURY S 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 1POUCY X JECT 1 ILOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER $ A AUTOMOBILE LIABILITY rCOMB)NED SINGLE LIMIT 1,000,000 (Ea accident) g X ANY AUTO — BAP2477206 7/1/2020 7/112021 BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS�� ONLY AUTOS p BODILY INJURY(Per accident) $ _AUTOS ONLY AUTO ONLY (PRelsDI ent1 AMACE g $ A X UMBRELLA UAB` X OCCUR EACH OCCURRENCE S 1,000,000 EXCESS UAB 1 CLAIMS-MADE PBP2870943 7/1/2020 7/1/2021 AGGREGATE g 1,000,000 DED X RETENTIONS 0 $ B WORKERS COMPENSATION If X PER OTH- AND EMPLOYERS LIABILITY STATUTE ER ANY PROPRIETOR/PARTNFJxrEXECUTIVE ��Y-�I-pN�� ENWC162970 7/1/2020 7/1/2021 E.L EACH ACCIDENT S 1,000,000 OFFlCERIMEMBER EXCLUDED? t 1 N I A (Mandatory In NHj EL DISEASE-EA EMPLOYEE S 1,000,000 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,Addltionai Remarks Schedule,may be attached If more space Is requlnad) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Energia LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suffolk St. ACCORDANCE WITH THE POLICY PROVISIONS. 242Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE ACORD 25(2018/03) ©1968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD f t HIP i (. 1 y mS _ p LJ u` C � '�i'� m e - e k i. )._ 11 hi,ti a1 c 2 7. 7-,,. , E' ig g. ll I l'l ;.* i . a 8 $ iu t a � a �t e.-e P y Ca ii " i. s k 1—;:, ,,,, !St IS t 'i t,", G. '•- .-p —,...51 ,,,,-4 r 0 .6 - -'5..' . l• • - a ksw, :.;:, ,0 „s ,, ; i , . * €° twi �', -a-+-_• .tat 'yy �; k e S • - $i i ` t2 ' %¢ � I �;tri i '' s Commonwealth of Massachusetts — _ Division of Professional Licensure Board ofuiidimg Regulations and Standards • Ciartsfirithfioll Suipervisor CS-iJa25 Q • Expires:09102/2021 THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELD MA'01038 0. 7,r F Cotaetrii __ ,, , `✓'/r '/1/".. wuiVo//, ij/. /474�r/4411/4 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 THOMAS ROSSMASSLER 7 242 SUFFOLK STREET ,�.,e(a.(; i_______ HOLYOKE,MA 01040 Not valid without signature Undersecretary DocuSign Envelope ID:A6DBODBB-15FC-4180-AA63-349CCF3F3F72 RISES ENGINEERING" OWNER AUTHORIZATION FORM Katherine Kamins (Owner's Name) owner of the property located at: l2.- (Property Address) (Property Address) hereby authorize C�`4 (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. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. LtlDocuSigned by: t1P ' §6§, eture 6/17/2020 I 1:29 PM PDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com