32A-044 (5) BP-2021-2099
13 CHERRY S'r COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-044-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2099 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 6000 ENERGY PROTECTORS INC 101143
Const.Class: Exp. Date:06/I6/2022
Use Group: Owner: EDWARDS DANIEL
Lot Size (sq.ft.)
Zoning: URC Applicant: ENERGY PROTECTORS INC
Applicant Address Phone: Insurance:
64 PAXTON RD (774)253-0277 6S62UB0G29826021
Spencer, MA 01562
ISSUED ON:11/01/2021
TO PERFORM THE FOLLOWING WORK:
INSULATION
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.
Signature:
• i'
6 .›.2 •.„
II
Fees Paid: $65.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
ti
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The Commonwealth of Massachus s CE/V
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Board of Building Regulations and St dare s . . ICI'ALITY
Massachusetts State Building Code, 7 0 C R OCT 2 6 20 cJ E
i 21 , .
Buildmg Permit Application To Construct,Repair, eno :to Or Demolish a R. ised ar 2011
One-or Two-Family Dwelli g tsPr
OF gUl
This Section For Official Use NOATHgM�TNG iNSP
BuildingPermit Number: I` A �N MA ot���
Ip�"� �-G/ Date Applied:
2 .� �,J
'c irl' ; �( 1I/ ' ' I
Building Official(Print Name) Signature Uo ! D to
SECTION 1: SITE INFORMATION 1.1 Ptroperty Addre ressrl C L 1.2 AssC�s Map&Parcel Nun /C
1.1 a Is this an accepted street?yes no Map Number Parcel Number
11
1.3 Zoning Information: 1.4 Property Dimensions:
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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 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: tt
p an,k Edlw c rctMai-quo() O 1- 1 ,/"AA- O t O c,0
Name(Print) City,State,ZIP
t. 1 C.h .erry St- 4i3-311/41 -S y zv
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of U9,is Other d/Specify: ! s4L Cil to
Brief Description of Propose Work': Ct K% S e 1.1 di-v c& % siti 4--e—,1r l
f tr C ' c3 I CA bocce-et - id , y✓1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ l0 0 OD 1. Building Permit Fee:$ Indicate how fee is determined:
j 0 Standard City/Town Application Fee
2.Electrical $ 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: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $L� 00 a 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-101143 6/16/22
License Joshua Dada e
Number Expiration
on Date
Name of CSL Holder U
List CSL Type(see below)
64 Paxton Rd
No.and Street Type Description
Spencer, MA 01562 U Unrestricted(Buildings up to 35,000 cu.ft.)
p Restricted 1&2 Family Dwelling
Cite Town.State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
774-253-0277 SF Solid Fuel Burning Appliances
jdada79@hotmail.com Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 172960 8/19/22
Energy Protectors Inc. — HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
64 Paxton Rd ___ jdada79@hotmail.com
No.and Street Email address
Spencer,MA 01562 774-253-0277
Cit}'frown,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 Issuanc of the building permit.
Signed Affidavit Attached? Yes 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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 this application is true and accurate to the best of my knowledge and understanding.
Print( pt ner'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 mvw.mass.goy/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
Aqu
Massachusetts •
•
4
DEPARTMENT OF BUILDING INSPECTIONS '
212 Main Street a Municipal Building �.
. ,. Northampton, MA 01060
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: ' roc`0vrl acA
The debris will be transported by:
En er5 L rL \em.rS
Name of Hauler:
Signature of Applicant: Date:
The Commonwealth of Massachusetts
►�_* 1, Department of Industrial Accidents
{ _ e_ 1 Congress Street,Suite 100
_Cs';_1 Boston,MA 02114-2017
=�, www mass.gov/dia
v�* Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):Energy Protectors Inc
Address:64 Paxton Rd
City/State/Zip:Spencer,MA 01562 Phone#:774-253-0277
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with 1 1 _employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ID Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.pRoof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑✓ Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box=1 must also fill out the section below showing their workers'compensation policy information.
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:Ace American Insurance Co
Policy#or Self-ins.Lic.#:6S62UBOG29826021 Expiration Date:
`9/01/22
Job Site Address: U U Lh Iv C T City/State/Zip: d r c`"s o l 14 01066
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: o'd/A1- Ct-d Date: 1 0-/ -2-0-1, L t
Phone#: 7 ` aS 3-V a7 7
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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
�� � r�Y DATE(MMrDD1YYYY)
�-• CERTIFICATE OF LIABILITY INSURANCE 08/30 J
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 CONI AST
NAME! Nina Arroyo
Coonan Insurance Agency,Inc. I�n�coHNo,Exu_ 508.987-7122 F ,No), 508-987-7152
267 Main Street ADDRESS: Nina@coonaninsurance.com
Oxford,MA 01540
INSURER(S)AFFORDING COVERAGE NAIC II
INSURER A' AIX Specialty
INSURED INSURER B: Safety
Energy Protectors,Inc. INSURER C Century Surety Insurance
64 Paxton Road INSURER D:
Spencer,MA 01582
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.
ODLSl1BR POLICYEFF POLICY nib
'LR �I TYPE OF INSURANCE )N80 Vy\O POLICY NUMBER (MM/DD/YYYY) (MM/DO!YYYYL LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
DAMAGE-10 RENTED
CLnIMS-MADE X OCCUR
PREI.NSES(Ea occurrence. S 100,000
MED EXP;Any one person) S 5,000
a y L1N-H714840-00 08/31/21 08/31/22 PERSONALSADVINJURY S 1,000,000
GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000
X POLIO l I PRJECOT LOC PRODUCTS-COMP/OP AGG S 2,000,000
S
OTHER
AUTOMOBILE LIABILITY COMBBII EDISINGLE LIMIT s 1,000,000
ANY AUTO BODILY INJURY(Per person( S
—
AUTOS SCHEDULED 6236519 12/23/20 12/23121 BODILY INJURY(Per acdde"x; S
B AUTOS ONLY X AUTOS y
XHIRED X PROPERTY DAMAGE NON-OWNED $
AUTOS ONLY AUTOS ONLY !Per accidentl
S
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 3,000,000
c EXCESS LIAO CLAIMS-MADE y CCP1005749 08/31/21 08/31/22 AGGREGATE S 3,000,000
DED RETENTION Si S
WORKERS COMPENSATION PER O .
STATUTE ER
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETORJPARTNER/EXECUTIVEr7 N!A E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
II yes describe under
DESCRIPTION Of OPERATIONS below - E.L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached it more space Is required)
Workers Compensation insurance certificate to follow under separate cover. Action Inc.and National Grid USA Its direct and Indirect parents
subsidiaries and affiliates shall be named as additional insured on Commercial General Liability and Automobile Liability policies
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.
Worcester Community Action
Council
484 Main St.ste.200 AUTHORIZED REPRESENTATIVE
Worcester,MA 01608
I
L . ,1444/ 0 i' - -- L.
1988.2015 ACORD CORPORATION. All rightsrved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AC® CERTIFICATE OF LIABILITY INSURANCE DATE
31/202 )
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(Ies)must 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
NAME: Nina ArrO/O .
COONAN INSURANCE AGENCY PNciHe•n; (508)987-7122 iira-
1 ,N,J,
ADDRESS: Nina@coonaninsurance.com
267 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC e
OXFORD MA 01540 INSURER A: ACE AMERICAN INSURANCE CO 22667
INSURED - INSURER B:
ENERGY PROTECTOR INC INsuRERc:
INSURER D.:
• .
64 PAXTON RD INSURER E
SPENCER MA 01562 INSURER F:
COVERAGES CERTIFICATE NUMBER: 690758 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.
I EXP
LT6 TYPE OP INSURANCE SR !Am
SUER
POLICY NUMBER IMMID 'YYYYI I POLICY/ ) LIMITS
COMMERCIAL GENERAL LIABILITY ! EACH OCCURRENCE $
--" DAMAGE TO RENTED
CLAIMS-MADE OCCUR _PREMISES Ms occurrence.)_ ,$ _
MED EXP(Anton,person) S
N/A PERSONAL 6 ADV INJURY f
EN L AGGREGATE LIMIT APPLIES PER: , GENERAL AGGREGATE S. .
.' J�ECT POLICY[ I l _:LOC i PRODUCTS•COMP/OP AGG $
i OTHER: S
AUTOMOBILE LIABILITY 1 COMBINEDIINGLELIMIT $
I LEA saadc_sa
ANY AUTO BODILY INJURY(Per person)_I!
' 'ALL OWNED f 4:SCHEDULED HIRED AUTOS • N/A • BODILY INJURY(Per accidaht)'$
AUTOS AUTOS (Per accident)
NON•OWNED PROPERTY DAMAGE +� $
I • $
UMBRELLA LAB OCCUR EACH OCCURRENCE $
--r EXCESS LNB CLAIMS-MADE N/A AGGREGATE $
' DED �� I RETENTIONS E $
WORKERS COMPENSATION .X gfATUTE i ERH-
AND EMPLOYERS'LIABILITY Y/N
'ANYPROPRIETOR/PARTNER EXECUTIVE ! E.L.EACH ACCIDENT f$ 500,000
A OFFICER/MEMBEREXCLUDED? N/A NIA NIA 6S62UB0G29826021 09/01/2021 09/01/2022 --" '' —' ""7
(Mandatory In NH) EL DISEASE••EA EMPLOYEE' 500,000_$
Ilia
f es,descnbN under ' EL DISEASE•POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
•
N/A
DESCRIPTION Of OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Ia required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to
employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this
certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at
www.mascgovnwd/woriters-compensation/investigationsi.
Sole proprietor has not elected coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Eversource National Grid ClearResult ACCORDANCE WITH THE POLICY PROVISIONS.
120 Turnpike Rd Suite 200 AUTHORIZED REPRESENTATIVE
Southborough MA 01772 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs and Business Regulation
1000 Washington Myst - Suer 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
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DocuSign Envelope ID:5970F561-8985-4E65-94C5-FC274F47ED50
RISE
ENGINE i RING
OWNER AUTHORIZATION FORM
Daniel Edwards
(Owner's Name)
owner of the property located at:
11 Cherry Street
(Property Address)
Northampton, MA 01060
(Property Address)
.e,tPr)
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hereby authorize C.'1� /7 }r�-.�;
Subcontrfactor(to be filled in by office)
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.
O as fi,warits - -
OwWhf` '50f6tUre
6/20/2021 l 8:50 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com