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B '-2023-0101 123 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 43-009-001 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-2023-0101 PERMISSION IS HEREBY GRAN ED TO: Project# INSULATION 2023 Contractor: License. Est. Cost: 3000 ENERGIA LLC 108421 Const.Class: Exp.Date: 02/19/2023 Use Group: Owner: S DONNELLY BRIAN F&MARINA Lot Size (sq.ft.) Zoning: WSP Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2 1 22A HOLYOKE, MA 01040 ISSUED ON: 01/27/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: (� ' � Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • / 4 J N _ bv kr c The Commonwealth of Massachusetts ( (9493 FOR Board of Building Regulations and Standards:' `�` MUNICIPALITY Massachusetts State Building Code, 780 CMR 7r n„ �� USE 06�,, ` isedar 2611 Building Permit Application To Construct,Repair, Renovate Or ri . One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number:)/7- �'( l Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 123 WESTHAMPTON RD 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 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: MARINA DONNELLY NORTHAMPTON MA 01062 Name(Print) City, State,ZIP 123 WESTHAMPTON RD 908-279-5003 mdonnellykcgmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition b Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:INSULATION Brief Description of Proposed Work2:INSULATION-WALLS 3"DENSE PACK CELLULOSE SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Labor and Materials) Official Use Only 1.Building $3000.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire / Suppression) Total All Fee l/ 6.Total Project Cost: $ Check No)13ICheck Amount: Cash Amount:_ 3000.00 0 Paid in Full 0 Outstanding Balance Due: T SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 108421 2/19/23 BENJAMIN BORDEN 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 2/16/24 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 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 ❑ 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 BENJAMIN BORDEN/ENERGIA LLC to act on my behalf,in all matters relative to work authorized by this building permit application. 1 'It-VT-ACNE-6 I4CkT 1/8/23 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 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. 1/8/23 Print Owner's or uthorized 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 . �!<< ta: '. so S'ri F---f! a;. H DEPARTMENT OF BUILDING INSPECTIONS ti� ,: 212 Main Street • Municipal Building J`4, s �': Northampton, MA 01060 r jy `^0� 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: USA WASTE BOSTON RD WILBRAHAM MA The debris will be transported by: Name of Hauler: USA WASTE Signature of Applicant: Date: 1/8/23 City of Northampton oa�N�.tr Fo\ ... ...s! ?tea .,•L,, S:� eC� Massachusetts ("" ,T. 0,040 DEPARTMENT OF BUILDING INSPECTIONS J )4 ,P 212 Main Street • Municipal Building �f�4 ,. 0\- Northampton, MA 01060 V � Property Address: 123 WESTHAMPTON RD NORTHAMPTON Contractor Name: ENERGIA LLC-BENJAMIN BORDEN Address: 242 SUFFOLK ST City, State: HOLYOKE MA 01040 Phone: 413-322-3111 Property Owner Name: MARINA DONNELLY Address: 123 WESTHAMPTON RD City, State: NORTHAMPTON MA 01062 I, BENJAMIN BORDEN/ENERGIA LLC (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 1/8/23 Permit Authorization mass save Form SNtnsp:throwers energy r txsenc y Site ID: 4696020 Customer: MARINA DONNELLY Marina Donnelly I, ,owner of the property located at: (Owner's Name,printed) 123 Westhampton Rd 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. H4RIN,4 DONNE-WI Owner's Signature: 01 / 09 /2... Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only Document Ref:WWQ2S-TN4SJ-3M5QM-RKWND Page 6 of 8 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations si h s Lafayette City Center 1113 Jf 2 Avenue de Lafayette, Boston, MA 02111-1750 wwx.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]** 4.❑ We are a non-profit organization, staffed by volunteers, l 1.❑Health Care 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: A.I.M. Mutual Insurance Insurer's Address: 123 WESTHAMPTON RD City/State/Zip: NORTHAMPTON MA Policy# or Self-ins. Lic. #WMZ-800-8008072-2022A Expiration Date:7/01/2023 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, under the pains and penalties of perjury that the information provided above is true and correct. /-—Signature: "`� Date: 1/8/23 Phone#: 413-322- 111 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Commonwealth of Massachusz•ts Division of Professtona'. Licensure Board of Building Regulations and Standards ConstfUd idtAtlppr>as s ENERGIA LLC "'- 242 SUFFOLK STREET ° CS-108ti21 Facpires:02119/2023 HOLYOKE,MA 01040 BENJAMIN BORDEN i - 112 RYAN ROAD 1 y FLORENCE MA 01052 , Commissioner d ie K. %r , THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 165169 02/16/2024 Boston,MA 02118 ENERGIA LLC - BENJAMIN BORDEN T ,) 4._____ . - 242 SUFFOLK STREET m 4?,; HOLYOKE,MA 01040 ,,,a • Undersecretary Not va id without signature ..-----"'" ENERLLC-01 JOCELYN ACCP/?® CERTIFICATE OF LIABILITY INSURANCE DATE DIYYYY) 7/5/2022 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 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 I CONTACT Jocelyn IM.II Douglas Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 Aoo llEsstjocelyn@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:A.I.M. Mutual Insurance Company Energia LLC INSURER c:Markel Insurance Company 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 • SUER POLICY EFF POLICY EXP UM TYPE OF INSURANCE . yyyp POLICY NUMBER M DDAA D► AI ,M.A © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 ■ CLAIMS-MADE X OCCUR PBP2870943 7/1/2022 7/1/2023 DAMAGE TO RD ' 500,000 IIPRE SE E.oENTE n-., $ MED EXP An one•erson I S 5,000 PERSONAL 8 AOV INJURY S 1,000,000 I GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ■ POLICY X JECT X LOC PRODUCTS-COMP/OPAGG s 2,000,000 IIIOTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY $ © ANY AUTO BAP2477206 7/1/2022 7/1/2023 BODILY INJURY Per.erson S ■ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ EP V� PROPERTY IIAMAGE III AUTOS ONLY AUp TO ONL� Per accident $ I $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 Mil EXCESS LIAB CLAIMS-MADE PBP2870943 7/1/2022 7/1/2023 AGGREGATE $ 2,000,000 . DED X RETENTION$ 0 $ B WORKERS COMPENSATION X PTRT TE EERH AND EMPLOYERS'LIABILITY YIN WMZ-800-6008072-2022A 7/1/2022 7/1/2023 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ FFICERIMEIMBER EXCLUDED? N NIA 1,000,000 (Mandatory n NH) E.L.DISEASE-EA EMPLOYE $ If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Equipment Floater PBP2870943 7/1/2022 7/1/2023 Leased/Rented 35,000 C Pollution Liability CPLMOL106305 4/1912021 4/19/2023 Pollution 1,000,000 i i DESCRIPTION OF OPERATIONS I LOCATIONS 1 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 Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ;237A/-• ,t I'`^1i I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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