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31A-096 (6) BP-2024-0617 57 VERNON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-096-001 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-2024-0617 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 2000 ENERGIA LLC 108421 Const.Class: Exp.Date: 02/19/2025 Use Group: Owner: LAWRENCE PAMELA HOLABIRD Lot Size (sq.ft.) Zoning: URB/WP Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2022A HOLYOKE, MA 01040 ISSUED ON: 05/16/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/W EATH ERIZATI ON 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: ie./2- Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Ric , / ,.i , • De. :... # -_ :Tt �Qw HeM ',o.4 City of North mpton�r S j • `,9c- Building Deg nt ��?, / INSULATION f 212 Main Streero#1,1m „; ;_ Room 100 /.�1 S �" .. Northampton, MA 01060 ,"r`r�onc � phone 413-587-1240 Fax 413-587-1272 ONLY _ •__ r APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address. This section to be completed by office 51 V r R t I/`. / ST Map Lot Unit WORTH NgP To 14, 1 A O i v go Zone Overlay District (� Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: PAMELA LAWRENCE 57 VERNON ST NORTHAMPTON MA 01060 Name(Print) Current Mailing Address:413-387-8066 SEE PERMIT AUTHO Telephone Signature I 2.2 Authorized Agent: ENERGIA LLC - BENJAMIN BORDEN 242 SUFFOLK ST HOLYOKE MA 01040 Name(Print) Current Mailing Address: 413-322-3111 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2000.00 . (a)Building Permit Fee 2. Electrical • (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee rP 6 4. Mechanical(HVAC) C/•C/1 5. Fire Protection o. Total=("i +2+3+4+5) 1 2000.00 i Check Number I gei QQ This Section For Official Use Only Building Permit Number:'c/���1''(,//;;/�7 ate Issued: Signature: /77 5- l 6 2,y Building Commissioner/Inspector of Buildings Date ivelice @ energiaus.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 BENJAMIN BORDEN 108421 Name of License Holder License Number 242 SUFFOLK ST HOLYOKE MA 01040 2/19/25 Address Expiration Date 413-322-3111 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 ENERGIA LLC 165169 Company Name Registration Number 242 SUFFOLK ST HOLYOKE MA 01040 2/16/26 Address Expiration Date Telephone 413-322-3111 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... . .X No 0 Brief Description of Proposed Work NOTE: INSULATION ONL Y INSULATION -ATTIC FLOOR 10" OPEN BLOW- HATCH THERMAL BARRIER POLYISO FG DAMMING - RIM JOIST FG BATT BENJAMIN BORDEN/ENERGIA LLC . 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. BENJAMIN BORDEN/ENERGIA LLC Print Name 5/13/24 Signature of er/Agent Date PAMELA LAWRENCE as Owner of the subject property hereby authorize ENERGIA LLC - BENJAMIN BORDEN to act on my behalf, in all matters relative to work authorized by this building permit application. SEE PERMIT AUTHO 5/13/24 Signature of Owner Date City of Northampton t,�,,,ri da Q Massachusetts DEPARTMENT OF BUILDING INSPECTIONS '''' 3 U �ti�A 212 Main sthamp on, M cipal Building Northampton, MA 01060 r;S , ''- 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: 57 VERNON ST NORTHAMPTON MA 01060 (Please print house number and street name) Is to be disposed of at: BOSTON RD WILBRAHAM MA (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USA WASTE (Company Name and Address) 5/13/24 Signatu of Permit Applicant or Owner Date 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 (,..-- j4, r' sic„ Massachusetts F`, el tl DEPARTl�NT OF BDILDING INSPECTIONS r. 0 ^'a�1r� 212 Main Street • Municipal Building �J�y,�_ '� Northampton, MA 01060 R ink MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 57 VERNON ST NORTHAMPTON MA 01060 Contractor ENERGIA LLC Name: 242 SUFFOLK ST Address: City, State: HOLYOKE MA 01040 Phone: 413-322-3111 Property Owner PAMELA LAWRENCE Name: Address: 57 VERNON ST City, State: NORTHAMPTON MA 01060 BENJAMIN BORDEN (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 5/13/24 The Commonwealth of Massachusetts Department of industrial Accidents y: 1 Congress Street,Suite 100 I I 3 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name(Business/Organizational/Individual): ENERGIA LLC Address: 242 SUFFOLK ST City: HOLYOKE State: MA Zip: 01040 Phone#: 413-322-3111 Are you an employer?Check the appropriate box: Type of project(required): ✓ 1. I am an employer with 14 employees(full and/or part time)* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in any 8. Remodeling capacity.[No workers'comp. insurance required.] 9. Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required]+ 10. Building addition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. 11. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs sheet. 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. ✓ 14. Other INSULATION c. 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. tHomeowners 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 attach 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. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIM MUTUAL INSURANCE Policy#or Self-ins.Lic.U: WMZ-80�0-{�8008072-2023A , / Expiration Date: 7/01/24 Job Site Address: Si \ 40V ST N, o a ( 1 ���� 14 /t-tA 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,and that clicking this checkbox and typing my name in the field below will act as my signature. Name: Benjamin Borden Date: ivelice@energiaus.com Phone#:: 413-322-3111 Email: mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM I, Pamela Lawrence owner of the property located at: (Owner's Name) 57 Vernon Street Northampton (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization 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. Paluela Latareace Owner's Signature 04-04-2024 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: tl&i€G/A- Participating Contractor Date Document Ref:BJ5CJ-SAASB-YP9UI-A29V4 Page 1 of 1 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 02J16/2026 Boston,MA 02118 ENERGIA LLC _ BENJAMIN BORDEN 1 242 SUFFOLK STREET 1 1 ''• :0 HOLYOKE MA 01040 Undersecretary of valid without signature Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Consttl� 6� ?yvlsor CS-108421 02/19/2025 BENJAMINRD , 242 SUFFO ST,i �) HOLYOKE mg oie4Q vrU 4 /3. ;J HiIw• .�� Ge_RTI 1/CAT2 ®F- LIA%\ L_ \/ .t� S� R )i ca_ PA, CK ENERLLC-01 ALYSSA AC.CiPM CERTIFICATE OF LIABILITY INSURANCE DATE(M 6/20/20233YY) 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 weer Alyssa Perusse Phillips Insurance Agency,Inc. PHONE I 97 Center Street (NC N ,Ext): FAX No): Chicopee,MA 01013 qSS;alyssa@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE _ NAM* INSURER A:State Automobile Mutual Ins Co • INSURED INSURER B:A.I.M.Mutual Insurance Company 33758 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMMIDD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/1/2023 7/1/2024 DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) 5 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGAI E y 2,000,000 POLICY X JET X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LU181UTY (Ea accident $ X ANY AUTO BAP2477206 7/1/2023 7/1/2024 BODILY INJURY(Per person) $ — OWNED SCHEDULED _ AUTOSRREE�� ONLY AUTOS BODILY OEM BODILY INJURY(Per accident) $ _ A�TOS ONLY AUTOS ONNLY (Peer PROPERTY $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE PBP2870943 7/1/2023 7/1/2024 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Y WMZ-800-8008072-2023A 7/1/2023 7/1/2024 1,000,000 OFFICER ROPRIETOwIXCL DED?ECUTIVE N" N/A E.L.EACH ACCIDENT/MEMBEIR $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Energia LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. 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