10-012 (2) 507 KENNEDY RD BP- 2011 -0731
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 10 - 012 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- 2011 -0731
Project # JS- 2011- 001215
Est. Cost: $3010.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 26397.36 Owner: O'BRIEN EDWARD F & ANDREA M
zoning: RR(100) / /WSP Applicant: ENERGIA LLC
AT. 507 KENNEDY RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:41512011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC 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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/5/20110:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0731 .
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 507 KENNEDY RD
MAP 10 PARCEL 012 001 ZONE RR(100, )/ /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ,/•f!
e
Typeof Construction: INSULATION
New Construction
Non Structural interior renovations
Addition to Existin
AccessoKy Structure
Building Plans Included:
Owner/ Statement or License 92540
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Cii6mittee
Permit from Elm Street Commission Permit DPW Storm Water Management
e o ' io
Signature of Buil in O Kcial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
Department use only
City of Northampton Status of Permit:
4\ uilding Department Curb Cut/Driveway Permit
16 to 212 Main Street Sewer /Septic Availability
Room 100 WaterNVell Availability
Northampton, MA 01060 Two Sets of Structural Plans
one 413- 587 -1240 Fax 413 -587 -1272 Plot/Site Playas
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address This section to be completed by office
S 0 7 k" (' G) ?? ( J �. Map Lot Unit
1, { ` ` Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record 5G 7
Name (Print) — , Current Mailing Address:
�� -• `�" Telephone
Si ature Z726
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5)
Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [oi Decks
Brief De r tion oposetrj
Work: 4C. 4AL,5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. If New house and or addition to existing housing, complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /Z,9 ' D ''- ��� as Owner of the subject
property
hereby authorize
to act on my be If, in all ma tters relati towork.KMorized by this building permit application .
ll z t i
ature of Owner Date
I, as Owner /Authorized
Agent hereby declare that the statements and informati@K on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
0 l
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder As 1 AS S 1Gt—
License N
Address 1 Expiration ate
9 3
Signature Telephone
8. Registered Home Imorovement Contractor: Not Applicable ❑
�, LG l,-G /!0 9
_C ompany Na ilne Registration Number
l // A/a
Address ExpiratioA Datef
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M,G.L. c. 152, § 25C(6p
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...... ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill:
(volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES l
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
kv 600 Washington Street
Boston, .'Mass. 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (t3usiness'Organi / ation In(tiv ideal
Address: ," _
City /State /Zip: �� ''r` Phone #:
Are you an employer' Check the appropriate box: �, Type of project (required):
1. k I am an employer with — L j L� ------ 4. 1 am a general contractor and 1 b. New construction
employ (full and or art time).* ha"c hired the sub - contractors
P' Remodeling
2. 1 am a sole proprietor or partner- listed on tyke attached sheet.
ship and have no employees These sub - contractors ha%e X. Demolition
working for me in any capacity. employees and have workers'
1. Building addition
[No workers' comp. msurance comp. p. insurance. ++
required] 5. w c are a corporation and its 10. Electrical repairs or additions �
3. 1 am a homeowner doing all work officers have exercised their 1 1. Plumbing repair, or additions
myself [No workers comp. right of exemption peen MGL
insurance required] c. 152, � 10), and we have no 12. Roof repairs
employees. I no workcrS'
13. Other }! , r
comp. insurance required.
"An% applicant that checks box iil must also fill out the section below showing their workers' compensation police information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contactors 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, then must pro%ide their workers' comp. policy number.
ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name
T - i.:._ ice ------- — _ , . , L ,
Policy # or Self -ins. Lic. i t_ -t� �d -t �� -� Expiration Date:
Job Site Address: City State Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date).
Failure to secure coverage as required under Section 25a of MGI, 152 can lead to the imposition ofcriminal penalties of a fine
up to S 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
5250.00 a day against violator. Be advised that a cope of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify un r the pad s and penalties of perjury that the information provided above is true and correct.
S 1)uli , I i 11
PrmtNunrc: I�•__',,��:` +� I'ltnnc °4:
–
Official use only Do not write in this area to be completed by city or town official
i
City or Town: Permit /license #:
� I
Issuing Authority (circle one):
l.Board of Heath 2. Building Department 3, City /Toscn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ,
I
Contact person: Phone #:
Property Address: A &eo/f I � -
Contractor --�/
Name: / [ ^.oG�141�of�ftisfs fie✓
Address: _ �'To �v� /�' 5
City, State: 1T� �yd �<.c 1'Y! r7 �Q
Phone: `Zt/� — 3
Property Owner
Name: GyQ-Y 6 , �1ii
Address: -ofe4 `ee41f f /N,0f 01O.53
City, State:
j ,�fsrr�g /� (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 3/lo l I
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T HOMAS 8 R066MASSL f silury to p(ow,%s * current editum of the
1 MAIN STREE State Illad4ift Code
HATF EL'-" MA 01034c, Ak 1 aww for revocsocto (if this license
Refer to WWIA Mi Gos!Dfts
"All"I tof inkIIN tflui U't, unh
tMttr OU'Unte, 01Airx fwf+av the trx1mrAtion date. it jound return to:
HOME IMPROVEMENT CONTRACTOR yll , j ,j ( 4 i ft Anti Husinv— Regulation
�`.� Reqistratjon� tiI
Expi %I
S'REE'
1 wl, rtItautt tits ti A T U rl'
2 DATE IMMOO�Yyyyj
ACCOR" CERTIFICATE OF LIABILITY INSURANCE �'c , _11
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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 INSURERtS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ios) 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).
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PRODUCER NAME
Janes 1: Dowd PHONE
FAX
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E-MAIL
ADDRESS
PRODUCER
CUSTOMER AD6
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INSURED INSURER A
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INSURER C
INSURER D
INSURER f
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE OfEN 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
'IkSR ADDL SUER POLICY EfF POUCYEXP
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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,
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