42-043 669 wtsmwyrm RD BP-2011-0219
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 42`- 043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0219
Project # JS- 2011- 000380
Est. Cost: $860.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 25047.00 Owner: JOHNSON FRANCIS & LUCY HARTRY
Zoning: SR(100) //WSP II Applicant: ENERGIA LLC
AT. 669 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON. 9/15/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL CELLULOSE WALL 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 9/15/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0219
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS /PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 669 WESTHAMPTON RD
MAP 42 PARCEL 043 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: INSTALL CELLULOSE WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
AccessoEy 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
INFORMATION PRESENTED:
I_, Approved 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 Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Offici 1 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.
City of Northampton
3 2010 Ouilding Department
S�Q 212 lain Street
Ri 100
Nd�ampton, MA 01060
phone 413- 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION '
1.1 Prooerty Address Fhii "e o#rteRtt.Ik
Hoare
SECTION 2 - PROPERTY OVVNERSHIP /AUTHORIZED AGOT
2.1 Owner of Recor `
Current Mull! g Address:
Telephone K (3 51 u ^ C/O
S
Signature /
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature - - v Tele
8EC1IgI+} 8 _EST ►�.T C�)rNS! 2UCTI014 COSTS
Item Estimated Cost (Dollars) to be Official Use Only
comp leted by rmit applicant
1. Building C3 & v � (a) Building Permit Fee
2. Electrical l � (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fi, Protection
6. Total = 0 +2+3+4+5) Check Number
thls Section For Offlciaf flee On
Building Permit Number: Date
Issued.
Signature;
Building Commissionerlinspector of Buildings Date
New House Addition ❑ Replacement windows Alterations) Roofing
Or Doors ❑ K7
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [[] Siding [0] Other (C ]
Wo ef Description of Proposed ��Syt, � /
Alteration of existing bedroom Yes No Adding new bedroom Yes /` No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet T
r
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 X 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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 78 . OWNER AUTHORIZATION - To} BE COMPLE'T`ED WHEN
OwIlIERS ASENT OR CONTRACTOR APPLIES T=OR SUILDMG PI RMTT
I, , vet S as Owner of the subject
Y property
hereb horize F�� �jt n 1
to on f, in all matters relative to work authorized by this bull 'ng permit application.
/M
Signature of 901hrjdr bate
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.
Print Name
Signature of owner /Agent Date
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 ::.
Rear
Building Height
i
Bldg. Square Footage % . .....
..__ ;
Open Space Footage _ %
(Lot area minus bldg & paved g „
par
# of Parking Spaces
Fill:
1
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued. _. �..
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ®. YES
IF YES: enter Book Page and /or Document #' _ �...._...�__
i
B. Does the site contain a brook, body of water or wetlands? NO ( DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading,, S� avation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO (fv%
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
89CTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Superv An A Not Applica ❑ 1
Name of License Holder : — T - 0 M 1� ll'v' / \�5 (,��
License Num r
Address Expiration Date
(� f'1 _
Signature Telephone
�rt4iwMi"ffiw . Nsle Not Applicable ❑
ALL [
P5 ) AJ
Company Name Registration Number
�,
Address �(► ( r�1 ` �/ �� Expiration Date
Telephone 4 I )
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.102
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...... ❑
a-
The current exempti "homeowners" was extended to include Owner-occu ied rnas" one (1) or two(2) families
and to allow such homeowne engage an individual for hire who does not gseess a license, provided that the owner acts
as su ervisor. CMR 780. Slat Section 108.3.5.1.
Definition of Homeowner Person (s) w wn a parcel of l which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwe or detached structures accessory to such use and/ or farm
structures. A erson who constructs more than o e ' a two- e r hi/, shalt no b considered hom ner.
Such "homeowner" shall submit to the Building Official, on `a acceptable to the Building Official that he /she shall be
responsible for all such work Performed under the building perm
As acting Construction Su eryiso our presence on the job site will be regw om time to time, during
rte g and upon
completion of the work fo is this permit is issued.
Also be advised tha ittfreference to Chapter 152 (Workers' Compensation) and Chapter 153 (fLia of Employers to
Employe25�'in`u 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofji•e of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
F7
Name Musincss organi/ation India idual i. C.,
LUC
Address: 5_ - . o p V
- ,
City/State/Zip:
X 0 Y.4— .N Akck- Phone#: LAI3- - - 2 Oqc?-31 (I
F. an employer? Check the appropriate box: Type of project (required):
I I am an employer with 10 4. 1 am a general contractor and 1 6. New construction
employees (full and or part time),* have hired the SUb-contractors
7. Remodeling
2. 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees T hese sub-contractors hit c 1 8. Demolition
working for me in any capacity. employees and have xxorkers'
9. Building addition
[No workers' comp. insurance comp. insurance.
required] 5 . kk e are a corporation and its 1 10. Flectrical repairs or additions
3. 1 am a homeowner doing all �\ork officers have exercised their
myself 1\() workers' comp. right of exemption perm '061. 1 1. Plumbing repairs or additions
insurance required/ c. 152. 1141. and we ha\,e no 1_I Roof repairs
employees. o no \% orkcrs*
1 13 Other TP
C01111), insurance required.
ny applicant that checks box fl must al fill out the
section below showing, their workers' compensation police information.
+11ornewAners who submit this affidw. it indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 that check this box must attach a additional sheet showing, the name of the sub-contractors and state whether or not those entities have employees. if
the sub-contractors hav em they must provide their workers' comp, polic number.
I am an employer that is providing workers compensation insurance for mY emplt�vees- Below is the police' and job site
information.
Insurance Company Name: C, roL
or Self-ins.
Policy ;7 Lic. �:
Job S . S ite Address: c- ('its State /ip: Expiration Date: 0 IV
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 ot'M(fl, 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 STOP WORK ORDER and a fine of
$250.00 a day against violator. Be advised that a copy of this statement nia\ be tor\karded to the Office of Investigations of the
DIA for coverage verification.
I do herby certvl un er h pa is and penalties of perjure' that the information provided above is true and correct.
Owe b � � � /aU l 0
3,
(o
Official use only Do not write in this area to be completed bY cite• or town official
City or Town: Permitllicense #:
Issuing Authority (circle one):
(.Board of Heath 2. Building Department 3. Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person:
�la..:trhu•ett. Url�artment .d Nubltk Restricted to: 00
Board of Buildnm- Re---ulation% and pp- Unrestricted
Construction Supervisor License 1G - 1 2 Family Homes
License. CS 92540
Restricted to. 00
THOMAS B ROSSMASSLER Failure to possess a current edition of the
100 MAIN STREET Massachusetts State Building Code
HATFIELD, MA 01038 is cause for revocation of this license
Refer to: WWW.Mass.Gov/DPS
EKprratr.>n 9`2!2011
t .,moll a.nrr tr- 4606
,��av f�•omdnurcuwu�� r f . �li�.:arc�iuseld:
Office of Consumer Affairs &Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
-s Registration: 165169 10 Park Plaza - Suite 5170
mss= Expiration: 1/11/2012 Tr# 292481
Boston, MA 02116
Type: LLC
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET �� - - -` .3 �✓ �►�
MA 1 4
HOLYOKE, 0 0 0 Undersecretary Not valid without signature
06/31/2010 TUL 16:36 PAX 1413536602C Dowd Insurance ®001 /001
Client#: 33645 ENELL
ACORD -ti CER OF LIABILITY INSURANCE DATE 10210
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
James J. Dowd & Sons Ins ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
14 BObala Road HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 10300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Holyoke, MA 01041 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA Northland Insurance Company 34754
Energla, LLC INSURER B: Guard Insurance Group
242 Suffolk Street INSURER C: Commerce Insurance Company
Holyoke, MA 01040 INSURER D.
INSURER E:
COVERAGES
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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN3K 001
LTR r NSPI TYPE OF IN3URANCE POLICY NUMBER POLICY POLITY EXPIRATION LIMITS
A GENERAL LIABILITY WS061839 02117/10 02117111 Enc: -+ OCCURRENCE $1
X COMMERCIAL GENERAL LIABILITY DA 'W ES T O tEa occurrence) RENTED 310010M CLAIMS MADE OCCUR MED EXP (Any ale person) $5,000
X BI Ded:500 PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE s2 000 000
OWL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO s2,000,000
1 17 POLICY PR4 LOC
C AUTOMOBILE LIABILITY BBRC17 02/17110 02/17/11
ANY ALITO COMBINED
aaccident SINGLE LIMIT $1,000,000
ALL OWNED AUTOS
BODILY INJURY $
X SCHEDULEDAUTOS (Par person)
X HIRED AUTOS BODILY INJURY
X NON -OWNED AUTOS (Prrlident) $
PROPERTY DMAGE S
(Per arddon*)
GARAGE LIABILITY j AUTO ONLY- EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC 5
AL'TOONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR E CLAIMS MACE AGGREGATE $
S
.1 DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND WC110773 02/16110 02/16/11 1 WATU- oT--
EMPLOYERS'UABILnY ER
ANY PROPRIETORIPARTNER/EXECUTIVE I E.L. EACH ACCIDENT $1, 0O0 000
OFFICER/MEMBER EXCLUDED? EL. DISEASE - EA EMPLOYE 1
I es, deserAe under
SPECIAL PROVISIONS below E.L. MEASE - POLICY LIMIT $1 000 000
OTHER
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ElmEEAVOR TO MAIL __ID_, DAY$ WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $0 SHALL
I IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATM.
AUTHORIZED REPRESENTAIIV
ACORD 25 (2001/08)1 of 2 #S71379/M71366 DWGJR 0 ACORD CORPORATION 1888
AyFax - Energia, LLC To:Linda LaPointe (14135871272) 14:19 0911411OGMT -04 Pg 02 -03
Property Address:
Contractor
r
Address:
City, Mate:
'' - ..
Property Owner
_.
City. State � � -- L_ _ S) L - - --
6 a-- `(tt'(raCto'fj -&f i and -& 3m, that thb `€ldtr ing t ir,*ar, t�u
to insulate does not have any open sir (knob and tube) wiring in the spaces to be insulated and
that,i have ,nmgtClad the ,rrrsVWgy QWrer.W a copy - Ws affidavit
Contractor signature /Mv,
Date ,
Zn0 1 ZLZTLBtCTP YVJ -)Z�TT OTOZ/gT/Ui