17A-222 Property Address: 1 { 5 -re_e
Contractor �-�-( ;�
Name: I V�.��IM 0 S / 2 S S i c
Address
City, State: "4) 1 1) h 1:// 4_0 01 0 L ib
Phone: L //3 - 32 Z - . -V( I
Property Owner '
Name: ` t Y r 1 4 • I j ('
Address: 1� X_ k/o pie c 34 - -reAv. .
City, State: C ��'� � O i r 1� o
I, e-0 S 5 ( c✓" (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.
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Contractor signature //#
Date 2' 1f / ( o
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Z00f(j ZLZTL$S£Tt' XVd LZ:TT OTOZ £I /60
The Commonwealth of Viassuchusetts
Department of Industrial ,4tvidents
'
Office of Investigations
6011 II ashinglim Street
Boston, Sloss. 1)2111
MCI% I 'Via
Workers' Compensation Insurance Affida% it: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (lio,irh:,.(h-paildalion En_
Address: _ S O
City/State/Zip:_ .()104 6_ i3 - 3d-c3- H I
.Acuou an employer? Check the appropriate ho J spe of project (required):
am an emplos et %soh 0 4 I and a ccnct 1 I r). \co. construction
emplmee, t ill ind or pa, t time) ' rire■1 the •ii
I am a sok proprietor or nartocr tiic Reinodelrw .hecl
ship and have no emplo I lie,- ir ira ta 8 Demolition
ssorking for me in an ... empios c And
9 Building ackthion
No ssorlser-: in,uran,e los"u an...
required I \A e o r e rporuii list ; ti I lectrical repairs or additions
4. I am a home‘w,ner (foiui l! all isuk tticr id eerej then
I I Plumbing repairs or additions
nrs self 1No ssorker,` ruzhi , *1 c‘cirirg ion perm \It tl
Insurancc required' I -.‘ 4) .01,i ssc u ii Roy! repairs
)ther LOPAArtir561?0
,:ori)11
n) applicant that cuece,, hu• toi mull aiMu fill out its sr', Is n taloa shoning their a,olscr,'Ininprn,atton poiscs.snformI.on ,
+llolneon nen *kw submit this *Mold ioulitation they are doing all o•wk and thy') hire outside contractors must submit a nen land.% if indicating such
ontartor, that rhea, this hot must attach an additional sheet shimunz the ninny of the suh-contraclor, and OM,' tihether or not those entities halt emplo•en. If
the sub-rontrortort hake e veva. flits must rot Me their wrier,' tom ). sct aumber.
I am an employer that is providing workers' compen.tation insurance for mv employees. Helon is the policy and job site
information.
Insurance ( °wan). \ante ClUar C 15(./f CiroLT
PoIic or Self-ins. I .ic \piration Date c2/I 1-0 1 ti)
Job Site Address ' 114k /lp
Attach a copy of the workers' compensation polic■ declaration page (shossing the policy number and expiration (date).
t allure to secure emerage as required tinder - t;2 can e,id to the imposition orcriminal penalties °fa fine
up to $1,500.00 and/or one ear linpn,oilmeni ,is %%e;! ie r tic orb i `•P)1 WORK ORDER and a tine of
5 a da‘ against violator hk u1\ !sod that a etups b In, nia\ he ti)1A■arcled to the Office of In\ estigations of the
DIA for coverage ■eritication.
1 do herby certi • un er he pa s and penalties of perjury that the information provided above is true and correct.
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Official use only Do not write in this area to he completed hy city or town official
(its or 'To% n: Perm ir)icense
Issuing Authority (circle one):
I.Board of Heath 2. Building Department 3. its Isissi, ( lerl. 4. Electrical Inspector 5. Plumbing Inspector
6. Other
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Construction Supervisor ,.. zenst- Restnctad to: 00
OD - LInrestricUid
IC; - I 2 Family Holmes
License CS 92540
Restricted to 00
TI-IOMAS B ROSSMAS,SLER Failure to possess • current edition of the
100 MAIN STREET Massadnuetts State Building Code
HATFIELD, MA 01038 is cease for revocation of tbis license,
Refer to: WW1V. Mass.Gov/DPS
c- -,„-s- , ....,„el- E ti,lr.ti,...1' 92 20'
r-r 4606
-
: COIN APO01 1
1,1cen.e or registration %slid for indisidul use onl■
()nice of Consumer 1 1ffairs di Rumness Regulation
HOME IMPROVEMENT CONTRACTOR before the espiration date. If found return to
Office of Consumer . and Business Regulation
RegniTatio n : 165169 10 Park Plata - Suite 5170
Expiration: 1/1112012 Tr# 29248'
- ... lio.ton. NI \ 021 lei
Type; LLC
ENERGIA LLC
THOMAS ROSSMASSLER ii I i
242 SUFFOLK STREET
i. ci
HOLYOKE, MA 01040 I odersecrelars 'NIA s ilid without signature
CTION 8 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
ame of License Holder S ASS t e r 9 d S 0
License Number
! (3h ln/l t f S4 NrAf e,(d wig- 4.) to 3 Ss ,p2A
kddress Expratioti D e
/1X ., L /13 - 322- 3/11
Signature Telephone
Not Applicable ❑
LCC )tpsr69
C prnanv Nyhe Registration Number
c-7 5 A9e4' 6 Addre Expir 1 / /
on D to
Telephone V /3j'1,e' 3///
SECTION 10- 1NORKERS' COMPENSATION INSURANCE AFFIDAVIT (M,G, ,.. 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 4 1K No ❑
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
,
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fl CTION 5- DESCRIPTION OF PROPOSED WORK (check all anot cable)
New House ❑ Addition n Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [[ ] Siding [Clj Other [010
, ,...74 - 4-t,• -, .
Brief Description ,of Proposed /,
Work: /Of IA CC / /,/ /G SP /h 5'✓ /A ,'n Pt - //c / ' 7 J A/4 //5 y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
- x s.z..i`.a , . ..," , ,..r...' ., _.._ « .i. .
.'' .G'" ,n_? i:.aA',. °..vs...c � , : "ii .. %
. E. .- r.
..�ito �.ar..,t_i.. *; a,a . ' __ a �Z . : .f ..�. ,— .d .s. *. �:
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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION 78 - OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 1/c vv / vO✓ I Z i , ' A, -71'; _, as Owner of the subject
property /
hereby authorize
to act on my beh in all matters rel 9"0$4"^h441-AC
ative to work authorized by this building permit application.
S' a ure of er - 1- Dat
Q S 7 cf/ylA15 °..- � , as Owner/Authorized
Agent hereby declare tha the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed der the pains and penalties of perjury.
/in 4" i� 36/
Print Name
Lz /u
Signature of ner /Agent Date
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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:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
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 0
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 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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` s �' d a i,t '"' .�
City of Northampton ? " . ' .
Zft�` . ding Department �a� �t k
4 r 'f`s G s m �B L f t x a z rc! i tarp .S;
, 2 M ain Street s � �� i
jOk ` _; '` oom 100 P
5 Sex � �
Nort MA 0106 Ai � .
� � phone 413- 587 -1240 Fax 413- 587 -1272 _'
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 * SITE INFORMATION
1.1 Property Address: 9'2 This section to be completed by ice if
414 a l ° t � C+ne _ ,.__
Elm St. OfeblOt C:B D a#ct
SECTION 2 _PROPERTY OWNERSHIP/AUTHORIZED AGENT
LiAwner of Record: J cif / �
m Name (Pri Current Mailing Address Cy/ 007_
,2111,I Telephone
ure 49
2.2 Authorized Agent: l (,
71't, &3f �
-1,142-- S t�/L- J , �.J / d�6
Name (Prim Current Mailing Address:
(4 /3 32 - 1 IIt
Signature Telephone
SECTION 3 ESTIMATED ONSTFtUCTION COSTS _
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building I I/ �/ / // n / I (a) Building Permit Fee
2. Electrical ` % (b "Estimated Co of
_
3. Plumbing Construc#ron Total from (6) st Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ` � /. / Check Number ‘' ! i
This Section For Official Use Only
Date
Building Permit Num ber: issued:
Signature:
Building Comm
isionerlinspeetor of Buildings Date
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File # BP- 2011 -0623
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 188 NORTH MAPLE ST
MAP 17A PARCEL 222 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction 4sse Attic
f ie
Non Structural interior renovations
Addition to Existing
Accessory 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:
p proved 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 Dela
/ d , 7 ' 1(
Sig . re of guild ng Official 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.
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BP- 2011 -0623
GIS # COMMONWEALTH OF MASSACHUSETTS
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 -0623
Proiect # JS- 2011- 001011
Est. Cost: $4542.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 17641.80 Owner: AZMITIA HARRY NORMAN JR
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 188 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON :1/13/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC INSULATION - AIRSEAL ATTIC
BEFORE BLOW
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 1/13/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner