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16D-031 Property Address: - 1 r ` . ` Contractor i Name: �I wv S� SS GiS S1 Address: .)-q 3- 5 ° t , v ,= - 5 . City, State: .__ ..- f , b _1(Q ,13: j) I Phone: L I 13 - .-3 - 3 ( ( 1 Name: Owner , _9..ae[ -� ,--e., Oar) x Address: L ? £-L i S-{-- City, State: T to 1. .r 11/1 I, %� f Q J /C CSS4 r (contractor) attest and affirm that the building t 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 j.,<X___.------------ / . Date 1 ( /2-/( 1- . Z04i; ZLZTLSS£Tr IVd LZ.TT OTOZ /£T %80 ■•• ••••11 1 • • Accma CERTIFICATE OF LIABILITY INSURANCE DATE (IMILDEVYYYY1 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 POUCIES 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 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 CONTACT PHONE ' . FAX 4 IAIC, No Eat, _ (A/C. No) E-MAIL ADDRESS PRODUCER CUSTOMER ID , INSURER{S) AFFORDING COVERAGE NAIC INSURED INSURER C "c INSURER B ' A : : I, , • it INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: ; • REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVF'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 SUC.1- POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NulABER MIA/DD/YYYY MWDONYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED COMMERCIAL GLNERAL iAP,IL 11 PREMISES )Ea occurrencej I • CLAIMS-MADE OCCUR MED EXP ;Any one person) PERSONAL & ADS INJURY S• GENERAL AGGREGATE C,EN*. AGGREGATE IMIT APPL IFS PER PRODUCTS COMPIOP AGG ; POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT lEo acc,deN ANY AUTO BODILe NuoR); Per person, $ AL, C.WINeD AL)T05 BODIL Y INJURY t Per accoenu S .SCI ACTOT, PROPER DAMAGE ' HIRED AUTOS (Per accrdent) NON-OWNED ADIOS UMBRELLA LIAB OC,CL, EACH OCCURRENCE EXCESS LIAB OLAIMS.MADE AGGREGATE DEDUCTIBLE 5 RETENTION $ WORKERS COMPENSATION WC STATU- AND EMPLOYERS LIABILITY TORY LIMITS ER Y N ANY PROPRIE TORWAR NEFOEXECUT ISE ; E L EACH ACCIDENT OFF ICER/AEMBER EXCLJDEj, N A (Mandatory In NH) L DISEASE ; A EMPLOYEE S it yes describe Jnber DESCRIPTION OF OPERATIONS SEOW S . DISEASE - POLICY LIMIT 5. DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101 Addlhanal Remarks, SchodoW it more apace la requored) '1■-• ' ' ' , . ' ' 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. AUTHORIZED REPRESENTATIVE 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ■••=1111M11111111111• , .... NI 4 I N - t a 1 hlt1 MCrit 01 Ptiblit NAVI * N Board ill Buddintt Bet:Walton% and **taiiitirdN Construction Supervisor Ltcense E 1c ense CS 92540 THOMAS B ROSSMASSLER 11111°. 1 * 100 MAIN STREET HATFIELD, IVA 01038 E x p tr atIon 9/2/201 3 ( , iliiiill , so , itt I Tr: 794 t . :44. 6.4....,...w.a./44 4/ ., iki,uaoltiramiZi License or registration valid for individul use only Office of Consenter Affairs & Busiaess Regulation before *lie expiration date. lf found return to: : It `t4 NONE IMPENSMENT CONTRACTOR Office of Consumer Affairs and Business Regulstion ft .4' Registration 465169 10 Park Plaza - Suite 51'70 Expiration: 1/1112012 Trig 292481 Boston, MA 02116 Typo: LLC ENERGIA LLC THOMAS ROSSMAMER 242 SUFFOLK STREET ,,,,s-L."---,,,,-Ait klU idL HOLYOKE, MA 01040 t'ildtrsircrttary Not valid without signature ,, . � , � -aft.- TheCommomwes/th of Massachusetts u Qenurtwentwf Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 *vww.mwaxx'govxwxa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ` ' / / ~- ��mmm«(uu^in�s,vevu.woo^|no/""mu|)� ��' 1�p * ,\ / �` ' ( ( (`- �� �r ~ Address: .,~ \ (� � �* � , ' - V-1__. )-\ City/State/Zip: \\^i ^ m'/, ( �\ ` L J' ` Phone#: L � - , �( _ \ ( ` - _'", ` ` `` 'r`° `' ` .L . ' . 5 ',^cr � ` � Are you auomnp>nyor'��:bcck the appropriate box: Typxo[ project (rogoirwd): i CK | um^o employer with lc) 4 I ant a general contractor and I ^ New construction employees (full uudwr part tnnc)~ have hired the sub-contractors / 7 Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet, ship and T��^�mx�cu'w~�u Y.4. Demolition "nrkngkx any capacity. empkycmnn� have wnr ns' / / | |Mv� workers' comp. `o^oome comp. iwvqocc.� ' | 9. Building addition required] 5, We and its 10. Electrical repairs or additions 3 I *ma homeowner doing all xodk officers have exercised their || Plumbing repairs ",additions myself [No workers' comp. right of exemption penn M6L insurance required] ~ c. |52.§ \(4), and ,c have n" |2� Roof repairs / employees. ` "'- workers' —.( 13. t4 Other (r\ k ^ /`.` | comp. insurance re4"`*o| � ' ---------- ---- ------- ---------- ' 'Any applicant that check box m must also till out the section below showing their workers' compensation vu/,r/"w,m^uvn. iy^mww*,, who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ^ new affidavit indicating such. tc"mvm",^ that cheek this box must attach xn additional sheet showing the name ", the sub and state whether ", not those entities have employees. If the sub-contractors have m' levees they must ',rviu"their workers' corn.z lies number. lam an employer that Ls providing workers' compensation insurance for my employees. He/OK' 1S the policy and job site information. r` / Insurance Company Name: C. 7`' / \ iil�, ,- i.,I ,^ � . ) p ' ' . Policy #v,Sd�ivaL� �� L� ( ' ) [^pinokmDxu� ^7/|(- /��c/,- � � . `__ / / Job 6iu Address! C`ry"Sute'Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and epiration (date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine upx`Si5U0.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S25o.00u day against violator. Be advised that a copy at this sta maybe a to the Office of Investigations of the D{6 k` m verification. r ,u�u�c I do herby certify un i r the pai s and penalties of perjury that the information pro vided above is true and correcL Yigo^m/s: 0w/, c)1 / - / ( ( Prim Name: -7\, u., - )c`� � �� /t: ^ . Ph* -SJ„) - .3 ( / ` rofficial use only Do not write in this area to be completed by city or town official / Cit or Town: Permit/license #: Issuing Authority (circle one): LBoard of Heath 2. Building Department 3. City/[vwoCler4 4. Electrical Inspector 5. Plumbing Inspector } 6. Other Contact person: Phone � -- _ __ ___� r ) SECTION 8 - CONSTRUCTION SERVICES I 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Reaisternd Home tmnroyemeft Goniractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- 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 ❑ 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 be/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 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition [] Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [0] Other Brief Description of Proposed Wont:, fi r, 1,0 f ( 6/4(.74A.1 i,, ftt /i G+rr ,n ,?2 rto. 1,-7 ,`- Alteration of existing bedroom Yes No Adding new bedroom Yes / No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. 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 stones? 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, - TiV ('Z)U CA (1\i $0 , as Owner of the subject property hereby authorize 7/4.56 filar /451/7441i l » to act on my behalf, in all matters relative to work authorized by this building permit application. / ' ' a tune of - r Date I, /l 1,0/1/' 4 J /lift c IJ /�.. , as Owner /Authorized Agenf 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 )/72_// Signature of Owner /Agent Date r Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning j This column to be filled in by , F Building Department fi , } ,r„ 1 Lot Size Frontage Setbacks Front Side L: R: 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 S ial Permit /Variance /Finding ever been issued for /on tie site NO c J DONT KNOW O YES Q 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 Q DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , Date Issued: C. Do any signs exist on the property? YES © 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 IQ NO 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 ® NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Department use only `' Q City of Northampton Status of Permit: R�j� V Building Department Curb Cut/Dniveway permit 212 Main Street Sewer/Septic Avai ii ty w 1 takk Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans - or s`"M � oe cow 41 c - 587 - 1240 Fax 413 587 - 1272 Plot/Site Nn Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION I 1.1 Property Address: This section to be completed by office lei ? L "j 1 - Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Current Mailing Address: 1",' . ' . � �.i �� ✓. _ .%' Telephone < - 7 0 9. • . .ture J .2 Authorized Agent: VL. r CA S igxsfGvl a jS f ,.a ig , 14i 9 e/e «e Name (Print) Current Mailingess: - '/3'3 22- , 3',1 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building / (_ 3 (a) Building Permit Fee 2. Electrical Y � J (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) /5 3 , ( 5 ChedcNumber � p 11 This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0453 APPLICANT /CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111 PROPERTY LOCATION 62 LILLY ST MAP 16D PARCEL 031 001 ZONE URA(13)/URB(87) / /WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �,!>�i7 Fee Paid // ``��''�� Ty eof Construction: INSTALL ATTIC INSULATION New Construction 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 INFOJMATION PRESENTED: 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 /1 07 if Signature of Building 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. . 62 LILLY ST • BP- 2012 -0453 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16D - 031 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- 2012 -0453 Project # JS-2012-000739 Est. Cost: $1564.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 14592.60 Owner: MAIDANA JACQUELINE L Zoning: URA(13)/URB($7) //WP Applicant: ENERGIA LLC AT: 62 LILLY ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 WC HOLYOKEMA01040 ISSUED ON:11 /8/2011 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 11/8/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner