23A-161 Property Address: G b' r.: , 4 5.1.4e r /
Contractor
Name: 7 r� ; /.:s
Address: f �.-
City, State: / .��,� /y
Phone: 5//j • 5`G e • C
Property Owner
Name: 1 /- rr -
Address:
City, State: 0 / G .z
I, (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
68£66 •tIi Jailor...w n )
Z60Z /6/£ :uoile.ildx3
9£O.O V; '1:1 ' •9adlvJVF:
i/ tJC 3
OOOMN2J )
OI'SM :ol palaulsayi
68£66 is SO :asua3l1
asuaon /lleload5 aosimadng uollanalsuo0
p:nt "pualS pur suo!jup ' i }i 71uipi!ng ;!A p.nt0H
�talr.� )ll(l d . 10 just .ilt(I)II - sll•l.ii(oPssltik,
OfticeWro umer airs i sines` o License or registration valid for individul use only
= =Y _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 153287 Type: Office of Consumer Affairs and Business Regulation
' i _ Expiration 11/1412012 DBA 10 Park Plaza - Suite 5170
Boston, MA 02116
T ERGY SREGIALIS�'S.
c ; 410P
MIKE GRENWOOI
55 CIRCLE VIEW
HAMPDEN, MA 01038 Undersecretary Not valid w' out signature
PATRONS MUTUAL INSURANCE COMPANY OF CONNECTICUT
GLASTONBURY, CONNECTICUT
ARTISAN CONTRACTORS POLICY DECLARATIONS ;1
SLNYT WT
Policy Number: CTR0011514 RENEWAL Effective date: 10/14/10
—
• NAI IE,P INS WD:.: A GENa 7680
MICHAEL GREENWOOD RICHARD R GREEN INSURANC AGENCY INC
DBA THE ENERGY SPECIALISTS 11 ALLEN ST
55 CIRCLE VIEW DRIVE HAMPDEN, MA 01036
HAMPDEN, MA 01036 (413)566 -0028
Policy Period: from 10/14/10 to 10/14/11 12:01 a.m. Standard Time at your mailing address shown above.
Insured is: INDIVIDUAL
Business Classification: CARPENTRY - RESIDENTIAL Code: 10030
LIABILITY COVERAGE..
COVERAGES LIMITS OF INSURANCE
L. Bodily Injury and Property Damage Liability $1,000,000 Per Occurrence $2,000,000 Aggregate
M. Medical Payments $5,000 Per Person
N. Products /Completed Work $1,000,000 Per Occurrence $2,000,000 Aggregate
O. Fire Legal Liability $50,000 Per Occurrence
P. Personal and Advertising Injury Liability $1,000,000 Per Occurrence
........................................... ...............................
DESCRIPTION AND LOCATION OF PROPERTY
Loc. 1: 55 CIRCLE VIEW DRIVE HAMPDEN, MA 01036
Loc. 2: 34 FRONT STREET INDIAN ORCHARD, MA 01105
COVERAGES LIMITS OF INSURANCE
Loc. # Building # Limit ACV
A. Building
B. Business Personal Property 1 1 $2,500
2 1 $2,500
C. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS
Increased Property Off Premises: Automatic Increase — Coverages A & B: 0% ANNUALLY
Property Deductible: $500
S :IECT TOT ; FO;T WINGGTORMSG AJ DEN O' RSEMENTS ....... ......................_........ _....
AP -100 Ed: 2.0 AP 0611 01 99 AP 0643 12 99 AP 0432 12 03 AP -222 Ed. 2.0 GL -895 Ed. 2.0
PG 5521 06 05 AP 0700 01 08 AP 0688 06 02 AP 0690 06 02 AP 0692 06 02 AP 0365 10 06
AP 0233 01 08
PREMIUM AND:BII;TING:INFORMATION ......................................... ...............................
ANNUAL POLICY PREMIUM: $1,125 $650 Minimum Earned Premium Regardless of Term
ENDORSEMENT PREMIUM: BILL TO: Direct Bill To The Insured
TERRORISM PREMIUM: $25
. ........................ ...............................
MORTGAGEES ........ ............ ...............................
PRINTED: 08/30/10 INSURED COPY THIS IS NOT A BILL
----
•
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts
(800) 876-2765
NCCI NO 40959
POLICY NO. WCC 5009547012010 J
PRIOR NO. I NEW BUSINESS
ITEM
1 . The insured Michael Greenwood dba The Energy Specialists
Mailing Address: 55 Circle View Drive Hampden MA 01036
(No. Street Town or City County State Zip Code
® Individual ❑ Partnership 0 Corporation ❑ Other FEIN 56- 2624364
Other workplaces not shown above:
2. The policy period is f 0 /16/2 10 tc .10,16/2011 _ 12:01 am. standard time at the insured's mailing address.
3. A. Workers Compensation Insurat i e: f'.irt One of the policy applies to the Workers Compensation Law of the states listed hers;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100 , 0 0 0 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,00 each employee
C_ Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 0306 A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
T Code Total Per $100 Estimated
.otal Annual of Annual
No. Remuneration Remuneration Premium
INTRA 842600
SEE EXTENSION OF INFOR TION PAGE
•
Minimum premium $ 500.00 Total Estimated Annual Premium $ 13,249.00
As indicated, interim adjustments of pr emium shall be made: Deposit Premium $ 3,534.00
❑ Annually ❑ Semi Annually 0 Quarterly ® Monthly
MA Assessment Chg.
$13,020.00 x 6.8000% $885.00
Q ecea
This policy, including all endorsements, is hereby countersigned by 10/29/2010
Authorized Signature Date
GOV GOV KIND PLACING' CLAIM a NAME I SAFETY •
STATE CLASS AUDIT OFFICE r FFiCE . CiaWkTK GROUP The Fairway Agency Inc
MA 5645 8 507 _ j 305 Forest Street
WC 00 A(11 -88)
Bridgewater. MA 02324
Includes copyrighted material of me National (c;' ;.. ; TMaensaty+, l:ssuranoe.
used with its permission.
•
The Comtnenwealth ofMassachusetts
Department of Industrial Accidents •
E 'R .= r Office of lnvestzgatlwns • -
" - t �� 600 Washington Street
t. - Boston, MA 02111
'`'� .-� : = www.mass.gov/dia • •
-Workers' Compensation Insurance Affidavit BuiIclers /Conirac ors/Ele icians,Plumbers - .
Applicant Information - Please Print LegTI
Name (Business/Otg on/Individual) :. 74> £- - r , / .5A- c , q./ S�/ S • .
-Address: 5-T. C/ t i � ;. 61 - •
City /State/Zip: ,, �• ` s # 4 / /1 C% ? Phone-#: Se C - % -
Are oa ana employer ?.Check the appropriate'bo� Type ofprojeet (required):. /
1.I am a emp w 4_- Q I ant a general contractor and I •
employees (full and/orpart time).
: have hired the 6. Q New construction
2-0 I aria a "sole proprietor "or partt cr- . listed on the.attached sheet 7. Q Remodeling
ship and have >o yecs These sub -contractors have. g_ Q Derti flit irm -
working fox me "in c Io_yeesaad have workers' - . •
ed] - 5. 0 We are a corporation and its • 10 .Q EItx t ical repass or additions • • 3. 0 I am a homeowner doing all work
• officers have aesaised tlaefr. - 11.Q Plumbing repaixs`or additions
elf o worlcars' right of exemption per MGL - ' • -
12.0 kofiepairs
insurance a regaired.) t . : c- 152, §1(4); and•we have no " "
employees: [No workers'. • - ' 13.0 O ther - .
• . . " - Comp- inStrototereqOiated.j • . •
• 'Any applicant at checkrbas amostaiso fill of be section belatvshowing P y • .
tHomeownes itthis: av gtheyaredoingallWarkandthe •.hiteoutside most stbmatanewaffidaritindicaangc't-'
CConuxtras that chick this box toitstattached an anal sheet showing them= of the snb•conhactats and statewit craot tis'have .. -
employees.Ifthesus- cxntra tshaveemployees, tbeym nstprovidetheir : - " •
- .I ant an employer thatisprovidmg workers' coarpensation insurance for by eMplay Below is t&e policy and job: site
Insurance Company Name: J . " • .s.: .
Policy# oi ins: Lie: #: ) C . 0 $Cam:. (\ &c Ye -.: , (.- /6 _././
r
lob Site Address:: 6h' 1. -v S/� City/StafefZip -: , fi r
- Attach a copy of the workersr compensation policy dedarafion pa (showing the policy number.: and_expiration date).
Failure _ to secure coverage :asre idi& .Section'25 fMGL c 1 cad Iead'to the nnpoiiiihn &5f cr>m r e ra i es'of a
fine tip to S1,500.00 and/or one-year _*'_* 4+**� +� . as well as civil penalties in the form ofa STOP WK -f OR RDl and a fine
• ofttp to"$250 00 a day against the violator. "Be advised that a cxpy of this statement Miry be• forwarded to the:0f' of
lnvestraatt n fati A m ce cotr era�e c on. = : - _ - .777.7„ . ±:,L.•=71.7:_•.....„_ . _ ' -
.rd —iiii ," e . under thepails. - .�": 's.erl - deaLabnv
— ... / 'th forraaif sinprav
Phone•#l: 5 l• - / S - - ... - . • •
Of�icsal use only Do not write in this area, to be comp _ by .city Or town officiaL
City or Town: . - Peruiit/I icense # •
I . Issuing Authority (circle one):
. :1. Board of Health 2. Bu ldin Department 3. Cityfrown Clerk . 4. Electrical Inspector 5. Plumbing Inspector
6. Other . . •
Contact Person: Phone #:. .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction /
Supervisor: /� / Not Applicable ❑
Name of License Holder : (/mss / �j�rr.°��c..n
) 99
/
r « License Number
5 e° t./4"-0 t./4"-0 �
A-, �``/' l /`f'1 Dk ( ____ i „,
Addres Expiration Date
Signature Telephone
9. Rectistered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
r / ,o„ ./ i .r+.- , Are .a.‘. ' // /V/..k
A•dress Expiration Date
Telephone Y //' C- / fr
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 1
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 10835.1.
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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other A]
Brief Description f P oposed
Work: / �/� 1 CP /% 5C j 4
Alteration of existing bedroom Yes V No Adding new bedroom Yes r/ _ 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 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, js+ , as Owner of the subject
property 7 /
hereby authorize 7%, ,1-e $ e , 4 /i . S�.f
to act on my behalf, in all matters relativ tdwork authorized by this building permit application.
2 J /DM :3-/ -/7
ignature of O ner Date
I, 7,
•
L -;./ >> fame—« /. ,
` f , as Owner /Authorized
Agent hereby declare thfhe 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.
ne�
/"/�<hr/ &CC.— c4)0r�
Print Nam-
3/7"
Signature of 0 er /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: 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 Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit �
ECEIVED 212 Main Street Sewer /SepticAvailabiltty
Room 100 Water/Well Availabtliti .,
MAR 2 �l! I I Northampton, MA 01060 Two Sets of Structural Plans I
phone L13- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
DEPT. OF BUILDING INSPECTIONS Other specify
Nf1RTHAMPTf)N MA r i nn0
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
6 r 5 f Map Lot Unit
1 !? / U ,t Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
%ce / . /17 6S-
Name (Print) Current Mailing Address:
pis y ‘7.)1 5'
Telephone
Signature
2.2 Authorized Agent: f
7// G .� mss , f ilci �� 5 f S 5 ��i�c /� �•'• �r //‘--3 z9i
Name (Print) Current Mailing Address:
Signatu - / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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 = (1 + 2 + 3 + 4 + 5) 7v c. Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature
Building Commissioner /Inspector of Buildings Date
68 PINE ST BP-2011-0758
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 161 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 -0758
Project # JS- 2011- 001251
Est. Cost: $1700.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS99381
Lot Size(sq. ft.): 14026.32 Owner: HERLIHY ALICE
Zoning: URB(100)/ Applicant: THE ENERGY SPECIALISTS
AT: 68 PINE ST
Applicant Address: Phone: Insurance:
55 CIRCLE VIEW DR (413) 566 -1058 WC
HAM PDENMA01036 ISSUED ON:3/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC & AIR SEALING
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 /C'himney:
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 3/24/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner