29-512 :My Fax - Energia, LLC To:Linda LaPointe (14135871272) 14:19 09/14/10GMT-04 Pg 03-03
, .
Property hadress:
Contractor
Name: i\0VIA6,5 vkil-aS-
f. S■gtz.%.V4-
City, State: -H-c) .k..vo 4-e An
Phone:
Property Owner \. \ I 12-4
Name: r v
Address:
City, State: 1:11 PAO, . 0 k 0(o)
TIe1/4,-*Atcri_oss ss\ e (contractor) attest and affirm that the building I intend
,
to imtilate doe.p.nns have aryspan air rinb and t tv11.wiring in the_sbaces to be insulated and
_that_l 1 the, property owner with a cow of this affidavit
Contractor signature JjJJJj
Date
zooz ZLZTLR.E:Tr I,Z:TT OTCIZ/CT/60
Client#: 33645 ENELL
ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE 15W 0
PRODUCER T HIS 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 REND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 10300 __ _� i
Holyoke, MA 01041 INSURERS AFFORDING COVERAGE I NAIL #
INSURED _ __ _ �.
Energia, LLC INSURER A Northland Insurance Company 34754
. INSURER B Guard Insurance Group
245 High Street IASt 1, c Commerce Insurance Company
Holyoke, MA 01040 NyJItFR c _�_.
COVERAGES
INSURER (
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 1 U ' HE 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 BC 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.
111SRM�ILOa T YPE OF INSIURANCIE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS lTR /NSRC ._ DATE riVWDOlYYS DATE IMNVOONY)
A X GENERAL LIABILITY WS061839 02/17/10 02/17/11 EACH OCCURRENCE _ 11,000,000
X COUMFS.CIAL GENERAL .,AB.LITY DAMAGE TO Fi R rw) ENTED 5100.000
I P� f nonrron
CLAMS I
lM .XcJR I j MEDEXP IArry orle parson) 15,000
r— ........_ _ ' PERSONAL d AOV INJURY 51,000,000 ...
_ GLNLIiAL AGGiLGAIL $2.000,00
GENT AGGREGATE LIMIT AP -LIES p + I 1 'RODUCTS COAIPJOPAGO s2.000,000
POJCY PRO. -
JFCT i1 Loc
C AUTOMOBILELIAsIUrY BBRC17 02/17/10 02/17/11
: SINGLE Lima 51,000,000
Ea acc
ANY AUTO -!Ea aec Ism)
ALL OWNED AUTOS
BODILY INJURY S
X SCHEDULED AU TOS - - :Pepe' cr)
X HIRED AUTOS f BODILY INJURY $
X NON-OWNED AUTOS
Pa: a�0enti
PROPER*" UAMAGE S
I ,Pe.,d�,t;
GARAGE LIABILITY 1 ALTO ONLY - FA A✓GIOUNT 8
I
ANY AJTO CTHER THAN , EA ACC 5
Ali TO ONLY: AGG S
EXCESS IMBRELLA LIABILITY + -"ACH OCCURRFNCF 5
7 OCC CLAIMS MACE I AGGREGATE_ $
$
DEDUCTIBLE 1 S
I RETENTION 5 wC 5A H- S
B WORKERS ' COMPENSATION AND WC110773 02/16/10 02/16/11 l
EMP • S' LIABILITY TT^RY I T IMTITLL S 1 0T PA
ANY - • C»l/PARTNEWtxcCU ror 1 F i FAO, ' ACCIDENT 5300,000 _. ^.
OFF ER EXCLUDED') F L DISEASE - EA EMPLOYEE *500,000
If vox :Ce umar
SPECIAL PROVISION M lcwv EL. DISEASE - POLICY LIMIT , 5800,000
OTHER . ..r.� ___......_...__. .
1
DESCRIPTION OF OPERATIONS! LOCATIONS f VEHICLES 1 EXCLJSIONS ADOED BY ENDORSEMENT, SPECIAL PROVISIONS
Springfiled Partners for Community Action, Inc Action, Inc.,National Grid USA and its
subsidiaries and Keyspan Energy Delivery and its subsidiaries, MTC, G.L.C.A.C. Inc.
•*10 day notice for non - payment
CERTIFICATE HOLDER CANCELLATION
SHOL LD ANY OF Tit ABOVE DESCRLED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO NAIL. 3Ae DAYS Wvrr EN
NOTICE TO THE CERTWCATG HOLDGR NAMED TO THE LEFT. BUT FALLURE TO DO 80 SHALL
IMPOSE NO OeLIGAY OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
[REPRESENTATIVES.
AUTHORIZED RREPRESEENTATI
/(f
ACORD 25 (2001/08) 1 of 2 #S71075/M70390 SXP 0 ACORD CORPORATION 1988
OW The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
t 600 Washington Street
Boston, Mass. 02111
www.muss.gov /diu
Workers' Compensation insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (13usincssd )rganiiatiun India iduul) : , 11Pi r q) •
c.... L.� _ -- -- __ - --
Address: 0 2 Lid- Tfo Y JJ t t
City /State /Zip: 4.$o y,.., AC, O'bL6 Phone #• I A13' .3.g, 1
A,ou an employer? Check the appropriate box: Type of project (required):
1. 1 I am an employer with (Q 4. I am a general contractor and I 6. New construction
employees (full and or pan time).* have hired the sub - contractors
7. Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub - contractors have 8. Demolition
working for me in any capacity. employees and have workers
9. Building addition
(No workers' comp. insurance comp. insurance.
required] 5. We are a corporation and its { 10. Electrical repairs or additions
3. l am a homeowner doing all w ork officers hay exercised their I
myself (No workers' comp. right of exemption perm \4( 1 . I I . Plumbing repairs or additions
insurance required] + c. 152. 04). and we hale no 12. Roof repairs
employees. (nu worker,' 13. O (J .O ther t in,
comp. insurance required.( ��
`Any applicant that checks boa #1 must also fill out the section below showing their workers' compensation policy information.
+Homeowners 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, they must provide their workers' comp. polies number.
/ am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guar a \ S u r e NCe Ciroul9
Polic a or Self-ins, 1 ic, T4: W \ \ 01-1-3 Expiration Date: 2 J) ( 11
Job Site Address: City State hip:
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 M(al. 152 can lead to the imposition of criminal penalties of a tine
up to $1.500.00 and /or one year imprisonment as well as civil penalties in the Corm of a STOP WORK ORDER and a fine of
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
1 do herby certi .' un er • he pa' s and penalties of perjury that the information provided above is true and correct.
Si_nuture. 1 ' c:: ____ _. ihrte C d /It /; io
Prim .' anw. ' — L s l S A&. SS1 ,'h L ?) — 3,9-c, - I cg l
Official use only Do not write in this area to he completed h)' city or town official
City or Town: - -- Permit /license #: I
Issuing Authority (circle one):
1.Board of Heath 2. Building Department 3. ('ityffown Clerk 4. Electrical inspector 5. Plumbing Inspector
6. j
Contact person:
----- ___..__ —_ -- Phone #:
\Irss4c husctl• Oh•p.trtma'ut •.1 l'ul'l/. `.11,1• ,yed o; 00
lit Board uI Buildint Re•
Construction l.tta•tt..11141 'l.ut,Lt1.1• Unrestricted Super 4 tsor censt IG - 1 2 Family Homes
License CS 92540
Restricted to. 00
THOMAS 8 ROSSMASSLER _ 1 Failure to possess a curtest 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
4 • it1U111••N• /1. 1 -•
'7,60 ( 4•441 4174.44440ol f/I ,1. /4t...,. het .r//.
Office of Consumer Affairs & Busioes Rrg ul.unn license or registration salid for indisidul use onl■
tbefo HOME IMPROVEMENT CONTRACTOR
re the expiration date. If found return to:
Office of (•onsumer Affairs and Business Regulation
Registration: 165169 111 Par'. Plaia - tiuite r+l'11
Expiration: 1/11/2012 TO 24248•
Boston. %1:A 02116
Type: LLC
ENERGIA LLC
THOMAS ROSSMASSLER /�
242 SUFFOLK STREET , ., ` I / \-/ 1✓ v
HOLYOKE MA 01040 l nder.ecretar. Not wild w ithout signature
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : TO ek 055 M I�55t* 1 7:-).( 0
S `f ' I b10 M a 0/174f License Numb
J GJJJtt, 'v' /, e I (i
Address Expiration Date
c's 37 3)1(
Signature / T- ep f• -
9. Registered Home Improvement Contractor: Not Applicable ❑
E1 iA 1,1,U 1 bi) L9
Company Name Registration N ber
7)41/ 5\WU- Bi r�tiya1(, 0► 0 ( ti �
Address Expiration Date
;Jai / 11 . //� i / Telephone it 1 3 - 22 Rio
/ / vir
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 buil ing permit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
The current exempti • • for "homeowners" was extended to include Owner - occupied Dw e s i n gs of one (1) or two(2) families
and to allow such home• ner to engage an individual for hire who does not possess .-ii ense, provided that the owner acts
as supervisor. CMR 780, 'xth Edition Section 108.3.5.1.
Definition of Homeowner: Pe • (s) who own a parcel of land on whic • e /she resides or intends to reside, on which there
is, or is intended to be, a one or two : • ily dwelling, attached or de : ed structures accessory to such use and/ or farm
structures. A person who constructs mo han one home i , wo -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Buildin• Sfficial s a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under t io: a uilding permit.
As acting Construction Supervisor your pres- • e on t' - 'ob site will be required from time to time, during and upon
completion of the work for which this pe is issued.
Also be advised that with reference to apter 152 (Workers' •mpensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulti • : in Death) of the Massachusett eneral Laws Annotated, you may be liable for person(s)
you hire to perform work for . u under this permit.
The undersigned "homeo er" certifies and assumes responsibility for co • iance with the State Building Code, City of
Northampton Ordina• es, State and Local Zoning Laws and State of Massachu • s General Laws Annotated.
Homeowner : ignature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors I:3
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [El]
Brief Description of Proposed SJ� /1/, I co 0 A /,, C �/ n� , L D ��
Work: ----- 11��'' l� t / ( l:.
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 X 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
�nn .� ^R.&��f�
1, \) ��l Iw V ��t� , as Owner of the subject
property
-...--- V ty , M ,51 ( L �- C- / A LA, �-
hereby authorize � �M 1 `
to act • half, in all matters - - , to work authorized by this building permit application.
ignatur- of Owner Date -Q ( 0
I, , 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.
` O w a a 55 INAJ L --- .
Print Na 1
Signature of Ir a Ag: nt r r Date
f•
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
211.Main Street Sewer/Septic Availability
ft4ti \ ' Ro • 100 Water/Weil Availability
'), ' Northampton, MA 01060 Two Sets of Structure! Plans
co<Cl3 phone 4. -587 -1 • . Fax 413- 587 -1272 Plot/Site Plans
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
5 "TA?-(' i -‘ CLL Map Lot Unit
P\ O, o 6Z Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
vp t?R-6V ‘ \ 5 774- CI V-CIA
Name nri'r
v
� (;� `� Current Mailing Address:
C �l� '/ Telephone l r SS t ' 1 �� V
Signature
2.2 Authorized Agent:
Ev — nn A),o65 e53L&- 242 5offo . ) tM a
Name (Print Current Mailing Address:
322 31 CV1q/K1 Signature U 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) g Check Number j (lf2 0 �j � S
This Section For Official Use Only (( UU '"'
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0218
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 15 TARA CIR
MAP 29 PARCEL 512 001 ZONE URA(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 R�
Typeof Construction: INSTALL CELLULOSE 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
INF ATION 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
D /
Signature of Building Offi 1 ate
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.
15 TARA CIR BP- 2011 -0218
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 512 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 -0218
Project # JS- 2011- 000379
Est. Cost: $925.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 5967.72 Owner: VANDERGRIFT JEFFREY & ELEANOR
Zoning: URA(100) //WSP Applicant: ENERGIA LLC
AT: 15 TARA CIR
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 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 9/15/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner