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31B-277 (7) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information. Please Print Legibly Name (Business Organvation Indititduall �� .� \Q ) L c ) S aro 1 k City /State /Zip: TtOl( t t,14 , MP 01040 Phone#: U (?) - . (1 Are you an employer? Check the appropriate box: rType of project (required): • 1. 1 am an employer with 4. 1 am a general contractor and 1 b. New construction employees (full and/or part time).* have hired the sub- contractor. Remodeling 2. 1 am a sole proprietor or partner- listed on the attached sheet. ` ship and have no employees These sub - contractors have ( (. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. I required] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself ]No workers' comp. right of exemption perm MtiL insurance required] + c. 152. 1(4). and we have no 12. Roof repairs employees. [no worker;' 13. .Other l rOvla. ont comp insurance required. *Any applicant that checks box All must also fill out the section below showing their workers' compensation policy information. +Homeowaen 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- eoaoncton have employees, they must provide their workers' comp. policy cumber. / am an employer that is providing workers' compensation insurance for try employees. Below is the polio and job site information. / Insurance Company Name: C" tics _ h SUra n ce. C- ,co up Policy # or Self-ins. Lic. u: En V) C 31q y 33 Expiration Date: / i (. / 1 3 Job Site Address: ('ity'State'Zip: 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 M61. 152 can lead to the imposition of criminal penalties of a fine up to ] S250.00 a day against violas r. Be advised that as copy o civil penalties f thiss atement n maybe forwarded to WO ORDER Investigations fine of the DiA for coverage verification. 1 do herby ce • unde the pains and penalties of perjury that the information provided above is true and correct. Signanire Daze: /I V / i a. Print .Wane: t w+orvul9 �SSMO,55 ,tY Phone 3 -3.2.2 ' 3 l 1 _ r Official use only Do not write in this area to be completed by city or town official City or Town: Permit /license *: Issuing Authority (circle one): 1.Board of Heath 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other Contact person: Phone #: i AR ° CERTIFICATE OF LIABILITY INSURANCE 5 /1 61 { ) 5/16/2012 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 pollry(les) 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 NAME: Mary Conroy James J. Dowd & Sons Ins, PHONE I FAX 14 Bobala Road IuG.NO.E:n:413 -S1R -7444 (AIC,No1:411- 516 -6020 Holyoke MA 01040 •DORE as: PRODUCER CUSTOMER ID a: ENELL INSURERS) AFFORDING COVERAGE NAIC INSURED INSURER A: Northland Insurance Company Energia, LLC INSURER B: Commerce Insurance Company 134754 242 Suffolk Street Holyoke MA 01040 INSURERC:Guard Insurance Group INSURER D:TOrus Specialty Insurance Company INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 773382656 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POUCY EXP LTR TYPE OF INSURANCE IN8R WVD POUCY NUMBER {MMIOO/YYYY) (MMIDDIYYYYI UMITS A GENERALLIABIUTY Y WS096521 2/17/2012 2/17/2013 EACH OCCURRENCE 51,000,000 TO X COMMERCIAL GENERAL LIABILITY PRS(RENTED PREE E SES {Ea occurrence) 5100,000 CLAIMS -MADE OCCUR MED EXP (Any one person) 55,000 X 500 Deductible PERSONAL 8 ADV INJURY 51,000,000 GENERAL AGGREGATE 51,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG 51, 000, 000 7 POLICY IF LOC B AUTOMOBILE UABIUTY BSRC17 2/17/2012 2/17/2013 COMBINED SINGLE LIMIT 51,000,000 (Ea accident) ANY AUTO BODILY INJURY (Per person) S ALL OWNED AUTOS BODILY INJURY (Per accident) S X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (��)' $ X NON -OWNED AUTOS 1 S D X UMBREU.AUAB OCCUR 70874c110AL1 9/14/2011 9/14/2012 EACHOCCURRENCE 51,000,000 EXCESSUAB CLAIMS -MADE AGGREGATE 52,000,000 DEDUCTIBLE 5 X RETENTION 510,000 $ c WORKERS COMPENSATION ENWC319433 2/16/2012 2/16/2013 X WCSTATU- 014 AND EMPLOYERS' UABIUTY TORY LIMITS ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT 51,000,000 OFFICER/MEMBER EXCLUDED? IN N I A (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE 51, 000, 000 If yes, desaibe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 51, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, W more specs Is required) 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 r oot; /4 , ® 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD 410 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen astir License: CS-092540 • ``.,r.tis 4 , A, ., . THOMAS B BIASMA SLER A e, p 100 MAIN . i HATFIELD *A ' # r '- ' 1 �. mot ~�'~ "� fte NA Expiration Commissioner 09/02/2013 c I Office orcoa a � eamen Rez o License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 165169 Type: Office of Consumer Affairs and Business Regulation a Expiration: 1/11/2014 LLC 10 Park Plan - Suite 5170 i Boston, MA 02116 EI3ER't'IA LLC THOMAS ROSSMASSLER / 242 SUFFOLK STREET s / �`/ HOLYOKE. MA 01040 L ndersecrc►ar■ Not valid without signature f I — . Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 4 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 *ck COO per as Owner of the subject property hereby authorize 0./W,.5 � OSS /I QSS4t' to act on my be alf i all atters relative to work authorized by this building permit application. X _ "/^--------- G L Signature of O er Date 1, / - "-- 0,, 1 ' /e , 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. 7 o a,S' aSS / '14r Print Na 04.2- Sig ature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not pl Applicable El Name of License Holder : 7 "7AJ D SS �/27a SS /ef' / 2c5 License Number 2,2- S le / L.SV M /yle oia f/ i Address Expira ion 9/3 - 3111 Sign ture Telephone SECTION 13 - 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 Version 1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Y■ LLCi Not Applicable ❑ Company Name: l i e t0v4 1 4 PON iln 6-3 Responsible In Charge of Construction 292 1'Zt. 1 6 1 04, Addre 64 Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING 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 0 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: /�6gZ. r O A( ,TIC -C 2 loci SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ 4Hi Hazard ❑ 3A ❑ Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B [ ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1S` 0 1st Q 2 0 2n d 0 3rd 0 3rd Q 4 0 4 Q Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) 0 Total Height ft 0 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system El Versionl.7 Commercial Building_Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 5 S* Map _ Lot 277 Unit Zone Overlay District ,4 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i cy Ca o"er .5/ S a e. S Name (Print) Current Mailing Address: 7/3 - 5BS/ - 2301 exl. 11(0 Signature e>` ( Telephone 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature 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) $7,3/55 . O a Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -1168 APPLICANT /CONTACT PERSON ENERGIA LLC ADDRESS /PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111 PROPERTY LOCATION 51 STATE ST MAP 31B PARCEL 277 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE n (, 6 ZONING FORM FILLED OUT �J.. Fee Paid 1' j�j �'�c> �'e Building Permit Filled out r / Fee Paid , 2C Tvpeof Construction: Insulate & Airseal attic � New Construction (1 11( Non Structural interior renovations Addition to Existing Ct 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 INFOfilVIATION 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 m. i b elay d iteie 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. 51 STATE ST BP- 2012 -1168 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 277 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- 2012 -1168 Project # JS- 2012 - 001991 Est. Cost: $7355.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 7579.44 Owner: COOPER RICHARD E & CATHERINE M Zoning: CB(100)/ Applicant: ENERGIA LLC AT: 51 STATE ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 HOLYOKEMA01040 ISSUED ON:6/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: Insulate & Airseal attic 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 6/26/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner