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« The C'ommonweulth of Massachusetts Deportment of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gor/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (13usinessorganiiation Indkidualt F. neif I &,_ LtJC.,, -- s C ' Address: 0 2 1 40 1 U _ o I I L_ 34'v L(°. City /State /Zip: 4kkoY.../ lv o . - MI-16 Phone #: l 'A l' J.d' — J 1 A, an employer? ('heck the appropriate box: Type of project (required): f I . Dk I am an employer with (Q 4. I am a general contractor and 1 6. New construction 2. employees (full and/or part time).* have hired the sub- contractors 7. Remodeling 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. r required] 5. We are a corporation and its i 10. Electrical repairs or additions 3. I ant a homeowner doing all w ork officers have exercised their myself [No workers' comp. right of exemption perm MCI. ( I I • Plumbing repairs or additions insurance required] + c. 1522. § I(-I). and we have no 12. Roof repairs employees. I no workers' comp. insurance required.) 13. Other 1: 1 ( V "Any applicant that check box #I must also fill out the section below showing their workers' compensation policy information. +homeowners who submit this afftdas it indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. t(untactors that check this box must attach an additional sheet showing the name of the sub- contractors and state whether or not those entities have employ If the sub - contractors have employees. they must provide their workers' comp. policy number. / am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: CAM( 0 t h C JvYah"C�- Cr3 Policy :F or Self -ins. E.ic. 4: LO G \ \ 01- Expiration Date: .G2 fi (0 l � 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 MCil. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and /or one year imprisonment as well as civil penalties in the term of a STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of this statement maybe for arded to the Office of Investigations of the DIA for coverage verification. I do herby certi .' un er he pa' s and penalties of perjury that the information provided above is true and correct. Si nano'e. 1 b 2222— _ -- nats A I APo t o Print Name 11..n S ( RC) ssn.M, sslCr Phone L2 - 3a (o — \S60 Official use only Do not write in this area to he completed by city or town official i City or Town: Permit /license #: Issuing Authority (circle one): ].Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: — ------- ___— __ - - - -- 2222_---- - - -_ -- Phone #: • Client*: 33645 EWELL ACORD CERTIFICATE OF LIABILITY INSURANCE 0 A TEs / o D " PRO ICER TIPS CERTIFICATE 11$ MINJE0 AS A MATTER OF MFONMATION Janes J. Dowd & Sons Ins ONLY AND CONFERS NO RIGHTS UPON THE CER1VICATE 14 Bobala Road 1 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXMOOR ALTER THE COVERAGE AFFORDED BY /1M POLICIES BELOW. P.O. Box 10300 Holyoke, MA 01041 INSURERS AFFORDING COVERAGE ?INC ar MAUREO NSUR,MR A Northland Insurance Company 34754 E1lergia, LLC PNS:A1ER 8 Guard Insurance Group ■ 242 Suffolk street NSultER C. Commerce Insurance Company Holyoke, MA 01040 NSAER D: I i - NSJRER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSW -M.) U T NE INSUREC NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TC WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TC ALL TIE TERMS, EXCLUSIONS ANO CONOIT)ONS OF S,1CH POLICIES AGGREGATE LIMP'S SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS LTR TYPE OF IN5URtANCE POLICY NASSER OIITEYj W Y ANTS A GENERAL LIABILITY WS06/839 02/17/10 02/17/11 EACH OCCURRENCE 3 1.000,000 X COMMERCIAL GENERAL U Pq ABLPT" .yita ..,1 s100.000 IIU CIAS MADE 1 --- xc &H MED EXP IAN are mew) i5, © 81 Ded:500 PERSONAL 1 *Dv NJURY 31,000,000 GENERAL AD0REOATE 32.000.000 GENL AGGREGATE LAST I L ST APPLIES PER. PR0000TS • COMMPIOP AGO SZ�O. 00 . POUGY I- ,. JECT r a,: I _ _ ____.._.___ — C AUTOMMOS.LE UABL.I Y BBRCI7 02/17/10 1 02/17/11 1 s 000 COARMNEU SINGLE OMIT ,000 ANY AUTO l6 so:4 v) ' ALL OWNED AUTOS BODILY NJJR" S X S AUTOS (Par prior)) © HRED AU OS ) BODllY NJJR'+ S © RC's- OYJNEDAUTO:. (Pr ) ■ PROPER -Y G.04AGE I (Pr aOtlCaK) 5 GARAGE LIABILITY - A. TO ONLY - EA ACQOENT S ANY AUTO OTIf R -tAH EA ACC ; S A.TO MY AGG ' S EXCESS/ UMBRELLA LI8IUlY .... ,EACH O:,CJRREVCE S ' DCCUR 7 CLAMS W. 8 AGGREGATE S S aF.nucnet. S RETENTION $ 3 -- C BTA ' S WORKERS COMPENSATOR AND W C 110773 102/16/10 02/16/11 (tt LSS ti ; ( . EMPLOYER" UAaLTTY EL EACH ACCIDENT f1,000,000 ANY PROP'WETOWPARTNER/6XFCUTNT i OFFICERNEI, R EXCL'JOE07 EL DISEASE EA EMPLOYE01,000400 1 yas, dnGW �aqr SPECIAL PROVLSInN8 DMOw El DISEASE • POLICY UNIT 31,800,000 OTHETN DESCRIPTION OF OPERATIONS / LOCATIONS , VEHICLE3 EXc LuSsOsis A00ED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION `SHOULD ANY OF THE ABODE DE ICRIBED voUCE$ SE -RISC LLEO THEME TIN EXPIRATIDN DATE THEREOF, THE 15314/40 INSURER WILL ENDEAVOR TO MAIL _ILL DAYS WRITTEN NOTICE TO THE C NITIFICATi; HOLDER NAMED TO 11E LEFT, SILT FAIWR3 TO D05O SHALL IMPOSE NO OSLIOATION OR LJABIJTY OF ANY ONO UPON TM IIEMIRE& R3 ASSETS 011 REPRESENTATIVES. AVTNOR4ZED RHPIWISHITA,, . ILO , //� y ..y,exsApp/ 41 ACORD 25 (2001/08) 1 of 2 #S713791M71 366 DWGJR a ACORD CORPORATION 1008 r • • I 11a..achuwrtt• - Uepartnu•nt nt Publi ' Restricted to: 00 40 Board of r uildint uction S u per v is o r t. and �tanrL Const 00 - Unrestricted ruperisor License - 1 2 Family Homes License CS 92540 Restricted to: 00 THOMAS 8 ROSSMASSLER Failure to possess a current 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 " - - - Exp 9/2/2011 c ..ru∎ni',warri Tr:: 4606 Office of Consumer Affairs &Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: n Office of Consumer Affairs and Business Regulation ti� Registration: 165169 10 Park Plaza - Suite 5170 Expiration: 1/11/2012 Tr# 292481 Boston, MA 02116 Type: LLC ENERGIA LLC THOMAS ROSSMASSLER kl.. ` � /% 242 SUFFOLK STREET s 4.! r 5 ._______ i t HOLYOKE, MA 01040 t'ndersecretary Not valid without signature . , Property Address: 0 C i 0 . r t -,- 112 ") ,JA t_j_ki- Contractor ■...,-1 Name: \ \,....oi,, \ C (7 5) v \ Address 1 ,-‘ _ ( A o i -, f <__ -- y1 • _______ c V city, state: 1— 0 \ L /___.1 \tr\qc-\\, (: Phone: Property Owner i , \ Name: '..__:\, ___ L.-, Address: Q C . ( ) ),L, :-.-.- ) () City, State: I , MLAILa:, ' .r.)_2(__,A _ (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 Li ()/e zooZ zi.gtl.sstr XVA LZ:TT OTOZ/CE/60 _ , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder r a`He_A r ( (_ SLi C) License Number ++ 1b(-) 11 P ,t ) 4s l a te /I Address Expiration <� 1 3 _rJ - Signature Telephone 9. Replstered Home Improvement Contractor: Not Applicable ❑ LLC 1�s Company Name Registration Number 4 Address}} (1 1'1 I \ 2 Expiratio Dat 4(A 1 1 \ \\ • t v lJ Telephon l ` J) ,, T l I — 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 'J 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 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 ED Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (p Siding [O] Other [A Brief Description of Proposed Work: ih`ie I v,c;nA ck.AiO1/\ th "- `l Alteration of existing bedroom Yes No Adding new bedroom Yes No' �C Attached Narrative Renovating unfinished basement Yes ✓ 1 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 budding 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 4 /("= S /4' 6- ./ t , as Owner of the subject property / / � hereby authorize G- f' 2 / , / ct to act on my behalf, in all matters tSlative to work authorized by this building p rmit application. / 6/ ` y // v Signature of Owner Date I ) r- � -fir (Pei 1.4.4 a -C-(LO v k Gr—ert 4 k , 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. t Yz s(sir Print Signature of Owner /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 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES i IF YES: enter Book Page and /or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 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 ® NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 174 t3 / )4y (,-- - Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability s, Room 100 Water/Well Availability <4i Northrampton, MA 01060 Two Sets of Structural Plans ,,C\,)' phone 413 =587 -1240 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: j This section to be completed by office I Z92 iJ r7 TS ; 7 12 --<,d Map Lot Unit ti� / t eii (7 ° Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of C 9 1 7tz ��i A Name (Print) Current Mailing Address: e /0674 1 W3 , S $? ; -/ i' -deg /.. 4 ' h,,y—..; Telephone Signature r 2.2 Authorized Agent: b A. ( -r$ 2 - S u 1 ( 1, H- /-1- 4- a (C3 q v Name (Printt)) / / Current Mailing Address: �.�1 ( t "l), 3 - 3 1 (- Sig ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building () z (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) $ a \ (_;.,Z - _ ..7)t. Check Number 60.1 0.13-- This Section For Official Use Only Building Permit Number: Date ../h/ , s /� / q Signat ��i..�'l ' _ Building Commissioner /Inspector of Buildings Date BP- 2011 -0453 GIS #: COMMONWEALTH OF MASSACHUSETTS i ; 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-2011-0453 Project # JS- 2011- 000733 Est. Cost: $2027.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 48787.20 Owner: HAGUE GERALD C & SUSAN C Zoning: SR(100) / /WP/WSP II Applicant: ENERGIA LLC AT: 1292 BURTS PIT RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 WC HOLYOKEMA01040 ISSUED ON:11/16/2010 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 11/16/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner