17A-181 The Commonwealth of Massachusetts
�_. Department of Industrial Accidents
_,1��•_= ! Office of Investigations
600 Washington Street
` �!= Boston, MA 02111
"'•� «' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Energia, LLC.
Address: 242 Suffolk Street
City /State /Zip: Holyoke, MA 01040 Phone #: 413 - 322 -3111
Are you an employer? Check the appropriate box: Type of project (required):
1. ® I am a employer with 10 4. [l I am a general contractor and I
employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
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 10.0 Electrical repairs or additions
3 . ❑ 1 am a homeowner doing all work officers have exercised their I L O Plumbing repairs or additions
'
myself. [No workers' com right of exemption per MGL
Y' [ comp. 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.® Other Insulation
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached 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. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Group
Policy # or Self -ins. Lic. #: ENWC319433 Expiration Date: 2/16/13
Job Site Address: - /�/ ' V• City /State /Zip: /.ewe Atito/42_
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 MGL c. 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 form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce • and the pains and penalties (perjury that the information provided above is true and correct.
Signature: Date: /W 2_
Phone #: 413 -322 -3111
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 Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
L i.0 1 . 4 ,...,..,h4, 8 , iithil ....11..0,,,,, tviiiii p.innw se ,. jik
,
Construction Supervisor License
Lt en CS 92540
THOMAS $ 14 088111ASSLER ,.
100 MAIN STREET
HATFIELD, OM 01038
E apo soon 9
( .0...at-4..swi Tr 794
. ...
** oractAmiltialltiAs Lsecuse or reglatravou valid for iudiridui use ontr
before the expiratiou dass. It bead reborn to:
1t CONTRACTOR
Office of C ouslimar Albin sad ausiaess Regulatioa
05109 Type.
10 Park Pim - Suite Slift
N ir ERAiralion: 1111/2014 LLC
Restos. MA 02116
tA LLC
THOMAS ROSSNASSUER
11/
242 S*JFFOU( STREET
HOLYOKE. MA 01040 t aders• cretars %at '.Mid without signature
_._
ERTIFICATE OF LIABILITY IN
�ATh�lEi,y� � INFORMATION �,, ABC INSURANCE �,��,
R INSURANCE OR Y AREND, EXTEN UPON THE CER7ifiCA
ER, AND THE CERTIFICATE HOLDER. A ACT sETl p COVERAGE p c IN AFFORDED s 1
, AUTHORIZED
ikirr Is an .. ISSUING �iR;(/$)
'der. potic• TrI
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on this prtll days not AWED. subiloct �htsttw
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RT EL :773382656 REVISION ) LI TERM H BEEN ISSUED TO NUMBER;
ANY REQ IR OF THE FRANCE AFFORDED OF ANY CO CT OR OTHER NAMED„ T VVITH THE RESPECT
SUCH POLICIES. LIMITS SHOWN MAY N THE AVE R$ QED HEREIN IS M SIISJE CT 70
r • , � r EEMJCEO BY PALO
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2 . ^j CIAiMS
/ 17/2012 ..,u44
' 2/17/2013
EAt2 i $1,000.000
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :_7d/?d.5 TRo ss,,ssk r 72, 5 P
License NLmber
2 5 2 SEA'S / / �� l3
Address / Expiration to
1 AL1 3- 22-
Signature v Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑ /
siJ 7O
r
[
Company Name! � RegistratiO N Of<
- _ _ Vo
Address / ( Expirati Date
Tele hone
p �/3 322 - 3 ///
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 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
11101/2012 09:38Ar1 4133413441 LAIRKIN -ROSS PAGE 01
(, SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aop!icab!e!
f J 1
Now Heuer: f ^dui*i^ 11 ca ». Windows l w!• r..� r� l
1—J E l a i Or Doors 0 i J _ ; -1 LJ
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [P Siding [DI O) eer
8net Description of P opo ei L
Work: / /kW/ /Q 04 -7 4 _ 7 / 0 R 2� eP/�
Alteration of existing bedroom Yes? No Adding new bedroom Yeso
Attached Narrative Renovating unfinished basement Yes /›"C.- No
Plans Anacnea RN! - Sneet
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. !s there a garage attached?
C. Proposed Square footage of new constructicn. 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
hin • A fw wetlands? N .. 1, cti •thi 1 0n r 1 Yes
�1..
is construction �7y {i; 1111 IVV ft. of :..liCfi Ills: Yes No. tS �.VliJif ll4llCl:i 1iViil ill+ iVU yr. AIL JVtiIC':.i+ i GJ IV41
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
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
l l ✓ r Tq- `- as Owner of the subject
property
hereby authorize •1!.►'�j 1 .
to act on my behalf, in all matte relative to work authorized by this building permit application.
Signature of Omer r Date p t
1, ��ng 0 �u -S131 , as Owner /Authorized
j Agent he eby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u =er the pains d penalties of perju .
Print Name //
3 gnature of • 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 Q
.................. .....................
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO i
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1110112012 09:41AM 4133413441 LARKIN -ROSS FAG: 01
—
Department €ise only
c t . J .y City of Northampton Status of Permit:
— ` `� -- 13uilling Department Curb CutlDr€veway Permit
212 Main Street Sewerlseptic Availability
5 2 I darn 100 (Waterf`rVell Availability
l`
N t1a ptan, MA 01060 Two Sets of Structural Plans
pEPT. of su 5871-1240 Fax 413 -587 -1272 Plot/Site Plans
NORTHAMPTON, MA 01060 A Other Crtarifrt
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
srCTION I - $ITC .INFIIRMATIO! 1
i
This section to be completed by office
1.1 Property Address:
ti 3 ,s. r4 fr# sp Map Lot _ Unit
c- wrz-r€ —tic Ate+} District
0(062.
�3 v� 3 gay..tsc iCl
an St. District CB District
E
SECTION 2 - PROPERTY Y OWNERSHIP /AUTHORIZED AGENT i
i
2.1 Owner of Record:
6.1, ..4 ,{ .. t't 3 f.1. .+R4f}t -!t f.n -riv. et O l(,' tc7.-
;. .. (t3...., ( C. _ t Mailing Addr uva
,
Telephone
Signature
2.2 Authorized Agent:
.t L547/(LiY ' /7(O 7
l
me (Print) / Cu nt Mailing Address
E _ f /3 32
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
tern i Estimated Cost (Do€ions) to be 1 Official Use Only
` tiu b 'a 1iCa..{ (
LVi%�t`v v��u iii �d ,
1. Building { 4 Q v € (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
i 1 Constructor from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
fi Fir protection
6. Total - (1 +2 + 3 +4 +E) ( ! . r .,Z) Check Number ���r��alirt I
This Section For Official Use OnI
_si €ii:.... 0,......1 Ri,.r..,S...+... 1 Date
Q
inn c ernI t.( ur-,.eJsr: / Issued'
! {4
Signature:
Building Comtnissicnerlinspector of Buildings Date
File # BP- 2013 -0530
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 193 NORTH MAPLE ST
MAP 17A PARCEL 181 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / p 9 Ars
Fee Paid
Tvpeof Construction: INSTALL FLOOR INSULATION
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License 92540
3 sets of ' ans / Plot Plan
THE . I LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN . 0 RMATION 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
- of '' Dela
/ /7
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.
193 NORTH MAPLE ST BP- 2013 -0530
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 181 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- 2013 -0530
Project # JS- 2013- 000857
Est. Cost: $875.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 7187.40 Owner: ROSS VANESSA & ELIZABETH LARKIN
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 193 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:11/9/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL FLOOR 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 11/9/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner