49-027 (3) i
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Construction Supervisor License
0
THOMAS B ROSSMASSLER Z
100 MAIN STREET
HATFIELD MA 01038
Ullice of f a r∎ S i ii'40 .. tr ^ui�t:n I.ircn.c te I c^i.traUun . s lid tur tndtx idol use mils
HOME IMPROVEMENT CONTRACTOR heturc the expiration date. If found return to:
$ ()nice of ( on\umer 1ffair And Business Regulattun
,4 Registration: 165169 Type 7
Expiration: 1!'.1,2014 111 !'ail. Ylaia - Suite S1"11
- ,'•• Ku \torn. NI 1, (1211()
ENERGLA
HOMA:r., ROSSMASSLER
)42 SUFFOLK STREET _ _ 1 _ 01/4,..,„/ ' \
HOt YGK; Mr. 01040 1 ndcrse■ reta■ \nI . ahtl N11110111 •t2nxture
I d CERTIFICATE OF LIABILITY INSURANCE 5 1 '
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 POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. •
IMPORTANT: 11 the certificate holder Is an ADDITIONAL INSURED, the pollcy(Ies) 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 holier In lieu of such endoreement(s).
PRODUCER IIE Mary Conroy
James J. Dowd & Sons Ins, ?FAX
14 Bobala Road REMI:41 3-53S-7444 1 (AC,N0):413- 536 -6020
Holyoke MA 01040
cusTOMan ID /: F2JELL �_—_ _.
—__ �iAFFORDeNiCOVERAGE ^__._.r_ _.__ NAIC/
INSURED _ - - - -.. -- - -. - - INSURERA : Northland Insurance Company ______ -
Energia, LLC
I
242 Suffolk Street SURER IS : COMMer ce Insurance Company 34754
.- .- - -....
Holyoke MA 01040 wSUOMRC:Guard Insurance Group_______
e0SURERD:Tor1Ls $Decialty__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 WI TH 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
_ /pppl�y
. L� TYPE OF INSURANCE � ', "'� ,. POLICY NUMMI IISMIQpIY IM j LOOS GENERAL y I Y 1 'WS096521 2/17/2012 2/17/2013 1
.EACH OCCURRENCE ; $1,000,000 DAMAGE TO RENTED ,
X__COMMERCIAL GENERAL LIABILITY :PREMIS OSCIM�MIq) $100 , 000 1
-1- J CLAIMS.MADE L 1 OCCUR MED EXP (Any one person) S , 000
X 500 Deductible 'PERSONAL &ADVINJURY $1,000,000
NE AGGREGATE $1, 000 000
! _ -- - _ GENERAL AGGREGA
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $1 , 000 , 000
POLICY i I LOC
i
B AUTOMOBILE LIABILITY j I BBRC17 2/17/2012 2/17/2013 COMBINED SINGLE LIMIT S1, 000,000
ANY AUTO (En )
— BODILY INJURY (Per person) S
ALL OWNED AUTOS ! r
BOOILY INJURY (Per acodeng S
X _SCHEDULED AUTOS
■ PROPERTY DAMAGE S
X ' HIRED AUTOS ! (Per )
X NON -OWNED AUTOS S
S
D X 1 uMarEw►uAB ' , OCCUR , ' 70874C110AL1 9/14/2011 9/14/2012 ' EAcJi $1,000,000
f
j CLAIMS- MADE'' , AGGREGATE $2,000,000
i
f DEDUCTIBLE r 5
—
X RETENTI. 10 ^000 S
C A1& EMPLOYERS' t1Aae.lr ,ENWC319433 2/16/2012 j2/16/2013 X - • M- -_
TORY LIMITS . FR
ANYPROPR�EXECUTIVE YIN '
E.L. EACH ACCIDENT $1, 000, 000
OFFICER/MEMBER EXCLUDED? N,j N 1 A . 1 _ - , - ,
(Mamlday In NR) I E.L DISEASE - EA EMPLOYEE $1, 000, 000
•- IIPTI
.. ON OF OPERATIONS below I E DISEASE - POLICY WAIT 01, 000, 000
DESCRWBON 04 OPERATORS l LOCATIONS 1 VEHICLES (ASKS ACORD 101, Addltional RmssAcs schedule, If man spun Is regrind)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OEA POLICES BE GANCELLED
BEFORE THE EXPIRATION DATE THEREOF NOTICE DILL BE DELIVERED
• IN ACCORDANCE VYRH TEE POLICY PNOVENON3.
,
AUTHORIZED RaPstesasranve
1 rose, di* -
1 ,
®1988 -2049 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
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): Ener• la, 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. ❑ 1 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. fl Demolition
working for me in aci employees and have workers'
g any capacity. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 'I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.1:+ Other Insulation —
comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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: 7/�' Rl '/', / /< City/State /Zip: j e 4' 2i
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 tine
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 c ify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: _ Date: // .24/2
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 #:
*�ar1r t4
t y `4
4011k .r'
PA RTICIPATING
CONTRACTOR
mass save
&MAIM Shroudf MrrCY Nfktenc-
PERMIT AUTHORIZATION FORM
1, M'CFC/c , owner of the property located at:
(Owner's Name, printed)
7/6 // 1 11( Pri
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
Owner's Signature
// 9 r 7 .
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participatin Contractor Date
Rev. 12132011
City of Northampton
4101) �,P, ; S `' : .�` S ic
Massachusetts k `4
DEPARTMENT OF BUILDING INSPECTIONS I h
4 v 212 Main Street • Municipal Building ` � 4 C '
v Northampton, MA 01060 3"?�
Property Address: 7j(# d_rI/ /// Z1 4
Contractor
Name: 7 ASS I €C
Address: 2•kl2 S LC Q' k-
City, State: / e / / / /e', ti,z(---
Phone: y/2 - 322- 5/ /l
Property Owner
Name: 7"/J / /e / LYJh
Name:
Address: 7/1, 7k' %4// X /
City, State: 1/"./C % If d ' 2-
I, '/i 1 ,_ !► L ___ • , 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
//20/2
k
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su isor: Not Applicable ❑
Name of License Holder : /n 4S Tossykassler f 9!' License Nu
2g2 SQ v IK St • / 4Die f ,14 /ds q 2)13
Address Expira tion Da e
Y/3 3 - 3///
Signa re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
'e /cJ 1l4 5//o 1
Company Nimg/ Registration Number
20 Sic Ik. s ' 1,
Add Expira on ate
/ ) /_ / �e / /11/4 / Q "/ Telephoner /2 - .322. 3/! 1 / 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.
je
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
f
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) Ei Roofing J
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0]] N Ot jr
Brief Description of Proposed
Work: /175///4"4.61d — : r ,4d41 Dfval to '12.,3 . oA4e. Sweep
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 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
I, i %7 c>"7 , as Owner of the subject
property
hereby authorize .� -eh' /a---
to act on my behalf, in all matters r lati - to work authorized by this building permit ap.licat on.
t r l t
Signature of Owner Date
I, 0 /Y1 L,,( ( SS "ASS 1 -e_i(' , as Owner /Authorized
Agen hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed un erthe pains and penalties of perjury.
0IX ac -- 2.oss rkassl4r
Print N
Z
Signature of Owner /Agent Date
Aminir
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 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q 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 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
_� Department use only
1 City of Northampton Status of Permit:
2 6 emu Building Department Curb'Cut/Driveway Permit
car iK 212 Main Street Sewer/Septic Availabit y
DEFT. OF BUILDING GI INSPECTIONS Room 100 WaterNtleli Ava la ltty
NORTHAMPTON MA 01060 orthampton, MA 01060 Two Sets of Structural Plans ,
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: This section to be completed by office
7/a P rJ // ?J. Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
— Te Dr S 7/40' % // d . rpier
Name (Print) yA� Current Mailing A r ss.
'( 4-ticheL Telt'pn e - 0
,32
Signature
2.2 Au orized Agent:
S tr(VoIk rxGS a4s ,xrss 1 e a .
Name (Print) Current Mailing Address:
5 2 2 - ) 1
Signature T lephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 ) 5-00 6 (a) Building Permit Fee
2. Electrical V (b) Estimated Total Cost of
Construction from (6).
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection e� rr
6. Total =(1 +2 +3 +4 +5) 1 6v o : O Check Number v L15.
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0587
APPLICANT /CONTACT PERSON SOTO HECTOR S & IDA S
ADDRESS/PHONE 716 PARK HILL ROAD FLORENCE (413) 586 -3078 0
PROPERTY LOCATION 718 PARK HILL RD
MAP 49 PARCEL 027 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /SS-6
Paid
Typeof Construction: 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-0 - N PR'SENTED:
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
ay
AOM#A110
Signature of Buildin ■ • f icial 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.
718 PARK HILL RD BP- 2013 -0587
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 49 - 027 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 -0587
Project # JS- 2013- 000949
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 79714.80 Owner: SOTO HECTOR S & IDA S
Zoning: Applicant: ENERGIA LLC
AT: 718 PARK HILL RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:11/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: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 11/27/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner