24C-087 (2) Cu5tomer 1L1 r .?';`x_5_ Ctrstrni r Snore 4 jilr(1 ,l^.1 Addreii 23 ,.3. •:,s,,.;
t
u/r 4Ai /mil
KNOB & TUBE 11x1RJNG
Durinu the Energy Survey of your ht)tnc,. indications AI" knob and tube" wert round. This old style of wiring
involves inclividua) wires that am run through walls and ccilinvt in a hrw:ts_ ceiarnic "knobs" and "tubes" to
prevent contact with wood framing. The 1:noob ttlitl ttrlx. \cirittl; th:11 IlaS been noted #nay r,Yr ',Joyutre cenpnr lrt b.: mare.
c.
Even iiTtlic onser•.'cr4i wiring appears LO be inactive. there may stilt be active knob ;Ind tube circuits hidden inside walls
or other inaccesssible areas orate. hot:sc.
The Mass Sufic PTogrurn requirements require tbtu t•ott have the hnttie checked by at licensed electrician and certified ns
bcing c;f'url (r•rir a knob ,f ruie wiring where 'seeded. before institution and/Or nit scaling work can be done. YoUw
electrician should Itll out and submit a copy of this document to the Center for f'co'i'echoolney (Cli iti order to vcriry
the absence or inactivity of ttie knot) rind true wiring itn the nrcos of your borne where we are proposing ittstilatiati w t ?u
installed. Out IO the ltatrilit.• involved in sitlrtirte such a form, wesuggest you shun' or describe this forth to your
electrician before hiring hint ro inspect ■ hotnc to he sure bestte h willln to sigh it. The Cutter for
EcoTt'chnolt►t,�'„y f) and the M1as Sarc pr r'an) %% rely oft the electrician determination and certification below and
nt: i r innceurrrte.
Your tulle could benefit from i adon and.or air sealing in the:
,
SO Attic Slope I tenor 0 Basement + Ank Flour 0 Knccwull Fluor
\Volts
* Only after this certification is received by CET can u Contract he isiued for
energy saving insulation and/or air sealing work. '
Electrician's Certification
('t'hta form iA invalnl %lien uu) yunliftcu lions; nrattestations urr:ittdd1114,i
Company Name + Addn;ssJ3f ° �- 7 'o f £ l ee'T4? ;'7`J —
6 7_Af J' r y . - y" . 4 _ ° s,. _ L t 7
i:iectrieil s Same C S Licefa ra _Li 898 r Q
l have pesfanned an impeciioo oI the wiring at the hotite of;
! at 3 ,rt.•�S!�$o- 5 -i- , i lA/Q �s .
t0�► 's � ,ct tStieret Attd Bess) ( Cir o •)
Upon completion of mt• inspecttun i have found that there is no active knot► grid tithe tiring in the area(s) rioted
helms*.
t fiEr ,AtticStolle t;xterinr 1 8:txcrtient ` Artic Floor ,. Knee Ftour
Walls
Electrician' sSignature D!te
Plea,ce moil this ccriilieation loiter o; Center for Eco fcchttnio y
320 Riverside Drive t -A
Flcreticc. MA Cl 1 062
Or fns to: 413-586-7351
Nev.
Please call 8i111 -23S -1221 with any questions or concerns.
Customer (Ii1Jit -its ss hurt ca►nptctvd) - ll Customer (Tony — Yellow Auditor - fink
4ok ; 1r �
PARTICIPATING
mass save CONTRACTOR
S.Vin9S thous* enemy efficiency
PERMIT AUTHORIZATION FORM
i � ir y �� , owner of the roperty located at:
,. P
(Owner's Name, printed)
2 ---- 1 s6,- - -tent. 1 , / /i1
Street Address) (City/Town)
(Property � � tY )
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.
Ad e
Owner's Signature
/ //5 — -// - — -- e—
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:
AO
Participati 4 Contractor Date
Rev. 12132011
The Commonwealth of Massachusetts
Department of Industrial Accidents
=51i1 1 Office of Investigations
Tx: : - - 600 Washington Street
t - Boston, MA 02111
• •~~' `•��� ~,
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organizationilndividual): 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. ❑ I am a general contractor and I
employees (full and /or part- time).* have hired the sub- contractors ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have S. ❑] Demolition
working for me in acit employees and have workers'
g any capacity. y 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q l
3 . ❑ I am a homeowner doing all work officers have exercised their 1 1 . 0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13. C4 Other Insulation
comp. insurance required.]
Any applicant that checks box #I 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.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities ha%e
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:2_L4S i aSe) t � Cit /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 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 5250.00 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.
1 do hereby certify u er the pai s and penalties of perjury that the information provided above • true and correct
Signature:' _ Date: �1_
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. Citvfiown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O
Name of License Holder _110 ni CAS loss sl _ 9J "
License umber
_942 +i aI I• . , , ' v : .. ' 2 - (3
Address I Expir on D e
a
L LL y /3_ - 3 2.2 3/ /,l
Sign. we Telephone
Not Applicable 0
1�?e , //,5
Company Nam n� J Registration Number
?A_ u ( 1< SL- Ild [ L04- 0 oil 1 /,, IN
• Address 1 - • 1 - Expiron Vate '
//, /
. 4 . .I --
Telephone � 1,3 - ` '322-,3 I l
fir
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
■
i
11. - H Et ta
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
strictures 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 nine 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 personi 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 ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Actg [0] Othe!
//Jf
Brief Desc ti n of Proposed
Work: _./ 5 / 1vg //US///A /ht ,)G�t/...".1C /C K".&11'LOSE JIIDdh Si be.-0 WALLS
Alteration of existing bedroom Yes No Adding new bedroom Yes 7'c 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, ( T�j9/1 j .er , as Owner of the subject
property
hereby authorize -/ / G'L__.
to act on my behalf, in all matters elaf e to work authorized by this building permit applicati n.
ee Pe( it , , 1 g) C� 4 t ze L i t 2k�)Z
Signature of Owner Date
I i 11 ,„ • Vass er , as Owner /Authorized
Agent hereby declare that the sta ements 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.
-- 0rn. .c .o-Cs kr
Print Name
1.� <L i •
Signature of /w /Agent Date
I
Section 4. ZONING All Information Must Be Completed. Permit Can Be Dented Due To Incomplete Information ::
Existing Proposed Required by Zoning
This column to he tilled in by
t Building t)epanment t
r l k
I
Lot Size
I — —
Frontage
Setbacks Front -
Side L: R: L: R.
. Rear
Building Height h
Bldg. Square Footage " ,
,
Open Space Footage ,,
(Lot area minus hidg K paved
parking)
4
o of Parking Spaces
I
I Fill: 1
I & Lo ation) •
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 0 DONT 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 O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb (Gearing. grading, excavation, or Filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO O
i
IF YES. then a Northampton Storm Water Management Permit from the DPW is required.
i
9
i
1
at
(� ,✓ 3 '
IPT City of Northampton
��
Building Department .
3 2012 E 212 Main Street
otrar. or Room 100 :� .� t�
NORTHA MPTON,M40cpTiONS Northampton, MA 01060 7 { o x elr t
N• • e 13 -587 -1240 Fax 413- 587 -1272 {� ° ;__,_,,,
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
�3 /7 T Map Lot Unit
/ 1/0 720 1 / 1 0 27a14 : Aft / Zone _ _ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/ ///) ,4 /,ec 2 3 JfJ54j//dSZ.
Name (Print) Current Mailing Ads d y
— l ' III �� r IM1 t ' ' { `
^ .- nt 1 �_ y
_ j i U 1 I ►• 4 Vii Telephone
; , : y /
Signature
2.2 Authorized Agent: keiilA /i I lb 0 _, , t. - 2k0.. � 1 k S-� �y
Name ( / Current Mailing Address:
Ai ,/L y(3 - 322- al( (
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
Construct from (6) .
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection l
6. Total = (1 + 2 + 3 + 4 + 5)! l/� , O v Check Number
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0618
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS /PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 23 MASSASOIT ST
MAP 24C PARCEL 087 001 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
Fee Paid /iQo
9
Typeof Construction: INSULATE WALLS
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 FOL ••ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO t. 1 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
D - molition Delay
�� 7/ 9 .
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.
23 MASSASOIT ST BP- 2013 -0618
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 087 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 -0618
Project # JS- 2013 - 000999
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 6011.28 Owner: ALPER GLEN
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 23 MASSASOIT ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:12/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE WALLS
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:
FeeTvpe: Date Paid: Amount:
Building 12/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner