17D-023 (4) 4*
f
PARTICIPATING
mass save C- .� R
S+,Mas thou!' crrargv etMdeneY
PERMIT AUTHORIZATION FORM
1, ?X %mai 64 , owner of the property located at
(Owners Name,)printed)
iayta
(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.
•wner's Sig ature
0 1)(01 .
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Horne Energy Services
Participating Contractor to the above referenced project:
Participate Contractor Date
Rev. 12132011
Customer 1:620 g S Customer Name ('�;- f l Gk J/ Address CAS S 7k02_—
KNOB & TUBE W[RING 1a(eftek
During the Energy Survey of your home, indications of "knob and tube" wiring were found. This old style of wiring
involves individual wires that are run through walls and ceilings in a house, with ceramic "knobs" and "tubes" to
prevent contact with wood framing. The knob and tube wiring that has been noted may or may not appear to be active.
Even if the observed wiring appears to be inactive, there may still be active knob and tube circuits hidden inside walls
or other inaccessible areas of the house.
The Mass Save Program requirements require that you have the home checked by a Licensed electrician and certified as
being free of all active knob & tube wiring where needed, before insulation and/or air sealing work can be done. Your
electrician should fill out and submit a copy of this document to the Center for EcoTechnology (CET) in order to verify
the absence or inactivity of the knob and tube wiring in the areas of your home where we are proposing insulation to be
installed. Due to the liability involved in signing such a form, we suggest you show or describe this form to your
electrician before hiring him to inspect your home to be sure he/she is willing to sign it. The Center for
EcoTechnology (CET) and the Mass Save program will rely on the electrician determination and certification below and
will not be liable if inaccurate.
Your home could benefit fro ulation and/or air sealing in the:
❑ Attic Slope Exterior ❑ Basement Attic Floor I KneewaIl Floor
Walls
** Only after this certification is received by CET can a Contract be issued for
energy saving insulation and/or air sealing work. **
Elects ician's certification
(This form is invalid when any or alterations are added.)
Company Name & Address tkr7
`fa !P Roaad / � /n14 0.327
S tei l
Electrician's Name R lt(; ,5' License # ' a ,, /i'
I have performed an inspection of the wiring at the home of:
MIft — Irk Z,I Z 14 9 1 1Gn at 6/S -5 - el4 ,j 97(49 in lOrrJj cC'
(Owner's Name) (Street Address) (City)
Upon completion of my inspection I have found that there is no active knob and tube wiring in the area(s) noted
below.
Attic Slope ® Exterior is Basement ■ Attic Floor E Kneewall Floor .
Walls
Electrician's Signature ,,f //e
�• �� Date
Please mail this certification letter to: Center for EcoTechnology
• 320 Riverside Drive I -A
Florence, MA 01062
Or fax to: 413 -586 -7351
Rev. 5/24/2012
Please call 800- 238 -1221 with any questions or concerns.
Customer (mail. -in when completed) - White Customer Copy— Yellow Auditor -Pink
` I a • . . [ , hi v.,4 .11. 0 .10.411141cm ■.1 i'u1.10. ',.d. 1.
fi.0rrd .41 $u114iln_ Kc_u1.tt ..uui "1.un11.4t d.
Construction Supervisor t_
t' 8 ROSSMASSLER
� e
100 MAIN STREET
HATFIELD MA 01038
L 2
9 20' -
Utlirr o f k a4n S 1Y<1pt.. tc; u6t0 n 1 10 4'10•l' t.1 11 'L'I%IrigiUun ,, Aid Iu1 0nd1% 1du1 u.r "Ilk
HOME IMPROVEMENT CONTRACTOR hclorc the rt plratwn date. If found return to:
4 office of ( on•umer Affair. And Ku.incss Kegul:ulon
• I .4 Registration: 165169 Type
7f Expiration 1!11,2014 _.. 10 Pars, Piaii* - Suite 4 11'0
Roston. N1 \ 02110
NERC
-iOMA;. RC,SSMASSLER /
/42 S...... j l i W
OLK STREET 1
_• •
-,CL YOKE' M%- C1040
■ ndrr.e,i \„1 ∎.4hd V. lthOuI .12n.4turr
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ACCORIIIFF CERTIFICATE OF LIABILITY INSURANCE DATE EASIDDNYYY)
k illwoo•e-- 5
TICS CERTIFICATE 13 ISSUED AS A MATTER OF SWORMATION ONLY AND CONFERS 110 RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTW1CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIM covetAae AFFORDED BY THE POLICIES
SELOW. THIS CERTIFICATE OF Itssuituica DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATWE OR PRODUCER, ANO WM CIVITHICATE HOLDER. •
IMPORTANT: 11 0* nertlfitate holder Is sn ADDITIONAUL INSUREA the polling* must be endorsed. If SUBROGATION 13 WAIVED, subject to
the terms end nonagons of the pain', nertein ponds* nay nsouire an endorsement_ A stammer* on thls centenato does not confer rights to the
cendicate holder In Neu of such endoreemengs).
reocucnt
Mary Conroy
James J. Dowd & Sons Ins. Tnu
14 Bobala Road . .' Edt 411 -
1-5187444
1 i pvc03031411-516-6020
.,
Holyoke MA 01040 ....... . „
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ammikatgigkl
_ misumiaa AFFORDING COVERAGE NAIC II
,_ . . .... .._ _
INSURED
INSUMER A : Nor thlsnd Insurance Company
Energi a , LLC
242 Suf folk Street eisumit s :Conmerce Insurance 0pmpApv 34 7 59
Holyoke MA 01040 , NsuRIER c :gusrd Insurance Group
INSIRRIM D : To rus....„40gc is). ty I new rs_nce Company
INSURMI E :
INSURER F 1
COVERAGES CERTIACATE NUMBER 773382656 REVISOR NUMBER:
MRS IS TO CERTIFY THAT THE POLICIES OF 04M k ETED INSAWWWE OWN DOBAD TO THE INSURED NAMED ABOVE FOR 714E POLICY
PERIOD INDICATED. NO'TWITHSTASENNO ANY fr „ TERM OR COND/RON Or ANY CONTRACTOR OTHER DOCUMENT %MTN RESPECT TO
WHICH TINS CERTIFICATE HAY SE ISSUED OR MAY NOWAK THE PSSURANCE AFFORDED ST 114 FOLIC48 DEECROIED HERM SS SUBJECT
70 Au. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LAME SWAMI MAN HAVE BEM REDUCED SY PAID CLAIMS
EAR ADDLMOISE
OR TYPE OF INSURANOE Itallt vnma PCBJCVNUORIBt ANSIWARAVY.' UNITS
A enrenai.voimurt : Y WS096521 2/17/2012 :2/17/2013 EACH OCCURRENCE ' $1,000,000
1
1
• COMMERCIAL GENERAL 9ABILITY , DAMAGE TV RENTED
t PREMISES Ma 001sPencD , 81 " . 000
C.LAIMS-MADE I ; OCCUR . 4/06 Exp (Mn, sajners0s) 1_ 45, 000
!X 1500 Deductible , PERSONAL & ADV 114,1URY " $1 , 000, 000
GENERA/. AGATE 6
GERI AGGREGATE UNIT APPLIES PER PRODUCTS - COMPK/P AGG $1, 000.000
1 1 1
1 POLICY 1 1 M : 1 Loc i . i $
f ' 1
B I AUTOMOBILE LJABILITY BBRC17 2 /17 /2012 '2 /17 /2013 COMBINED SINGLE LOSIT
11,000.000
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1. , I ANY AUTO (Em acamn0
SOLELY INJURY LPN person) 1
ALL OW14:0 AUTOS ! ""--- ......_
BODILY INJURY (Pst imams s
SCHEDULED AUTOS
. PROPERTY DAMAGE $
x IMRE° AUTOS " (Par secant)
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, X ! NON-01414ED AUTOS '-'
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D :X UMINEUA UAS OCCUR . .
70874C110AL1 9/14/201.1 9/14/2012 EActi accuRAE/cE 1 11,000,000
. .
Incase UAII CLAINS-su■DE ,
AGGREGATE $2 , 000,000
DEOUCTtBLE . $
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IX I R6TE.mOI4 $10.000 $
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C " COMPERSADON EmAC319433 12/16/2312 1 ;2/16/2013 ;X A O
TORY LIMITS FR
1 ANDIMPLOVEMIE UMMLITY Y i X , , -
ANY AsomussoassonwesAmscums E I. EAcH ACcicENT 31,000,000
OFFICERIMBRIER EXCLUDED? 14 NIA , ■
GIWIMMEE SE MS EL. DISEASE - EA EMPLOYEE $1,000,000
11 0MITIPTION lifts OF OPERATIONS Wow , 4 E. l DISEASE - POuCY LIMIT Si , 000.000
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DASCRIFFION OF °MATIONS/ LOCATIONS AIIINICUM WORM ACM/ RR. Adellenal Rawls NIBN fawn Wes N1/
CERTIFICATE HOLLER CANCELLATION
SHOULD ANY 00 1140 ISOM MISCRIMED MUCUS OE CANCELLED
WORE THE EXPIRATION WE MEW Nertica WILL m DEuvditEo
ea ACCORDANCE t11114 ME !CUM' retevision.
AUTOCROSS IMPRIBINGITAlinrt
, . ■ ,
01000-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (20011/09) The ACORD name and logo are registered marts of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
II h f .. �f Office of Investigations
'�,_= _ 600 Washington Street
= .' Boston, MA 02111
' • i m v. 5 www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/individual): Etter• 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):
I . ® I am a employer with 10 4. [] I am a general contractor and 1
employees (full and/or part-time).*
have hired the sub- contractors 6. El 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 any capacity. employees and have workers' [2 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
q �
3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
'
myself. [No workers' com right of exemption per MGL
Y [ comp. 12.❑ Roof repairs
insurance required.] t c. 152, §l(4), and we have no
employees. [No workers' 13.1X1 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 hay 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: ` 4 _ r - City/State/Zip: y,/ece ��Ul/G
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 ce . ii un ' ' r e pains and penalties of perjury that the information provided above is true and correct
Signature: // Date: /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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder . . (,Z / ijG_S r.s S. _1-e_r r_ z5 - yo
/�� License Num r
2 I SL . %2& ill _ q -2 AI - -- ---
Address Expiration ate
yr3 3.22 - ,3///
Signature Telephone
Not Applicable ❑
Company Na 1 nn '/ Registration Numb-r
2 3 rQ- L k \ � - % a U V / 1 f
Addrv, Expiratio eat -
/ / Telephone 9 /13 - 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 budding permit.
Signed Affidavit Attached Yes No ❑ j
11.- Hem 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
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 he required from time to time. during and upon
completion of the work for which this permit is issued.
Also he advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injunes not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for peronr s t
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 E
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q r ng [D] Other}
Brief Description of posed
Work: scr o / roro — 4.11 C....10Ar °reat ('P (hk (r.6-eTb R 3 /4't u fh
Alteration of existing bedroom Yes ) No Adding new bedroom Yes , No
Attached Narrative Renovating unfinished basement Yes . -47. 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
1, 1 c el Aat? , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matt- re •tive to work authorized by this building permit application.
See ?ern1i ' d �,� ce 1/110) 12
Signature of Owner Date
f) Y r— Q_ 0 SS Ykci. SS I`e tr' , 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.
0 rytaS 0 SsmaSS I -Qr
Print Name
2 0 2
Sign.ture of i ner /Agent Date
t:
+r.
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Dented Due To Incomplete information
Existing Proposed Required by Zoning I
'Thy: column to he tilled in h■
Building I>cpanmrnt
Lot Sizc _.
Frontage
p
Setbacks Front ,
t
1 1'
Side L: — R: L. R.
i
Rear
i.
1
Building Height
Bldg. Square Footage
1 i
Open Space Footage ", — _
:Lot arca menu. hidy, & pad
` park Ingi _ {
of Parking Spaces
I Fill:
( 1.ot & Lsauon) -
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: r
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 1
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
i
i
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
ii
I
IF YES, describe size, type and location:
:i
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
t
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 0
IF YES. then a Northampton Storm Water Management Permit from the DPW is required.
r
9
I
i
3
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REC C. � City of Northampton
fj
: uilding Department ,
v ---------
� � 1 k 2012 \ 212 Main Street , , , •�_> ,s ,,,1 ,
...A Room 100 r ,,r�Y
- P E jO " • hampton, MA 01060 T S &
o f s,y��o r.3 i "� p 1oso
fl P NCRTH " : one 413 -587 -1240 Fax 413- 587 -1272
a rt s
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
95 S . _ , Map Lot Unit
/� Zone Overlay District
/" //e,,ce1 /� Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
'4g,--tiy./.6-,e y„ „, , 1 A/
Name (Print) y I_ Current Mailin Adddress: `t
see- Verv1. A4 T � -' l etcrl� Telephone
� ` - 3 1��
Signature
2.2 Authorized Agent: I > // o rnQS I aSS rxas� ie �' 2kt 2 SLi-Q-Qo 1 l� S`�• �� /�� j �
Nam ( ) Current Mailing Address
- - Y/3 3 2 2- 3 t c
Sign re 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 c-
6. Total = (1 + 2 + 3 + 4 + 5) /2t 7° ,s . C) Check Number /9t� � A ..1
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
File # BP- 2013 -0646
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 95 STRAW AVE
MAP 17D PARCEL 023 001 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 e � t
Fee Paid � "o�
Typeof Construction:_INSTALL 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 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 - olition Delay
// — / `17
Sign. -. - o tuilding Offici 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.
95 STRAW AVE BP- 2013 -0646
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D - 023 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 -0646
Project # JS- 2013- 001057
Est. Cost: $2700.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 9583.20 Owner: BOUGHAN PATRICK
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 95 STRAW AVE
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 - 3111 WC
HOLYOKEMA01040 ISSUED ON:12/12/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 12/12/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner