37-022 C
ET
•
CENT"I-:R FOR ECOLOGICAL TECHNOLOGY
112 Elm Street, Pittsfield, MA 01201 Tel (413) 445-4556 Fax(413) 448-6054
241A W. Housatonic Street, Pittsfield, MA 01201 Tel (413) 448-2234 Fax (413) 443-8123
320 Riverside Drive-1A, Florence, MA 01062 Tel (413) 586-7350 Fax (413) 586-7351
e-mail: cet@cetonline.org website:www.cetonline.org printed on recycled paper
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ir 11
PANTOMIMES
ININTRAMON
11
PERMIT AUTHORIZATION FORM
I,
1 v `aL`-'���(i ,owner of the property located at:
�c.J�J�...J
(Owner's Name, printed)
'24 (ft.est)&la( . L4 lie C KA ( f .M
(Property Street Address) (Town)
hereby authorize Energia,LLC a Mass Save Home Energy Services Program assigned
Participating Contractor to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property,
(Owner's Signature)
(Date)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
=1�i� Boston, MA 02111
. ,
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business Organization ►ndi■idtta►1: 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):
I. I am a employer with 10 -t. ❑ I am a general contractor and I
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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
INo workers- comp. insurance comp. insurance.-
required.) 5. We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their i 1.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.) " c. 152 §1(q).and we have no
employees. [No workers' l3.® Other Insulation
comp. insurance required.]
-,111 applicant that checks toy r,I must also till out the section belos■ shossntg their ssorkers.compensation polio mkumation
I tomeos+ners s+ho submit this attidas it indicating then are doing.all■sork and then hire outside contractors must submit a nes+atlidas it indicating such
=Contractors that check this box must attached an additional sheet shotsinm the name otthe sub-contractors and state sshetheror not those entities hose
emplasecs lithe sub-contractors hale cmpto■ees.the must pros tde their ■+orkers comp-popes number
I am an employer that is providing workers'compensation insurance for mh employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual Insurance
Policy or Self-ins. 1.ic. WC5-31 S-389490-013 Expiration Date: 2/17/14
Job Site Address: 2 yT City State.lip:( :40-(1V 66✓/`irl
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
tine up to 51.500.00 and/or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 certif,under the pains ant enalties of perjury that the information provided t boy- is true and correct.
Signature:
Phone =�__ 413-322-3111__-- -----
Official use only. Do not write in this area,to he 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 Su ervisor: Not Applicable ❑,,II
Name of License Holder: /1l Cc S C)SS 6X..4_SS it"r` 2
r
License Number
2�� �-� O< << s-f. ��� U ��P MA � 21 �
Address ( Expiration ate
(a322
S gnature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
L---r) /&31 �9
Company Name Registration Number
2.k-(2._ - k AAA- 01 0 q
�
Address ( Expiratio Date
Telephone ct(3-322-3 i 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 buildi g 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ri Roofing ❑
Or Doors [l
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding[❑] Other
Brief Description of Proposed hjt _
Work: �/�l D /DI? /J ?<e- Od/1 ��
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' ...Tity I,
* iccL1. , as Owner of the subject
property
hereby authorize 5/7tE /� ( C.
to act on my behalf, in all matter rel 'v . o work a horized by this ulding permit application.0-F5-fiK_ A .4_6_,
Lce_e_ a r ilk+ ,Signature of Owner Date
MlIllllllllIlI
I, 7'!0 C4c 0 _ Au. , 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 and r the pains a alties of perjury.
�D1714S 1 o SSSSk`er
Print Name
// _-/' l 3
Signat e o Owne 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 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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.
RECEIVED _._ Departroent use orgy
L City of Northampton Status of Permit:
MAY — 2��3 Building Department Curb Cunt iveway Permit
212 Main Street Sewer/SepticAvailabilty
OF BUILDING INSPECTIONS Room 100 Water/WelfAva�rility
NOMNAMPPON,IAAal o Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Pfot(StePla
Other Speccify
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
2'/ M-r- LAuREL 1'A-T-4 Map Lot Unit
Flo RG'V� I MA—
Elm Zone Overlay District
St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
?EGG/ �,4Cl O b 2�/ /I T u.1L 1'A-TI+
Name(Print) �- .. .(3-(14A- Curre t'MMailing Address:
See- rm , `^��"6 M4&C1te , Telephone
% - X534 — LQ 1 `�
Signature
2.2 Authorized Agent: // #1// i sster 2 2 .c,� 1 S-> • dI4/
Name(P t) Currr t Mailing Address:
/3 :32.2 -3///
- Telephone
Signature
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building - o6 (a)Building Permit Fee
2. Electrical /615-0 (b) Eta
Construction stimaed Tot from Cost(�of _
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection `/
6. Total=(1 +2+3+4+5) l' 00 Check Number di3' 45J
inF Official Only
This Section For 0 c a l Use O y
Building Permit Number: Date
Issued:
Signature:
Date
Building Commissioner/Inspector of Buildings
File#BP-2013-1079
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 24 MT LAUREL PATH-600 FLORENCE RD
MAP 37 PARCEL 022 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out r /3g
Fee 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
INFO ION PRESENTED:
pproved 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
opip)or-� oliti�ela
Sig . e of Building fficial 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.
24 MT LAUREL PATH-600 FLORENCE RD BP-2013-1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-022 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2013-1079
Project# JS-2013-001775
Est. Cost: $650.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): Owner: MACLEOD PEGGY L
Zoning: Applicant: ENERGIA LLC
AT: 24 MT LAUREL PATH - 600 FLORENCE RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 Liability
HOLYOKEMA01040 ISSUED ON:5/14/2013 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 5/14/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner