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24D-263 (2)
001140„rwi1/4\ ir t PAIMCNIATING CONTRACTOR w PERMIT AUTHORIZATION FORM I, S72/412 T \ll/A4 Al�Z. ,owner of the property located at: (Owner's Name, printed) /5 C-L� 'z)4-G& A-VE . _A/6 7W,4 (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) 7((it r 3 I (Date) ... . c L n : x i 3 -: - - 5 ,... 3 - , 0 a ,..... 4.- kip Z. n I 'C'S :1', ■". ''. 1...) .1:5' 0 o g a cu .- (.4 = i.-.: AL ip....simermisokrd......-.0,0,,Jege,--,„.....;Al rn 0) 14- , 1 fill rD g rz, _ . z i 43a.siends e.-:-•aortspitosrmat oaf*, : 8 f it i [p lip r—r , , tom mr-let ..*** < ; . ,....,Tap,orsatiorate '4 e• 1(% ; .6 1 cu - 3' i. 6.=0.a*imilt MO...vaisai 6 r i I -.1 •34 n ;1... ILI-Li ' " x * 1; 1 • 1„,,,, , ..., . 0 1 —co 1, cli ticuitivrovroti•t. .; 0 3 x • la )s-rel'og•411141Mercert.1 g sr D) i ao , __,.. I , ti 1 _4, • 03 . PC 1 ..,..o.,...........J. ..ar.isIG...1.......i. 1:4 t „7". $..• '.1 .:•-•-;. .:,.;••,.. it 1,,,-4 _,;,.. . . i 0...,., .. i .1",,; .I`.- '...':P.' ;.• ••••,...'..•' ' '.• • A 0 i..t7-. ...•%'. ' ';.' — • •• . , 0 4 . ,. 2 ' a i :'41 . A 0 .,„, t , . ,:.....:..i -....,.:1.,..i..i! : -.., .r a' (N 0 rri ..4: 1:: .... .1, , ' aIi 0 ''' •',-" Id .- . .D i = :1, 1.--.• )...) ' . , .. . .0 vi § in t __. til*Is ZSZ:i3lt1 ' ‘ . 0 i .... t j. ..' . f * 64.6 .61144t rk. 40 ' ' • • • >ety-000lfb , i .". .. . • - - t n) .., ... , , • • - 4' . ,.. , --, . . . L 0,e44 We•n..I.a MI a•deo..14—* lid . v t2A1.10/Mt IMO WiirralifirM I On 4..1 et au ... . . I L r,,, ... . . k ' . t.■ 9L£111)-£1011 £6tr . .: ; i el 01 • , ' : .!' '. ••;s zt,*as Top o o a co !I it co , - --------6011004.0 t.--.---i.. Hit e i / • ' ' ''' - • .9Z,::-VSGS-IP r, 1/) 1,, • i • -- ' -• , etcycrusca.i.:1 te..virl.CICParogo=mpaPPA.........r.a.---vrrrit'S' . . ..• .4,0,04K • . • 0 .. CS L 11011. 1/4211''t- Aeraz44.440 - porPiyplaktd 9 t 21 I(P ..c., x 3 '4' f)/It4itilocifuj )9, ern-v....at&4 )4A -La JAL, .... ...... . / PC1/. epvntillot;A • 1.--,47. totiz iillald i-l'iL. piioce4441- - 61 2.5q D eXbi- ' p - c4(3 -32 -8"1 2.f The Commonwealth of Massachusetts Department of Industrial Accidents ' i !=; Office of Investigations - 600 Washington Street ' '}= s Boston, MA 02111 It*4 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): I.Ed I am a employer with 10 4. Li 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' comp. insurance.: 9. ❑ Building addition [No workers' comp. insurance P required.] 5. 0 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.❑ 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 13.® Other Insulation employees. [No workers' 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: Liberty Mutual Insurance Policy #or Self-ins. Lic.#: WC5-31 S-389490-013 Expiration Date: 2/17/14 Job Site Address: /5 C.- igbAL. t/E- City/State/Zip:,/1a R-77/14071-6 Al tt{A- 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:-✓�/C �'" ' Date: j7 �.3 9 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 ❑ Name of License Holder: % ' _""�QS 1 �cJL3/e, 959?- 2 Sf ) //e V-Z• £/ i /� �,/ 2 License 1912 ube/b Address Expirati a /3 . 322 —, /// Signature Signature Telephone 9,Renistered Home Improvement Contractor: Not Applicable ❑ (iK Company ame Registration N ber 2_ LiWo\it: SA • 1-1 15\ lc AAA el0A0 Addtess 1 I Expirati D e /1/17(-- -- /� Telephone y(,)"322'3((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 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 $ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [a)! Decks [Q - / Siding[Dl Other 45tv-AT)d IV Brief Descri n of Proposed /Work: //cSIIG �?14J A-?7/GP1f012o10Ft( 73LOWM CEuAcLOS6-Td 12.3 g, Alteration of existing bedroom Yes V No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement YesiX No Plans Attached Roll -Sheet sa.,If New house and or addition to existina 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 as Owner of the subject property hereby authorize 6 to act on my behalf, in all matters relative to work authorized by this building permit application. re/4 (TA cm(Q Fd l2/('C ' / 4a16- Signature of Owner Date 7 I, 7p r',4S O SSij,+ LE(e , 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. °SS it( t s51-�e. Print Name Signature o Owner/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 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 O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , 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 0 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. e City of Northampton E © I_C \'' s ,.,16` Building Department '"° �j. 212 Main Street SEP 19 2013 ,,1 j Room 100 -fNl rthampton, MA 0411036_5087_ `W phnn 41 i-587-1240 Fax 1272 Electric,Fiumcing&Gas a ,iectiol1� 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 /5 C-LEAlbALE AVE . Map Lot unit IVO ,TMM7'TO N, /NIA Zone Overlay = Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SToiRT utM RA EZ _ 55 M,6�TA&L H -Ro . LeV6 rrMk Name(Print) Current Mailing Address: < 2M I T k�T Fo2M ATTACt�� Telepho e/� - Sy 9-57e/( Signature 2.2 Authorized Ascent: 1/d/yAA6 1?oss,(t0kssi-ea 2y2 S ( Fc)LK ST. Akoi.Voke, RA Name(Print) Current Mailing Address: S//S -322 -,&1i 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 Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) ,/!/ d, d Check Number 5410 155 4.2<< Tilt Section For Official Use Oc r Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0343 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 15 GLENDALE AVE MAP 24D PARCEL 263 001 ZONE URBC100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 073/fb y��{ Fee Paid I Typeof Construction: INSULATE ATTIC FLOOR 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 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 De i• iti.-.D 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. 15 GLENDALE AVE BP-2014-0343 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D-263 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-2014-0343 Project# JS-2014-000584 Est. Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 9278.28 Owner: WARNER STUART Zoning:URB(100)/ Applicant: ENERGIA LLC AT: 15 GLENDALE AVE Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:9/23/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC FLOOR 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 9/23/2013 0:00:00 $55.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner