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31B-058 OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at la_ �-Ao (Property or)-- - , m�&' 60 (Property Address) 4 hereby authorize X, VV-6i'f 0, (Subcontra an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date FECIEW OCT - 8 2014 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License:CS492540 THOMAS B R06S s 100 MAIN S18$9T HATFIELD MA 01 J�• " cXpEration Commissioner 09/02/2015 Utrct of Consumer Affairs&Business Regulation License or registration valid for individul use only EIMPROVEMENT CONTRACTOR before the expiration date. If found return to: on: 165169 Type: Office of Consumer Affairs and Business Regulation ration: 1!672016 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 ENERGIA LLC THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE,MA 01040 _.✓ `'� .. .. -.. Undersecretary Not valid without signature r Ac�� CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDIVYYYY) 3/7/2014 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: H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to the term and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRocuceR JAMES J DOWD&SONS INSURANCE AGENCY INC 14 BOBALA ROAD SUITE 3 PHONE EAx HOLYOKE, MA 01040 ,,IIIIAL 8+18UR 8 AFFORDING COVERAGE NMC e NSURERA: LM Insurance Corporation 33600 INSURED A LLC MrIS~B 242 SUFFOLK STREET muRmc HOLYOKE MA 01040 NsURERD: NSURW E COVERAGES CERTIFICATE NUMBER: 19458008 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 WITH 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. ILA TYPE OF INSURANCE NUMBER EFF POLIICY ow LIMITS COMMERCIAL GENERAL UABLIrY EACH OCCURRENCE $ CLAWS-MADE F OCCUR TOR g -- MED EXP(Any one person) S PERSONAL 6 ADV INJURY $ GEOL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S POLICY 0 JECT F LCC PRODUCTS-COMPIOPAGG $ OTHER. $ AUTOMOBILE LIABL ty COMBINED $ Ea a i nI ANY AUTO BODILY INJURY(Per person) $ ALL OWNEO SCHEDULED AUTOS AUTOS BODILY IWLOtY(Per accident) S HIRED AUTOS AUTOS S $ UMBRELLA LU1B OCCUR EACH OCCURRENCE $ EXCESS IL!" CLAIM"ADE AGGREGATE $ I S A WORKERS COMPBISATION WC5-31 S-389490-014 2H 712014 2/17/2015 AND EMPLOYERS'U ASL fY Y/N V ANY PROPRIETORIPARTNERO(ECUTNE E 1.EACH ACCIDENT $ 1000000 OF'FICERIMEMSER EXCLUDED7 a N/A (Mntdsforyin MI) El DISEASE•EA EMPLOYE $ 1000000 If qa.deserDe under DESCRIPTION OF OPERATIONS below EJ.DISEASE-POLICY LIMIT S 1000000 DESCRPTIDN OF OPERATIONS/LOCATIONS I VOUCLES(ACORD 101,Addleonal Ranrarks Sduduls,rwsy be seachod If mwo space Is requlrcd) Workers compensation insurance Coverage apples only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensat on coverage. CER71Fi rit nap CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE WIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MJTffOW23150 REPREBENTATNE L.M Insurance Corporation ®19813-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CEOS NO.: 19459006 Anne Chandler 3!7/:014 4:36:50 Ph Page 1 of 1 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): 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): 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 6. 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 g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No 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 11.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.® Other Insulation comp.insurance required.] *Any applicant that checks box#I 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-389490-014 Expiration Date: 2/17/15 Job Site Address:Z�Z,'5 AV12 74JY ! 11). City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration ate). 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 er the pains and penalties of perjury that the information provided above is true and correct. S'yan.ature: Date: IdIZZ 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.SSuJp)ervisor: Not Applicable 0 Name of License Holde : / ��/`1 S 1�. J/"'l f� J �� LJ—y n License Num er 25/2 S t1FF0 k S7':Address Expiration Expiration to �-- . 322 - 3" Signature Telephone 8.Restlstemd Home Improvement Contractor: Not Applicable ❑ ,ee&"alA- -6!5/1401Y Company Name Registration o% Numb r 2�2 St�lcFdtk ST ,,�L . 0/ova 1 _ Address Expir ion D e Telephone .3:s 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 buildinE 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[E--3] Other Brief Descr. t' of Proposed Work:/I/SuI TrD/V TD /177/2(2- Alteration of existing bedroom Yes o Adding new bedroom Yes _Le_ 5 Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existino housing,comalete 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, S [.��r� / A� as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, k 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. ,�d,A►AS i2oSSNt�L.ER Print Name Signature of 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 Q DON'T KNOW © YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 Q DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 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 0 NO 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 ® NO /� , IF YES,then a Northampton Storm Water Management 'Permit from the DPW is required. �: r a -_ _: ... __ __ _ _ City of Northampton 'us ► Building Department � � � ji , 212 Main Street ow Room 100 A'Northampton, MA 01060 Tyi±tti-Sep Qfiti'~Fits phone 413-587-1240 Fax 413-587-1272 P" 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 0'Z j1&AId 2' U' K *b . Map Lot Unit WA?7W,#,if Zone Overlay District ���/ lQ� Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: o� Name(Print) Current ailing Addre Tel p ne Signature 2.2 Authorized A-gent: �1 i�1�S 2 o SS�t sSt_C�P,, - ``SC F;ocOV`ST Name(Print) _ Cu rent Mailing Address: & -'s Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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) 1 7 lCheck Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0469 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 19 LANGWORTHY RD MAP 3 1 B PARCEL 058 001 ZONE URA(89)/URC(11)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existini 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 INFORMATION PRESENTED: proved 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 Del y Si re o uildmg t5ffic ia 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. 19 LANGWORTHY RD BP-2015-0469 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B-058 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) CateQory: INSULATION BUILDING PERMIT Permit# BP-2015-0469 Project# JS-2015-000898 Est. Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. 1): 6708.24 Owner: MIEHER STUART R zoning URA(89)/URC(11)/ Applicant: ENERGIA LLC AT. 19 LANGWORTHY RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.1012812014 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 Siznature: FeeType: Date Paid: Amount: Building 10/28/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner