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49-027 (5) Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: C814HOW r THOMAS B '. 100 MAIN STREW[' s HATI:MLD MA 61 �,�.•,, .�J..lfL�s. , ", Expiration Comnussioner 09/0202015 f'����:nrrtrrrarrarErrll�rY"•�/.p•,,;rrr/rr.,r•!/ .Qk Office of Consumer Affairs&Business Regulation License or registration valid for individul use only E IMPROVEMENT CONTRACTOR before the expiration date. if found return to: istratiOn: 765169 Type: Office of Consumer Affairs and Business Regulation irallon: .1/f;172b16 LLC 10 Park Phum-Suite 5170 Boston,MA 02116 ENERGIA LLC THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE,MA 01040 Undersecretary No#valid without signature i AC4t>R& CERTIFICATE OF LIABILITY INSURANCE DA1`E(RM1OCiWYY) 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($),AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: tf the o drfiate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. V SUBROGATION IS WANED,subject to the terns 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 andaim.Sn s. PRootlaw JAMES J DOWD&SONS INSURANCE AGENCY INC 14 BOBALA ROAD SUITE 3 mum AN HOLYOKE, MA 01040 -MAIL WSUR 9 AFFORD"COVERAGE NAIC e MURERA: LM Insurance Corporation 33600 INSURE ED INSURERS:LLC INSURERS: 242 SUFFOLK STREET MURERC: HOLYOKE MA 01040 1 rra RC r1euRER E: COVERAGES CERTIFICATE NUMBER: i945ma 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. INN ADM MISR LTR TYPE OF NBURAHGE -POSY I E3'P LIMITS COMMERCIAL GSA'LIABILITY EACH OCCURRENCE $ CIAddS,MADE OCCUR DAM=TO PRFMII__6 s - .17 S MEO EV one ) S PERSONAL 6 ADV INJURY S GEWL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY❑JPERCf 7 LOC PRODUCTS-COMPIOPAGO $ S AU'rOMOIRLa LIASIAT I _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED D AUTOS AU OS BODILY INJURY(ParS=WMM) $ HIRED AUTOS AUTOS S S UMBRELLA LIAO OCCUR EACH OCCURRENCE $ _ DfCE83UAB CLAIMS4AADE AGGREGATE $ S^ A WOMORS COMPO ATION WC5-31 S-389490-014 211712014 '2/17/2015 R AND SWIANMI LIABILITY Y - ANY PROPRETORIPARTNEROMCUTNE YIN E.L.EACH ACCIDENT S 1000000 owin WAEMSEREXCLUDED7 f 7N NIA (MmdWryie NN) EL.DISEASE.EA EMPLOYEE S 1000000 I=d dnabe OF OPERATIONS bebw E.L.DISEASE.POLICY UMIT S 1000000 Callow qN OF OPERATIONS f LOCATIONS I VEHICLES(ACORD X01,Addlborol Rwnwfw$dwdW N n,ry ba aUschad I!more gmpa Is ragW rod) Workers compensation insurance coverage applies 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 compensation coverage. CERInFICATF MCI CANCELLATION TACCORDANCEWITH ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORJ: 1MMON DATE THEREOF, NOTICE VALL BE DELIVERED W THE POLICY PROVISIONS, REPREENTATTYE nce Corooration ®198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo am registered marks of ACORD CUT NO.: 19656006 Anne cbandlec 3/7/2016 4:36:50 Pei Pape t of 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/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.[Z 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, F1 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.+ 9. ❑ Building addition required.] 5. We are a corporation and its 101_j Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself o workers' right of exemption per MGL Y � comp. 12.E] Roof repairs insurance required.] c. 152,§1(4),and we have no employees. [No workers' 13.21 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.#: WC/5/-31 S-389490-014 Expiration Date: 2/17/15 Job Site Address: ;n1 moe - '� �� City/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 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 unde the pains andpenalties of per'ury that the information provided above is true and correct. Silln ature: Date: //V 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#: mass save cownumm PERMIT AUTHORIZATION FORM I, — 'j-7-o' , owner of the property located at: (Owner's Name, printed) (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. Owner's Signature // �-- 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: AV A A I. 4 - Participating Cbntr aw Date Rev. 12132011 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suuppeervisor: ,l r� A ) �� Not Applicable ❑ Name of License Holder: •?//v.�tA� 62 VJJ M � 54a2. _ License N mbe s u FPO L✓K s -, iYac.Ya�� Nt -- Address Expiration to op 22 Signature Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ A /- M&ZA-- 14�s7l/X ' Company Name Registration yNumb9f 2q2 SN,Ff-6Lk ST• doi-lDISC AAA a qo / // Address I Expiratio bat Telephone q(3-322-31t1 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 E] Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition C] New Signs [o] Decks [❑ Siding[O] O r Brief Description of Proposed 9,u4AT,/ON �� �>d i AJ& Z*0409W L �C-�2 tOdt YlSo Work: ��TI 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 housinsa, 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, ��� as Owner of the subject grope hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. SEA �ER� I r Aq_nf o a l Signature of Owner Date I, 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. Print Name 04 Signature o er! nt 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 © DON'T KNOW ® YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. o Department use only ": o City of Northampton Status of Permit: °� ? Building Department Curb Cut/Driveway Permit �'" z 212 Main Street Sewer/Septic Availability r' Room 100 Water/Well Availability } o Northampton, MA 01060 Two Sets of Structural Plans c7 Z phone 413-587-1240 fax 413-587-1272 PlotlSite Plans c Other Specify LICATION 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 714�p IVXRk N I LL 3� . Map Lot Unit /i�M 6�C�( /� �j� Zone Overlay District L-v 016 2 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: &6'e:22?4 Name(Print) Curren Mailing Ad ress, G/ �.�,C3 &Z to ! ��ZIM Te�hone Signature 2.2 Authorized Agent:Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building / r ad (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) j9d Check Number '(J This Section For Official Use Only Building Permit Number te r: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0470 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 718 PARK HILL.RD MAP 49 PARCEL 027 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Typeof Construction: INSTALL INSULATION TO OVERHANG New Construction Non Structural interior renovations Addition to Existina Accesso1y 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"ATION 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 e e Si re of Buildin g Official Dare 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. 716 PARK HILL RD BP-2015-0470 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 49-027 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-2015-0470 Project# JS-2015-000899 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.): 79714.80 Owner: SOTO HECTOR S&IDA S Zoning: Applicant: ENERGIA LLC AT. 716 PARK HILL 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 INSULATION TO OVERHANG 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 10/28/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner