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31A-098 L www.victoryenergysolutions.com Victory Energy Solutions WHPC Home Performance Contractor 1 Hartford Square,New Britain,CT 06053 CONTRACT 860-357-5590 FAX 401-123-1234 Page 2 PROGRAM CMA-HPC CUSTOMER PHONE DAT CLIEN M WORKORDER Patricia Wright (413)586-7790 02/19/2015 412054 00001 SERVICE STREET BILLING STREET 67 Vernon Street 67 Vernon Street SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Northampton,MA 01060 Northampton,MA 01060 JOB DESCRIPTION Total: $2,956.82 Program Incentive: $2,292.61 Customer Total: $664.21 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Six Hundred Sixty-Four&21/100 Dollars $664.21 - is ry nergy 3100,39—P, NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE DAYS. www.victoryenergysolutions.com Victory Energy Solutions WHPC Home Performance Contractor 1 Hartford Square,New Britain,CT 06053 CONTRACT 860-357-5590 FAX 401-123-1234 Page 1 PROGRAM CMA-HPC CUSTOMER PHONE DATE L N M WORK ORDER Patricia Wright (413)586-7790 02/19/2015 412054 00001 SERVICE STREET BILLING STREET 67 Vernon Street 67 Vernon Street SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Northampton,MA 01060 Northampton,MA 01060 JOB DESCRIPTION AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) (4)working hours. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality. $300.00 ATTIC ACCESS:Provide labor and materials to weatherstip the perimeter of(2)attic hatch with Q-Ion. $50.00 KN EEWALLS:Provide labor and materials to install 3.5"R-13 faced fiberglass batt insulation to(80)square feet of kneewall area. $105.60 WALLS:Furnish and install blown in Class I Cellulose to(1294)square feet of shingle and/or clapboard exterior walls.The butt of the upper course of your wood siding is cut to drill holes into the wall sheathing behind.The holes are then plugged and the wood siding is reinstalled using stainless steel finish nails.Touch-up painting,if needed,will be the customer's responsibility. $2,264.50 BASEMENT CEILING:Provide labor and materials to install(94)linear feet of R-19 unlaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $164.50 BASEMENT DOOR:Provide labor and materials to insulate the back of the basement door leading to the bulkhead with 2"rigid board that meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all edges and scams with FSK tape. $72.22 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Or Address: C_Q �S© City/State/Zip:WpA,), r'i oil'1 .C-7 0 — Phone#: 'i 30 t'1 IS Are you an employer?Check the appropriate box: Type of project(required): 1. 5I I am an employer with 3_ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling 2. 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required] 5.❑ We are a corporation and its 10. ❑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 perm MGL insurance required)t c. 152,§ 1(4),and we have no 12. ❑Roof repairs employees.[no workers' 11 VOtherao +,I ck-A comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this boa must attach 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: �SLA -p f_% rg, r-, CC- t�(J Policy#or Self-ins..Lii�c.#: y H © 12.(),5 ,r Expiration Date: Ll t� 5- Job Site Address: (D 7 V- nor-) �j City/State/Zip:r b r h a y1 I t A 191 01 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Print Name: ownnQc eO Cp T Phone A- T)"}-3ULo—41- g� 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 Heath 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-t❑ Name of License Holder:/' , 71 f °e) i '' P /a'T°1/ License Number c he; S �L W- bef-I I bin , M4 Cold° �l Address Expiration Date Signature v Telephone 9.Reaistered Home Improvement Contractors Not Applicable ❑ OYl S 8-69. -7-- Company Nam Registration Number I gar-fArd <Sq // /s-// h Ad/ddre/s+}s f� Expiration Date -fa 1 C7 (J(DDJ 2—� Telephone A)b E3 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 buildigg 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 ED Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [O] Other Brief Description of P oposed Work: "� ei rI P a .� SU C(`f 70>4 Alteration of existing bedroom Yes No Adding new bedroom Yes JL,� 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 I,'�r t C i rte, ' J r t[dh \ as Owner of the subject property hereby authorize �^T I J+ CfT lC �- to act o y behalf, in all matters re ative to work authorized by this building permit application. Signature of Owner Date I, e J'0 Y7­1 /'�/Cl� U as Owner/Authorized Agent hereby declare t at 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. A C" 1 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: V 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 Sp ial Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: `, IF YES: Was toe permit recorded at the Registry of Deeds? NO . DONT KNOW 0 YES IF YES: enter Book Page and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES l IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES NO Val 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,exc tion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. L ` of Northampton Status otPermit: Department use only 8 Iding Department Curb CuttDriveway Permit 3 2��5 VIA. 12 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric,Plumbing& as Inspe mpton, MA 01060 Two Sets of Structural Plans Northampton,p(� agA13-5 -1240 Fax 413-587-1272 Plot(Site plans Other Specify 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 t0 V{r h J c-,N S Map Lot Unit Zone Overlay District Ivor-fh ca,nr,p-�n , mA- �,�o�v Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J:Sc t- r i C i a- lJ r-u tifi �� Vre r n�r� Vii- ,fir_-t hrr r�Trrlr�— Na n t - _ Current Mailing Address: Telephone L(� Signature 2.2 Authorized Agent: MLele 15- IV JCh ids qye , J&al farm, Name(Print) Current Mailing Address: gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted 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 =0 +2+3+4+5) Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0837 APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q PROPERTY LOCATION 67 VERNON ST MAP 31A PARCEL 098 001 ZONE URB(100)/WP(12)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC BASEMENT.KNEE WALL INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108212 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 m y S' o uil mg 60ffiefai 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. 67 VERNON ST BP-2015-0837 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A-098 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-2015-0837 Project# JS-2015-001620 Est. Cost: $2957.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VICTORY ENERGY SOLUTIONS LLC 108212 Lot Size(sq.ft.): 21126.60 Owner: WRIGHT PATRICIA Zoning: URB(100)/WP(12)/ Applicant: VICTORY ENERGY SOLUTIONS LLC AT. 67 VERNON ST Applicant Address: Phone: Insurance: 1 HARTFORD SQ SUITE 206 (877) 306-4483 O WC NEW BRITAINCT06052 ISSUED ON:31412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC, BASEMENT,KNEE WALL 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 3/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner