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CONTRACT
PAX 401423-1734.
PROGRAM
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lbomm ran (630)854-$020 OV21 15 409393 omol
w B6%0 Road Sao Bridge Road
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Fiorenee,.l #IDI.(}62 Florence,MA,01462
JORDESCRIMON
"I"oiml: . $3;114.77.
Pmgram Incentive: $2�M�38.
Custiamr Total: $713.38
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Thotlias Jordan (63.0)8S4-5020. 01/21/2015 408383 00001
SEEM XTRSEr Wow 1910=1
540 BrWV Road 54 :B60gc gDad
WOOM CM XVAtL2P MAW aff.CAM 20
Florucc,MA 01062 Flomce,MA 01062
JOB DESCRIMON
Alit SEAT INQ Pmvidc labor and mu eiials to seal areas of Yana home t8i9tnat ovas*ft ewm atr f . This ww1c will bt
pwf yrAd.izt oobctn wrttb tW use Of 4=W tools 2nd diiaP=k Wft b:a im that:yow boot w111 be left witlt.a beattbU Pavel of
air OvAsoW god indoor air quality.Mocrials to be xpcd to sgW y=bcmw can mduda caaU fotmtt,Wiping sad vtbet
{xodu A% Prkuzy arms for seating include sir icd6o4p iv ag.t 6;stGrCllDd t and admi wibmtcd acres(wiod ke
oftwally add—wd.)(8)walking hours,
At me aanapktion Of ft wtAb"ia>aion work,and at m WdiGioulll cyst to the t umwww.a final dl~door audlor cwmbwdim
safi'<ty artatysis w+ti!tae anud+aetea fy tlta'6tkt•+doet�2Ctor m e�,ure if it tY of mr bndoarr aia qualuy.
5600.00
DACG:)?t�OVitk Leber and aaLrdiels m ittatap a 12"layst otfi�8�ulfecad frbx�1s to(4b��fives for de�matiug
putposee.
$9430
ATTIC Clams:f Ct3inkc added to(%I)squint fact of opea epic
S1;21t9;30 : .'
ATTIC ACCESS:Povi4clabwaudmoftialsto tas�tW be bwk of(!)xak hmb*Jet 2''Clgid.Tfttaoitaie botxri'lfxeZrsspip see
$W.4o
V'ENTIlA7`M:Prmoc tabor and mawish to irwali(2?l2"4ienirfer'ttai�liriiom"wof vavt(a)bt iocncassc h7Ptiiatigtt in anise
arez& The vtm can M suppW ip(cimle color)blade,Moan,gw1or null Polish.
$238.20
CRAWI SPACE Provide tabor and is to tasW a2S)squm feet of"fined fibaglass itlstdatiott to tltt raawtspi W oGit*
$447;75
BASWEN CEH N6:Prori(le labrtr aril wA&i&W iii W(61)lkww tact uaEaard 8bctow hwAadw tp the pormwow
cQ'ttte b2ststrrntt veiling.at.tfyc lnrree siil.
5106.TS,
SASEMID4 0001L Provide labw and menial%to insotete.dv:bock.of ft bssematY door sat ft ti the botidicad web 2"tigid
band ibat maces the s0aiO=R-316.5.4 m d Seal all od8es and=W With FSK tapo.
$72,72
REMOVAL lteodavt•(225)sgwW.fi dofb,t*&C irmwip m fm ttit rravvEspa�c Wive
5146:25
The Commonwealth of Massachusetts
Uq9Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Or h
Address: ��A,3t_1,JP0 CA C 0
City/State/Zip: t. r'►'ECtlf1 C QGC62— Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. 3l I am an employer with 3_ 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.$ 9• ❑Building addition
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' 13.V ther-
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners 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 box 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: ] �( U rar-A [,e�^(o, CQ 5-n
Policy#or Self-ins.Lie.#: y 14 �n 5 Expiration Date: y Lgot 5'
Job Site Address:5yC Vr 1_ 0 PA City/State/Zip:WQC:�oia yv--%�00101 01062-
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: Z Is
Print Name: 1� �r1n nn CpyP Phone#. V7-3Uto-141-C TS
Official use only Do not write in
this area to be completed by city or town official
City or Town: Permit/license#: T
Issuing Authority(circle one):
I.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 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: M �v l J (11(1 r l � ' '32 12—
License Number
chokS 11Ciou')h .m0 - (0 12 c) �
Address Expiration Date
4 1-I ?2
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
16-+ 2-
Companv Name Registration Number
Address Awn /� (��r7 �/rj Expiration Date
UMJ r � wn I u 1 CD Telephone, , )2Uj 9
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 build in 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 F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other
Brief Description of Proposed
Work: t� a4n ��<p�m� � �f�m I �(1i
( 0�1
Alteration of existing bedroom Yes \/r No Adding new bedroom Yes _LZNo
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
71�Ir a �1 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, M'1 6 G1 cy- i 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.
J-\ ,Zs, i
Prin
Signature of Own gent 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 Spe ' l Permit/Variance/Finding ever been issued for/on the site?
NO P 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
IF YES: enter Book Page', and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO, P-'-"DON7 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 0 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, ex 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
7MAR 7ED
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availabilityhampton, MA 01060 Two Sets of structural Plans
87-1240 Fax 413-587-1272 Plot/Site Plans
Other`Specify
D�f' f�#C,�N CQ: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
54012)r t Ckn Map Lot Unit
J Zone Overlay District
�a� +t�Q�- p�--®�n rn�r t� �o� z.
I Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'Thorn o� <x n 5'A Q k' & a
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:P a ,�y��n ' l me(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 C) (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 qJ
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0859
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q
PROPERTY LOCATION 540 BRIDGE RD
MAP 17D PARCEL 004 001 ZONE RIO 00)/RR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out .f�1 n
Fee Paid
Typeof Construction: INSTALL INSULATION,DAMMING,VENTILATION
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
INF RMATION 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
D e y
Sig o u ding Cffficial 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.
540 BRIDGE RD BP-2015-0859
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-004 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-2015-0859
Project# JS-2015-001677
Est. Cost: $3015.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 108212
Lot Size(sq.ft.): 122839.20 Owner: JORDAN THOMAS
Zoning: RI(100)/RR(100)/ Applicant. VICTORY ENERGY SOLUTIONS LLC
AT. 540 BRIDGE RD
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 306-4483 O WC
NEW BRITAINCT06052 ISSUED ON.•311712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION, DAMMING,
VENTILATION
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 3/17/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner