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17D-044 (6) ss saves nationalgrid MERE W"W YOU.HERE FOR You. MASS tJ PRE-WEATHERIZATION BARRIER CONTRACTOR • .•. Brian Seidl Rebate Recipient(N different): Site ID.SDODD2198M 62 Straw Ave Project ID:P00000203226 Florence.MA 01062-14" Malling Address(if different): Customer ID:COD000208299 Phone, Date of Assessment:01.03.201 a Email: �' State:.. Zip: Phone: Energy Specialist:CJ Hanley EVALUATION ENERGY SPECIALIST KNOB&TUBE WIRING ®Contractor is to evaluate the selected locations where weatherization reoommendations have been made to determine If active knob&tube wiring exists: Q Attic Exterior Walls Basement Q Attic Floor Q Knee We11 Fkhor Attic Slopes MECHANICAL SYSTEM,HIGH CARBON MONOXIDE EVALUATION ®Contractor Is to evaluate the selected mechanical system(s)below and provide service,If possible,to reduce high carbon monoxide levels as measured In the undiluted flue gas to below 100 ppm: O Heating System 0 Hot Water System ❑Other: DRYER VENT EVALUATION Q Contractor is to evaluate the,dryer vent and provide service to property exhaust the vent to the exterior. CONTRACTOR EVALUATIONS KNOB&TUBE WIRING Upon completion of rrty Inspection 1 have found that there Is no active knob&tube wiring In the areas)checked off below., Q Attic Exterior Walls Basement Q Attic Floor Knee Wall Floor f��Attic Slopes CONTRACTOR INFORMATION t < <� Company Name: C O`er �✓ c Address: . 1M.f.�lh� City. f�"S�[�t1.��� State:�` ZIP: QlOe�, Contractor Name: t5� Uoense A: 0 C7~ V Federal ID it: 10 1 0 131 have read,and agree to,the Tencts&Conditions of the Pre-Weatherizatfon Banter Incentive. Contractor Signature: Date:0 MECHANICAL SYSTE I CARBO NOME EVALUATION ❑The selected mechanical system has been evaluated and serviced.Testing results of carbon monoxide In the undiluted flue gas are as follows: C]Heating System CO ppm Q Hot Water System CO ppm Q Other CO ppm DRYER VENT EVALUATION ❑The dryer vent has been exhausted to the exterior. CONTRACTOR INFORMATION Comparry Name: Address: City; State: Zip: Contractor Name: License#: Federal ID q: ❑1 have read,and agree to,the Terms&Conditions of the Pre-Weatherization Barrier Incentive. Contractor Signature: Date: CUSTOMER INSTRUCTIONS Submit signed and completed copies of this Contractor Evaluation Report and a copy of the paid Contractor Invoice to: Pre-WX Barrier Incentive,CIO CET,320 Riverside Drive-1 A.Florence,MA 01062;or email to CustomerSupport0cetonline.org Customer Signature: Date: '.1„m„N-;& ^���� CONfRAPCTO� mass save SerMys lNOU4h�WYeMide'rY PERMIT AUTHORIZATION FORM I, 01/1- j r.o�r+ �1 ! I owner of the property located at: (Owner's Name, printed) ,( C;Z A, - Dl-' Rbllekwl- (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. OL vmr. Owner's Sign re 0(- 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: 4 Participating V ntractor Date Rev. 12132011 City of Northampton �,y, SAS. A sic (� Massachusetts i s �3 DEPARTMENT OF BUILDING INSPECTIONS y.. 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: C�� 5; z4 �Y� Contractor Name: �f/Ojl1S 12ySSyb(�SS�.�Q Address: 2 2 SIICer � S% City, State: 1, 1*114 O///Za Phone: y/3 ' 3 22 —:9 !c Property Owner Name: //�/2�.4Al Address: City, State: LD�E�C G , MA— I, 'r"/zi S %?05SRASSL6(42� (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date 2.7 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.(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. E]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' comp.insurance.+ 9. ❑ Building addition [No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.17711 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself o workers'com right of exemption per MGL y t p c. 152 1(4),and we have no 12.❑ Roof repairs insurance required.] ' § 13.® Other Insulation employees. [No workers' 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: //''12/17/15 Job Site Address: (,P2 S79—�I'�E• City/State/Zip:15(qp �66 AA NA02 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 certi ndr{the pains andpenalties ofperjury that the information provided above is true and correct. sign 'L_ Date: 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 7 8.1 Licensed Construction Swervisor:C 1 ' Not Applicable ❑ Name of License Holder:��M p Z aS5JMA-SS L-�2. 1 2-�� V License Number 2u2, SuPP-Ot-K C fli�i-q ukEECA Address Expira I Date 4(3 '322- .311 1 Signature Telephone 9.Realstered Home Improvement Contractor: Not Applicable /p A5 C Company Name Registration Number ?=t 2- S-u FF cr '5T t+ot-gotti��M& / I! Address Expirati D Telephone�G{3' 32z- 3lc l 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 Exem don 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 ID Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Ot Brief Description of Proposed Work: _iV.S1144-T/0W' 11 14Q 5(4e-4 wAUS b6NSE-A4cK C6tAuULd56 Alteration of existing bedroom Yes o Adding new bedroom Yes v o Attached Narrative Renovating unfinished basement Yes Plans Attached Roll -Sheet 6a.if New house and or addition to existina housina, complete the following: a. Use of building : One Family wo 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, ��� N _RA 1--b ( as Owner of the subject property hereby authorize �/V to act act on my behalf, in all matters relative to work authorized by this building permit application. SSE Pe—"C r A- &rt ua i�agAA 4!�71:2 711Y Signature of Owner Date 1G0S5*A 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. ��dA�A�S �2dsS/�4SsLE2 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 © DON'T KNOW © YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW Q YES 0 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 O 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 Q NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. DepttertE►fX l �� 1= �� ity of Northampton i s of Permit: I j , wilding Department Cwt�t oliveway P mfi JUN 3 0 i! i 212 Main Street sewrr/S�atleAvallWfity ��� Room 100 W ift r/Well Ahab", - hampton, MA 01060 Two Sets of tfuctural�#��rts Electric F n it K,ecti 49.3. 587-1240 Fax 413-587-1272 iilt mitts► other`s fy APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: /z 5r1MV AVE Map Lot Unit ,GU Q.C—A)CS / /1/1,0 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: mmd -'i3741:b 1' k/ AVE. Name(Print) Current ling Ads; Q��(T q-&M40 Q M " Telep oh ne Signature 2.2 Authorized Aoent: -2VjedAkA,s ?-0ssj4ASS'! 4� SIB ng4g S I. 44LUkC.m.- Name(Print) Current Mailing Address: _ q13 - 32-2- 31 c i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building Od (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) l/a Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0004 f APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 62 STRAW AVE / L MAP 17D PARCEL 044 001 ZONE URB(100)/ 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 WALL INSULATION 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 INFORMATION PRESENTED: b--,1CP'—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 D itio Delay Signature of uil mg 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.