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31B-021 Property Address: LA Contractor Name: _ 7�� -.v r �, /✓rr c S Address: ��{ City, State: c�,,��✓�a �,�} Phone: - j/�'- S-G / - S- Property Owner Name: --- --------Address_-------�-�--�-�--�i��----��-- --=---- - ------- -------- City, State: N�h���., ✓� ��N r r`'� I. 714 L�117,y S�r�s`c/,`I�S (contractor)attest and affirm that the building I intend to insulate does otr� ha 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 ffi CERTIFICATE OF LIABILITY_ INSURANCE °ATE{MMro°mYY} 01/16/2015 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 DR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONrRA(:T BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms 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 endorsement(s). PRODUCER 413-566-0028 413-566-0090 NAME:c Richard R. Green Insurance AgencV, Inc. Richard R. Green Insurance Agency, Inc. PHONE 413-566-0028 FAX N.I.413-566-0090 32 Somers Road goo IIESs:richardgreeriins@charter.net PRODU'ER cusrOMER ID R �_ Hampden, MA 01036 INSURERS AFFORDING COVERAGE NAIC/I INSURED INSURER A:Patrons Mutual Insurance CO. of CT Michael Greenwood INSURER B:Associated Employers Insurance Co. dba The Energy Specialists INSURER C:Commerce Insurance 212 Ames Rd. INSURER°:__ Hampden, MA 01036 INSURER E` INSURER F: I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW 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. IN5R ADOL SUBR pDLICY NlJM3ER _ MR JUDNPYY MM 6DNYYY LTR TYPE OF INSURANCE LIMITS GENERAL LIABILITY I A � EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurcence S CLAIMS-MADE P11 OCCUR MED EXP(Any bne person) S BOP2698685 10/1412014 10/14/2015 PERSONAL&ADV INJURY S GENERAL AGGREGATE S GE AGGREGATE LIMIT APPLIES PER: i PRODUCTS-COMP/OP AGG $ POLICY I PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per parson) 5 C ,/ ALL OWNED AUTOS BBMJ27 01/05/2015 01105/2016 BODILY INJURY(Per accident) S V SCHEDULEDAUTOS PROPERTY DAMAGE $ V/` HIREOAUTOS I (Per accident) V S NON-OWNED AUTOS S UMBRELLA UA6 r/ OCCUR EACH OCCURRENCE S EXCESS LIAe CLAIMS-MADE AGGREGATE S 1,OOO,DOO A CXS21"11578 1011412014 10/14/2015 DEDUCTIBLE S RETENTION S _ S WORKERS COMPENSATION VVC STATU- ! O cTH- AND EMPLOYERS'LIABILITY YIN Y OFFIC£Ri RIETORIEXCLU0RIE ECUTIVE a NIA WCC 5009 547012014 10/16/2014 10/16/2015 E�.EACH ACCIDENT $500,000 (Mandatory In NH) I E.L.DISEASE-EA_EMPLOYE $500,000 If yes.desatbe under + DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT I s 500,000 t DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Addlfonal Remarks Schedule,If more apaco Is required) Subject to policy terms and conditions. Sole proprietor excluded from coverage on the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION For Insured's Records Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Insured's Records Only ACCORDANCE WITH THE POLICY PROVISIONS. For Insured's Records Only For Insured's Records Only AUTHORIZED REPRESENTATIVE For Insured's Records Only For Insured's Records Only ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009149) The ACORD name and logo are registered marks of ACORD '.-Iize tt'czrrnzoncaeactiz cf vozu�ucftueecr License or registration valid for individul use only Office of Consumer Affairs&Business Regulation V, e,,gistration:ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation % 153287 Type: 10 Park Plaza-Suite 5170 iration: 11/14/2016 DBA Gaston,MA 02116 -THE ENERGY SPECIALISTS kilKE GRENWOOD 212 AMES RD. �� �— _ _ _---------- iAMPDEN,MA 01036 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License: CSSL4)9MI r- MICHAEL E GRE 212 AMES ROAN _ HAMPDEN MA 8103 i, 1 ma c– ), Expiration. Commissioner 03109121215 Z j4 t t OWNER AUTHORIZATION FORM i s I 1 (ownees Name) owner of the property located at (Property Address) -- (Property Address) hereby authorize /74P - (SubcorrtraCtOr) an authorized subcontractor for RISE Engineering,to ad on my behalf to obtain a twilling permit and to perform work on my property. 4sne; ture Date a The Commonwealth of,32assachusetts -- Department eyfIndustrialAccidents j1t 1 1 Congress Street, SItite 1 M 13ostore,114 0211 4-2017 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): The Energy Specialists Address:212 Ames Road _City/State/Zip: Hampden, MA 01036 _ Phone #:413-566-1058 Are you an employer? Check the appropriate box: �y —1 Type of project(required): 1.] I am a employer with 3 4. [] i am a general contractor and i employees (full and/or part-time).* have hirF,ci the sub-contractors 6. [� New construction 2.❑ i am a sole proprietor or partner- listed on the attach:d she€-t. 7. ❑ Remodeling ship and have no employees These stab-contractors have g. [] Demolition an capacity. employees and have workers" working for me in 7 y p ty' 9. (] Building addition [No workers' comp. insurance comp insurance.1 required.] 5, 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.0 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 Insulation - employees. [No vworkers' 13101 Other comp. insurance required.] "Any applicant that checks box 41 must also fill out the section belov, 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. 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,thev 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:Associated Employers Group_`_ Policy#or Self-ins. Lic. #:WCC50091547012012 - _ - Expiration Date: 10_16-2015 Job Site Address:_/ �d •�_�/ Attach a copy of the workers' compensation policy declaration pag.°(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A o_f Mt33l.,c. 1 °;'r 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 under a pena 'es of perjary that the information provided above is true and correct. Signature: -------------- Date: Phone#: 413-566-105 Official use only. Do not write in this area,to be compieted by cih or town official. City or Town: Permit/License# Issuing Authority(circle one): i. Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: !,Uane : � r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ❑ i Name of License Holder: �� ( �� f < �ht t �.._( �p d,el License Number Addres Expiration Date SGG° /o 5- Signature Telephone �� e I 9. Registered Home Improvement Contractor- Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 builclin 2 permit. Signed Affidavit Attached Yes....... No...... ❑ ell 1 L - Home Owner Egem flon 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-vear 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 I Alteration(s) Roofing Or Doors ❑ L_ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [CJ Siding [0] Other[01 Brief Descripti of roposed / Work: A�� 3 r/�CJ�o Sr A �iT�` c,� 14,41 A00 14 on A qIs N!'T c�t 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 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? - — i f. Method of heating? Fireplaces or Woodstoves_ Number of each I 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 . L 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 property hereby authorize Z;6 to act on my behalf, in all matters relative toV k a thorized by this building permit application. Signature of Owner Date as OwnerfAuthorized Agent hereby declare tha tl�e state ents 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 N - 1 Signature of O edAgent 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&pared parking) #of Parking Spaces -- Fill (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 0 DONT KNOW e YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 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 vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO f IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only j City of Northampton Status of Permit: Building Department Curb-Cut/DriuewayPermit J 212 Main Street Sewer/Se pticAvailabiiity 1 AUG 2 Q Room 100 Vvaterf'W4 Avaflab#i y ll Niprthampton, MA 01060 Two Seiso€ ucturat Flans phon 141�-587-1240 Fax 413-587-1272 Plo(Site Plans Offier,Specify . i l 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 Map Lot Unit f i TU,J M Zone_ Overlay District E Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i e,4 A A/ ' - Name(Print) Current Mailing Address: ` ri y- /3 Y7 Telephone — I Signature 2.2 Authorized Agent: —III Name(Pri�!L,._r Current Mailing Address_ AD r�- Signature Telephone ` SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by hermit applicant _ 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 1 3- Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection N A 6. Total = (1 +2 +3+4+ 5) a t Check Number This Section For Official Use Onlyj Building Permit Number: Date Issued: Signature: I Building Commissioner/inspector of Buildings Date File#BP-2016-0232 APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS ADDRESS/PHONE 55 CIRCLE VIEW DR HAMPDEN01036(413)566-1058 PROPERTY LOCATION 16 ALDRICH ST MAP 31 B PARCEL 021 001 ZONE URC(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 ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 99381 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: aiff 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 Demolition Delay Signature of Building 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. 16 ALDRICH ST BP-2016-0232 GIS#: COMMONWEALTH OF MASSACHUSETTS MV:Block: 3 1 B-021 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0232 Project# JS-2016-000388 Est. Cost: $1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY SPECIALISTS 99381 Lot Size(sq. 1): 6098.40 Owner: MUSANTE ELIZABETH A TRUSTEE Zoning. URC(100)/ Applicant: THE ENERGY SPECIALISTS AT. 16 ALDRICH ST Applicant Address: Phone: Insurance: 212 AMES RD (413) 566-1058 WC HAMPDENMA01036 ISSUED ON.812612015 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 Signature: FeeType• Date Paid: Amount: Building 8/26/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner