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25C-259 (11)
To: Linda LaPointe Page 2 of 3 2015-10-20 21:05:56(GMT) 1 41 332231 55 From:Tom Rossmassler 10/1512015 09:03 14135071272 NTGN BLD DEPT PAGE 02/02 Property Address. Contractor Name: Address; 2 city, tita: ll Phone: /, 6 Property Owner Name: � �S AA WJ L-C(f tl /� City, State: it��T , t��4�/ ,•k,� Q/��(�'�} (contractor)attest and affirm that the building i intend to instJtata does not have any upon air(knob and tub.-)vviring Pn the spaces to be insulated and that 1 have provider(the property ownar With a¢p 2:f this afttdavrt. Contmctor signature Date mass save thyll�♦'WSr►�"K'Mrrty �V' PERMIT AUTHORIZATION FORM i, Benjamin Levy ,owner of the property located at: (Owner's Name,Primed) 9 Fair St. Northampton (Property street address) (city) 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. X Owner's s gnaturo Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date a ra o� For Gfdctt ua Ot►Ir Rev.12132011_.�.._.___....._._...�,. __......._.._.._......._.�. - -w.. ._�,.___._._... .�._.__.p.�....._,.__�... Scanned by CamScanner CERTIFICATE OF LIABILITY INSURANCE M/DDlYYYY, 7/71207/2015 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 OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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). CONTACT PRODUCER NA E: Mary Conroy James J. Dowd and Sons Insurance Agency Inc. PHONE dd FAX No: 14 Bobala Road c o - E-MAIL Holyoke MA 01040 ADDRESSES: mconroy @dcwd,com cUSTdMER to#:ENERLLC-01.` INSURERIS)AFFORDING COVERAGE u I y NAIC# INSURED INSURER A:HDI-GerliT_O America Insurance Com a ( __ Energia, LLC INSURERB:TOrus National Insurance Company 242 Suffo_]c Street '- Ho_ycke MA 01040 INSURERC: INSURER D: _ INSURER 15: INSURER F: COVERAGES CERTIFICATE NUMBER:1282823167 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 CONTRACTOR 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. INSR ADDL SUBRI LICY EFf POLICY EXP LIMITS LT. TYPE OF INSURANCE POLICY NUMBER �- A GENERAL LIABILITY Y Y SGGCC000186815 7/1/2015 7/112016 EACH OCCURRENCE 181,000,000 TO X COMMERCIAL GENERAL LIABILITY R III S920.9u�pLW)_ _ S100,'000 CLAIMS-MADE I-- I OCCUR MEDEXP(Anr�eneponon) 55,000 _ PERSONAL&ADV INJURY__ $1,000,000 GENERAL AGGREGATE S 2,000.000 GEML AGGREGATE...GATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AC-G $2,000,000 POLICY I PRO- LOC l S A AUTOMOBILE LIABILITY Y Y FAGCC000186815 771/2015 7;1/2016 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED AUTOS BODILY INJURY(Per arr Aenti S X SCHEDULED AUTOS PROPERTY DAMAGE I S x HIRED AUTOS (Per accident) X NON-OWNED AUTOS S I ! B X UMBRELLALIAB - �oCCUR Y TORUS123 ;7/1/2015 %11/2016 EEACHOCCURRENCE_ s2,000,101 _ EXCESS LIAR_ CLAIMS-MADE I ( AGGREGATE $2,000,000 DEDUCTIBLE X RETENTION 510,000 I S A WORKERS COMPENSATION IY IES'7GCC0001$6815 (7/1/2015 17i1/2016 g WCSTATT• q AND EMPLOYERS'LIABILITY I ANY PROPRIETORIPARTNEMEXECUTIVE B a E.L.EACH ACCIDENT S' 000,000 ` OFFtCERiUVMER EXCLUDED? ,000,800 I (Mandatory in NH) i E.L.DISEASE-EA EMPLOYE S 1 If yes,describe under I I E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below i i I I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA71ON DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD r^:��r`frniirurrvrmrrr�/�r�'/(r...rn%rr.r//, Office of Consumer Affairs&Business Regulation License or registration valid for indiretul use only �'' r�dOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: — -j Office of Consumer Affairs and Business Regulation t3 egistration: 165169 Type: xpiration: 1/11/2016 LLC 10 Park Plaza-Suite 5170 ;,� Boston,MA 02116 ENERGIA LLC THOMAS ROSSMASSLER J ' 242 SUFFOLK STREET PP HOLYOKE,MA 01040 Un dersecretary Not valid without signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-092540 Construction Supervisor t _ THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELD MA 01038 y 4 r_,JZ. ;K Expiration: Commissioner 09/0212017 The Commonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations -s i A 600 Washington Street a ; Boston, MA 02111 =sue www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/Individual): Energla, 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): 1.5d I am a employer with 24 4. ❑ i am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workers'w d h employees and o working for me in any capacity. 9. F-1 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 1 I.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12,❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.®Other Insulation comp. insurance required.] Any applicant that checks boa#I 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. :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: HDI - Gerling America Insurance Company _ Policy#or Self-ins. Lic.#: EWGCC000186815 Expiration Date: 7/1/2016 Job Site Address: ? S/ • 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 a er the pains and penalties of perjury that the information provided above is true af correct. or Signature: 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#: Manow City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: T-' The debris will be transported by: ! � 1� Y✓A S�� The debris will be received by: � Building permit number: Name of Permit Applicant d Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 81 Licensed Construction Supervisor. Not Applicable Name of License Holder:�Lfd.H Q S"l=L�"� 020q 0 License N ber 2 q 2 Su 66d--� s� IO�� 6 A� = Address Expiration D e - 2- 311/ Sign ure Telephone 9, Registered Home I provement Contractor: Not Applicable ❑ Companv Name Registration Number / /// /A� Address r� Expiratio ate Telephone�1J -21 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' g 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other Brief Description Proposed Ivs S / G Q G�GU,C.GSGc/ice'©�,�� Work: 7 Alteration of existing bedroom Yes o Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes 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 fami 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 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. �J / �,*l / l Signature of Owner Date (/G(l,SSAAL , IZ- 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 /�- D ' Signature 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 Q DON'T KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW O YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO Q 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. -RECEIVED Department use only i City of Northampton Status of Permit: Building Department Curb Cut/Dnveway Permit OCT 9 2��5 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEPT oF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON Mnotoso 413-587-1240 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: � �HAP7�� l�- SmlN Name(Print) Current Mailing Add es "7G� �C.K 7 /T K Ay r� Teleph!V4 t new Signature 2.2 Authorized Aaent: 7� ��- Name(Print) Current Mailing Address:A. qL3 . 3Z ��l( Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building CV (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 Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0492 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE01040(413)322-3111 PROPERTY LOCATION 9 FAIR ST MAP 25C PARCEL 259 001 ZONE URC(58 /S�)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out V 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 92540 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ON 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 of ion Delay Si ature of Buifffiing O cial 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. 9 FAIR ST BP-2016-0492 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-259 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-2016-0492 Project# JS-2016-000829 Est.Cost: $1700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(ss . ft.): 12414.60 Owner: LEVY BENJAMIN Zoning:URC(58)/SC(42)/ Applicant: ENERGIA LLC AT. 9 FAIR ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.•1012212015 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 10/22/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner