36-142 (4) 0 F L VIA S�L i Si Eu N S U IRA N3 CE E DATE(UW0WWM
C E Rlq 1 5/5/2015
THIS CERTIFICATE IS ISSUED AS A NIA-1 TER OF INFORMA11ON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OF, NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CEPM, FICATE OF INSURANCE DOES NOT CONIS-11TI17E A CONTIRAC.T
BE-DWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT* Iff 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 Cc"T CT
.,NAIAEt Brian Gallagher
BNC P-gen- cy, 1--c. PHONE (914)937-1230 Fp c.NaT.[SIP)9371224
s-
Soutb- RidgG S eet EAIAIL
cost
.7-"7ye 51:00k NY 1.0573 INSURER(S)AFFORDING COVERAGE NAIC'
INSURED INSURER A:Se1eCtiVP- InSUZ�a=P- Co of S-C. 19259
iysuRERa.-StarNat Insurance Co
npany 40045
Enargv- P--z LLC wsuREac-.Landmark American Ins Co. 33138
DS-A,. Tiie Enc----g' Sto-�e INSURER D.
131 01a Pozits 7 INSURER E: i
Broo1c'-F-i-J-d CT 0680A- INSURER F:
COVERAGES CER-171FICALTE NUMSER.CL15424 65662 REVISION MiMBER•
Ti-IIS IS TO CERTIFY THAT THE POUCiES OF INSURANCE LISTED BELOW HAVE 13r=EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N01ANI1 HSTANDING 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.
NP i JADDL I POUCYEFF POLICYEXP
iYPEOFINSURANCE 11rJSR ATM POLICY NIJUIRER I(MI-XIDDryyyy) frawnwwv) Uv1ITS
-RALLIASIL(Tv
EACH OCCURREICE 15 1,000,000
COMLIERMAL CENERAL UABILITY uANIM31-tu RENSEO
0
9RE?'.1tSEs ie
CL4NJS4.VDG 50 OCCUR_ 2153542 3I27/2015 3127/ZO16 ',!EDF-XP(Arr1 P—n) 3 5,()00
FERWRAL 30
GENERAL AGGREGATE is 2,000,000
PRO- COMKOP AW I S 2,000,000
1 C-al L AGGREGATE U?ZIT APPLIES PER:
N,
PRODUCTS-
POLICY"rx I'IE(7 F�LOC I is
AUT0P.I091LELtA6!UTy MIT
1'Goo,000
ANY,,UTO
ALL SCHEDULED 2153542 BODILY INJURY(-"pemon) is
AUTOS AUTOS 130DILY INJURY fP�.=idenVj 5
ME NON-WVEO PROPERTY DAMAGE
AUTOS (Per acodeml is f
Iq ts
Uil
ISRELLALIA
E;XFSS UAB DE EACH OCCURRENCE is 5,000,000
AGGREWATE is 5,000,000
OED RETENTIONS
2153542 In/271- 127/2016
WORKERS COrPIPENSATION
N"
AND EtAPLOYERT UAMLITY 4 y Ir.ITS
ANTY PROPPff PJP,,-ME1JEXEC1J!TJE 1,000,000
3137,9 EL EACH
V.11andatory in 114) 1,
1i, ee5awe�,d4' r-I /15/2015 0115/20-16 -LOISEASE-ESIMPLOYEEI 1,000,000
n
-E—L DISEASE-POLICY U1.1171 s 1,000,000
---17 S 0 4 4 3127/2015 3/27120!6
LWIT 2,000,000
DESCRIPTION OF OPERATIO.451 LOCATIONS I VEHICLES(Aft-16n ACORD 101,Adtfitiona)Ramalim Srhadul,,,if more spuelll
is inquired)
"EIRTIFIGXi E HOLDER CAMCELLA-00N
SHOULD A1,11f OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E;(PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE tAnTH THE POLICY PROVISIONS.
AW HDRUTM REPRESF,4TA-nvE
0 Colabella/BGAL.-u
'4cor-D 25(2010105)
(D-1988-2010 AGORD CORPORA-110M. All fights reserver.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
600 Washington,street
Boston,Mass. 02111
i4Jbm.mass.govIdita
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers
Applicant Information PIease Print Legibly
�fYie(BusinesslOrganization/Individual): / —T 1
Address: �)' (J A R__�
citVista _T C Phone#:
r'
.ire ou an employer?Check the appropriate box: Type of project(required):
1. 4 t am an employer with 4_ ! I am a general contractor and I b. !:j New construction
employees(full and/or part time).'* have hired the sub-contractors 7. Remodeling
2. E 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' q. �Building addition
[No workers'comp. insurance comp. insurance. i
required] 5. We are a corporation and its 10, —1 Electrical repairs or additions i
3. I am a homeowner doing all work officers have exercised their 11. =1 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL i
insurance required]if c. 152,$ 1(4),and we have no 12. _ 000f repairs
employees. [no workers' 13.vi Other Ui•1/
comp. insurance required.]
Any applicant that checks box A 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
he sub-contractors have emptoyees they must provide their workers'coma.policy number.
am an evipiloyer that is providing workers'compensation insurance for my employees.Below is the policy and job site
inforatiWott
<nsuranee Company Name: � [}��)r n'1 C A liven c"'4/ --+--(l
°olicy#or Self-ins.Lic. s )U -� ?s C�j Expiration Date: (�n �� ®��Q
ob Site Address: oU l �� � r✓C City/StatelZip: �0✓�Y►ZP� 1 V(P
.-�.ttach 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
$250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification. _
do herby eerie r the ai pe es of perjury that the inforrnatiorr provided above is true and correct
Signature: Date:
Print iVame: / ,r' J^ Phone':: —
Official case only Do not write in this area to be conTleted$y city or town official
City or Town: Permit/license#: I
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 9:
_r
till
masss save O,�P�R
�tp =�aff kwa 1r�
PERMIT AUTHORIZATION FORM
I, David Bond owner of the property located at:
(Owners Name,printed)
300 Brookside Circle Florence
(Property Street Address) (City)
hereby authorize the Mass Save Borne 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 Signature
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
ISO [i)
Far Wit ft uas Only
Rev.12132011
City of Northampton 212 Main Street, Northampton, NIA 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: � 77�`CX��Srt�e CllrG-
r
The debris will be transported by: r,"�
�r
The debris will be received by:
Building permit number:
Name of Permit Applicant o
t
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
License Number
Y, I(N S��ld-4 MA a zS-7-
Addre s Expiration Date
Signature
Telephone
9.Renlistered Home Improvement Contractor: Not Applicable 0
Registration Number
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidg/it must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ing permit.
11. - Home Owner Exemption
The current exemption for^homco"mnem^was extended uoinclude one(1) or ^wo(2)fami}ios
and m allow such homeowner m engage un individual for hire who does not possess ulicense,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Derinition 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 fati-tily 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 P-Criod shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a forrn acceptable to the Building Official,that he/she shatl 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 pen-nit is issued.
Also bn advised that with reference to Chapter |52(YVockom`Compensation) and Chapter |53(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable fvrpemou(s)
you hire mper5puu work for you tinder this permit.
The undersigned"homeowner"certifies and assumes responsibifity 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 F-1 Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Cj Siding[l3) Other I
i Brief Description of Proposed ', '� D ; aG
Work: Cellulose- r '"
Alteration of existing bedroom Yes No Adding new bedroom Yes Y No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
i 6a.If New house and or addition to existing housing. complete the following:
j a. Use of building : One Family Two Family Other
(� b. Number of rooms in each family unit: Number of Bathrooms
i
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
i 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
1 I�T.1�(i �. as Owner of the subject
property
hereby authorize l �S
i to act on my behalf,in all matters relative to rk authorized by this building permit application.
see- 46cliA
2 1
i Signature of Owner Date
l 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.
i
� Signed under the nand pe alties of perjury.
U
jPrint Name
15
Signature of Owner/Agent Date
Section 4. ZONING ALI 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
Rear
Building Height
Bldg. Square Footage %
Open Spa e Footage %
(Lot area minus bldg&paved
L4 of Parking Spaces
volume&Location)
A. Has a Special Permit/Variance/Fl ever been issued for/on the site?
NO 0 DON7KNOW /-A YES 0
IF YES, date issued:
IF YES: Was the permit recorded atthe istry of Deeds?
NO 0 DON7KN0V YES 0
IF YES: enter Book Page and/or Document#
B. Does body NO /�\ DONTKNOVY '�� YES
' ' \^� �^� \^~/
IF YE5, has a permit been or need to be obtained from the Conservation Commission?~' ` Needs to be obtained \~�/�� Obtained y-�\�� Date Issued:
' '
C. Do any signs exist un the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions o/signs intended for the property! YES ��/—� NO ��/��
IF YES, describe size, type and location:
E. Will the construction activity disturb( hng.gmUing e aUon.orfi||ing)ove/1aos �
oriai�puofaoommonp|an
that will disturb over 1oxm ��? YE8f l N�
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
I Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
.;� Northampton, MA 01060 Two Sets of Structural Plans
1 s phone 413-587-1240 Fax 413-587-1272 PlotlSite Plans
Other Specify
LC APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
10 G
1'-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
circ-
Zone Map Lot Unit
oo ��o��i � Overlay District
1 d f ce" 1 D D 2- Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
12.1 Owner of Record:
VO4 ;00 . La i Crc
Name(Print) Current Mailing Address: 01002-
Telephone Li 13 _ c^
i
Signature
2.2 Authorized Agent:
t' S PC) x I
Name(Pri Current Mailing Address: 01Z57
�-75- 2c)LLLV 'S
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
13. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+ to to.. 3 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0842
APPLICANT/CONTACT PERSON THE ENERGY STORE
ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888)840-6641
PROPERTY LOCATION 300 BROOKSIDE CIR
MAP 36 PARCEL 142 001 ZONE
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
Buildin4 Plans Included:
Owner/Statement or License 106024
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demo * * lay
S re 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.
300 BROOKSIDE CIR BP-2016-0842
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 142 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-2016-0842
Project# JS-2016-001427
Est. Cost: $2166.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: THE ENERGY STORE 106024
Lot Size(sq. ft.): 15202.44 Owner: BOND DAVID G&CAROL H
zoniny,: Applicant: THE ENERGY STORE
AT. 300 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC
BROOKFIELDCT06804 ISSUED ON:11512016 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:
TLIIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTyne: Date Paid: Amount:
Building 1/5/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner