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30B-007 To:City of Northampton Page 2 of 2 2015-12-17 17:50:53(GMT) 14133223155 From:Tom Rossmassler 12/14/2015 14:52 1,4135671272 NTDN 'SLD DEPT PAGE g2102 Prrsper#y Addcess: f6g " U Contractor Flame: Address. Phone: ., �Z/ 5-22 Sit, Property Owner Name: Address; ! City, State: (contractor)attest and afflrm that the building I intend to insuiabE does not have any open air(knob and tube)''ring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date 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: Ce MWA1612 S The debris will be transported by: y✓ The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant OWNER AUTHORIZATION FORM (ohs t+Mtme) cep'of the pmp q b at .1S S/ - ) ca► ) tweby wftft C�2� -------------I . (�bc�rttrac� an su tortwd abcwtaftr for RISE EMbmft,la act on my tam to ottdn a tOtng permit and'a perform wo*on my pWft. owmes OCT 7 4 20 15 l� 1 The Commonwealth of Massachusetts Department of Industrial Accidents 1 - Office of Investigations �'- 600 Washington Street J,4>� Boston,MA 02111 wwminass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apalicant 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 ap rate box: Type of project(required): 1. 1 am a employer with 24 . I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. 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 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers'comp. insurance comp. insurance.+ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.R 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 employees. [No workers' 13.® Other insulation comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors mist 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. 1 am an employer that is provitling 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: 7/112016 Job Site Address: � 2NE� �✓ City/State/Zip: ?!�Aert�Alc , k4 /��Q ze 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 staternent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under a pains and penalties of perjury that the information provider!above is true and cnrr ct. Si nature: Date: 2 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 8.1 Licensed Construction Supervisor: Not Ap*bDle Name of License Holder: 1/��� License 7 Address Expirati Dat Signatur Telephone 9 Reaistered Home Improvement Contractor: Not Applicable ❑ Company Name Regi ratan N tub Address Expiratio .4er Telephone S/,(/ 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 buil 4 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 fann 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 Alterations) ❑ Roofing ❑ Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q S'ding[O] Other Brief Descri tion of Proposed Work: - qQ 'To � 0 �C.C, SC 1 Alteration of existing bedroom Yes No Adding new bedroom Yes —b4-WQ - Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the followin : a. Use of building : One Famil 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 Ul Gu( 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. SE g Zjz'a/ -7- W-eyrlld / 2 A/' /� ignature of Owner Date T�/Q,#g (2 JSS,&IJ SS7/ as Owner/Authorized Age Kt 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 n n "`f Signatur 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 Q DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW © YES 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 Q 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 © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 © NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only ` City of Northampton Status of permit:, uilding Department Curb Gutt'Drivewey Permit ' , ,015 212 Main Street Sewer/Septic Avai►ability DEC Room 100 Water/Well.Availability No hampton, MA 01060 Two Sets of Structura►Plans p ot1 87-1240 Fax 413-587-1272 PlovSite Pans t 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 waj&2 s7• Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSH IP/AUTHORIZED AGENT 2.1 Owner of Record: _ NV�(Prriin�tt))�—�'— Current Mailing Add s Signature 2.2 Authorized Aoent: k0 Ss11fA SS1-A,? 57• lf4L Name(Print) Cur ent Mailing Address: Signature/ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building p0 (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) d Check Number �l This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/inspector of Buildings Date File It BP-2016-0784 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE01040(413)322-3111 PROPERTY LOCATION 88 WARNER ST MAP 30B PARCEL 007 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid af7 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 92540 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: roved 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 Demoliti Delay Signature ofl5ullding 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. 88 WARNER ST BP-2016-0784 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-007 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-2016-0784 Project# JS-2016-001327 Est. Cost: $700.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 38115.00 Owner: LUCEY DAVID J& SUSAN M zoning: URB(100) Applicant: ENERGIA LLC AT. 88 WARNER ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.1211712015 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- 12/17/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner