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24D-223 252 PROSPECT ST BP-2016-1143 GIs#: COMMONWEALTH OF MASSACHUSETTS MU.-Block:24D-223 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cates4ory: INSULATION BUILDING PERMIT Permit# BP-2016-1143 Project# JS-2016-001965 Est. Cost: $1905.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq. ft.): 7492.32 Owner: KAMINSKY JQEL STEVEN&JODY ANN ROSENBLOOM Zonis. URB(100)/ Applicant: THE ENERGY STORE AT: 252 PROSPECTS Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON:3/30/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WALL & CRAWLSPACE INSULATION POST THIS CARD SO IT IS VISIBLE FROM THE $TREET 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 3/30/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1143 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888)840-6641 PROPERTY LOCATION 252 PROSPECT ST MAP 24D PARCEL 223 001 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&CRAWLSPACE INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building 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 li ' f� Si of ui ing fic al 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. i FWR 2 9 9ple Department use only I' City of Northampton Status of Permit: DEPT of r C t n -.,-- . ! ►voa7Np,,rr '+s 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 phone 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 ?C0 5r—,o C Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5 2 IP�-O�s�2CL� � Name(PrinT Current Mailing Address: Telephone Signature 2.2 Authorized Agent: 01257 Name(Pri Current Mailing Address: L-)S 209 - 1158s- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be: Official Use Only com leted by permit applicant 1. Building (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=(1 +2+3+4+5) 1 CID �?2 Check Number This Section Fo'r Official Use Only i Building Permit Number: Issued: ed: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Complet d. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be tilled 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 O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT 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 O DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) Ph Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs ',[01 Decks Siding[[31 Other[❑Ij Brief Description of Proposed G�wl5�t Work: n'r SPCll, _-l—nC ) 4 WG-lie, W'Ail CeI1JOS?_ C J Alteration of existing bedroom Yes No Adding new bedroom Yes No ` Attached Narrative Renovating unfinished basement Yes No i SJR Plans Attached Roll -Sheet sa.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? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mosscheck 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, of') as Owner of the subject property al- hereby authorize 75—L0 4t- (�s to act on my behalf,in all matters relative�to n�orw rk author' ed by this building permit application. d 5/Z3i Signature of Owner Date I, r 15— o n6er C ASV as Owner/Authorized Agent hereby declare that the statem� ents anddiinformation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. soo Print Name Signature of Ow gent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 1(�r j���jp�l� S joko'2-—1 License Number MA 8(i 14 A s Expiration Date q 7s 20 9 -wsnS- Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ I-)K sQZ Company Name Registration Number C)o � :2 &Q-Qa a(XUy iollb Address Expiration D e I Telephone g y D:tzG l I SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDA�/IT(M.G.L.c.152,§25C(6 Workers Compensation Insurance affidaKgpermit. st be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the buil 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 108.3115.1. 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 buiildine 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 City of Northampton 212 Main Street, Northampton, MA 01 060 Solid Waste Disposal Affidavit In accordance of the provisions of IVIGL 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: 52. 'P _ 2G UP6& S-+- The debris will be transported by: O r is The debris will be received by: Building permit number: Name of Permit Applicant r Date Signature of Permit Applicant s:!.✓rte �� IE fid,ttr2 tom,t SAW EPIG HEmw ' ► _ OWNER AUTHORIZATION FORM (OwneftI, E-2A;a V,41�A-% lm) oww of properly bcaw at: th►addr�) c ) hereby suftoft an auf wkwd subo ftctorf+or RISE Englneedng,to act onpW betvlf to obtabr a bulft permit and m per[orm warts on my pity.This form Is only vald wkh a d9ned CDWJVA 1 L xI- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): TE Cara r I STORE Address: 31 ©1-D aTe. 7- Ci /State/Zip: R g1=II&D, r--r o(pSoq Phone#: -9115-9140 - U6141 Ar you an employer? Check the appropriate box: Type of project(required): L I am a employer with 4. ❑ I am a general contractor and 1 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 g. ❑ Demolition workingfor me in an capacity. employees and have workers' Y p tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions q ] 3.❑ 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 Y [ p 12.0oof repairs insurance required.] c. 152, §1(4),and we have no [ employees.'',[No workers' 13.M Other—W e.esd / on comp. insurance required.) *Any applicant that checks box#1 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: 13 dr- /,4sot2Arice QE CY . hoc. _ Policy#or Self-ins. Lic. #: 6 N U WC,©1 3 1 3-49 Expiration Date: g/1 s/2o 1 lv i Job Site Address: `J� l(c�S_PeC-� City/State/Zip: Q(r r 1 - 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 MOL 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 ce yy er the aims nd penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 ACC]IR" CERTIFICATE OF LIABILITY INSURANCE 5!5(2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A D CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 'ERTIFICATE 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 polpcy(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). PRODUCER No ECT Brian Gallagher BNS' Insurance Agency, Inc. IP NE (914)937-1230 1C No.(914)937-1124 111 South Ridge Street E- RL .bgallaghez@bncagenc:y.aom r _ INSURER(S)AFFORDING COVERAGE NAIL# Rye Brook NY 1.0573 � IN%URERA.SeleCtiVQ Insurance Co of S.C. 179259 !iNSUREO IN URERS:Sta=Net Insurance Comm ant40045 'Energy Prz LLC iN.ViRefic.Landmark .American Ins Co. h3138 DBA: The Energy Store AN RERa: 131 Ol.d. Route 7 INSgJRER E: -._.....____.�...�--- 113rookfield CT 068041 INs RERF: COVERAGES CERTIFICATE NUMBER.CL1542465662 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 INDICATcD_ 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. _ INSR TYPE OF INSURANCE1ADDLr99SR1 --T POLICY E POLICY EXP ulsl#Ts -- T i POLICY NUMBER MMID MwODtYVYY ! 'GENERALLIABILITY { i— E CH OCGURREtk E S 1,000,000 cRA Ltr,riL!'il' ? I DAMA TUR NIEO CO,t4d1,G.RC!AL G-NE L q _ " i i } ! PREMlSESfEaacpvrrenesl- 1 S 100,000 A i i _.J CI-AIIA.&MADE Lx Occur js2 X53542 0/27/2015 3/27/2016 MED EXP(Arpr oneperson) S 5,000 PERSONAL&ADV INJURY 5 1,000,000 GENERAL AGGREGATEJ S 2,000,000 GEN.L AGGREGATE LIMIT APPLIES PER PRODUCTS-COt IPJOP ACG S 2,000,000 JECT �� f } I POLICY t n'PRG- ! LOC ! 1 AUTOMOBILE LIASILITY GOMBiNEO SrNGLE LIMIT (Ea,acadenn S 11000,_000 {`.,{1 pyy AUTO INJURY(Per Person) S A I ALL OWNED -QCHECULED ,52153542 3/27/2015 6/27/2016 BODILY INJURY Pel acadent) S ��- AUTOSAUTOS NON-OWNED f 1 I� PRCIPERTY DAMAGE S .tr'2c0 F.if CS t Aures II ! II--I I II fF I S X I UMBRELLA UAB X I OCCUR i € � I EACH OCCURRENCE S 5,000,000 EXCESS LIAR r-111-!LAIMS-MAD i AGGREGATE �t 5,000,000 DED RETENTION- S2153542 S2153542 3/27/2015 /27/2016 sty - $ WORKERS COMPENSATION i S I X VVC STATU- OTH- ANO EMPLOYERS'LIABILITY Y J N ' SdIl1Iy - ---- s ANY PROPRIETORIPARIT4ER;EXE;CUTIVE F-"-'iii N t a' i I E+-F1kCH ACCIDENT 5 1 000 000 i 0-r=sCERIFdEr,16ER'=XCLUOE07 (- - '- (MandatoryInNH) i Nd7WC0131379 4/15/2015 /15/2016 E.L OISEASE-EA EMPLOYEE S 2 OOO OOO ityes,c escsco under I DESCRIPTION OF OPERATIONS be!a.vj I E.L.DISEASE-POLICY IJMI1;5 1,000,000 C ' Professional Liability HR7S0441 /27/2015 13/27/2015 LlhltT R 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) Proof of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O Colabella/BGALL ACORb 25(2010/05) (D 1988_2010 ACORD CORPORATION. All rights reserved. INS025 n ir:n , Th.Af nPr)Homo—I innn-a rartiictnrnri mar[rc of Brnpn City of Northampton Massachusetts r w � DEPARTMENT OF BUXUiXHG INSPECTIONS 212 Main Street • Municipal Building4a � a Northampton, ,MA 01060 Property Address: 2 TrK e- S Contractor Name: (�I Address: 'PC) 19-0�}< 11 g 1 City, State: ►l�fi '� 2�C1 AA- o i zs-7 Phone: 1'I 5 Property Owner Name: ��77 Address: G 5 2 PrU SD _c City, State: /V ( 0 /060 SLp&tLL65 (contractor)attest and affirm that the building I intend to insulate does n t 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. r Contractor signature Date I C9 1—