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30B-066 (4) r na►: �M._'. THIS 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 4/22/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Stephanie smith 278 Riverside Dr,Florence,Ma 01062 Name(Print) Current Mailing Address: 413-575-0845 see attached permit auth.form Telephone Signature 2.2 Authorized Agent: Thomas Rossmassler 242 Suffolk St,Holyoke,Ma 01040 Name(Print) Current Mailing Address: 413-322-3111 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 680.00 (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 09 6. Total=(1 +2+3+4 +5) 680.00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings 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 O 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 O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DON'T KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES Q 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 © 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 0 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 Alterations) ❑ Roofing ❑ Or Doors M Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [❑ Siding[O] Other INSULATION Brief Description of Proposed Work: open blow cellulose class I-walls.6"r-21 cellulose sloi2es '/ Alteration of existing bedroom Yes—V---40 Adding new bedroom Yes �---N"o Attached Narrative Renovating unfinished basement YesQle Plans Attached Roll -Sheet 6a. If New house and or additio/n� to existina housing, complete the followina: a. Use of building : One Family%U 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 STEPHANIE SMITH as Owner of the subject property THOMAS ROSSMASSLER-ENERGIA LLC hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED PERMIT AUTH.FORM �I i p)Ike Signature of Owner Date 1 THOMAS ROSSMASSLER-ENERGIA LLC I, , 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. THOMAS ROSSMASSLER Print Name /A 4/19/16 Signature of r/Agent Date SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder THOMAS ROSSMASSLER 92540 License Number 242 SUFFOLK ST,HOLYOKE,MA 01040 9/2/17 Address Expiration Date 413-322-3111 Sig ture Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ ENERGIA LLC 165169 Company Name Registration Number 242 SUFFOLK ST,HOLYOKE,MA 01040 1/11/18 Address Expiration Date Telephone 413-322-3111 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 building permit. Signed Affidavit Attached Yes....... NI 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 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 City of Northampton Massachusetts W � DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: 278 Riverside Dr,Florence,Ma 01062 Contractor Thomas Rossmassler-Energia LLC Name: Address: 242 Suffolk St City, State: Holyoke,Ma 01040 Phone: 413-322-3111 Property Owner Name: Stephanie Smith Address: 278 Riverside Dr City, State: Florence,Ma 01062 Thomas Rossmassler 1, (contractor) attest and affirm that the building I intend to insulate does not 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. Contractor signature Date 4/19/2016 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwiv.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant 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 appropriate box: Type of project(required): 1.Y I am a employer with 24 4. F1 I am a general contractor and 1 6. 7 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. n Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity, employees and have workers' 9. EJ Building addition [No workers'comp. insurance comp. insuranceJ required.] S. ❑ We are a corporation and its I O.n Electrical repairs or additions 3,❑ 1 am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.Fl Roof repairs insurance required.]tc. 152, §1(4).and we have no employees. [No workers' 13.91 Other Insulation comp. insurance required.] *Any applicant that checks box#I must also IIU 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. tContractors 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 %vork*ers*comp.policy number. I am an employer that Is providing workers'compensation insurance for any employees. Below is the policy rind job site Information. Insurance Company Name: HDI - Gerling America Insurance Company Policy#or Self-ins.Lic.#: EWGCCO00186815 Expiration Date: 7/1/2016 Job Site Address:, 0_9 L C6 i At D r- City/State/Zip: e10fY,_nre, wk.,t- 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 tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido lteretycerIffytin er the pains andpenalties of perjury that the Information provided above is true and correct. Sinature: Date: Phone#: _413-392-3111 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health Z. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: RISE60 Shawmut Road,Unit 2 1 Carlton,AAA 020211339-5024336 ENGINEERING - www.PJ$Eenginearing.com Eltiaiancu=ngrgized. OWNER AUTHORIZATION FORM 1, (OwndVs Name) owner of the property located at Properly Addres.,j o � c (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. Owner's-Slinature Date �- 2016 U �