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11C-063 75 ARCH ST i BP-2016-1389 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IC-063 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-2016-1389 Project# JS-2016-002392 Est. Cost: $2200.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY SPECIALISTS 99381 Lot Size(sq. ft.): 24742.08 Owner: SWEENEY FRANCIS J& LINDA M TRUSTEES Zoning: URA(100)/ Applicant: THE ENERGY SPECIALISTS AT: 75 ARCH ST Applicant Address: Phone: Insurance: 212 AMES RD (413) 566-1058 WC HAMPDENMA01036 ISSUED ON.5/25/2046 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 5/25/2016 0:00:00 $65.00 212 Main Street, Phone(413)5$7-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1389 APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS ADDRESS/PHONE 212 AMES RD HAMPDEN01036(413)566-1058 PROPERTY LOCATION 75 ARCH ST MAP I IC PARCEL 063 001 ZONE URA000)/ 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 Existiniz Accessory Structure Buildine Plans Included: Owner/Statement or License 99381 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO jMATION 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 D o ' ' ela Sig of r ding 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. ECEI E Department use only 2 4 2016 City of Northampton Status of Permit: wilding Department Curb CuttDriveway Permit 212 Main Street Sewer/Septic Availability MPT..OF BUILDING INSPECTIONS NORTHAW70N a 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 c3 16 S�3 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SC--) r.J Y Name_(Print) Current Mailing Address: CfYL _ Telephone Signature 2.2 Authorized Agent: "-f,4 O/c L Name Current Mailing Address: 4fignature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ba (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) vZdGcG.G'c Check Number ®� This Section For Official Use Only BuildingPermit Number: bate Issued: Signature: Building Commissioner/Inspector of Buildings Date <..�t Y r .fes/'u � S �^ o 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 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 0 DON'T KNOW1 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Z DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES i NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F-� Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [(] Siding[0] Otherxj Brief Descrjption of Posed ro / Work: 1g," � 7 ("�/�v %.S r �c� �i lrr C ./)`�✓rJ .!�/'o.m L J`7I �r s ti r car r� Alteration of existing bedroom_ Yes— No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes —�C No Plans Attached Roll -Sheet 6a. If New house and or addition to existing hous]nq. c'omplete 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 i 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 1, /–/���/­,r, .3 �c.. re 1.+ r ir _ as Owner of the subject property 7- 1 hereby authorize / li r' -^J r f i J to act on my behalf, in all matters relative to rk au orized by this building permit application. Signature of Owner Date I, / �1r L•�r..� rte 'J ff as Owner/Authorized Agent hereby declare that the tatem nts 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. /"�ti r/ +— Prin me Si ture of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Appliiccabble! ❑ Name of License Holder: _)Q0 License Number Address L Expiration Date 5 e Signature Telephone 9. Registered Home Improvement Contractor:'{ ' Not Applicable ❑ Company Name Registration Number Address —T Expiration ate Telephone }4�e' A, .- 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 buildingpermit. Signed Affidavit Attached Yes...... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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.�J. 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 theJob 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 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston,Mei 02114-2017 www maCss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): The Energy Specialists Address:212 Ames Road City/State/Zip: Hampden, MA 01036 Phone#:413-566-1058 Are you an employer?Check the appropriate box: Type of project(required): LK I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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. F1 Demolition working for me in any capacity. employees,and have workers' insurance.: 9- E] Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 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 insurance required.] t c. 152, §1(4),and we have no 12.❑ Roof repairs employees. [No workers' 13.n Other Insulation 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. =Contradtors 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 wo#kers'comp.policy number. 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Associated Employers Group Policy#or Self-ins. Lic. #:WCC5009547012014 _ _ Expiration Date: 10-16-2016 Job Site Address: ' S H e /, .S f_ _ _ City/State/Zip: Z-r /s i .,el .4 Cj/63.3 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 verificat' n. do hereby ce �derth�epain penalt erjury tltgt the information provided above is true and correct �' Si nature: Date: Phone#: 413-566-105 b' 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#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of IWIGL 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: _ Ze r The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant s Date Signature of Permit Applicant �%/ae�ayrzrruinmeallfz d��/l�Ca�;rut�ic�sef7`a Vepgistration: Office of Consumer Affairs&Business Regulation License or registration valid for individul use onlyMEMPROVEMENT CONTRACTOR before the expiration date. If found return to:153287 Type: Office of Consumer Affairs a.nd Business Regulation iration: 11/14/2016 DBA 10 ParkPlaza-Suite 5170 Boston,MA 02116 THE ENERGY SPECIALISTS MIKE GRENWOOD 212 AMES RD. HAMPDEN,MA 01036 Undersecretary Not valid without signature Massachusetts Department of Public Safety ` Board of Building Regulations and Standards License: CSSL-099381 Construction Supervisor Specialty MICHAEL E GREENWOOD 212 AMES ROAD HAMPDEN MA 01036 Expiration: Commissioner 03/09/2018 1 i AC<:>RE0 CERTIFICATE OF LIAOILITY INSURANCEDATE(MMIDDIYYYY) 01/11/2016 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($), 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). COT PRODUCER 413-566-0028 413-566-0090 AME Richard R.Green Insurance Agency, Inc. Richard R. Green Insurance Agency, Inc. HONE _413-566-0028 A ."x);413-566-0090 _ 32 Somers Road DRESS:richardgreenins@charter.net R0DUCER Hampden, MA 01036 INSURERS AFFORDING COVERAGE NAIC R— INSURED JNSURERA-Patrons Mutual Insurance Co.Of CIT Michael Greenwood NSURERB:Associated Employers Insurance Co___ dba The Energy Specialists SURER C:Commerce Insurance 212 Ames Rd. INSURER 0: Hampden, MA 01036 SURER E: SURER F: COVERAGES CERTIFICATE NUMBER: 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 QF 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. INTRA TYPE OF INSURANCE INSR SWVn POLICY NUMBERMNUDD� MOUCY XP LIMITS GENERAL LIABILITY EACH OCCURRENCE S1,000,000 A r/ COMMERCIAL GENERAL LIABILITY _PREMISES{Ea occurrence_ $ CLAIMS-MADE F1/1 OCCUR MED EXP(Any one person) N _ BOP2698685 10/14/2015 10/14/2016 PERSONAL 8 ADV INJURY S 1 QOD QQQ (� GENERAL AGGREGATE 3 GEN PO 2,000,000 � PROGATE - -1 APPLIES�L AUTOMOBILE LIABILITY COMBINED PRODUCTS-COMP/OP AGG _s.2,0 QMjECT Q I( COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S1,000,000 BODILY INJURY(Per person) S C ALL OWNED AUTOS -- BBMJ27 01/05/2016 01/05/2017 BODILY INJURY(Per accident) S SCHEDULED AUTOS PROPERTY DAMAGE �_v HIRED AUTOS (Per accident) S i NON-OWNED AUTOS S S ✓ UMBRELLA LIAB ✓ OCCUR EACH OCCURRENCE S A EXCESS LUIS _. �1 CLAIMS-MADE AGGREGATE $1,000,000 _" CXS2111578 10/14/2015 10/14/2016 DEDUCTIBLE �. S RETENTION S S IWORKERS COMPENSATION WC$TATU- / pTH- AND EMPLOYERS'LU6IUTY YIN i AOFF NY PROPRIETORrPARTNEeZEXECUTIVE WCC 5009547012014 110/16/2015 10/16/2016 L.EACH ,5 00000 B (Mandatory In ER EXCLUDED? N/A E L DISEASE-EA EMPLOYE S SOO,000 {(Mandatory In NH) II yyes,descnbe unser EL DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below DESCRIPm TION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Raarks Schedule.H more apace Is required) Subject to policy terms and conditions. Sole proprietor excluded from coverage on the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION For Insured's Records Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insured's Records Only ACCORDn E WITH THE PORATION DATE LICY PROVISIONS. WILL BE DELIVERED IN For Insured's Records Only For Insured's Records Only AUTHORMEO REPRESENTATIVE For Insured's Records Only Richard R. Green Insurance Agency, Inc. ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are Keglstered marks of ACORD