30A-020 (5) 37 CLEMENT ST BP-2016-1461
GIS P: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-020 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-2016-1461
Project# JS-2016-002506
Est.Cost: $2700.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 179401
Lot Siee(se. ft.): 64468.80 Owner: STARR ELISE L
Zoning: SRO 13)/WP(60)/SI(0)/ Applicant: POTENTIAL ENERGY LLC
AT: 37 CLEMENT ST
Applicant Address: Phone: Insurance:
4D QUEEN TERR (860) 620-4433 WC
SOUTHI NGTONCT06489 ISSUED ON:6/9/2076 0:00:00
TO PERFORM THE FOLLOWING WORK: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 6/9/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1461
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 4D QUEEN TEAR SOUTHINGTON (860)620-4433
PROPERTY LOCATION 37 CLEMENT ST
MAP 30A PARCEL 020 001 ZONE SR(113)/WP(60)/S1(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 21. JI /OS
Building Permit Filled out
Fee Paid
Typeof Construction: INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 179401
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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
gliti704 ,v •el.
/ VVV
Sig : . o m + g tticial 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.
pega
City of Northampton <
Building Department47+1
freew �Y' " . ' "� `�'
212 Main Street � 4,YE:1a" -riLQ . fi, i.�i Kix`a' '�,
Room 100 8 -' °
Northampton, MA 01060 � t ��
usm x
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
M`J SECTION 1 -SITE INFORMATION
' 1.1 Properly Address::? I.J- -/- This section to be Completed by office
'c) I 0I t r i V 11 x-11 t t t l,/,
Map Lot Unit
Flo rY�Ctr,hi/t C. 10(C_ Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
n l i<e Slav )i ctovn#St. Fioyeice M4 Omoz
Name(Print) Cunent'�N}Tlaili Add
Telephone' r' 0l➢ ' K" t
Signature
2.2 Authorized Agent:
Potential �r�erg LCC. (9ueen 'ref r: l& )*11v� 4i)n,CTO(04hZ/
Name(Print) / Current Mailing Address:
, --r_.
?XL) 421p- 1413
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building PermitFee
2. Electrical (b)Estimated Total Cost of
Construction from(8)
3. Plumbing Building PermitFee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 27Q().(?D Check Number /o7.3.. *QS.—
I This Section For Official Use Only
Date
Budding Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) ,.-F,
New House EI Addition 1111 Replacement Windows Alteration(s) I/ I Roofing fl
Or Doors D l"'
Accessory Bldg. ❑ Demolition ❑ New Signs EDj Decks ID Siding ED] Other ICU
Brief Descrption of Proposed et
Work: �Cm% e ISSU laioi(1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba.it Hew house and or addition to existing housing.complete the totlolslno:
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. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORy � APPLIES FOR BUILDING PERMIT
I, >1i�, 2'_ 1.1I' , as Owner of the subject
Property ( � /'� [� /
hereby authorize P(The�/1I 10,) 1n9iv( t LC,
to act on my behalf, in all matters relative to work autho' this building permit application.
Signature of Owner e
I. R5-1( i ( I i 6 1 14VVG�I � as Owner/Authorized
Agent hereby declare that the statemen[da information1.,L.- (on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and pen es of perjury.
E:°tFvr"lC1,I e /JL ,CC ! , - sate;� e`i
. ,
Print Name - /
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constriction SpuC,vis/o�e �/' ' Not Applicable ❑ } (�
Nemo of License Nader_Nil.l iC1@c 1e,KIti, V l.5FA- IO(c104
i, license Number
ADC.0PPM 1.a0. 'Ilthiwet614I ;T( 'G4c ahnz7lI61
Address Expiration Date
00-42to 14 / 3 -^T
Signature Telephone 1�t'(. ' N-
p. aes5 Home Imorovsmsnf ctoc . \ Not Applicable 0
Nid CAC mei t€1V c EXific�1P,l64Z]t/) ; LLC1 ', 17Q4- ;i
Company Name / Registration Number
1F (0/leer!!T€rr (�i)Ltlh) rflor) Cr O&4-c� 7jzgji
Ad ress ,,tt ) Expi tion D e
Telephone CM/42W 1413
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 No 0
11. Home Owner Esemotion
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 1089.5.1.
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 venom 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 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
Owner Authorization Form
I, Elise Starr
(Owner's Name)
Owner of the property located at
37 Clement Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize Potential Energy LLC , a certified Mass Save Home
Performance Contractor, to act on my behalf to obtain a building permit and
to perform work on my property.
Owner Signature
1/27/16
Date
The Commonwealth of Massachusetts
c fl Department of Industrial Accidents
=i?/= s 1 Congress Street,Suite 100
<I.I,MJ Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name�minn �
ess/O „iizationqndividu4) ,.tendo\ Energy LLC/Nichnins Meister
Address: 4 D (vueeh Terrace.
ty p:,^�i. Ii /, jr. / CT t tan Phone#: 0 U20-t t
C •
i /State/Zi
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with '5 employees(full and/or part-time).• 7. ❑New construction
2 1 am a sole proprietor Or pamrcrship and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
30Iamahomeowner doing all work matmyself.[No workess'com.insurance required.]
4.01 am a homeowsrr and will be hiring contractors to conduct all work on my property. I will O❑Building addition
=sum that all contractors either lave workers'compensation insuance or arc sole I1.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
501 an:a general contractor and 1 have hired the subcontractors listed on the attached sheet
These subcontractors have employees and have workers'comp.insuanat 13.❑Ruofreppa/irs ! /, �/
6 We arc aco tion and its officers have exercised their 14.. Other �I 1(k HO a ( {%/ t
-❑ Toro right MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#I 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 mer submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-convacton and state whether or not those entities have
employees. lithe subcontractors have erploym,they must provide thew workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: HQYorUTncxrcinc f. roup
/� f�p / tit/r,
Policy#or Self-ins.Lic.#: 2l-SB3M RE SO.9 Expiration Date: U p t 0 5/201 I0
Job Site Address /-) �i IeVriw�t c9-1 reef- city/studzip:j'HQr/CVSLi r)YID 0iift2.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify n the pains—and penalties of perjary that the information provided above is true and correct
Signature: 1----.-7 -7- ... c:—.:pp '. Date: 4 I I I jb
Phone 9: ( kQV ) j;20- 44-33
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CliennX:82429 ME1STNIC
ACORD,„ CERTIFICATE OF LIABILITY INSURANCE DATENAWDEVEMS
07/31/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the poticy(ies)must be endorsed.If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement($).
PRODUCER Cjjrrt4T Audrey Lamontagne
Fredette Carlson Agency .580583-0943 Jr .. 860-585-0038
PO Box 2456. alanlontegne@ft*ins.com
Bristol,CT 06011-2456
INSURE/NN NG COVERAGE
860583-0933 Ins Group
wdc•
INSURER A:Hartford Ins Grooup 19882
INSURED MSURER a:
Nicholas Meister DBA ._ -._....— __.. . _"_._1, _.
Potential Energy LLC .�xslNrcR c: _..
INSURER 0:
4 D Queen Terrace
INSURER E:
Southington,Ct.06489
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTFY THAT THE POLICES OF INSURANCE LISTED BELOW WAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE POLICY PERIOD
MDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF MY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
Ty EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.Cr
L.tR WISE OF INSURANCE IA POLICY NUMBER -..., i�f IIOMnf TTl, llAlfTS
A GA FM USX, ' x 02SBMRB0509 087052015 08/0512016 EACH OCCURRENCE $2,000,036
X COMMERCINAENERM�I1walury 1,B YSI 1sllpq�plryEOrt_L s 1_ooD,o6o _ .
CLAW-MADE [XJ OCCUR MED exp!Anyone remora! $10,000
FFRSONAL B AOV INJURY s2,000,000
GENEwLAGGREa,TE $4,000,000
GEM AGGREGATE.LMT APPLIES PER (RWVCTS-COM IOP MC $4,000,000
xPOLICY l JJrcT I ,� LOc jw $
AUTOMOBILE MINUTE COMBINED SINi1LE LIMIT
!Eaeol0en1) _.{.S
ANY WIC / emu'SCURFNNW)m) iS
AAll UTOS OWNED I SCHEDULED I BODILY NNRFWmeaw-WW1`.
AUTOS
HIRED Autos .Amos Apar acciden1)
A XUNRRA"Luc X OCCUR 02WECCR0745 08/051201508/05/2018LEa.LH OCCURRENCE s1,000000
EXCESS W OAIMS MICE AGGREGATE $1,000.000
DED X RETENTCNSIOL000 s
A WORKERS CpRPEISATION ' 02WECCROT45 D8/052015 os/os2016X TgSRVI IVI OTH-
MYI EMPLOYERS'MBLm f - TONY)Wrts W
ANY RICERIEIORPARTNERJEXECUTIVET�NII E L.EACH ACCIDENT $506600_
OFFICER/MEMBER EXCLUDED> I Y NIA
Nseesteryin MO EL DISEASE-EA EMFLOYEEI$500 600
Itym Zs-fI.IA jr,x
DEECR �CN CE opERATIGNs+LoM,. _.._ :EL DISEASE.POLIGYLgei Is500,O0D
I
iOr OflIUrpJS I LOLATnIS I SMALLER(Atbcn ACOrm lel.Addebnal Rmuie RdMv b.a nom space b required)
Columbia Gas of Massachusetts is additional insured on general liability and umbrella liability per written
contract or agreement
CERTIFICATE HOLDER CANCELLATION
Columbia Gas of Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
4 Technology Drive Suite 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough,MA 01581
AtmMIIr.OORImo REPRESEHTATWE
I Jr/ r.rte CA.J ..
W 1988-2010 ACORD CORPORATION.AO rights reserved,
ACORD 25(201005) 1 of I The ACORD name and logo are registered marks of ACORD
#5716666151716683 FCAJL
o If/P *011?11/011 wea/IA Vivi ILJJI(AfUJr(/J
■ Office of Consumer Affairs and Business Regulation
3 '.„ 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 179401
Type: Individual
Expiration: 728/2018 TI 419291
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE
-
SOUTHINGTON, CT 06489
Update Address and return card.Mark reason for change.
scn+ G 20M-0511D Address D Renewal D Employment D Lost Card
,\ _.. /L, t .,.rr..A/, /' /( - /,,..,v/,
Office of Consumer Affairs&Bosses.Begot do. License or registration valid for individual use only
Y HOME IMPROVEMENT CONTRACTOR before the expiranoo date. H fsaod retun tis:
.� ; Regis�on: 179401 Type. Office of Comumer Mfain sed BusinessRegvbtios
Expiration 72812018 Individual 10 Park Plaza Suite 5170
- Boston,MA 116
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE
SOUTHINGTON,CT 08489 Undersecretary Not valid without signature
Massachusetts -Department of Pubic Safety
Board of Building Regulations and Standards
('onctruc[inn Super i.ur L & 2 Famih
:censeCSFA-108184 .
NICHOLAS MEISJER
4D QUEEN TERRACE
Southington CT 66489 `
%/„...aur.. " rxp:rador.
Comm¢sioner 04/272019