44-083 903 FLORENCE RD BP-2017-0001
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-083 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0001
Proiect4 JS-2017-000006
Est. Cost: $7783.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGY SAVERS OF AMERICA 84919
Lot Size(so. ft.): 15289.56 Owner: MISSIEN MATTHEW M&LAURA GERYK-MISSIEN
zoning: Applicant: ENERGY SAVERS OF AMERICA
AT: 903 FLORENCE RD
Applicant Address: Phone: Insurance:
3339 BOSTON RD (413)283-6695
W ILBRAHAMMA01095 ISSUED ON:7/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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: OI: 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:
FeeTvpe: Date Paid: Amount:
Building 7/1/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
/ ;%
Department use only
C/:
City of Northampton Status of PermitBuilding Department Curb CWD¢vewayPermit
212 Main Street SewerlSepbtlAyallapipty
Room 100 Water/Wel AvailabWy
Northampton, MA 01060 Two Sets of Structural Plans
c phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 rooerN Address, This section to be completed by office
gos Pore-I*e KrA Map Lot Unit
V la (-a-rt Ca- mck' CIC(pZone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Lrrii- eryK 4 16syce � �3 �I�run(�w_ -d ) Elorerc�
Name(Print) /p a ,�.�� Current M d res -30C1/�
C-Sf �� �j�. cI i c rc, Telephone
Signature
2.2 Authorized Agent:
13 ///��� o- Etat os -F y& vers ,33`3q ibN,s�rt L Liv\b Ao w-
N.melint) / Current Mailing Address:
• a., : Tj 413-2-10- (I(D '3
-tore Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r-00-C
.$- 1"Ig I 'D O (a)Building Permit Fee
2. Electrical t �j 'DO (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) IS 19 g 3• o ` Check Number 875a SI//7f
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable)
New House ❑ Addition ❑ Replacement Windows Aheration(s) ❑ Roofing M'
Or Doors ❑
Accessory Bldg. El Demolition ❑ New Signs [❑I Decks [❑ Siding[Q) Other[a
Brief Description of Proposed, (
Work: �2mav� 1 L y p( S+_. 1 ierclln%-
Alteration of existing bedroom Yes No Adding new bedroom U Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
ea. 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. Messcheck 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
1- 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
rOR CONTRACTOR APPLIES FOR BUILDING PERMIT
x--u1tk Cef t5 `\ _.... _... ,as Owner of the subject
ProPeM 'n1
hereby authorize a ' r `Sav e.r S Vc"' t e_0._ . aInC • ..
to act on my behalf,in all matte :I Live to work authorized by This building permit application.
(see at4c t- St smtitA CE`440Ci' Cc 11)- I tS
Signature of Owner (� ate
f t, 0_11 }CCS ,as Owneriiithorized
Ag reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
a belief.
Signed utder the pains and tenalties of perjury.
t.
Pint : p ( /�c
dr !.r. W � ' 1191)) `
Sig 7.ure'f Owner/Agent Date
Office of Consumer e%a
Affairs and Business Regulation
10 Park plaza- Suite 5170
Boston,Massachusetts 02116 '
Home Improvement Contractor Registration
Restoration; 127893
ENERGY SAVERS OF
Expiration: 1/20/2017: Nitrate rPorr°8"zit
JOSEPH GULLINI AMERICA INC
3339 BOSTON RD.
WILBRAHAM, MA 01095
/ o eomaeq Update Address and return art Mark
0AdtlraerSen reason foe cheese,
0 Renewal Q Swploymeat ❑ Lon Card
•
11) Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Contraction Superrbor
License:CS-$*19
RA
JOBBED` - %
3339BOSTONRO
WILIIRANAMPS
v+ ,r,n�' Expiration
Commissioner 09148!2011
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
' t.
Name of License Holing: r .r _.. t_t- '
license Number
-53j 7 zn it i I6y(; GIN- 0109c
•• ess .� Expiration Dale
;.,a1 k �)d03-tc;LR� ' i -2.s -(0693
'• alum Telephone
S.Rea stared Nome improvement Contractor Not Applicnble ❑
oer • ► •
IQ2 $93
mpany .m= Registration Number
, 53 9._ eisk")n "fid r 1-Q5= Ill
`AddressI ir� -�(� ( Expiration Date
(/ t...1.. 1f i •$ I I\� DIQ(c- Telephone '/..L3 J& j
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25G(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 PA7 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 aril,
as supervisor.CMH 780, Sixth Edition Section 108.331.
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 Wildfire 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 perforin 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 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: ero3 � DRY1CSfll
-
The debris will be transported by: ( k c& 1�Ct ca /tc �rL
race -
The debris will be received by: CSR- \1o_Ls It\C� U .>_, L g60_ 13 �(F
Building permit number: UU J
Name of Permit Applicant u. n6 C._ l &Sr C
(07911 (0 J
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department ofIndustrialAccidents
to
=4,7j_ Office of Investigations
' '- 1 Congress Street,Suite 100
s aaaj q° Boston,MA 02114-2017
cak' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (' Please Print Leeibly
Name(Business/Organization/Individual): (" •f1 ,'
Address:3�33Q
City/State/Zip:h' P: (,OI I fry* 01 UScbone u: 3- ' .3 ( 'S _
Air-,e,you an employer?Check the appropriate box: Type of project(required):
LOB I am a employer with 4. ❑ lam 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. 0 Remodeling
ship and have no employees These sub-contractors have 8.
❑Demolition
workingfor me in anycapacity. 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.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]' c. 152,§1(4),and we have no
employees. [No workers' i 3gbther (1P tip iy 0 c
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 his affidavit indicating they are doing all work and then hire outside contractors must_submit a new affidavit indicating such.
:Coniraators that check this box must attached an additional sheet showing the name or the sub-contractor,and statewhether or not those entities have-
employees, If the subcontractors haveemployees,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 fob site
information.
Insurance Company Name: q C)C.-[{�, v_AY ;)�D b
tty
Policy#or Self-ins. Lie-."?#: �,��.—�Uk.n� � Expiration Date: 1— Lo
lob Site Address: AC3 I"-•ko City/State/Zip:F1Zr-4,021\\ 0yo �
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under the p s and penalties of perjury that the information provided above is true and correct
Plronc#e L(13i -223 Date: Co (2 /i W
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
. Contact Person: Phone#:
„ ,aca113II MEAL INSURANCE 11'11:18a.m, 03-07-7016 I/1
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A4c?evr CERTIFICATE OF LIABILITY INSURANCE °"n""NIOVY1
09/0372018
THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION ONLY MD CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT APFIRMAMILY OR NEGATIVIST AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ENSURERIS),AUTHORMEO
REPRESENTATIVE OR PRODUCER.MD TNS CERTIFICATE HOLDER.
IMPORTANT: H W cmERpb holder a an ADDITIONAL INSURED,the poleyNn)must be mdoned. If SUBROGATION Is WANED,sob}al to
t e tema and conditionsof the policy,tort*poncho may combs en IMOMIMAIMIST.A ettnlonton this terBRate don not confer dglIsto the
nrdllefb holder In Eau Msuch nd noMM1$).
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3399 Boston Rd ammo:Arbon,Protection Ira Co 41380
Wilbraham,MA 01095
mnnnat
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NreRne.
COVERAGES CERTWICATE NUMBER: REVISION NUMBER/
THIS M TO CERTIFY THAT THE POWER OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUT(PERIOD
INDICATED. NOTWITHSTANDING ANY REONREMEM.TERM OR CONWHEN OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE WY BE ISSUED OR MAY PERTAIN.THE MEAN=AFFORDED BY THE POLICES DESCFSSEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS MID COMMUNE OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID pCCLAIMS.
lit a TMNnMIIRMCE POYPYWMnn IIJZan.JZ .
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CERTIFICATE HOLDER CANCELLATION
INSRECD
SHOULD Mr/OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Berm
FOR INSURED'S RECORD AACCOR WWIYNTTHHEFOUCY PROVISIONS.
Be DELIVERED M
WIWI=MPNLaaIAWNE
Q214444' 'rte
O 19857610 ACORO CORPORATION.All HEM.rnlyved.
WORD 26 t26HI@6f The ACORD on and logo en rs9liI nd marts ot AGGRO
MA REG.127893 ENERGY SAVERS OF AMERICA INC.
CT REG. 567734 3339 Boston Road L�
Palmer: 413-283-6695 Wilbraham,MA 01095 � Toll Free
Springfield:413-734-4777 19 888-882-4288
Greenfield:413-774-7777 Fax:413-283-9335
This agreement maQQ the A5 day of �bI I\Q 20 1 b between
. A- ( ' - w
C. X113- as-3o' I
eowners •
Of q- b clef c�-oAd Fwe �cc��w�A pia one
(
(stat yipLode)
Hereinafter called the owner and ENERGY SAVERS OF AMERICA INC.of the Town of Wilbraham,Massachusetts here-
inafter called the contractor,witnessed:
The said Contractor hereby agrees that it will for the consideration hereinafter mentioned,furnished all labor and mate-
rial necessary to install the following described work at premises located at:
xr,e
(Job Address)
Total Quantity No of Additional Work Total Total
Windows Purchased Panes Cash Price
Regular Double Hung Sliding Doors Down Payment 7 86
Picture Windows Siding Upon Start
3 Lite Sliding Windows Roofing MIER Upon Completion r 0 r
2 Lite Sliding Windows Bay Window --�
Casement Windows Bow Window
OTHER DESCRIBE r•—•F PL 4'oOi /S iv Get e a/Q n S'
Je S
Icr. 4ar. • FrO(YI RnoP •Ictc• or. - . :fj ,,,,
a , k, hl, rl en.+ €. . e •l
'rre •a�' decK, ffs\eI -cad wwkr but
t -. .• • a.h .- 4 ce, y lb.. -' ./ la -F a
Rg1' a, e :ar . • f d ria,/l:4 x`647_now- eel l�
N w• -e ✓e 4- e•kw- f . 1 ' bch7+$
an . . rP ,r' •. 'J
ca -(r •-co1/44 y A Z to,c14y/f' /?i. + EMI 04 • JO.I7-'
Estimated Start Date Estimated Finish Date
Contractor does not perform or assume any responsibility for any Painting.Staining or Wood or Wall Finishing on interior or exte-
rior.Md the Contractor does further agree with the Owner that(a)he will begin work within a reasonable time after the execution hereof,
and will prosecute it diligently and with due care,and in a good and workmanlike manner:(b)in doing the work.be will comply with all
statutes,rules,regulations and ordinances applicable thereto:
Contactor to procure all permits required by local law.Contractor shall provide public liability a workers comp insurances.
Due to the custom manufacturing of the product and its restricted use unless installed in its intended opening,if the Owner refuses
to permit the Contactor to proceed with the work herein,or in the event of any breach of the Owner of this agreement,for any reason
whatsoever shall cause the Owner to pay to the Contractor a sum of money equal to fifty percent of the price agreed to be paid,as fixed,
liquidated and ascertained damages.and not as a penalty,without further proof of loss or damage.
SELLER shall be excused for the period of any delay in the performance of any obligations hereunder when prevented from doing so
by cause or causes beyond SELLER'Scontrol,which shall include,without limitation,war,fire,or other casualty,governmental regulations
or contros,inability to obtain any of the materials Involved hereunder,or through acts of God.This agreement shall be binding upon and
inure to the benefit of the executors,administrations,heirs,successors and assigns of the parties hereto.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on
behalf of the owners to enter into this agreement
Owner authorizes the Contractor to enter upon the said premises and Owner agrees to obtain,if necessary consent to enter upon
all adjoining neighbor's pren'ses in order to enab:e the Contractor to do and complete the aforementioned work.
This contract represents that entre agreement between the Owner and the Contractor and no representation or warranty shall be
binding upon either party,unless inc1jded herein or on reverse side.
This agreement is subject to review by Energy Savers of America Inc.
You may cancel this agreement If It has been signed by a party thereto at a place other than an address of the
seller,which may be his main office branch thereof,provided you notify the seller in writing at his main office or
branch by ordinary mail pasted,by telegram sent or by delivery,not later than midnight of the third business day
date following the signing of this agreement. / /
IN WITNESS WHEREOF,the parties have hereunto signed their names this ati,3 day of /b
IAV, e - 7t- p��� �
g- :d by Em . Sa - ofv*r: 11C. Signed Xztc K_
Own'
Signed _ , Signed
E :.v Savers of America Inc. Owner