23C-015 (2) 545 RIVERSIDE DR BP-2017-0134
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C-015 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-2017-0134
Project# JS-2017-000217
Est. Cost: $1230.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THE ENERGY STORE 106024
Lot Size(sq. ft.): 189093.96 Owner: FRESHLY RONALD S&LINDA N TUMBARELLO
Zoning: URB(l00)/ Applicant: THE ENERGY STORE
AT: 545 RIVERSIDE DR
Applicant Address: Phone: Insurance:
31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC
BROOKFIELDCT06804 ISSUED ON.:8/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & BASMENT 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 8/1/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0134
APPLICANT/CONTACT PERSON THE ENERGY STORE
ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888)840-6641
PROPERTY LOCATION 545 RIVERSIDE DR
MAP 23C PARCEL 015 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 391 1
Building Permit Filled out
Fee Paid
Typeof Construction:_INSTALL ATTIC&BASMENT 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:
/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
Demoliti clay
S • attire-of Bui di g I icia 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.
Department useony
sive° City of Northampton Statue c(Pa mib
Building Department Gurb Cut/DmewayPerm*
29 ZIA 212 Main Street Sewer/&eplleAwrylati�
Room 100 Water/Well AvadaNAfy
01
60
yro Sets of Strusruni
oE'N�sus orv.W"o u 13-587-1240 F x 4103- 587-1272 TPlo rte Plans Piens
OtherSpeaty . `
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
545- RideRSiDE DR. Map Lot Unit
FLoR.ErJCE / MA OIO(P2_ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
fiord FRESHLFV 545- k;1VERstc& DQ. FLo4ErJCEI MA
Name(Pent) Current Mailing Address:
413—SS4— 1313
SEE AT77CHF D Telephone
Signature
2.2 Authorized Agent:
CHRISTOPHEC Al i ErJ /y3 NoFFMrW ST. T&Rtid&TO/J /'.r
Name(Pdnt) /y Current Mailing Address
Sano - Igo - 929 y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building P/r 230 (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) $4230 Check Number \'h / IyGo
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature:
Building Commissionerllnspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ilik column to he filled in by
Building D partmem
Lot Size
Frontage
Setbacks Front
Side L: R: U: R:.
Rear
Building Height
Bldg.Square Footage % '—..
Open Space Footage
I Lo,area minus bldg&paved
parkin:)
F of Parking Spaces
Fill:
(volume&Wcallolo -
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT 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 O DONT KNOW ei YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 0
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 0/
IF YES, describe size, type and location:
E. MI the construction activity disturb(clearing grading, ex vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK labeck all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. El Demolition El New Signs ID] Decks i❑ Siding[pi Other)k}ly
_... WeAmEettAnowt
Brief Description of Proposed ' It
Work: Ala Se-AL Attcc F yiASEM6e1T. /AJJ~TaLL OF Btouled-i4 CELWLaSE '7(r /fait FLeo2 .
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes )(',; No
Plans Attached Roll -Sheet
6a. 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 to 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
R Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
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 SewerPrivate well City wafer Supply
SECTION Ta•OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES IFOR BUILDING PERMIT
F:74hi e .as Owner of the subject
properly
hereby authorize C ✓ 5-YO J * . 'A
to act on my behalf,in all matters relative to work au lorized by this building pemiit application.
see krrAcHr~P 712 /tb
Signature or Owner Date
I, C99,1 s-roNec., A LL.E,sJ as OwnertAuthorized
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.
CHRJSTbeEiet ALLEr.�
Print .me
u, ,a 'rA0/ I 4/7 71g.,
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: GHRlsroPl}ER A LLE,J Io(0o12
License Number
1LIS MoFFwcArJ 517 ToRR1rA)CYron11 Cr o(0490 03/i s /2020
Abdree Expiration Date
r/
$(00 —14/0 9294
Signature / Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
F� e,'I PR2.1 LLC. / Ro6ERr n/EAL 111539-2-
Company
+S39-LCompany Name Registration Number
31 OLO RTEBteA5L FIELD, Gr o(o4oy oy/to Izol$
Address Expiration Date
Telephone S6%-912— 5'72T
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,upermit.
Signed Affidavit Attached Yes p 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 dues 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 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
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: sys (t %'6,zs,DE DR.
The debris will be transported by:
The debris will be received by: Nd DEBR\S
Building permit number
Name of Permit Applicant Ctte'sro Nea A Lt-e,4
Date Signature of Permit Applicant
City of Northampton
, r. asp. °�c...
Massachusetts �`� " `;
W a
�jK I IfRfT & DEPARTMENT OF BUILDING INSPECTIONS �L�}'m
w y1f � 212 Hain Street . Municipal Building rr
Northampton, Na 01060
�W YAH^�
Property Address: J -I 5 (R.'1 rS;Je_ Dr 1 veJ
Contractor
Name: THE Er.IEa61 STIR£
Address: 31 oLo RTE. 7-
City, State: 3eodc F.EL-0i (T
Phone: 1SS- to4(0- ta3ogq
PropertyOwner Fres 1 Lel
(�77
Name:ame: Oft
Address: 5LIS 1�, NE(Siae DrIv
City, State: I— )v(e,occ- rnA 010(99__
1, Cwt IS rep Rfjc A LI-6/4 (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 (�
'fz'J14
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
ph r. . /,
� ._ = Office of Investigations
e a
=gl= 1 Congress Street,Suite 100
' _ �'�- Boston,MA 02114-2017
V�1 www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): -The, Pregy S–ka
Address: J 1 Ola, IST 7
/
City/State/Zip: C 06%04_ Phone#: (' 'E p !pll
o- 19(pNI -
Are,y•ou an employer? Check the ap ropriate box: Type of project(required):
1.LI I am a employer with 27 4. ❑ 1 am a general contractor and 1
employees (full and/or part-time).' have hired the sub-contractors 6. 0 New construction
listed on the attached sheet. 7. EI Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g 0 Demolition
workingfor me in anycapacity. employees and have workers'
P ty t R ❑Building addition
[No workers' comp. insurance comp. insurance.
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 11.0 P bing repairs or additions
myself. [No workers' right of exemption per MGL
Y comp. 12. oofrI ^
enpp'pirs
insurance required] t c. 152,§1(4),and we have no
13. Other V /iZC1on
employees. [No workers'
comp. insurance required]
'Any applicant that checks hex#1 must also fill out the section below showing their;waiters'compensation policy information.
s Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConirnctom 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:_gNC "im watt/ Ajosy� 1 .fnc
Policy It or Self-ins. Lic. #:SNUl/L( (S?I3I1 S79 Expiration Date: N IIS) 20)7n
lob Site Address: 5 3 C'tver57C1� IJ C, City/State/Zip: IO(mu, ) Or79- 01062.
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.
1 do hereby ce :ft under the) pains pe fries of perjury that the information provided above is true and correct.
Signature: Lu Jk.4A s, (f Date: f'air/t to
Phone#: 4,(an - 4 4o - 9 z9 9
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#: