31B-089 File 4 BP-2016-0902 i '-
titt
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 0
PROPERTY LOCATION 152 STATE ST
MAP 31B PARCEL 089 001 ZONE URC(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 5'89 0
Building Permit Filled out
Fee Paid
Tvneof Construction: INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108212
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved 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
Demolition Delay
Signature of Building 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.
$55"/
Cil Rts e
Department use only
RECEIVED City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
DEC 2 212 Main Street Sewer/Septic Availability
3 2015 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
Deur
NOWRTHAMFTO N.Tj04 ohne 4 3-587-1240 Fax 413-587-1272 PIoVSite Plans
HAM146 e�Afi9
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
152 5'Fa+e. ST Map Lot Unit
Nor*Vick'4pton 1Massacv+use%s Zone Overlay District
01 0/4/0
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
David stern 152. State 9+. Nor+inptnn rv1A 010140
Name(Print) Current M ailing Address:es -9B 8 5
`See s19ned Cortise+) Telephone
Signature
2.2 Authorized Agent:
Michael GronPrtado 15 Nhcoht$ Avef Water-4OWf MA OY141_
Name(Print) _7 Current Mailing Address'.
f _ Sl1- 3ot,- Win
Signa e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cast of
Construction from(6)
3 Plumbing Building Permit Fee ✓//�"//� �-f
4. Mechanical(HVAC) / I 7Y11% ��
5. Fire Protection /��
6. Total=(1 +2+3+4+5) Check Number 5d nor
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
1
Frontage
Setbacks Front
Side L: R: L:
Rear
Building Height
Bldg.Square For age
--
Open Space Foo age %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Sp cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was t permit recorded at the Registry of Deeds?
NO DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NODONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES O NO d
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 cam
IF YES, describe size, type and location:
E. Nil the construction activity disturb(clearing,grading,ex ation, 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I0 Siding[O] Other Mr •
n 9410,41 Ort
Brief Description of Proposed
Work: (See Signed Con-frac-0
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -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. 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
It 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
I, DO)V1d Skcr n as Owner of the subject
property
hereby authorize M%ChgC t GlonFr t deity
to
act on my behalf, in all matters relative to work authorized by this building permit application.
see Stgned Con+1-ac+)
Signature of Owner Date
I, Michael GIonEr •ddb 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.
MIclnael Gioncrtdao
Print Name / /
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Nameof License Homer: Mtr? ael Gtoncr taao tot 2.12_
License Number
15 Ntcohis Aver WA*Cr+own MA 02412- (a/20'IR
Address - Expiration 666 ate
Y11- 3o(0- 4483
Sig ure e.cphone
9.Reoistered Home Improvement Contractor: Not Applicable ❑
1(01 $27
Company Name Registration Number
Victory Ener 3y Soluelon. ‘t 15 II Co
Address Expiration Date
One Nor Word S9uare, Telephone 1.11-$0(0'
New Hrt+crn , CS O.OS2. 4443
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 4 No 0
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 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 (See. St5ned Contract)
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
vela 1 Congress Stree4 Suite 100
I`y`^ _ 9-• Boston, MA 02114-2017
www.mass.gov/riia
Workers' Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbe it
TO BE FILED WITH THE PERMITTING AUTHORITY.
.Applicant Information r� 1+ C Please Print Legibh
•
Name(Business/Organiratim✓Individual): \II Liar 1 One1 snit t\bns
Address: a/ r or d _
City/State/Zip: N es. 1Yln .L 69'1)h-one 41 Dfm- aOJ.O(O - k 3
sore you air employer?Check the appropriate box:
pi
Type of project(required)
W
I I am a employer with 30 employees(full and/or pan-time).` 7. 0 New construction
2 i am sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
an capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3 I am a homeowner doing all work myself.[No workers'comp. Insurance required.]'
a D am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet ]3.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance r
6 We are a corporation and its oflicershave exercised their right ofexemption per MGL c 4�Oher�I�51 �} l X
152,§1(4).and we have no employees.[No workers'compinsurance required]
',Am applicant that checks box#1 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 must submit a new affidavit indicating such
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities hay e
employees lithe subcontractors have employees,they must provide their workers'comppolicy number
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
informalion ,, ,,s,s p
Insurance Company Name Ton --inat ]`(Lne Co
Policy#or Self-ins Lie. #_ xd I 3 t 0(0 L-IS Expiration Date- d S. f
4 Y
Job Site Address. (52. S+ck+e. ST City/State/Zip. Nor+Mo.M p ion l M
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date): 010 bib
Failure to secure coverage as required under MGL c 152, §25A is a criminal violation punishable by a fine up to 51.=00 011
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 8250 00 2
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 certi .tender the pains penalties of perjury that the information provided above is true and correct
Slee •...._ 8p t 1 Date:
Phone#. r7? ' 3 y`q T1�
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License# Ili
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#:
t�TTf! CS-108212
MICHAEL GIOI%RIDI]O
h'
15 NICHOLS AVENUE APT 1
r' Watenotsu MA (2472
��
..— D6/2012018
unrestricted-Buildings of an use group which
contain less than 35,000 cubic feet(991m')of
enclosed space.
Faiiare to ryvsess a current edition of the Massachusetts
State Building Cade a cause for revocation of this license.
For D3 licensing information visit: ....fait Gov/Dag
r'li,e c(oinm oI/(oect/i/ o`r'b/eaJJac%riJe/tJ
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 167827
Type: LLC
Expiration: 11/512016 Tr: 258839
VICTORY ENERGY SOLUTIONS LLC.
RAQUEL KENNEDY
1 HARTFORD SQUARE SUITE 206 - -NEW BRITAIN, CT 06052 . ---
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
Office of Consumer Affairs&Business Reguatioo License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 167827 Type: Office of Consumer Affairs and Business Regulation
Expiration: 11/52016 LLC 10 Park Plaza-Suite 5170
Boston.MA 02116
T;RY ENERGY SOLUTIONS LLC.
DI-AF IPL KENNEDY
AF SQUARE SUITE 206 e�_ �,_
i:'R(TAIN.CT 06052 Undersecretary
ry .'o[valid without signature