17A-274 (5) 29 FERN ST BP-2017-0363
GIS n: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-274 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-2017-0363
Project# JS-2017-000604
Est.Cost:$1600.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq.ft.): 5009.40 Owner: PADECK EDWIN M&JOAN F
Zoning: URB(1OOP Applicant: ENERGIA LLC
AT: 29 FERN ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:9/192016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL A 10" LAYER OF CELLULOSE TO OPEN
ATTIC
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 9/19/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0363
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 29 FERN ST
MAP 17A PARCEL 274 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid / 5
Building Permit Filled out r
Fee Paid
Tvveof Construction: INSTALL A 10"LAYER OF CELLULOSE TO OPEN ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 92540
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolitio• D-.
Si_.reo:u'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.
Department use only
�C� City of Northampton Status of Permit:
6 Building Department Curb CutlDriveway permit
,t. \ 212 Main Street Sewer/Septic Availability
c� Room 100 WaterMell Availability
Northampton, MA 01060 Two Sets of Structural Plans
roz phone 413-587-1240 Fax 413-587-1272 pot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.7 Property Address: This section to be completed by office
29 fern ST. Map Lot Unit
torence , MIR 010(07_ Zone Overlay District
Elm St.District Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
.\oo..n Padre r, 29 cern St. fi (Wen° , r.1nlora 2
Name(Print)�. A Current Mailing Address:
SE ¶'aE 17 AL&Tf OTelephone 32 7
0- 5[05
Signature
2.2 Authorized Anent:
1Y1OmA_ P>OSSMGSSISt.)f-EOI k Srt. HOlynka Mil
Name(Print) Current Mailing Address: (3109(.)
413-322-3111
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ;� ( 00 (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) 0 J. 6266 ' ° ° Check Number CiGIf7 16, L�
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Wt area minus bldg&paved
Ping)
#of Parking Spaces
Fill:
(volume&I tw tion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document tt
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. WII 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 O NO O
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
Or Doors ❑ /
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks IO Siding[cII Other @I]
1f1S11i%tiOYI
Brief Description of Proposed r
fl
Woriclttait a Io' laurr cellulose to (Spell attic
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes \i^'"` No
Plans Attached Roll -Sheet
ga.If New house and or addition to no 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. Masecheck Energy Compliance form attached?
h. Type of construction
1. 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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
WC,in � _O CUL- ,as Owner of the subject
property
hereby authorize -rnomos P>o.sfY1 SR LD r _
to act on my behalf, in all matters relative to work authorized by this building permit application
sF � tT * c t �trsr4
Signature of Owner R Date
—111I. f QmC,
as ossrnoS.S l e r .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.
u� t r L• .a4 , r
Print Name //b.
-
Signature of Owf 'litigant Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f7 Not Applicable ❑
Name of License Holder ()POOLS QTfSSm o.SS�e '( q2 ua
License Number
2 -n sufc-r sem. -HeP4QY-R Yuri ologo q12.111
Address
Expiration Date
(413- `g"2.2_- 3 ( 1
Signet Telephone
9.Registeredd Home Improvement Contractor. Not Applicable 0
.Rnt
fq La Company Name Reg Sion Nu Number
-7!-O su-f-fo s-t. ttOt\ OLe wog oi0Li0 I / ) ( I )$
Address Expiration Date
Telephone(113—A22.3)))
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 pe '
Signed Affidavit Attached Yes 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 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: 2S SPY Ya `ST. -EIf1CCY1Ut , YuiWI OIusZ
The debris will be transported by: Ac.L(E.e (41:74S76
-
The debris will be received by: ALL(eb t)el Cr 6--
Building permit number:
Name of Permit Applicant "G,144-S DSCed-rq Ssx.E,L
it
Date Si. ature of Permit Applicant
The Commonwealth of Massachusetts
_ ' el?
Department of Industrial Accidents
='>hf mm: Office of Investigations
Mitlfit=
_M 600 Washington Street
Boston,MA 02111
`"`'i77.aE� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizationIndividual): Energia, LLC.
Address: 242 Suffolk Street
City/State/Zip: Holyoke, MA 01040 Phone#: 413-322-3111
Are you an employer?Check the appropriate box: Type of project(required):
1.Igt I am a employer with 24 4. ❑ I am a general contractor and I 6. 0 New eonstntctian
employees(full and/or parttime).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.: 9. ❑Building addition
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 ILO Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MOL
12.0 Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees.[No workers' 13.E Other Insulation
comp. insurance required.)
'Any applicant that checks box NI 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.
%Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emploees. If the sub-conra;tors have employees,they most provide their workers'comp_policy number,
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: HDI - Gerling America Insurance Company
Policy or Self-ins. Lie.#: EWGCR000186816 Expiration Date: 7/1/2017
Job Site Address: 22 3=ern_ t&-t City/State/Zip:m V Cr1(R , M it Cl OCp 2.
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.
ens
Ho hereby certify and= the pains and penalties of pedury that the information provided above is? and correct
Signature: Pate: —V/Y>� /r/
Phone#: 413-322-3111
•
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#:
Cr •
Rto,, uune„h/,fir`.(/ujnr/rue/G --_— y
Office ofConsaner Affairs&Business Regulation License or registration valid for individul use only
i V i' ONE IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
. '-eglstmUon: 165169 Type: Office of Consumer Affairs and Business Regulation
• Expiration: 1/112018 LLC IO Perk Piano-Suits 5170
Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE,MA 01040 Undersecretary Not valid without signature •
to
Massachusetts Department of Public Safety
,8 Board of Building Regulations and Standards
License: CS-092540
Construction Supervisor
THOMAS B ROSSIASSLrtR
100 MAIN STREET
HATFIELD MA 010• -
N'jz Expiration:
Commissioner 09/02/2017
Accsta, CERTIFICATE OF LIABILITY INSURANCEDALE IMMIDDIYYYYI
765/2016
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(SI, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the poficydes)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),
PRODUCER IAL
NAME: Mary Conroy
Jamee J. Dowd and Sons Insurance Agency Inc. PHONEAX
19 Bobala Road Ittto,EMI:413-$`B-7444 T(AC.Non
Holyoke MA 01040 An•-, SS: ITCs: R AP•owd.Coi[„ _ ...
•TO
CUSTOMER ID S: EN EBLLC-01
_ INSURER(8)AFFORDING COVERAGE NAIL.
INSURED INSURER A:HD I_Seri trim Attie EL Ca Insurance Comps
Energia, LLC MUmmae:Totus National Insurance Company 25496
242 Suffolk Street
Holyoke MA 01040 INSURER C:
INSURER D:
INSURER E:
INSURERS:
COVERAGES CERTIFICATE NUMBER:2039052479 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 OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIICATE 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 TYPE OF INSURANCE NUB
BEEN
REDUCED BY PAID CLAIMS.
ILTR
3DBN pPOLICY
POLICY NUMBER I MIDDe I peEUYeY
LTR YY)I LIMITS
A GENERAL LiABILM YY MGCR00018.6816 7/1/2016 1/1/2017 EACH OCCURRENCE 1.000.
0
UMAAGL IUNtNILU 100„nm
X COMMERCIAL.GENERAL LIABILITY PREMISES(Ea oC gnprCeI f
CIAMSMADE X OCCUR MED EXP(MY one person] $
PERSONAL&ADV INJURY 51,000,000
GENERAL AGGREGATE '52.090,000
GEM AGGREGATE(MT APPLIES PERPRODUCTS.COMPOP AGC 82.000,000
POLICY I+• I(fr LOC $
A AUTOMOBILE LIABILITY Y Y FPOCR00019 8516 7/1/2026 7/1/2017 COMBINED SINGLE U MT 51,no 600
(Fa accident)
MY AUTO
BODILY INJURY(Pm person)
ALL OWNEDAJJTQS f BODILY INJURY(per modem) $
X SCHEDULED AUTOS I PROPERTY DAMAGE
X_ HIRED AUTOS (Per accident) E
NON-OWNED AUTOS ' S
$
B LK UMBRELLA LIMO OCCUR 4 y AS393N350AL2 7/1/2016 '1/1/2017 EACH OCCURRENCE $1,000,000
EXCESS LIAR CLAMEMADE AGGREGATE S1,000.000
DEDUCTIBLE S
X RETENTION 510,000 8 ,
A (WORKERS COMPENSATION E2cR0001B6e16 7/3/2036 7/1/2017 2 5WD8eu-X Oa-
MO
a-
A/OPROPOYERS'LIABILITY YI X.
ANY CERJMEETDR EXCLUDED' OITIVE E.L.EACH ACGDENT $1.000,000
OFFICER/MEMBER EXCLUDED? NIA I
IMenaetory In NNI E.1.DISEASE EA EMPLOYEEI 41,000,000
ty des me Omar
DF:GCRIPTION Of OPfNATIDN9 Mos E.L.DISEASE POLICY LIMIT I EL.000,OGO
DESCRIPTION OF OPERA¶ONS I LOCATIONS/VEHICLES (Atpth ACORD 101,Addition Remarks Scbd,le,))more spite I.r•qulredl
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE TIE EXPIRAON DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS,
SUMMER]REPRESENTA TWE
f7iND7/ ."'
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name end logo are registered marks of ACORD
1L/ 14/LUIZ 14: DL 141.100/kL/C IVINY DLL) uGrI YHVt UL/GL
Property Address: 2a r C-/eA) S ( •
Contractor
Name: T3 OM 9 S (? OSS t.tASSLE/Z
Address: Zr{ 2 54 FFd L/C ST'
city, state: /lDh /EE tiro Q/o./a
Phone: y (3 ' 32z- 3/7•/
Property Owner —50/1N PA"I)ECK
Name:
Address: 2-91 r G 6x4/ 5 /`
City, ✓2
State: 1 Alei1
EJC
,S
I, ' /F(U.A(AS (KOSSM4S9-&Q (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
Data Q / VA/
RISE60 Shawmut Road,Unit 2 I Canton,MA 02021 133830&6335
ENGINEERING www.RlSEengineering.com
OWNER AUTHORIZATION FORM
I. c-- 10Yl- 3 >kclec-
(Owners Name)
owner of the property located at
(foppe - Address)
10 ft evaP, bU- b I b lir ,
(Property Address))
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.This form is only valid with a signed contra.,
•
- , _
Own-J.ignature
Q6 ( � D
Date