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31A-208 (3) 8 WASHINGTON AVE BP-2017-0291 GIS4: COMMONWEALTH OF MASSACHUSETTS Mao-Block: 3I A-208 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:INSULATION BUILDING PERMIT Permit e BP-2017-0291 Project# JS-2017-000491 Est.Cost: $7500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grauo: THE ENERGY SPECIALISTS99381 Lot Size(sq. It): 10497.96 Owner: ICACZNANCK ALANA Zoning: URB(100)/ Applicant: THE ENERGY SPECIALISTS AT: 8 WASHINGTON AVE Applicant Address: Phone: Insurance: 212 AMES RD (413) 566-1058 WC HAMPDENMA01036 ISSUED ON:9/6/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: ADD R-42 CELLULOSE TO ATTIC, ADD CELLULOSE TO EXTERIOR WALLS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Seryice: 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: FeeTvpe: Date Paid: Amount: Building 9/6/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240. Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner File#BP-2017-0291 APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS ADDRESS/PHONE 212 AMES RD HAMPDEN (413)566-1058 PROPERTY LOCATION 8 WASHINGTON AVE MAP 31A PARCEL 208 001 ZONE URB(1001/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid C I (7yet) V 0:C. Building Permit Filled out Fee Paid Typeof Construction: ADD R-42 CELLULOSE TO ATTIC,ADD CELLULOSE TO EXTERIOR WALLS New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owned Statement or License 99381 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 olition : y • • j/G l.7/(1 t=ui ding Officia 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 City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans 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 Property Atltlr/ess'. This section to be completed by office t GJS.S%.-s ,.✓ Atir Map Lot Unit /V0.7144 A Ala— " 4 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /1/_ g k5 -g-t g , 1- w<, d. ' A-, r Name(Print) Current Mailing Addres 7.5 S/T 90.3 - /Vi":-.1 Telephone Signature 2.2 Authorized Agent: �/ _/4 (ewes SArr:. Gr IS at/.t AtIff N r/ /fc r7a i! A A Name(P'• Current Mailing Address: SGcJAG Y Signature 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 Cost of N/4 Construction from(6) 3. Plumbing Building Permit Fee /t%/9 4. Mechanical(HVAC) 5. Fire Protection N/4 6. Total=(1 «2+3 +4+5) -) IOo.u° Check Number / Id 0l5 This Section For Official Use Only Building Permit Number: Date Issued: Signature: 1 Building Commissioner/Inspector of Buildings Date RECEIVED SEP —6 2016 DEPT OE BCLLANG ENSPECPONS NORTHAMPTON,MA cIC30 Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning The column robe till d in by Building Dcpanmcni Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage -o I Open Space Footage (Lot area minus bldg&paved parkinel #of Parking Spaces Fill: Iv'olume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW f?,/ YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW (3 YES O 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 el 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 er IF YES, describe size, type and location: E. Will 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 NOy l IF YES.then a Northampton Storm Water ManagementPermitfrom the DPW is required. SECTION Si DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. 0 Demolition ❑ New Signs [C=1 Decks 14 Siding ICH Otherfe'If• Brief Descrig{ion of Proposed Work: ,./rf of terWrz.4 Pe Jo cl.�c /4z% /c r,.f /e.-.c.- 434//J Alteration of existing bedroom Yes,. P No Adding new bedroom Yes ire No Attached Narrative Renovating unfinished basement Yes ' No Plans Attached Roll -Sheet Ba.If New house and or addition to existing housing, complete the following: a. Use of budding: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 stones? C 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 Te,OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /1 .no A N zr .as Owner of the subject property T, hereby authorize TJ, et•J e. ec to act on my behalf,in all matters relative to • • auth• ized by this building permit application. Signature of Clymer S'eit pate 74' 1;410 _y ✓ e A' ,as Owner/Authorized Agent hereby declare that Cn 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. i• l eir e .e, .prl 400, Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor- /7 Not Appiicabie C Name or License Holder 'eic e/ 61irety L...)o c 1 SS Jf'/ -_ License Number Led Atte � � r a/a3 L en- ! Atltlr.. ;. -.? � � Expiration Date F Tree- /orL Signature Telephone 9.Renistefed Home Impr9vement Contractor: Not Applicable ❑ 7..1. L-l.,,.s S/Lc, /,v/3 /S-3 t F 7 Company Name / Registration Number /1? Anel r e/ A.-1/44-_,/ /'1�__ /r-/v/4 Address Expiration Dale Telephone yee-zed Y SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(WSJ.c. 152,§25C(8)) Workers Compensation Insurance affidavit must be completed and submitted with this application, Failure to provide this affidavit will result to the denial of the issuance of the building permit Signed Affidavit Attached Yes_ No ❑ 11. - Rome Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Uwellions 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 he,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 no the Building Official,on a form acceptable to the Building Official that he/she shall be responsible for all such work performed under the buitdine permit As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion ofthe work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 157 (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 far you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the Slate Building Code,City of Northampton Ordinances, Stale 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: b- cxs J .4 r The debris will be transported by: 2Z- L vt J/ ,corr,s /4/3 The debris will be received by: Building permit number: Name of Permit Applicant 74 E , 7 Ai'As 9 -C- /' Date Signature of Permit Applicant City of Northampton ..➢ i tit:"= ,y... < Massachusetts _. € rr kA; t t' DEFARTlCNT OF BUILDING INSPECTIONS 5._ ,ak ✓ 212 Main Street • Municipal Building ire.,,,,,,, o� Northampton, MA 01060 �t Wi Property Address: Se 60431 ,.f /a.,. A., r Nci-/4„/2/c_ Contractor Name: 71 6--t-, i Dir./c�/J/f Address: 4/1 /9^'J /' et //c A,/e, .M/,!' City, State: Phone: 5-C C : tic 41 Property Owner // L/ Name: //�nt /1 (cZ+Vc ,: 4. Address: I" erailltiryies A cd t City, State: N c,"/L—l_0 /_/, A 7, I, 74 Z"'r-t) ./et,C/.'l/J (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 signatures' Date The Commonwealth of Massachusetts Department of Industrial Accidents 1 Willie Office of Investigations __ I Congress Street, Suite 100 Boston, MA 0211 4-2 01 7 Y www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly The Energy Specialists Name(Business/Organization/IudEidual): Address:212 Ames Road City/State/Zip: Hampden, MA 01036 Phone#:413-566-1058 Are you an employer?Check the appropriate box: Type of project(required): l.❑ I am a employer with 3 4. ❑ I am 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.]' c. 152,§I(4),and we have no Insulation employees. [No workers' 13.n Other ------- comp. insurance required.] 'Any applicant that checks box el must also fill out 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 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:Associated Employers Group Policy#of Self-ins. Lic. #:WCC5009547012014 Expiration Date: 10-16-20116 Job Site Address: £ toss!,% A. A Cr City/State/Zip: Nov�/Kn�A �A 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 certify un er the ' a en hies of perjury that the information provided above is true and correct Signature: Date: 9 '‘ie Phone#: 413-566-105 S' 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#: .aacrn 0las«uacaurcEr ' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: @egistatiore 153287 Type: Office of Consumer Affairs and Business Regulation t„C zpiation. 11/14/2016 DBA 10 Park Plass-Suite 5170 - Boston,MA 02116 ENERGY SPECIALISTS I GRENWOOD \MES RD. 4� o PDEN.MA 01036 Undersecretary Not valid without signature atMassachusetts Department of Public Safety _. Board of Building Regulations and Standards License: CSSL-O99381 Construction Supervisor Specialty MICHAEL E GREENWOOD tt 212 AMES ROAD HAMPDEN MA 01036 - r..../..^^^ =xpiration_ Commissioner 03/09/2018 Ac izo oI CERTIFICATE OF LIABILITY INSURANCE pqTIMM°°'"Y ° 011112016 i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. OHS 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 pollcy(les)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 endorsememisl. I PRODUCER 'we"lEACT 4i3-566-0028 413-566-0090 - Richard R.Green Insurance Agency Inc. PAX Richard R.Green Insurance Agency,Inc- tee ris,Fau 413-566-0028 c,Nay413-566-0090 _ 132 Somers Road richardgreenins@charter.net PROOCUCER Hampden,MA 010366INSUREwLFFORmaO COVERAGE Neu _-T — INSURED INSURER A Patrons Mutual Insurance Co of CT Michael Greenwood INSURER s:Associated Er�loyers Insurance Co. dba The Energy Specialists wsuRERc Commerce Insurance 212 Ames Rd. INSURER D- Hampden.MA 01036 ixsuRERE INSURER F. COVERAGES CERTIFICATE NUMBER: 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 V1TH RESPECT TO V*UCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Alt THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOVM MAY HAVE BEEN REDUCED BY PAID CLAIMS. SSR TYPEOF INSRM¢E OAC"hPOLICY CY EFPOWYNIIMeER �IMWYr IMwOPmTrI LIMNS CENERALwSILO. IWNI,. 'i EAchOCC CE :31,000_000___. A J C s t = ,O. 1 I TAISSO-Dxe D 1.:340.089 fl. .E F.FBE .,_ c -usyA:E ✓ xc.R 1 I E E w ,r z 5999- 1 50P2698685 10/14120151 10/14/2016E=may D J - t 1..000000_ _.. I NERAa c 6^E_ x 2.004900 SALE NV P APP.LP PER ', POz„ s. a nP__„ z 2.004,092 I AUTOMOBILE LIT, .. 0"rs-Ds °MIT 51,000,000 I PA PCIPPII I ✓. E ,010s2017i 200 mow„ 5 C ✓ CATO° ° BBMJ27 avaSrzaTs, _ _.. HIR 5/ UMBRELLA tide .7 C.,C.F Pe>CSOCPLPSEACE I5 EXCESSWer vu, r. .G;REC,T- ,s 1200000 A - --- a50— I'. CXS2111578 100412015 10/14:2016. 5 .:T-ON 5 I , ''.e __.._. . WORKERS COMPENSAT,ON - s. / CS._,. 1a IM t 500,000 '' EFIEC,' E = EYYN:N I WOO 5009547012014 mn W20151 1011-/201s "CFE o _5500000 4 Ccse<To sbem„ I El MEWS nits,NTS 500,000 1 DESCRIPTION OP OPERATIONS'LOCATORS I VERICLES Attach 'S, Aaellesil st s Schedule i1 mom epn n ee a ^ei Subject to policy terms and conditions ,b Sole proprietor excluded from coverage on the Workers Compensation policy. CERTIFICATE HOLDER CANCELLATION For Insureds Records Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insureds Records OnlyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Insured's Records Only For Insured's Records Only AUTNORIZEOREPRESENTAIrvE For Insureds Records Only Richard R.Green Insurance Agency. Inc. ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD RISE, 60 Shawmut Road,Unit 2 i Canton,MA 02021 I 339-502-6335 ENGINEERING. www.RlSEengineering.com OWNER AUTHORIZATION FORM cM#r+,gk- (Owner's Name) owner of the property located pa't:n. i ` 1� (� is l��Fi4V 9y5 1H,(Prope Address/F .p� (Property7 RAddress) ltt-ts ►� W11a Oto hereby authorize /Xr z is f 4/✓ec,.c /i/1/-/ (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 contract. Ar's Signature 7` H L ari HOF LIVE Date �'