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109 WOODLAND DR BP-2017-0316 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35.252 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-2017-0316 Project JS-2017-000521 Est.Cost: $1800.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo: ENERGIA LLC 92540 IAA Size(so. ft): 34325.28 Owner: ARMSTRONG KIPP S&PATRICIA S Zoning: Applicant: ENERGIA LLC AT: 109 WOODLAND DR Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:9/8/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC FLOOR OPEN BLOW CELULOSE 6" 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 5/8/20160:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only RECEIVED ;ity of Northampton Statue of Parma: Building Department Curti CuUDriveway Permit _ OM 212 Main Street Sewer/SepticAvadabiiay N Room 100 WatedWet Avallabay No-thampton, MA 01060 Tvlu Sets of Struttwat Plans Ilablffilsoitsillarli113 5874240 Fax 413-587-1272 Plot/Site Plans • Other Saadi" APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1•SITE INFORMATION 1.1 Property Address: This section to be completed by office 101 Wood land Dr , Map Lot Unit flor$nCO3 bAti OtOTo2 Zone Overlay District Elm St.District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record; t 4Armccttonq 109 Woodland Dr. flOrcnc c fnf Name(Print) 4urtent Mailing Address: 0 I Oro z Sae a.ttn 13— ISO- 1381 S} ♦ 9et(ntt -Rol to �Y(h Telephone Signa 2.2 Authorized Mont: Erte rgla - fbµAS a-v SMHSSL& 7112 so+-e lK sr ttol9act Mit Name(Printf Current Maipng Address: 01 ego Li 13- 2)22 - 311 Signature Telephone SECTION 3-E TIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building � I I q 0 0. OCO (a)Building Permit Fee 2. Electrical O V (ts)Estimated Total Cost of Construction from(61,,, 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection n /' 6. Total=(1 +2+3+4+5) I1 800 „ "0 Check Number dir; This Section For Official Use Only Building Permit Number: Date Issued: q+^ e�y'r Signature ��i^�\ 7 T ! L� Bunning Commissioner/Inspector of Buildings Date • Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information MIME Proposed Required by Zoning Ibiscolwm tube filled in by Building Department Mill.11111111.1 1111.1111. Setbacks Front Side Rear ®�■�- Open Space Footage ®-- _ (tut area minus bldg&paved --- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obta#ned fl 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(clew dog,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over I acre? YES O NO O IF YES,then a Northampton Storm Wat©r Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) I I Roofing ❑ Dr Doors IC Accessory Bldg. ❑ Demolition ❑ Now Signs (0] becks [i7 Sidin [O] ONggr 11ryf �f 1 lGY'T213Y1 Brief Description of Proposed work: *t-iIC -Finny prn blow (ctw r Os, !n / " Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes y/" No Plans Attached Roll -Sheet sa.If New house and or addition to existing housing, complete the following: a. Use of building_One Family \ sm"' 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 Boor 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR.NAPPLIES FOR BUILDING PERMIT Y f c>? • y.f S Ono) ,as Owner of the subject property hereby authorize _( lots 'nt SS LR r to act on my behalf,In all matte relative to work authorized by this building permit application. FCC pt'rmtl oft ntiOriZo-r Yf form Signature of Owner Date T Onias PPaossrnaSS1Cr ,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. 11, 1. SQ$SmasS Cr Print Name Signature of Own:IA.ent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: j� r Not Applicable 0 Name of License Holder `TIInmaS PI)Sfvn1k\s IPr g25UD License Number ZUZ ¶ f011c s-t tko\ynrC Mn ()IOU0 4/ z 1 11 Address Expiration Date 413- - Si Signature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ gntr4i4 Itor, nig Company Name Registration Number 241- sof-folk. s-t. +(0iy0rc IA ft 01090 WI 1 IB Address Expiration Date Telephone 413—32.2-aI I I SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must mpieted and submitted with this application. Failure to provide this affidavit will result M the denial of the issuance of the building it. Signed Affidavit Attached Yes 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 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 awn 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: Lig T&SC St. Sri ne{fir 1 d , MS The debris will be transported by: -AI I I td W US'ic The debris will be received by: 411 l t 2& W eitkt Building permit number: Name of Permit Applicant T$IOM+k 5 2dSCMA-SSLSc -44"Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents I L W!•=; Office of Investigations =`re= ' 600 Washington Street _r ' Boston, MA 02111 •.� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 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.® I am a employer with 24 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g ❑ 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.❑ 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 insurance required.]r c. 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.E Other Insulation comp. insurance required.] Any applicant that checks box M I 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. tcontracton 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 art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: HDI - Gerlinq America Insurance Company Policy#or Self-ins. Lie.#yy: EWGCR000t186816 Expiration Date: 7/1/2017 OM Job Site Address: ) WOOd I Q flfl be City/State/Zip:-Ft ottn Cr MA 0100 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. Ida hereby certify under t e pains and penalties of perjury that the information provided abo egqis true and correct. nature: Date: �p 1 Ov Phone#: 413-322- 11 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#: 'wO° CERTIFICATE OF LIABILITY INSURANCE 7/5/2016DlYYTYI 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'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 fights to the certificate holder In lieu of such endorsement's). PRODUCER CONIACr NAME Mary Conroy James J. Dowd and Sons Insurance Agency Inc. PHONEex11:913-538-"1999 ; FAX No): 14 Scheid Road .MAIL Holyoke MA 01040 ADDRESS: mconrey@dowd.com PRODUCEtt CUSTOMERS)*:ENERLLC-01 INSURER'S'AFFORDING COVERAGE NAICM INSURED INSURER A:HDI-Gerllnq America Insurance COmpa Energia, LLC INSURER 8:Torua National Insurance Company 25996 292 Suffolk Street Holyoke MA 01090 INSURER C: INSURER DI INSURER E'. INSURER F'. 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 CERTIFICATE 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. IXSR DOL SUER POUCY EFF POLICY EXP LTR TYPE OF INSURANCE 'HSR WVO POUCY NUMBER IMMIOOrYYVY) ISe j/0.VYYYTI LIMITS A GENERAL LIABILITY V Y ELC-CR0001e6616 7/1/2016 7/1/2017 EACH OCCURRENCE 51,000.000 UAEE X COMMERCIAL GENERAL LIABILITY PREMISE6(Ea occurrence) 5100,000 CLAIMS.MADE X I OCCUR MED EXP(Any one person) $ PERSONAL ADV INJURY I$1,000,000 GENERAL AGGREGATE ;$2,000,000 GENL AGGREGATE LIMIT APPLIES PER' PRODUCTS-LOMPAP ASS $2,000,000 FT POLICY X PRO. IFCT f j LOC $ A AUTOMOBILE UABILI TY Y Y PAGCR0001668.16 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT (fa aeal0enl $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per acc:uent) X NON-OWNED AUTOS $ $ B X UMBRELLA LIAB OCCUR Y Y 85393MSOALX 7/1/2016 9/1/2017 EACH OCCURRENCE 51,000,000 EXCESS 1.1913 CLAIMS-MADE AGGREGATE 51.000,000 _ DEDUCTIBLE $ _ X RETENTION $10,000 $ A WORKERS COMPENSATOR Y CA00D1B601G ,7/1/2016 7/1/2017 % WCSTATU. [ETH. TR AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOP/PARTNER'EXEOITIVE i EL EACH ACCIDENT 51,000,000 OFFICER/HERBER EXCLUDED'? ❑ N/A IMandatorylnMl)er E.L.DISEASE•EA EMPLOYEE'$11.000,000 I deserve un J DESCRIPTION OF OPERATIONS be-ER EL.DISEASE'POLICY LIMIT $1,000,ova DESCRIPTION OF OPERATIONS I LOCATONS/VEHICLES (Attach ACORD 101,Additional hnmartn kheeuln,II more'pica IF require) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THEABOVE DESCRIB BODATEEIEPOLICIES CANCELLED BEFORE TDA EXPIRAMON DATE THEREOF,NOTICE WILL BE DELIVERED EO IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA TUE ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD r.-14e I:.,,,,,,n„rrwol/A irviroa.ae ,,,eia office of Consumer Affairs&Business Regulation License or registration valid for individul use only EtAyo MY"Vet urOME IMPROVEMENT CONTRACTOR before the expiration date. If Lound return to: i 185185 type: Office of Consumer Affairs and Business Regulation Expiration: 111112¢18 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 ENERGIA LLC THOMAS ROSSMAKM FR 242 SUFFOLK STREET �.c.xa`�w-- /S'a" ^� HOLYOKE,MA 01(440 Underseeretary Not valid without signature ✓ p Massachusetts Department of Public Safety Board of Building Regulations and Standards License:CS-092540 Construction Supervisor THOMAS B ROSSMA 100 MAIN STREDT SSteit r emir)MAMpppppp _ M . e ..,..- Expiration: Co missioner ti5/0212011