37-121 367 ROCKY HILL RD BP-2017-0289
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:37- 121 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: INSULATION BUILDING PERMIT
Permit t: BP-2017-0289
ProjectJS-2017-000489
Est. Cost:$2400.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS99381
Lot Size(sq. ft.): 61724.52 Owner: O'CONNOR THOMAS
Zoning: Applicant: THE ENERGY SPECIALISTS
AT: 367 ROCKY HILL RD
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-20 CELLULOSE TO 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: 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-2017-0289
APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS
ADDRESS/PHONE 212 AMES RD HAMPDEN (413)566-1058
PROPERTY LOCATION 367 ROCKY HILL RD
MAP 37 PARCEL 121 OW ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Gia/7 yLl/6
Building Permit Filled out
Fee Paid
TvpeofConstruction: ADD R-20 CELLULOSE TO ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99381
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
.- ' ii• it lay
Air
Signa reriui di- fTictal 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 WaterMell 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 Pro a Address. This section to be completed by office
36/ o(A ////r ./ Map Lot Unit
- C4 Ca rc Al /af Zone Overlay District
Elm St.District CB Distinct
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
Y4c.ncj 1eo Cl e / / v/
Name(Print) Current Mailing Address.
civ- OYf-7
Telephone
Signature
2.2 Authorized Agent:
Name�r Current Mailing Address
( - /d SY
Signa Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building oo (a)Building Permit Fee
..... pr, VOO= C .
2. Electrical (b)Estimated Total Cost of
E..0 J/9 Construction from 6-
3. Plumbing Building Permit Fee
/7
4. Mechanical(HVAC)
5.Fire Protection "de/
6. Total n.(1 +2+3+ 4+5) 42+/00, vc Check Number co)
This Section For Official Use Only ,
Building Permit Number: Date
Issued:
Signature:Signature:
guiding Commissiortec/lnspector of Buildings Date
" CEWED
SEP - 6 20i6
ogfn:OFPIP n'�G'H-" s
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 Dcpanmenl
Lot Size
Frontage
Setbacks Front
Side L: R: L. R:
Rear
Building Height
Bldg. Square Footage n
Open Space Footage ,o
(Lot area minus bldg&poked
parking)
#of Parking Spaces
Fill:
(teems&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW fa YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW 0" YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO el DONT KNOW O 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
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 07
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing.grading,excavation,or filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES 0 NO 0-
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apolicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors ri
Accessory Bldg. 0 Demolition ❑ New Signs (DI Decks [q Siding IDI Other cal(
Brief Description of Prop,ppsod
Work: Ale, /ea& re//u/a$c /G c //c
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes ' ' No
Plans Attached Rod -Sheet
6a. 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 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
k. Will building conform to the Building end 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
/4
//4/'r0CC„+.++o•- ,as Owner of the subject
property
hereby authorize , 4'- 6:,+n. f , i '✓/'K
to act on my behalf, in all matters relative , ork authorized by this building permit application.
9-e / l
Signature of Owner IA?
pate
..76' er�7^ff'' J4'c'. ✓/3 ,as Owner/Authorized
Agent hereby declare MI 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.
2 4.s/ 4 r..i LJO
Prins Na .+
Signature of 0 •ler/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:p. / Not Applicable LI
Name of License Holder: "tiL^A//N 5
4;GO e✓ SJf/
License Number
gill 4,0"e- Sr n /fin/age a.4 ,3' s-/F
Address /
Expiration Date
S-6e- /Oil k
Slgnatur Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
/4r L .."-f7 Pet s %'J/J /7J,.1 F7
Company Name Registration Number
epetve 4Are1 .' ci Mews h4 //-/Y-/ e Address Expiration Date
Telephone }Cl/r,f}
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 buildin permit.
Signed Affidavit Attached Yes No._... ❑
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 dweiling,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 he 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 thcjob 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 Codc,City of
Northampton Ordinances.State and Local Zoning I 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: 3 0 /(ac/.-j AIN r
The debris will be transported by: T/e 61-,7)./ l/leo s/i/1
The debris will be received by:
Building permit number:
Name of Permit Applicant T4 6:-73/ f,divs/ its
Date Signature of Permit Applicant
��wQ City of Northampton
Massachusetts we - vee
.
ft,
1 DEPARTMENT OF BUILDING INSPECTIONS 6 t,
kr 212 Main Street • Municipal Building F , ,,
\\.:...s'.. ,� Northampton, MA 01060 ss yN.'Yl~
Property Address: 3C7 /rar/j .//// r'
Contractor
Name: 7%,,. 6.r.y ?rrr'c /.,/i
Address: ofri //i`,rs , /
City, State: "teer.,l.;,x, "4
Phone: S c c- /ay,- __.....
Property Owner
Name: Zia H < ) C,C6N N dq<_.__.
Address: 3C7 7(oc4 44// 4/ __
City, State: Ak rN c, r/J
I,—1 it .6;r-s.), f#rr ic /it) (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
, - C-/ F
The Commonwealth of Massachusetts
, Department of Industrial Accidents
= "t' Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
Z "' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): The Energy Specialists
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):
I.• 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. n Remodeling
ship and have no employees These sub-contractors have g_ ❑ 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 I0.❑ Electrical repairs or additions
3.LI 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.❑ Roof repairs
insurance required.] t c. 152, §I(4).and we have no
employees. [No workers' I3.0 Other Insulation
comp.insurance required.]
"Any applicant that checks box p I must also fill out the section below showing their workers compensation policy information.
a Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new atTdavit indicating such.
-Contactors 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'comppolicy number.
lam 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#or Self-ins. Lic. #:WCC5009547012014 Expiration Date: 10-16-2016
Job Site Address: 3 G/ %c/� //// Y V City/State/Zip: /2a--get /SiJ
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 under the pains peteperjury that the information provided above is true and correct
Signature: Date: Cie%
Phone#: 413-566-105 r
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#:
anwea(eh of✓cca::achu eTh
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiratio0 date. If found return to:
e9istrdLon 153267 Type:
Office of Consumer Affairs and Business Regulation
zpiatlon: 11/14/2016 DBA 10 Park Plaza-Suite5170
.ts"J Boston,MA 02116
ENERGY SPECIALISTS t
%NIES RD.
PDEN,MA 01036
Undersecretary Not valid without signature
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: (SRL-099381
Construction Supervisor Specialty
MICHAEL E GREENWOOD
212 AMES ROAD
HAMPDEN MA 01036
tri-1I. Expiration_
Commissioner 03/09/2018
ACORD CERTIFICATE OF LIABILITY INSURANCE DAM
1MM0DTY"'
%.—i 0111/2016
i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
ICERTIFICATE 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.
I IMPORTANT'. If the certificate holder Is an ADDITIONAL INSURED,the policy(es)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/is certificate does not confer rights to the
certificate holder in lieu of such endorsement(¢).
PRODUCER 413-566-0028 413-566-0090CNa" ACT Richard R. Green Insurance Agency Inc. _
ONE
Richard R. Green Insurance Agency. Inc. A°M,c "e,Fm_qi3-566-0028 _DAC Nj.413 566 0090
;32 Somers Road ss richardgreenins@charter.net
PRODUCER
cYp 4M£P.IQ/D-._WRER___._.____
'Hampden MA 010.30 — IxsunEn'sLFFomm
mxccovEmACE ___ x. .
I INSURFD INSURER A:Patrons Mutual Insurance Co of CT
Michael Greenwood INSURER a Associated Employers Insurance Co_
doe The Energy Specialists 11`15URERC Commerce Insurance
212 Ames Rd. issuers - -_--_ --�- _
fHampdan.MA 01036 IxsuRr r
yisuadaF
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. NOTWTHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OP OTHER DOCUMENT%MTh 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
xsP INSURANCE II{[R'mKu"NUx3ER Mw000nyY II MM)0MMYY1Ioars
GENERAL aLSY 1 Imo- Ku"
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_._ ..____ WERE-AGGREGATE .. :'2000.000 _. .
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✓ 51 RES ALTOS Pe02RTD DAY.EDE
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A -- - - CXS2111578 10/14/2015 10/1412016 a WORKERS ADD o Ts /I
00,000
B ,ice GTVT IY I,NIA I WCC 5009547012014 10116/2015I 10162015 E P C..ce dstwW151111 El A1A5SE AA e EIsP00000
I 0s or CHEF 41- sen,. 1 1 1 EL CrSEASE PoC MT 55004000
I
VEHICLES OVUMACORN rot,Adeluaul R.Ivn.so.dule.U more agEe r,requrmal
Subject to policy terms and conditions.
Sole proprietor excluded from coverage on the Workers Compensation policy.
CERTIFICATE HOLDER CANCELLATION
Por Insureds Records Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For nSured5 Records OnlyTHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
For Insured's Records Only
For insureds Records Only AUmoeCED REPRESENTATIVE
For insured's Records Only Richard R. Green Insurance Agency, Inc
5198B-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 i20091D9) The ACORD name and logo are registered marks of ACORD
Permit Authorization
sue:�\
mass save Form
PARTI+a mu.a4n ew�preero.�av CAAIRRRAC UR6
"0111101,-
Site ID: S00050204497 Customer: THOMAS O'CONNOR
I, THOMAS O'CONNOR ,owner of the property located at:
(Owners Name,primes)
367 Rocky Hill Rd FLORENCE
(Property Street Aumeu) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature: l_1LJ—l0/I/-���—
Date: 4/76 /fl�U
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
•
9ic'4 h1//1 %" -C/ 4
Participating Contractor Date
oro
fflW
For Office Use Only
Conservation Services Group • 50Washneton Street.SUlte 3000 • Westborough,MA 01581 • 1800-480-7472
" Rev.062015