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22D-112 (7) 53 AVIS C1R BP-2017-0394 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22D- 112 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-2017-0394 Project JS-2017-000649 Est.Cost: $200000 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq.ft.): 37635.84 Owner: MCGOVERN TRICIA L&MARY J MARQUARD Zoning: URA(100)/WSP(I00)/ Applicant: ENERGIA LLC AT: 53 AVIS CIR Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:9/23/2016 0:00:00 TO PERFORM THE FOLLOWING WORK•INSTALL 10" LAYER OF CELLULOSE TO OPEN ATTIC SPACE 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 9/23/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0394 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 53 AVIS CIR MAP 22D PARCEL 112 001 ZONE URA(I00)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Bee Paid aft /)/r/ Building Permit Filled out UL Fee Paid Typeof Construction: INSTALL 10"LAYER OF CELLULOSE TO OPEN ATTIC SPACE 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 INFOR ION 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• •ela g—a31IY Signa 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. RECEIVED Depart,rent use only City of Northampton Status of Permit: SEP 22 2016 + Building Department ._cutiaLuttorivemalLewro 212 Main Street Sewer/Septic Availability ' Room 100 WaterANell Availability DEPT Cr nu:J r"; ^+S Northampton, MA 01060 Two Sets of Structural Plans enE;xns'rcN i.�a c,o--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 DWELUNG SECTION 1 is SITE INFORMATION 1.1 Property Address: This section to be completed by office 63 'Ru1% Of OA Map Lot Unit ctbYfl\LQ Ol0(0 2 Zone Overlay District Elm St.District Cs District — SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: MAN� Mara�axd 63 (NMS (M( ) -rtofentt_. Mi4 n11192 Name(Pn t) C�u�;egJ(Mallin Address 5 E e , -Lt ( 7 A141740 �sevm Telephone 984:1 Signature g.2 Authorized Anent: Fnex a - TUMQa5sttAssnfe 197 St7f-eo1K- St• -tiONOKk THA Name(Print) .--°-.------.--°-.--------- Current Mailing Address: A/- ' " '4 13- 3' ' - -31 i Signature Telephone 'ECG 3•ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1��p / -y4 One 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 �t 6. Total=(1 +2+3+4+5) tall 000, O0 Check Number 4451„4/4 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissionerflnspector of Buildings Dale t Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information MEI Existing ® Re Building Departmentd pmenfng This,wiumn ro be fiikd in by Building byZo IPIMMIIIMMIMIIMIIMIIIMIIIMII Setbacks Front Side alia Rear ®--- Bldg.Square Footage _®__- Open Space Footage -®alill_ (Lot area minus bldg a paved kin. 11111.1111.1111111111111. WM= MI MP=111111MIS SU A, Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O 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? NO © DONT KNOW O YES V 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 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. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it pan 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 S.-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Aheration(s) n Roofing ❑ Or Doors ❑ f Accessory Bldg. ❑ Demolition ❑ Now Signs (01 Decks [p [t Siding I3I Other i nSt) Dann Brief Description of Propoea work: ttl`Stalt IU" WAVY ye (nun nSe -ice) /wen cH ^rte/ S(t. nnJt Alteration of existing bedroom Yes T No Adding new bedroom Yes "' No // Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll -Sheet se.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? Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction L 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Mai\t MaY Pcla.Yt4 .as Owner of the subject Property hereby authorize T1"14VYt(:1 S tA1OSSYYI to act on my behalf, in all matters relative to work authorized by this building permit application. 5Ce peifm T iktarr o Signature of Owner sDate i n as pcs`o a & s 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. SSiiggnneed underdthe painsnand�penalties�of(perjury. 1tarf 4�.I�J TM..2�clti 4J .Xl Print C �I6 .... Name j Signature of Winer/Aggeott Date SECTION 8•CONSTRUCTION SERVICES 0.1 Licensed Construction Supervisor: Not Applicablel �Vt0 m Ne entrees.Holder: 1*,1 t11 G A V 4 U +! ._ g.25�1 License Number 242&*EO LkC c t Ob OU M (Lo(-1O 0211-1 Addres Expiration Date Sign Telephone 9. Reeegiisstteerrs'A�d../�Home Improvement Contractor: Not Applicable ❑ _ Company Ma fis ReRegistration(N Number 2L-tl SuCCauc St0.4-10 Ott MY 0i0g0 t 1 11 $ Addresstt �1122 k.JExpiration Date Telephone-s —32-�*2-31( SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,h 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 buildi permit. Signed Affidavit Attached Yes 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 168.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which hetshe 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 150k Address of the work: '53 PtV\S f 1Y l Ut The debris will be transported by: 1AA1 U d W aS}e The debris will be received by: f1O 4 waS--P Building permit number: Name of Permit Applicant \\Atm\ may VW( -70./( f2 M Date Signature of Permit Applicant City of Northampton % p' Massachusetts A S '' 14. v d DEPARTMENT OF BUILDING INSPECTIONS i rPe 212 Main Street • Municipal Building V< aC� Northampton, MA 01060 *DI Property Address: 53 /OA J C ( . Contractor 9,4/ U� A N(rt Name: � SSLE"/Z Address: $ 2 Sc/Pgda• S7 City, State: `/DLKOKf Aid ozafter 2ni Phone: 7 /.3 • 122 • 3/// Property Owner Name: a5/ 41A/1OAa.b Address: 53 A(L( S C-42C L City, State: -EL Q2sauce, AAA I, 7041 g0 SSmAsSLF (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 Cr/24/N • The Commonwealth of Massachusetts Department of Industrial Accidents - —ft ,Slip= Office of Investigations f - _ 600 Washington Street —AL= 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 0 I am a general contractor and I employees(full andr'or part-time),* have lured 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 subcontractors have g, ❑ Demolition workingfor me in anycapacity. employees and have workers' 9, ❑Building addition [No workers'comp.insurance comp.insurance.. required.] 5. 0 We area corporation and its 10.0 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 MOL 120 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 Il must also till 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 have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number, tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: HDI - Ceiling America Insurance Company Policy#or Self-ins.Lie.x: EWGCR000186816 Expiration Date: 711/2017 Job Site Address: `l424 f\JIS f IY( tA , City/State/Zip: IDYtf(t . Mjg_010 to . 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 MCI,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 DR for insurance coverage verification. I do hereb".. y certify it 1 the pains and penalties of perjuly that the information provided nbo.e is true and correct, Signature: ♦.,, Date: et U Phone#: 41 2-3111 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#: ACHORI£.7 CERTIFICATE OF LIABILITY INSURANCEDATE,MMAJDIYYYY1 ho-4--- 79502016 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 policyfes)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 Ileu of such endoreemenps). PROOULER LUN um,I NAME. Mary Conroy James J. Dowd and Sone Insurance Agency Inc, PHONE FAX 19 3obai_a Road .4 E.a:a13-538-7944 AIC.No: A Holyoke MA 01040 war ss: rr .,.r. 4.owd. 4 1 CUSTOMER ID F:b'NERLLC-01 IHSURERISI AFFORDING COVERAGE NAICY INSURED INSURER q;?IDT.-GErfrig AR1P('ICd In9llTdI10E Comps Energia, LLC INSURERS:Tonle National InFurance Company 25996 292 Suffolk Street .-I Holyoke MA 01040 INSURER C: INSURER D: INSURER E: _ MUURERF: COVERAGES CERTIFICATE NUMBER:2034052479 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.NOTWITMSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT y TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GYRI .. TYPE OF NIBVRANL£ ADOGIBW ink NM POUCH MmeER (M DONTYYC11 {POIJCY rI I LMRS A G6ffRALLIABILITY Y Y EGGCR0OO106915 7/1/2016 7/1/2011M11FAGS OCCURRENCE 51,000,000 1% COMMERCIAL GENERAL LIABILITY PREMISES oc $100,000 CLAIMS-MADE X OCCUR MED EXP(Any one amen] 2 PERSONAL 8 ADV INJLIRN' 51.000,000 GENERAL AGGREGATE (52,000,000 GEN'LAGGREGATE LIMIT APPLIES PER' PRODUCTS.COMPOR AGG 52000,000 '71POLICY F ] ;ITEn f� i OG A AUTOMOBILE LIABILITY Y Y lNCR000306816 7/3/2016 17/1/2019 COMBINED SINGLE LIMIT $1,000,000 da acedenq ANY AUTO BODItT INJURY iPe�Oawn) S ALL OWNED AUTOS " BODILY INJURY Wet [cidena S SCHEDULED AUTOS • PROPERTY DAMAGE HIRED AUTOS (Per acadenq t NONOWNEOAUTos S $ ..... 13 IMBRELLAIV'B _ OCCUR Y Y 8539310150AG3 7/1/2018 ]/1/2017 EACH OCCURRENCE $1,000.000 EXCESSLAB RAMS-MADE I AGGREGATE 51,000,000 DEDUCTIBLE $ X RETENTION $10000 $ A WORRERSCOMPENSAMiN Y ENyCRO2018021E7 /z016 7/1,"2017 K TOML1MiY$I rrH W MO EMPLOYERr BL/TY ANY PROPRIET0R/PARTNEFc EPITVE YIN � L.EACH ACCIDENT $1,000,000 IMgCOiery inDNEn IR GGLED, n E. NIA EL DISEASE EA EMPLOYEE $1,000.000 IHFNI VI OFOPERATION8 WEAN t ELDISEASE-POI GI LIMIT 51.000.ccc I f I DESCRIPTION OF OPER/MRS r LOOATOMSI VEWCLES (AMCM1 ACORD 101,ANIRIOnal'Remarks Sahedu10.11more'Mae Ie required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTMORQED REPRESENTATIVE 61988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name end logo are registered marks of ACORD V ...��. dirge'lam omtvaid/O'f unt-A:or/(J - 001a of Consulter Affairs&Business Regulation License or registration valid for indmdul use only N ` • E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: m gletratlon: 165169 Type: Office of Consumer Affairs and Business Regulation ' i ♦Expiration: 1/11/2018 LLC 10 Park Plata-Suite 5170 Boston,MA 02116 ENERGIALLC TFCMAS ROSSMASSLER 242 SUFFOLK STREET arY-Cs_l ^--_ HOLYOKE,MA 01050 Undersecretary Not valid without signature • Massachusetts uetts OReg umeol of Public Safety �®� Board of Building Regulations and Standards License: CS-092540 Construction Supervisor THOMAS B ROSSM,SSIFR nc 100 MAIN STREET HATFIELD MA 00.10 N j t CA_L. Expiration: Commissioner 09/02/2017 RISE } 60 Shawmut Road,Unit 21 Canton,MA 02021 1339402-6335 ENGINEERING www.RISEanginndnysom EfReur St."i'sd. OWNER AUTHORIZATION FORM r_47uitIr of (Ovmers Na owner of the property located at 7 3 # o , (Property Address) bPtyh1C1++- Gln,b2 (Property Address)� /�/(/�/� V hereby authorize 'V�' ` 74-- (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. Owner's lg : re '6 I (0, —y:, Date