24D-323 (3) 155 PROSPECT ST
BP-2017-0317
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-323 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-2017-0317
Project# JS-2017-000522
Est.Cost:$3000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor:
Grow License:
Use Gro
ENERGIA LLC 92540
Lot Size(sq. ft.): 4443.12 Owner: DOMINQUEZ KATHRYN
Zoning: URC(1001/ Applicant: ENERGIA LLC
AT: 155 PROSPECT ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
H O LYOKE MA01040 ISSUED ON:9/16/2076 0:00:00
TO PERFORM THE FOLLOWING WORIC:INSTALL BLOWN CELLULOSE CLAPBOARD
EXTERIOR WALLS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Rough: Rough: House# FoFouundandat:
tion:
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 9/16/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File II BP-2017-0317
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 155 PROSPECT ST
MAP 24D PARCEL 323 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 1/�JC
Fee Paid ( . e- u c/a-7 9 �4//
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL BLOWN CELLULOSE CLAPBOARD EXTERIOR WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 92540
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
ir .IiC.n Di y
Sig . ure o Bui ding 0 icial 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.
To. Northampton Building Dept Page 3 of 3 2016-09-0915.24.37(GMT) 14133223155 From:Tom Rossmassler
,_ City of Northampton
.p Massachusetts °� c+c
DEPARTMENT OF BUILDING INSPECTIONS
y
4 212 Main Street • municipal Building '2 S
ti0m
reAptq[
, � 01060 h'r
Property Address: /55 1' K nS €C7 ,57
Contractor �— C QSS a_a
Name: -a`t
Address: 249 LV
G S if. -0 K I{ �jI
City. State: 40 L 7 d IK MA-
Phone: y/3 - 322 - 3 !( t
Property Owner
Name: /L f17#e, /�/ 4
6/ Y
Address: /5 PROS�6'r /
City, State: �,{ / I 141/0/ /f (� 4
I, j�OPtA Q(ARAf}'SSLG4contractor)attest and affirm that the building I intend to
insula e does not have any open air(knob and tube)wiring in the spaces to he insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature / _--
Date
/ ,. /
DECEIVED tv Northampton Department use only
Ci of Status of permit:
ie Building Department Curb Cut/Driveway Permit
MI6 IP MT YO212 Main Street Sewer/Septic Availability
Room 100 WaterNVell Availability
1 � at4arnNpas�cnoNa NDrthampton, MA 01060 Two Sets of Structural Plans
i! NdfmMRrON,MAinine 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 Address: This section to be completed by office
Map Lot Unit
155 Prosiec-c srt •
NOt1amp-ton , MA OtOto o Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
tOmt\Ip rnongot/ 1S5 Prnso«rt S-I . Klor- nary,9snn-,mnw
Name(Print) Current Mailing Address: 010(A 0
See Otn)Y1Pf (A+Tttno forts Telephone SSl - 8(e5lz
Signature
2.2 Authorized Anent:
YtrrgI T41cMAS 245SMASSLQQ 242 soffovc S-r . Wit\IOU M49 0t64o
Name(Print) Current Mailing Address:413-322 - 81 1 I
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building VD Qt Si
IlV'\,\ ' 00 (a)Building Permit Fee
2. Electrical U V (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) it 3r Ute, 00 Check Number - f'
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
6 d Qg /?/V
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 Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot arta minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
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 O 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 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 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 ❑
0r Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks II] Siding[0l Omer
SNStt l AT101✓
Brief Description of Proposed
Work: XNSULAl.oW— WOWS 1r -tttit t0Inwl\ ccttOlnSI' c5poard poet ,
Alteration of existing bedroom Yes No Adding new bedroom Yes ` No wall$
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 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. 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Yin-V.1'N Yl Dorm new e ,as Owner of the subject
property
hereby authorize Entrqra
to act on my behalf, in all matrs relative to wodc authorized by this building permit application.
claC nwnr r OsYW or t) on form
Signature of Owner Date
1{'1nrnaS `F)ossm&c s 1? 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.
ThnrnAS ?)OSSm(ASS 1ec
Print Name
g(dO
Signature of Owner/ a Date l /l�
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: t7 Not Applicable 0
Name of liceThomas
license Holder: ' omas [%)ssrraSS t P C 9z GU o
License Number
ZUL cuffaI K- tioavnice Mn olotio x121 1I
Address Expiration Date
L113- 322- 3i11
Signatu Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Ehtrlla i(a519
Company Name Registration Number
Z42 SuffoIK Si . +inl'oiu MW 01040 II1111S
Address Expiration Date
Telephone 413322-311 1
SECTION 10-m WORKERS'Insurance aeENSAviO CE AFa d sub (M.O wi h.h52,§licC(o))
Wore de Comfthe Is u nceoftbuildsaffidavit st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the Issuance of the builds ermit.
• 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: CC{ frost Si. &pc- nryf r etrl M'A
The debris will be transported by: fit l-cd WQS1-C
The debris will be received by: Ruled 14/494 e__
Building permit number:
Name of Permit Applicant —Rto MPc S YLOSSMkSsLaC
Date Signatur of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
ert
. 9 ,_; Office of Investigations
_ 600 Washington Street
• '19 - Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant 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):
I.® 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 listed on the attached sheet. 7. ❑ Remodeling
partner-
shipand have no employees These sub-contractors have g
❑ Demolition
working for me in any capacity. employees and have workers'
cora . insurance. 9. ❑ Building addition
[No workers' comp.insurance P
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
yt c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] I3.® Other Insulation
employees. [No workers'
comp. insurance required.]
'Any applicant that checks box 41 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
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: HDI - Gerlinq America Insurance Company
Policy#or Self-ins.Lic.#: EWGCR000186816 Expiration Date: 7/1/2017
Job Site Address: 155 p roS pt cs &i City/State/Zip: N O rtyla rel p70n M-yt 0 1060
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 certt&und% the pains and penalties of perjury that the information provided aye is tr e and correct
Signature: Date: I (/V
Phone#: - -
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#:
A�COREJ CERTIFICATE OF LIABILITY INSURANCE 7/5/2016
THIS
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 policy(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
certllcate holder In lieu of such endorsements).
PRODUCER wit uu
NAME Mary Conroy
James J. Dowd and Sons Insurance Agency Inc. PHONE
DM:911-518-7999 j jnc, No:
14 Sobers Road kMAa
Holyoke MA 01040 ADDRESS: mconr'Cly@dowd.cow
PRODUCER
CUSTOMER ID e.ENERLLC-01
INSURER(SI AFFORDING COVERAGE NAIL*
INSURED INSURER A:HD I-Geri inq America Insurance Compa
Energia, LLC INSURER is National Insurance Company )25496
242 Suffolk Street p
Holyoke MA 01090 INSURER C:
INSURER 0:
INSURER E:
INSURER F:
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.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED 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.
(NSR MN R SUER POUCY EFF POLICY EXP
M
LTR TYPE OF INSURANCE R WM POUCY NUMBER IMWDOGI PII IMM/CONYTO LIMITS
A GENERAL LIABIUTY Y Y ErY.,CR0001B6816 7/1/2016 7/1/2017 EACH OCCURRENCE $1.000,000
R COMMERCIAL GENERAL LIABILITY PPREMIE( lE a aLNI[U 100.000
VAM AUL1 UHLN ILI) f
CLAIMS-MADE X OCCUR MED EXP(Any one q,mnl $
PERSONAL SADV INJURY $1.000,000
GENERAL AGGREGATE ,82,000,000
GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000.000
7 POLICY X IF f LOC E
A AUTOMOBILE UABIUIY Y Y EAGCR000186616 T/1/2016 '7/1/2017 I COMBINED SINGLE LMT $1,000,000
ANY AUTO (Es accident/
BODILY INJURY(Per person) E
ALL OWNEDAUTOS BODILY INJURY(Per accident) $
X SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Per accident) S
X NON-OWNED AUTOS iS
S
B X UMBRELLA LIAB OCCUR Y Y 5S393N150AL3 7/1/2016 7/1/2017 EACH OCCURRENCE $1,000,000
EXCESS LMB CLAIMS-MADE AGGREGATE _ $1,000,000
—
DEDUCTIBLE $
X RETENTION $10,000 E
A WORKERS COMPENSATION Y ENpCR0001e6816 (7/1/2016 7/1/2019 X WG STAT0. H
01 -
AND EMPLOYERS'LABILITY YIN TORY LIMITS ISR
ANY PROPRIETORIPARTNEREXEORIVE
OF.CERIMEMBER EXCLUDED, ❑ NIA EL. ACCIDENT $3.000_000
I(mndebcryy In WI EL.DISEASE EA EMPLOYEE,81,000,000
I DESCRIPTION OF OPERATIONS below E.L.LSSEASE•POLICY LIMIT I Si,090,000
•
L I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks ShcsCuls,If mere space Is reRu)nGl
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
19 1988.2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
�7r t.,,,,,,r,,,,,„r tti,lydraiaorA,,.,di
Office of Consumer Again&Business Regulator' License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
165169 Type: Office of Consumer Affairs and Business Regulation
Expiration: till/2018 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
292 SUFFOLK STREET . ..i
HOLYOKE,MA 01040 Undersecretary Not valid without signature
,
®
. Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License:CS-092540
Construction Supervisor
THOMAS B ROSSNASB
106 SINN STREET
ftATRELD MA BK
Ni^^r Expiration'.
Commissioner 0902(2017
RISE60 Shawmut Road,Unit 21 canton,MA 02021 1339402-6776
ENGINEERING www.RlSEsngmssring.com
OWNER AUTHORIZATION FORM
aRril .3 t �uce.
owner of the property located at
l5 5 * Si
(Properly Address
oat1k-CLIPAnn.j� h 0 taisbiker b lv6p
(ProperlyAddress)
^ 1 2
hereby authorize rive,e -//� LS
(Subcontractor) U
an authorized subcontractor for RISE Engineering,to act on my behalf to . ,b
516
mom*and to perform work on my property.This form is only valid with a sig ntract.
Owners Sign 3 )-"
1.19
Date
rrN..•
Permit Authorization yae''e `O,
masave Form i
awip eaggM1.�wpy,MfeeeyPARIMPATING
CONMALIMII
Site ID: S00050212146 Customer: KIPP ARMSTRONG
I, KIPP ARMSTRONG ,owner of the property located at:
(Owner's Name,ptlntedl
109 Woodland Dr FLORENCE
• IPropeny Sweet Address) (neyl
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: � J\ (/t
Date: 9 / 4 /C
•
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
CI ilp
GFAResult • ,50 Washington Street,Suite 3W0 • We9bpmurh,MA 03581 . 1806ee0.]47] Eli
For Office Use Only
Rev.102015 -