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41-073 (3) 51 LOUDVILLERD BP-2017-0484 GIS 0: ,... COMMONWEALTH OF MASSACHUSETTS Map:,Block: 41 -073 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate gory: INSULATION BUILDING PERMIT Permit# BP-2017-0484 Project# JS-2017-000801 Est.Cost: $5323.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const,Class: Contractor: License: tm_c_nneu THE ENERGY STORE 106024 Lot Sizey.ft.l: 84942.00 Owner: Laura Beltran zone Applicant: THE ENERGY STORE AT: 51 LOUDVILLE RD Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON:10/13/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 5" OF BLOWN IN CELLULOSE TO Al (IC FLOOR 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 10/13/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0484 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD (888)840-6641 PROPERTY LOCATION 51 LOUDVILLE RD MAP 41 PARCEL 073 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 03 Building Permit Filled out Fee Paid Tvpeof Construction: INSTALL —‘111;;;;;N IN CELLULOSE TO ATTIC FLOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106024 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR 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 i en oli[im � Signature of Building 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. GGGv\v�O Department use only R, r \6 City of Northampton Status of Permit: \� s Building Department curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability dE Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Sae 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 51 LooDJILLE RD. Map Lot Unit F oaErJCE, MA Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: LAJRA BELTRAr4 51 LoODVILL$ RD. Ft-0(2E4CE l MA o(01o2. Name(Pent) Current Mailing Address'. 2- oq -cb9 - S-941 SEE ATT-ACHED Telephone Signature 2.2 Authorized Agent: CHq sToPHE2 AL,LEA N3 HoEVv'lAnl ST- -Wag InErbe11lr opt9T Name riot) // ���,, A Current Mailing Address. (2/1. O Sloe -V8o -92-9q Signature 00 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 5323 •fl (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 �( 6. Total= (1 +2+3+4+5) r323 . 97 Check Number 3pp/ F�a This Section For Official Use Only Building Permit Number: Date Issued. Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Thic column m be filled in by NJrt 014 Building Department Lot Size Frontage Setbacks Front Side L: It: L: R: Rear Building Height Bldg. Square Footage Xk Open Space Footage Alt area minus bldg k pave parking) of Parking Spaces File. (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW ( S YES O IF YES, date issued: IF YES: Was the permit recorded at the�Re(gistry of Deeds? �l NO O DONT KNOW YES O IF YES: enter Book Page and/or Document it B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW CO YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO Sigf 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 2 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 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 ElAddition ❑ Replacement Windows Alterations) 0 Roofing ❑ Dr Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks i0 Siding[DL Other Id W_ERTHe£IzATrod_ Brief Description of Proposed Work: /PJ$TALL S OF 81aweI- 10 CEuVac5E T Arm. 1=a-062. Alteration of existing bedroom Yes .1( No Adding new bedroom Yes ,7r No Attached Narrative Renovating unfinished basement Yes J{_,_No Plans Attached Roll -Sheet ea.If New house and or addition to existing housing,complete the following: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: , Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f, Method of heating? Fireplaces or Woodstoves Number of each 9. Energy Conservation Compliance. Masscheck Energy Compliance form attached? II, Type of construction i. Is construction within 100 ft.of wetlands? Yes _ No, Is construction within 100 yr. floodplain Yes No i. Depth of basement or cellar floor below finished grade K Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i, LAURA ES erreari _ ,as Owner ofthe subject Property hereby authorize (;.r1Rt5ToPHEQ At-t-Enl to act on my behalf, in all matters relative to work authorized by this building permit application. SES,. ATTACHED to4413e._ Signature of Owner Date I. G /.I. . i L.L. .as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. C11RtnaPtinta ALLE, Printy(ame � � Ia/4/f(a Sire of Own /Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ,t Not Applicable ❑ Name of License Holder: CMRISTO PI1E1L Al-LCrJ IObo$Z License Number (43 HOFFNAJ.) 5'T TAgtrJCTTor)1Gr ot944o c13/ir/zo Addre s ( neExpiration Date S o— Lilo—q z 4 9 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Eos ERE'ty PRZ, LLC. f Ro6FRr AUE,L Ili 39 2 Company Name Registration Number SI OLP ROJTE I BecokFicL-p) Cr ofoloo-1loJlif Address Expiration date + Telephone lt?-$40-ds41 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 building 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 teo(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-pear 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 Gable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stale 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: ci toJWRLC Ro. The debris will be transported by: Ne DF B2A< The debris will be received by: No DEBR Building permit number Name of Permit Applicant CHetsroPtiro Atver4 _Lopti,to Ndia a A Date Signature of Permit Applicant City of Northampton �� Me,aa: •5 - r Ln Massachusetts q 4 L.l t tl- • DEPARTMENT OF BUILDING INSPECTIONS 1\®/1 P� aBf � 212 Main Street • Municipal Building �sr\% e Northampton, MA 01060 kn 1,-`‘‘ Property Address: 31 LaJOU!ti-E Q0, Contractor /� Name: CHR%sro PNEQ ALLEN1 Address: 1y3 HoFFWAn1 Sr. City, State: Tel2Rt A)GTon.1, CT Phone: 6(90- 440 —922314 Property Owner Name: LAJRA BEtTRANJ Address: ST Loo DJAL-tE R0, City, State: FLo R£.JLcI MA I. CARtsraP IfEg A LLEM (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 /0p-I1 Ile <c The Commonwealth of Massachusetts �— Department of Industrial Accidents c Office of Investigations 7. •-(ice-'j.: [_. .s r 1. 1 Congress Street, Suite 100 _r gr ,- --.04_,..=:ill! ��< »?� Boston,MA 02114 2017 wwwmass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual):/°z ` --T IPS Ece49y �S i )((-�.� _ Address: } ( ll A R4 ( ,4J( City/State/Zi I: p EI.S 0_, 1 ii ,p r�Phone#: I q r ;ti-lla "L( _ Are an employer?Check the ap,ropriate box: Type of project(required): 1. J I am a employer with 3 4. 0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time). have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. employees and have workers' p 0 Building addition [No workers' comp.insurance comp, insurance.t required.] 5. 0 We arc a corporation and its 10.0 Electricalurepairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 P bing repairs or additions myself. o workers' camp. right of exemption per MCL ILVJ{y x[ (N p 12. oofrer insurance requited.] i c. 152, §1( ),( and we have no I3. Other _. 14 employees. [No workers' �� . comp.insurance required.] eAny applicant Thai checks box ill must also fill out the section below showing theirwotkers'commotion polity information. t Homeowners who submit this affidavit indicating they are doing all mak and then hire outside contractors must submit a new affidavit indicating such. iConr actors that check this box must attachedan 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. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ��(' -i�� Insurance Company Name: �1-Y�_...E3I �f& af1Cy 1 11{]0 ..—. U Policy#or Self-ins.Lic.#: % _ A. & t 9 _ _ Expiration Date: cq I}� 2017 Job Site Address: St Lookshi-LE itt _..._City/State/Zip: ft DR Enlce i MA ©iobz 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 • _' under the pal. . a d penalties of perjury that the information provided above is true and correct. tall it Signature: I -(r- y. , a.. iF. Date: ICI4.J i(o Phone#: e6 bo- 4go-9244 99 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.Ctityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACORD® CERTIFICATE OF LIABILITY INSURANCE CATE iiAMMDM e YYT) I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY DR 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(ies) 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 endorsement(s), PRODUCER CONTACT Brian Gallagher —r: BNC Insurance Agency, Inc. _[Ax°NJ.F(e EnL (414)43'1-1230 ^( Noj (PIN 937-1124 111 South Ridge Street b a11a her@bnca ric Om EMALL a 9 ADppEsE 4 9 4e y.0 INSURERML AFFORDING COVERAGE NAM A Rye Brook NY 10573 INsuFERA Selective Ire Co of South Carolina 19259 INSURED INSURER aStarN t Insurance Company 40045 ENERGY PRZ LLC INSURER C:Landmark American Insurance Co. 33138 dba THE ENERGY STORE INSURER O.. 31 OLD ROUTE 7 INSJRER E- BAOOICFIELD CT 06804-1711 INSURERv: COVERAGES CERTIFICATE NUMBER:CL1641170511 REVISION NUMBER: THIS 15 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 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. EXCISIONS AND CONTEMNS OF SUCH PONGEES.uMris SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR __- .—.. .- ADOL SUSR �. �..... -... POOCY EFF POLICY EXP .....__ _. LIR TYPE OF INSURANCE NSD MED POLICY NUMBER IMMNDIYYYYI amoorrym LIMITS X comeanL4L GENERAL LIAaILRY EACH OCCURRENCE 5 1,000,000 DAMAGE EDREM ELL 100,000 A _ CLAIMS-MADE X OCCUR PREMISE$(FnJ occur&nte) 8 X Contractual Liability 52353542 3/27/2016 3127/2017 MEDEXP{AN ace rumor 5 5,000 .. .. ._. _. . PERSONAL&ADV INJURY 5 1,000,000 IGEN'-AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000 ;POLICY X 3ET . LOC PPGDUCiS.f.OMPIOP AGG 5 2,000,000 OTHER. X .. AUTOMOBILE GALLERY t COMBED. LE LIMIT 5 1,000,000 (ER aNJL —_ A IX ANY AUTO -BODILY INJURY(Feta, 1 ALL OWNFD SCHEDULED UTOS 02153542 3/21/MS ])2Tf203T BODILYMARYPe,MCPs HIRED AUTOS NOTWINED PROPERTY DAMAGE S ALMS Car accident) S I X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 5 __3,000,000 A '' EXCESS UAB _ CLAIMS-MADE AGGREGATE S 5.000,000 DED RETENTIONS S2153542 3/21/2016 $/27/2017 5 !WORKERS COMPENSATION , PER UTH- ANO EMPLOYERS'LIABILITY • STATUTE EN ANY PROPREiOPoP.lINEREXECUTNE Et N- EL.£104 ACCIDENT 5 1,000,000 OFCCEMEB Manxabm bWU) _%0.UOEp XIA SNUe4r0].31376 4/15/2016 4115/20].) 0 ------ In F.4 EVI<IYEE0 1,000,000 II deembe order �.1.. DESCRIPTION OF OPERATIONS Mow E.L.DISEASE.POLICY LAST S 1 000,000 C Professional Iiability tBR756563 3/27/2016 3/27/2017 LIMIT 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS L VEHICLES (AGGRO MDI,Additional RemrIs Schedule,may be attached if mom space IS required) Proof of insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF INSURANCE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE O Co Tabella/BGALL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014(01) The ACORD name and logo are registered marks of ACORD INS1125 menu *e+ r 1Xelel Ft� Permit Authorization as mass save Form e PARTICIPATING ri CONTRACTOR Site ID: 50129630 Customer: Laura Beltran I,_ Laura Beltran ,owner of the property located at: (Owners Name,printed) SI Loudvifle Rd Florence (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on fly behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: /al,[//i'- i yf -' Date: i / FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date For C.1Iv^Wit Prth Conservation Services Group • 50 Washington Street,Slate 9000 • Westborough,MA 01581 • 1800-ee0.1e12 Rev.062015