29-091 (2) 38 BRIERWOOD DR BP-2017-0573
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:29-091 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-2017-0573
Project# JS-2017-000931
Est. Cost:$1700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 17511.12 Owner: Mark Sellers
Zoning: Applicant: ENERGIA LLC
AT: 38 BRIERWOOD DR
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 Liability
H O LYO K E MA0104 0 ISSUED ON:10/25/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSU LATI ON TO ATTIC FLOOR OPEN BLOW 10'
CELLULOSE
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*I 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 10/25/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0573
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 38 BRIERWOOD DR
MAP 29 PARCEL 091 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 'N
Fee Paid 6
Building Permit Filled out
(11)N
Fee Paid v
Typeof Construction: INSULAT N TO TIC FLOOR OPEN BLOW 10'CELLULOSE
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
INFORMATION PRESENTED:
roved 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 PermitVariance*.
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
Demolition Delay
Sia . re .' :u' 'sing Metal 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.
OGi t d 1 Department use only
; pity of Northampton Status of Permit:
Bluilding Department Curb Cut/Driveway Permit
DE9t RL..
p,5 r r: �.._��'212 Main Street Sewer/Septic Availability
Room 100 ..W.NEfliattammPtilify.-_ --
Northampton,
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 Property Address: This section to be completed by office
TDC\Ctw� O� Map Lot Unit
Zone Overlay District
Eim St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Of Record:
twxrc ``f'l\e•'CS jf c..YVv OOd Dr. +—Myrnc2 MW
Name(Print) Currant Mailing Address: 3%Q Lt 2,
984.1E-1E Pent A-K.77-fr) Telephone
i 984
signature
2.2 AuthOrIzod Agent
7horrktS PloSSalaSi kc' 7-'-12 SUffoIK `si . 1immtiLt MYp
Name(Print) - Current Mainng Address: 0 Loci
Signature Telephone _
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building / 747aD (a)Building Permit Fee
idSC
2. ElecMcal (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) & ( 7d0 • 0O Check Number al,af
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Ail Information Aust Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thiscolumn to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: K: L: R:
Rear
Building Height
Bldg.Square Footage °o
Open Space Footage
(Lot area 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 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 Q NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over I acre or is it part of a common plan
that will disturb over i acre? YES Q NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION E-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows ABerapon(s) ❑ Rending n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O1 Decks ID Siding[ Other KZ(It ch) 1GlctOft
Brief Description of Proposed
Work: . Alftt1.4-T/dft) Ta ATTtc- -+ °/Z deer1 ("3tdot,J /Di ce“..ttypSC—
Alteration of existing bedroom__Yes ?G No Adding now bedroom Yes / No
Attached Narrative /// Renovating unfinished basement Yes ao
Plans Attached Roil -Sheet
Ga. If New house and or addition totoexisting housing, complete the following
a. Use of building:One Family `-r' 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
1, i\AC {1( SQ.\\CSC ,as Owner of the subject
Property
hereby authorize 7110In(.I.0 b3S MCA 5Stec
to act on my behalf,in all matters relative to work authorized by this building permit application.
Sf0 POeM, 7 4K7-/i d r/2 c/,y
Signature of Owner Date
I, -rno las c2)0ss{Y1Ca..\ (s v ,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.
Thos SO smnwsSLty
Print Name
/7 Signature of 0 er/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
yams of License Holder: 'Tf h)W 1r} a, _ C12SU el
License Number
:2 St`T+til K c`St. ricz jC11 t-1$\ f`,' NC; _2j 21
Address Expiration Date
Signature Telephone
9,Retilatered Homo Improvement Contractor. Not Applicable C
Encr:cG11Jo. _110S 1 U 9
Company Hdme Registration Number
Address Explratio? Date
.... _ _,.._Telephone412X—i2122-31,4
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152,0 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit Wilt result
Lin the denial of the issuance of the builJdyIg permit.
Signed Affidavit Attached Yes EI Na...... ❑
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 108.35.1.
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 ewe-veer 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 ail 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 maybe 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: TS% art Cif , Q C .
The debris will be transported by: �\\t.i Ck t ,JCCS'rZ
The debris will be received by: ic'ft\t kr\ u10.S1-t
Building permit number:
Name of Permit Applicant tvu,,r Y `\e :\\J f j
/ ( afre
Date Signature of Permit Applicant
RISE -f�: 60 Shawmut Road, Unit 21 Canton, MA 02021 339.502433S
ENGINEERING' www.RlSEenglnaering.com
OWNER AUTHORIZATION FORM
1, Mn 6QbL,e s
(Owners Name)
owner of the property located at
3S /3tf .i..,o o b fllLryes
(Property Address)
CDD rte- Mg . Qt_ 0r0g2
(Property Address)
hereby authorize
(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.
Ther Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners
responsibility to dose out this permit by contacting their municipality at the completion of this work.
Owners Signature
�ly�116.
Date
CONDOR CNoSnA1 -
'DNERGl f; > Hot'/ocr".
6.20[0
y1.\ Int t.tsfilMati IYEYitn ut irlirnYLRNSCtL.)
e ... Department of Industrial Accidents
.'—t=—rl
--f-7.4.--.74
"j Office of Investigations
y 600 Washington Street
- Boston,MA 02111
swww.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):
I.till I am a employer with 24 4. D I am a general contractor and I
employees(full and/or parttime).* have hired the sub-contractors 6. [ New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
a9. 0 Building addition
[No workers' comp.insurance comp. insurance
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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
12.0 Roof repairs
insurance required.]t c. 1 52,§1(4),and we have no
employees. [No workers' 13.R1 Other nsuiation
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 his affidavit indicating they are doing ail 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 to sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.poliey number.
l am an employer that is providing worhers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: HDI - Gerlinq America Insurance Company ,,_
Policy if or Self-ins Lie.4: EWGCR00018631 B` Expiration Date: 71112017
Job Site Address: ♦ 4 ' 133CJC)0' '<' City/State/Zip: \pat'rtc,+x, i Mt} Ot O tai
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 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the IMA for insurance coverage verification.
I do hereby cert under the ins and penalties of perjury that the information provided above is true and correct.
Sionature: Date: U
2.4
Phone#: 41.3-322-3111
f
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permil/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk d. Electrical Inspector 5.Plumbing Inspector
6.Other
' Contact Person: Phone#:
ACORD CERTIFICATE OF LIABILITY INSURANCE OATS
'
7/5/2016
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: R the certificate holder le an ADDITIONAL INSURED,the pollcy(Ies)must be endorsed, N SUBROGATION IS WAIVED,subject to
the bans and conditions of the policy,certain policies may require en endorsement. A statemem on this certificate dose not confer rights to the
certificate holder In lieu of such endoreement(e).
PRODUCER 1UN IAC(
NAME. Mary Conroy
James J. Dowd and Sons Insurance Agency Inc, PHONE FAX ""-
14 Bobala Road (5.LG.
los Ex¢4L3-538-]443 AID,St
Holyoke MA 01040 ADORZSt IsCOnrovvdowd.cam
PN
CURT MERRID k:ENERLLC-01
INSURER(S)AFFORDING COVERAGE NAICB
INSURED IN5URERA: WI-Gerling America Insurance Coopa
b7Jezgla, LLC Ms-REen:Torus National Insurance Company 25496
242 Suffolk Street
Holyoke MA 01040 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT 70
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.
Met ARM.SUER PCL.- • pOLpT •
CFR TYPE OF INSURANCE INS@ MVO PODGY NUMBER e. R L I tMMIWe 1 UNITS
GBfftGLLMBXJTY Y Y EGGER0003136816 1/1/2016 4/1/2014
EACH OCCURRENCE F1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES PREMISES IE�SCtuleence)11100,000
CLAIMS,MADE lX OCCUR MED EYP IMy me person] $
PERSONAL&ADS WIURY 11,000.000
GENERAL AGGREGATE $2,000,000
GERIAGGREQA"TE LIMITAPPUE$PEt: PRODUCTS.COMP/OP AGO $2,000,000
-1 POLICY IC IAF On f L°O 1 _..._.�
A AUTOMOBILE HARDTY Y Y EPaCR0001p6816 7/1/2016 7/1/2017 COMBINED SINGLE UNIT f .000.000
ZMY AUTO IFS 9aIen1
BODILY INJURY(Farpasar) $
_ lit OWNEOAUTOs ECOILY INJURY(Per accident) $
X SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Per wedeln
X NON.OWNEG AUTOS E
0 X UMBRELLA LSE OCCUR Y R 8539321150AL/ 1/2/2016 7/1/2027 EACH OCCURRENCE $1,000.000
EXCE SSLMB aMMS-MADE AGGREGATE 11,000.000
_ DEDUCTIBLE E
X RETENTION 510,009 yyyry�,, {1-
A WORMERS CaIPENBAIHIN Y Lw.aa0001a6816 '/1/2016 7/1/2017 X T0111SUM8.0 IOEW
AIO EMPLOYERTI use ryY
ANY PROPRIBTORPARTNERIEXECLTWE /If E.L.EACH ACCIDENT $1,000,000
OFFICERMEMeER EXCLUDED, ❑ NIA
Madam IA RI E.L.DISEASE EA EMPLOYEE $1.000,000
AIM= OPERATIONS Mks EL.DISEASE.POLICY omit $1,000.000
DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES (Meth ACORD 101,AddelonelhemeNt MNedwe,IT mere apes IN equlmdl
CERTIFICATE HOLDER CANCELLATION 10
SHOULD ANY OFX THEABOVEDESCRIBED POLICIESBECBECELIIVD
IN ACCO TDA CE WITH
THEREOF.NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH INE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
M
1085-2009 ACORD CORPORATION. All rights reserved.
ACORD 25)2008/08) The ACORD name end logo are registered marks of ACORD
^y/„.Wrut,'it,",ows/a,/-/4,..,4,,,//,
Li:, Office of Consumer Affairs&Business Regulation License'or registration valid for individul use only
IOffiOMIstratl0n:E IMPROVEMENT165169 Type:
CONTRACTOR before the expiration date. If found return to:
-
ce of Consumer Affairs and Business Regulation '
Wmtion: 1111/2016 - LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
ENERGIA LLC .
THOMAS ROSSMASSLER /fit-
242 SUFFOLK STREET .gg // /j t
HOLYOKE,MA 01040 nc - --• v--- ��� - - --
Undersecretary Not valid without signature
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-092540
Construction Supervisor
a
THOMAS B ROSSMASSLER
100 MAIN STREET ; _'
HATFIELD MA 01/038
�-M r Expiration:
Commissioner 09/02/2017
i<i 1V/ LO1] sM: 4t 141J]0/1[/t NI UI1 tlLL Utrl rAut VU Liz
Property Address: 3S BRIER OOi thik •
Contractor
Name: 17/tflh S !ASSN kst?-&t'
Address: Z/2 c4cc at_/< sr
CIIy, State: /L/ ,KE ,.,L17(- O/4 4/
Phone: ,/ //3 32.y E ///
•
Property Owner
Name: "gilt
gilt SEU_ S
Address: 3r #.6eewa 4.1 be •
City,
Stale: D-t21 lz��1 cE, M A OP/D eel'
1, 7770445 £0 gCM-SS 6e 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 ct this affidavit,
Contractor signature
Date /Oo//t/