10B-109 26 GROVE AVE BP-2017-0600
(Hs COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B- 109 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MOL c.142A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2017-0600
Project# JS-2017-000970
Est.Cost:$2623.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Claw: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size-set.ft.); 17119.08 Owner: ROODMAN GARY M&ROWENA F
Zoning:URA(100V Applicant: POTENTIAL ENERGY LLC
AT: 26 GROVE AVE
Applicant Address: Phone: Insurance:
4D QUEEN TERR (860)620-4433 WC
SOUTHINGTONCT06489 ISSUED ON:10/2812016 0:00:00
TO PERFORM THE FOLLOWING WORK:open blow insulation, vent bath fan, weatherization
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:
FeeTWpe: Date Paid: Amount:
Building 10728120160:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587.1272
Louis ttasbrouck—Building Commissioner
File#BP-2017-0600
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 4D QUEEN TEAR SOUTHINGTON (860)620-4433
PROPERTY LOCATION 26 GROVE AVE
MAP 10B PARCEL 109 001 ZONE URA(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
OSED REQUIRED DATE
ZONING FORM FILLED OUT �(
Fee PaidC
Building Permit Filled out �(
Fee Paid
Typeof Construction: open blow insulation,vent bath fan,weatherization
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106184
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolition Delay
-ar/(
'qrr- a 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.
Department use only
City of Northampton Status of Permit .. -
Building Department CurbCut/DmyawayPermit
212 Main Street Sew(eNSepUc Aqf jr
Room 100 WatemWea Availability
Northampton, MA 01060 Two Sats 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 Properly Address. This section to be completed by office
2t GYcve. Av i t p Map Lot Unit
Lads f MA O I 0 S 3 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
GCV & \Zwe,hCk Rcocmcd(\ )iuGycw Ave Lee,1s MA 01053
Name(Print) Cugnialin re66: r
SL�L G2uGk 01 f VlTelephonei2s g
Signature
2.2 Authorized Agent: •
Nam NPI lnchrIcs Me.i,s+eY ' en-hal �I Ea 1cCrrent Mling unSt� (� ns`o cI0(Dolb
ss
• mercy ! . q2((0
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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) 2r (D2 3 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature:
Building Commissionerllnspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) n Roofing Q
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[a] Other m -
Brief Desedptii l Y/ etto idle kiI�.j- t V{21 Il Oh Thin /MC then 701o�
Wok �1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.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
Se 9 aU f NOY
liA .as Owner of the subject
properly r
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature
ooff/Owner
(j (` ////// }-(� (y Da�tee p ����pp
IIIIMIIIMII
I, Ni loll ) M st v/?oI V71— CL/ Ch CV �� ,asOwner/Authorized
Agent hereby declare that the statements nd information on the foregoing application, re tj a and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
NIchc' Ias \ dSte K
Pnn(Name -
—_ __ . to zs� i U.Signature wn§i2Agerd--- Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sulpperviso�r: p p (Nott Applicable ❑ p (�
Name of Cleanse Holden N1 Chcigs Meer csA - 100) 1 (� 4
License Number
4D @uct rer�� SeAllingtCu� CT Oto 4 ',1 4�z�7 201 q
Address Expiratio Date
Signatur Telephone
9.Registered Home Improvement Co : - • Not Applicable 0
?O eatlai iCl/ rf Cls 111%1s�z� not LA U\
Company Name Registration Number
CUefill-k I Sc�ttliMCIli , CTC104 �� -1Iz � ) wig
AAddress J Expiration Date
3taCc4Ae
.x.— Xd
Telephone
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 bur ing permit.
Signed Affidavit Attached Yes No ❑
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 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 Law-s 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: 2\L &YD Q, kit)• ) ,k£(�S , rA�l (5\0S3
The debris will be transported by: Rilt,Int.1CL\ CYtYB )
The debris will be received by: VG, VAlori €6 '& e(1i( 1 I nc) -PI c tv i I \ -a)
Building permit number:
Name of Permit Applicant i\hcfdas M € 5 t 6 Y
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
1.•=-..T. =., Department of Industrial Accidents
W Office ofla vestigations
e'stn— • 600 Washington Street
a `�_ � Boston,MA 02111
www.mass.gov/dta
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Numbers
Anolicut Information Please Print Leelbly
Name ): YO PY"Y I0 I ! 'me VIII { L.i C jN i r..h;^. i Ct S Mese r
Addresa: , .c-IaF ( Terv-arE
city/stawzip: , tkingJOnfT06)4-6‘.(3 Phone*: SSIGO-4'Zli-1413 _
Awn an employer?Cheekmalappropriate bar Type of project(required):
I. I ma employer with 5 4. 01 am i general contractor and
employees(full aS/ar pais-t iic).a have hired the sub-conuacmn 6. ❑New coneuuctloe
2.0 I am a sole proprietorot panic- listed on the attached sheet 7. 0 Remodeling
ship sod have ao employees These s W ronuacton have 8. 0 Demolition
working for me in say capacity. en Ioyees and have wodnrs'
: 9. 0 Building addition
[No workers
rump.insurance �4
requited.] 5. p We arca corporation and in 10.0 Electrical rcPaka or additions
3.❑ I am a homeowner doing all work officers have exercised Sir 11.0 Phm tog reports or addition
tight ofMM.
repairs
myself.[No workers'comp. exemption perhave
12.0Rod
insure= fired]t c.152,41(4),and we have no
employees.[No workers' 13. Other Ill SIA lei tlCl/1
comp.mauance rewired.]
*My watt dot circle hos el IMO ab em m aeream here Moana,ant worms'cawa®dm policy inference.
t moemama man atbe;t ole ambvi,idieeMra ray re dorsal warted that hire dans emaamwr met snail a ore affidavit Mining won.
ttwasbn M check this box mat.trkcd in aridfl sheet iowioa rh nine a the rvlramaclars and saw Mere or ear those mads lam
anpbtaa. If the stthreameton have employees.dry mat provide ten%Man'mem Paanambec.
7w as employe drat is providing worsen'compendium Iiswraoafor my employees. Below Is the polity and job site
leforwedeme
insurance Company Naos l{ VI 1--(,)Y ,., K UY/?Vi ��, ki,;\,1, r.
)i�1
Policy al or Self-ins.Lk.ft:/'� % n�, 1= C �i t// 145 6Expiration Dae: . >/ --G
fob site Address:
W. l Trove. AV-E11Le _ cayistawzip: Le tai,Cl M A 0 \X53
Attach a copy tithe workers'compensation policy declaration page(abowing the policy nnmber and expiration date).
Failure to secure coverage as required under Section 25A of MO.e. 152 an lead to the imposition of criminal penalties of a
fie up to$150000 and/or doe-yeas imprisonment,as well a.civil penalties in the form ofa STOP WORK ORDER and a fie
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investintiow of the DIA for Tangency coverare VerlicatiOn.
Ids heneyese0 aniler/hepabu andpaod5W of nary rbarae informadam provided above fs true"and correct
--
Si acv _ Dat t0\21.11.\___Q____ _
Phone e: 0i�(;- 4Llir 141ci �
OB9cloitut ally. Do not write In Ebb ardor.w be congaed by hay anoxia official– - —_
City or Town: - PornsdNLransaa
Issui g Authority(circle one):
1.Board ofHealth 2.Baffin Department 3.City/Sown Clerk 4.ElectriW Inspector 5.Plumbing inspector
6.Other
Coabei Parson: Pb...d;
Owner Authorization Form
I, Gary 8 Rowena Roodman
(Owner's Name)
Owner of the property located at:
26 Grove Avenue
(Property Address)
Leeds, MA 01053
(Property Address)
hereby authorize Potential Energy, LLC , a certified Mass Save Home
Performance Contractor, to act on my behalf to obtain a building permit and to
perform work on my property.
(Owner's Signature)
9-1-16
(Owner's Signature)
Client#82429 MEISTNIC
ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATIMMmD"""I
7/27/2016
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:if the certificate holder is an ADDITIONAL INSURED,the holicy(ies)must be endorsed.If SUBROGATION IS WANED,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 hciAOMEncT Audrey Lamontagne
Fradette Carlson Agency wRn Sex 860583-0943 - -I talc wl. 860585-0038
PO Box 2456 EIAAIL
ADDRESS: alamontagarshep.com
Bristol,CT 06011-2456
INSURER(S)AFFORDING COVERAGE NAIL*
860583-0943 INSLRER A:Hartford Ins Group 19682
INSURED
INSURER B:
Nicholas Meister DBA — ------ -----
Potential Energy LLC INSURER C:
4 D Queen Terrace INSURER D
Southington,CT 06489 INSURER E:
INSURER F
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. NOTWITHSTANONG 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.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ANSA ADO!.SUER PC4JCY EFF POLICY EXP
LIR TYPE OF INSURANCE INSR NYD POLICY NUMBER IMMNONYYVI IMM/CMYYYI LIMITS
A XCOMMERCIAL GENERAL LIAERnY X 02SBMRBO5O9 08/05201608/05/2017EACH I I.Frn::F /2000000
eiswte I XI OLc..R DAMAGE REc'rj
'.Est-R,, $1,000,000
•
w r rr�.�LE
MED EPl rteY 1mni, $10,000
PERGU_NAL&ALA!NAJAF 12,000,000_
GEF ECA-1E 94,000,000
XN Prel
LOC PECcu CONw^_PAOC ;4,000,000
OTHER
A AUTOMOBILE UABwTY 02SBMRB0509 08105/201608/05/2017E rapoNEdeN,DSweLE Hear
,z,000,Goo
DODIL IJUR"(Pu poi:ib r
idLOYVVED T—pa1EL'JLEC pODIL"INJURN Por nowt? 9
AfrOS L r:)s
XAJTOS JEIJ -'OPERer DAMAGE
elRtU aU105 xNL0.5 ;Pe' oder: S __
A X UMBRELLA UAB H Occup X 02SBMR130509 08/05/2016 08/05/2017 EACH o r RBENcF 91,000 U00
EXCESS Luc MvrADE ACCAEGA1F I;1,000,000
EEO X RETENTION110,0OG
AND EMPLOYERS'
YERS'LBQIpN jPER
A 02WECCR0745 08/05/2016 08I05/2017 X
AND EMPLOYERS QATNEF .rIN `A TF IrFi
CECPPMe r CLLLE mTrJ` _LEA 1 ACC DEA' 950Q000
(Mandatory
andatr. BE< xa�eD yl rvlA
IMandd :nbs aL DsensE-�ErnnD ;500,000
LOSCP IPTDNo
OPERATIONS Delo. EL clsESE-......, .IMT $500,000
DESCRIPTION OF OPERATONs I LOCATIONS I VEHICLES IACORO 101,Addbonal Remarks Schedule,may be attached dmore space is rewind)
Columbia Gas of Ma is an additional insured on the General Liability and Umbrella Liability Coverage per
written contract or agreement.
CERTIRCATE HOLDER CANCELLATION
COI mbla Gas of Ma SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M
4 Technology Drive Suite 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough, MA 01581
AUTHORIZED
REPRESENTA1WE
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) 1 oft The ACORD name and logo are registered marks of ACORD
NS843449/M843422 FCAJL
41- on,wee ierover 4A c/C/1irrt, arAmie(6
r Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Regiahstion: 179401
Type: Individual
Expiration: 7/2812018 Trill 419291
NICHOLAS MEISTER
NICHOLAS MEISTER - -
4 D QUEEN TERRACE
SOUTHINGTON, CT 06489
Update Address and return card.Mark reason for change.
x:ei r 2A...111Li Address ["I Renewal D Employment ' , Lost Card
omee of Consumer Affairs&Bosoms Regulation License or registration valid for individual use only
F�2--,�%'? HOME IMPROVEMENT CONTRACTOR before the expiration date. ff found return to:
C—" Registration: 179401 Type: Office of Consumer Affairs and Business Regulation
.r �r Expiration: 7/28/2018 Individual IO Park Plaza-Suite 5170
Boston,MA 116
NICHOLAS MEISTER % _:-.r''
NICHOL AS MEISTER
4D QUEEN TERRACE
SOUTHINGTON,CT 96489 - — 4 W _.--
Umleaseenbry Not vsBitimat signature
assac husetts-❑court"-ent of Ru bon Safety
Board of Building Regui at:ons and Standards
(unstrucnon S 1 vnw,r 7 C2 Famils
_;cense CSFA-106184
NICHOLAS MEISTER
4D QUEEN TERRACE
Southington CT 66489
orrmissmner 04/27/2019