05-019 (10) 277 AUDUBON RD BP-2017-0832
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block:05 -019 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-2017-0832
Project# JS-2017-001390
Est. Cost: $1500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS99381
Lot Size(sq. ft.): 273992.40 Owner: CARNES RICHARD CHARLES&EMMA JANE
Zoning: RR(100)/WP(8)/ Applicant: THE ENERGY SPECIALISTS
AT: 277 AUDUBON RD
Applicant Address: Phone: Insurance:
212 AMES RD (413) 566-1058 WC
HAMPDENMA01036 ISSUED ON::1/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORK ADD 2"THERMAX TO KNEEWALL INSULATION,
ADD R20 CELLULOSE TO K-WALL 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 1/5/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0832
APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS
ADDRESS/PHONE 212 AMES RD HAMPDEN (413)566.1058
PROPERTY LOCATION 277 AUDIJBON RD
MAP 05 PARCEL 019 001 ZONE RR(IOOVWP(83/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSEI) REQUIRED DATE
ZONING FORM FILL. DO rf
FepPaid niera=
Building Permit Filled tut inner
Fee Paid fr
T teof Construction: ADD Y"FHE MAX e • EEWALL INSULATION ADD R20 CELLULOSE OSE TO K-
WALL FLOOR Mr
New Construction
Non Structural interior renovations
Addition to Existing
_ Accessory Stmcture
Buildin¢Plans Included:
Owner/Statement or License 99381
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION� PRESENTED:
ke`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 Pennirs 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
:on
,•.rlay ,.
.. ./ t . / Y /7
Signature o Cul dint to ¢ial Date
Note: Issuance or*Zoning permit does not relieve a applicant's burden to comply with an 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:
4 2011 I Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Yvell Availability
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
177 4c ci /n r' Map Lot Unit
Ler(IS/ /74 0/c S3 Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/C• // ,t
rob r/ (Gr u,- 3 o )7 AO eta ec
Name(Print) Current Mailing Address:
eC✓�" / Telephone, ',,,t / r/-Y- o/S S-
t/11tA
Signature
2.2 Authorized Agent:
17 Corm� S/9, c, c� '1/s 2/4 A.4 s /4.4-7104.-
Name ! Current Mailing Address:
5-GG /!c v
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
%5 CXi, cc
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
N/T
4. Mechanical(HVAC)
5. Fire Protection ,s1/4 '[2,
6. Total =(1 +2+3+4+5) /5'GO • c ` Check Number/77�j) #�J
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
This column to be filled to by
Building D yuvmen(
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage .o
Open Space Footage ro
(Lot area minus bldg&paved
park am)
tt of Parking Spaces
Fill:
I volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 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 DON'T 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 NO 0
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 ,el
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex vation,or filling)over f 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 n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing C
Or Doors 0
Accessory Bldg. D Demolition D New Signs [C] Decks [ Siding[C] Other i4
Brief Description of Proposed /
Work: A// L" 77,-. X 76 �Nrrx.>c//, i9,/./ /.,4; ri/,u/car A h-“),../7nc
// c i-
Alteration of existing bedroom_Yes / No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes 7(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
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, �r4 . //
/ l5. .v,:.J as Owner of the subject
property
hereby authorize no- e -4,sN{r 4,Or c/c/3J/f
to act on my behal n all matters relativLL�r,&O work uthorized by this building permit application.
t. r✓veld-el 97z/ .ate /s 7 Y/a
Signature of Owney // Date
I, /1' I- {Iters /3,15as Owner/Authorized
Agent hereby declare that the'statemeri 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.
PdnAlprarr
y
Signature of Owner/Agent - Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder: )e.4 el (yrer - r-'10G a 9 3 /
License Number
Ad � Expiration Date
5GL /ifC c/
Signet Telephone
9.Registered Home Improvement Contractor: Not Applicable
7/ G.pryj spite,. /j 11s />-32 7
Company Name Registration Number
Address Expiration Date
Telephone 5-6f. -/./C 9
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MOI.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 A/ No...... ❑
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 Iwo-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 huildinp 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: J7/ i> Cs/u 7r>/.S 7'7/9
The debris will be transported by: %/i L=�>Jl J�Jc,t/, ,fl
The debris will be received by:
Building permit number:
Name of Permit Applicant ,;L�,/
eir
-/ 7
Date Signature of Permit Applicant
City of Northampton
'^ Massachusetts r.e 's�(�(��@���y t
t -br. DEPARTMENT OF BUILDING INSPECTIONS Z Q$ -P,
�. : Y �. 212 Main Street • Municipal Building x`. `a
'�' Northampton, MA 01060 fly fl\
Property Address: _d 77 AJ/u ho-, 71,d__ _ _ �.4
Contractor
Name: /47 4";a37 get,.-7_1/5
Address: J/( ,,,,-1 ,-....-1
City, State: _ ' K ' -> /'#q
Phone: _CC 1=le Y...._.__
Property Owner � / l
Name: /((.5c..!.... f�y,.,,,, �.---
Address. 2)7 /71i Sly to.... e,i�..._^_ ..
City, State. ter "14 _.. .....
1, 776 o=,,,.. ,
44 'c/,ys (contractor) attest and affirm that the building I intend to
insulate does have any open air(knob and tube)wiring in the spaces to be insulated and that 1 have
provided the property owner with a copy of this affidavit.
Contractor signature ,
Date
/- %/7 ^—
The Commonwealth of Massachusetts
Department of Industrial Accidents
N Office of Investigations
-_--I_ - 1 Congress Street, Suite 100
Boston,MA 02114-2017
MA-W8):
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busis/Organization/Individuap: The Energy Specialists
n
Address:212 Ames Road
City/State/Zip: Hampden, MA 01036 Phone#:413-566-1058
Are you an employer? Check the appropriate box: Type of project(required):
I. I am a employer with 2 4. ❑ I am a general contractor and I
employees (full and/or part-time).'
have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have R. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers comp. insurance comp. insurance. 9. El Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their I LIE Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL n ❑ Roof repairs
insurance requires]-] ` c. 152, §I(4),and we have no Insulation
employees. [No workers' 13.❑� Other
comp. insurance required.]
'Any applicant that checks box Al must also fill out the section below showing their soden'compensation policy information.
Ilomcownen who submit this at t davit indicating they are doing all work awl then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box in cast attached an additional sheet showing the name of the sub-contractors and state whether or not those enmities have
employees. II the sub-contractors have employees,they must provide their worker'xrtmppolicy number.
I am an employer that is providing workers'compensation insurance fin my employees. Below is the policy and job site
information.
Insurance Company Name:Associated Employers Group
Policy#or Self-ins. Tic. #:WCC5009547012014 Expiration Date: 10-16-2017
lob Site Address: d)) /x... p� City/State/Zip: L. r e M 4
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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 cerci,• •r r the pai , n es of perjury that the information provided above is true and correct.
Si mature: — . Date' // %-/7
Phone#: 4135661058
Official use unit. 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#:
L onrnzonrcewaUh c f(Vflaodach
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
Ii Type: IndNdual before the expiration date. If found return to:
Mee of Consumer Affairs and Business Regulation
)ie!3227 Expiration 10 Park Plaza-Suie5170
15328 11/13/2018 Bost011,MA 0211_
The Energy Sperms
Mike Grenwood212 AMOS Rd.
Hampden,MA 07036
Undersecretary Not valid without signature
9 Massachusetts uetts Oe egumeotsf Pulic Safety
Board of Building Regulations and Standards
License: CSSL-099381
Construction Supervisor Specialty
MICHAEL E GREENWOOD
212 AMES ROAD
HAMPPDEEN MA 01/0'36
CA - Expiration:
Commissioner 03/09/2018
ACS K e CERTIFICATE OF LIABILITY INSURANCE DATE
A a AYAM eSt
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 policylies)must have ADDITIONAL INSURED provisions or 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 Me certificate holder In lieu of such endorsementlsl
Pacavt<ws 13^1305Thcr Ch slice E Davenport
REhard R Green Inc recons Agency,ins PARe (413)5E6-0028 FN WO%6 3090
07SomersRd WCC t1._.__.._ _ _LA H0/
Ham;!dan.MA 01086 <MITERS edavennorterichardoreeninsuranceam
INSURERRI A FFOROiNG COVERAGE NAicu
mSUREAA. PATRONS MUTUAL INS CO OF CT 145123
., nee
Michael 6!eemvoad rxwrscRe. CITATION INS CO 40274
dba Tae Energy SRC-cshst xuRSR e. Aesoaaled Employe";Insurance Company A0280
211 Ames Read
I'fanllpden.MA 01036 INSURER U
ie SJxFa E
INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER,
riIIS 50 CERTIFY THAT 115 POLICIES OF INSURANCE LISTED CROW HAV.PEEN ISSUED Tl THE INSURED NAMED ABOVE FOR THE POL ICY Et MCID
:JI
r- TED N:TVITHOTANOM6 ANY REQUIREMENT TERM OH CONDI]ION OF ANY CONTRACT OR OTHER DOCUMENT VNIH RESPECT TON 4ICH THIS
liTedPATEI IONS MAY BE ISSUED ORF MAY PERTAIN THE INSURANCE AFFOVE BE N ED CED eY P *0 DESCRIBED HEREIN IS SUBJECT TO All LITE }'QRhL`.
ZCLUSIONI AN)CONVRIGNS OF SUCH POLICIES LIMITS SHOWN MA", HAVE BEEN REDUCED 0Y CN!O CLAIMS
Luse WI UMBER nuCY r METW POOPS SEP
cr SSAS GENEIALNLE y+sn WWI l\. j 2O1t 4rOli LIMITS
.� oNNBeGAt GENERAL Aolwtt 80P2843II85 iR9N21'�6 ffi1A2Di} L i3O0EGO
v r 300000-Ram„.�._
MEDE.I 5000
14n OI 000 000
2 000 300
2C00L03
5
S AUTO/4061W yEVERY BB54J27 -- 01105/2016 01 052017 -.a°i„4N , R'r A E ' _ 1,NO ORO
b:eta I'Mie I IL e,,a,r.5
it 5
V
A 1 umEWELLA ace ✓ CXS2Il1.0 10/14/2016 101420'7 eN r. 1000000
CESS IWO' ..
en c Wok.8O05009S 0l€A 1¢16-"0IF) 10 &;2`57 ' v
acs _
=r F art c 500000
500.000
„ .R. E1 SR s 504000
ncncRPTIONOF OREM0Ox6r LsCAIIO SrVPNCLFS IACIJRU ray<vesIsel Prmnkr Sct JiO ,rvq Ca reamed U mare Ince Ir regaled,
S d S.polpolio/'Eros and conditions. Sole Proprietor excluded farm coverage an the Workers Compensation policy Additional Insured status is aurnmatic with e
.. artls to Ins f$er',eral Liabrlily and Auto Liability UOLaes when requested by wnllan Contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY Or TIE ABOVE DESCRIBED POLICIES OE CANCELLED BEFORE
TBC Energy Specialists THE ERPIRATIUN DATE THEREOF. NOTICE WILL BE DELIVERED IN
212 Ames Rd. ACCORDANCE WITH THE POLICY PROVISIONS.
Hampden.MA 010'36
AUTWOR2 C PEPRES'C.NTAme ...
Cl 1988-2015 ACORD CORPORATION, All rights reserved.
ACORD 25 l2(116/03) The ACORD name and logo are registered marks of ACORD