24A-051 (2) 149 BARRETT STBP-2017-0891
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:24A-051 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-2017-0891
Project JS-2017-001514
Est. Cost $3008.00
Pee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sa. ft.): 10846.44 Owner: CHAMBERLAND CHRIS
zoning: URB(100)i Applicant: POTENTIAL ENERGY LLC
AT. 149 BARRETT ST
Applicant Address: Phone: Insurance:
61 EAST MAIN ST (860) 620-4433 WC
BRISTOLCT06489 ISSUED ON:1/27/2017 0:00:00
TOPERFORM THE FOLLOWING WORK:OPEN BLOW INSULATION, VENTILATION
CHUTES, AIR SEALING, 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: O_I: 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 1/27/20170:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2017-0891
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 61 EAST MAIN ST BRISTOL (860)620-4433
PROPERTY LOCATION 149 BARRETT ST
MAP 24A PARCEL 051 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: OPEN BLOW INSULATI TILATION CHUTES,AIR SEALING
WEATHERIZATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building.Plans Included:
Owner/Statement or License 106184
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$�IATION 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
n01In n y
/- a 7/7
Si re 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.
Departs ent use only
City of Northampton Status of Permit:
�h Building Department Curb CutlorivewayPerm(t
i - 212 Main Street Seiv r/Septic Availability
Room 100 Water/Well Availability
\ Northampton, MA 01060 Tiro Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Ploi 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
v�1�I�✓�/�J� � I 1 Zone Overlay District
Elm at District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Y�S i
r o - M4 'IQ ( irrett StNC�rtY ampfiDn Mfl 61
Name(((Pnn Current MaCurrent Ma
Lo
J t. Telephone 1J-U 1 �V 1 r t •J•� O— 3�"
Signature
2.2 Authorized Agent:
Ni&i[�IQSMEISterjRten11Cyqynehla MG�e�St.P�nSWCTDL010
Name(Prod �7
1GO �,Ip—U2(G(G
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building (a)Building Pennit 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) 1 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner inspector of Buildings nate
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing O
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding[O]
Brief De � ht Pro
Workn, sn
uat�ov�, ,^-n�Uhorc-1w,teSipirsu,Air tHeviiat)ov�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house and or addition to existina housing. complete the following:
a. Use of building-.O amily Two Family Other
b. Number of rooms in each ford ly unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction, Di sions
e. Number of stories?
C Method of heating? Firehas or Woadstaves Number of each
g. Energy Conservation Compliance. Masscheck`F\nergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of tlands? Yes No. Is construction with, 00 yr. Floodplain_Yes No
j. Depth of
k. basement or r Floor below finished grade
Willbuilding c e
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, � )(Y ''R')OntV CAWrn kYlaV�d Moi�u 4�avk%VA CKMn Xrlave Owner of the subject
property
herebyauthorize
to act on my behalf,in all matters relative to work aul nz- d by this building permit pplication.
- �o1ea5�, S2eai����ed au�hov�� a�iw�
Signature Owner
Data
I, �� ,asOwner/Authorized
Agent hereby declare that the statements rd information on the foregoing apolication are true and accurate,to the best of my knowledge
and belief.
Signetl untler the pains and penalties of perjury.
Nida�Z S q nal � r
Print Name //ff
Signature of Owner/Agent ate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supereiiso/r':� NotApplicable
El
No..of License Holder: r�t/� VtA .�J�l� WFA - VD (j 7
D`1
License Number
SID NUew i E SbW-h gf-W, CF04M u / z� jzo� q
Add SID
s �— Expiation Date
-'�_ . 4�0 (120 4433
Signator ._i..- .-..__- Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
R*MW En ,�Q N % M -& 1 �quot
Com an Name Registration Number
uIJ 716I�W GU�hiv�(�}Gw CT O1o48 '1 ��zR /zber
Address J 7�� Expiration ate
Telephone 8l� -6c{/ 33
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 Dwellit es afore(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 in reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use bond of 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 buildine Permit
As acting Construction Suoeryisor 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)ofthe Massachusetts General Laws Annotated,you maybe Iiable for persons)
you hire to perform work for you under this permit.
The undersigned"homeownet"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, asdefinedby VIGL c 111, S 150A.
Address of the work: I y G (�(,IYVi rl (Sf Kf e
The debris will be transported by: I tcT ) h c l EVlt q til
The debris will be received by: Pq- {f'ySdV) Y)Cltoi) CT
Building permit number:
Name of Permit Applicant ki (,WaS
_ .1f7 J
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Of/ice of Investigation
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.ntass gov/din
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �/��' �P�lease Print Leeibiv +
Name Business/OrgeniratimJlndiviJual). '��'T f' �I �� �t t I�'� 1, �', (t iLL� {,
Address:
City/State/Lip:
Phoneiv:
�,WO 5i1 , �126'ilG
Are an employer?Check the appropriate box: Type of project(required):
ml
I.Far a employer with 1 4. ❑ I am a general contractor and 1
employees(Poll and/or part-lime)' have hired the sub-contractors 6. El New combination
2.❑ I am a sole propoetor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees "these sub-contracims have 8. ❑ Demolition
working for me in any capacity. employees and have workers' q ❑ Building addition
[No workers' comp. insurance comp. insurance.=
required.] S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work oficeis have exercised their I L❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12❑ Roof repairs
insurance requited.] t a 152, §I(4),and we have no
employees. [No workers' 13.�Other
comp. insurance required.]
'Any applicant that ehe L box WI mon assn fill nut tho section below shoring their workers'compensation policy insno arias.
t Haneavnen aha submit chis affidio it indicating they are doing all work and then hire outside contractors must submit a nese affdevit indicedrrg such.
tContmetors that doeek this box must attached am additional shat showing the name of the sub<oadmdom and state whetherser not those entities have
employees. If the sub-cantmcmrs have o+nploosxs they must provide their workers'events policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
Information. me �—�nr (' '/7
Insurance Company Na : ei���TLpai r aft C � Ci 1 1;ii
Policy N 01 Self--ins 1 icH G rV C�.1� 1!l -7 Expiration Data S/5/ 2 Q i
'' II II ((yy Q� D It y i.
Job Site Address_Lq`I L111Y�T II �I �e'�I __ City/StateYZlp: GMVt'[ MA 0Q0
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 MGI,a IS2 can lead to the imposition of criminal penalties of
fine ap to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the font ofa 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 ofthe DIA for insurance coverage verification,
l do hereby certify un#r the pairs and penalties of perjury that the information provided above is true and correct.
II
Siunamra
Phone B: lti�: - 5�''tli— `T LI✓
Official ase only. Do not write in this area,to be completed by city or town official.
City or Town:_ Permit/f.icense
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
G.Other
Contact Person: Phone 4:
Owner Authorization Form
1, Molly Hartford Chamberiain ,
(Owner's Name)
Owner of the property located at:
149 Barrett Street
(Property Address)
Northampton, MA 01060
(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.
2LI±*9�an ex�r an.�uiL
(Owners Signature)
(Date)
Clientlk 82429 MEISTNIC
ACORD. CERTIFICATE OF LIABILITY INSURANCE D7M12`7 �°"YYY,
7/27/2076
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 CONSTTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the Insincere holder is an ADDITIONAL INSURED,the R.H r(iasl most he endorsed.If SUBROGATION IS WAIVED,ALI to
the terms and conditions of the policy,Certain policies may require an endorsement.A statement on this certificate does not confer rlgMsto the
cedlficate holder In)leu of such endorsement(s).
PRUUI NAME.CONTACTAudrey Lamontagne
Fradette Carlson Agency A`S N,% Ex,860 583-0943 ac SR. 860-585-0038
PO Box 2456 ADDRESS: alamontagne starshep.com
Bristol,CT 06011-2456 INSURERISIAFFORDINGCOVERAGE NAree
860583-0943 INSURER A:Hartford Ins Group 19682
INSURED wsurlER e:
Nicholas Meister DBA -_— _--__-- -
INSURER C'.
Potential Energy LLC -- _-- _ --- _--— - — --
INEURPRID
4 D Queen Terrace
INSURER E,
Southington, CT 06489
suaae P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISS,ED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTVNTHSTANDNG MY REQUIREMENT, TERM OR CONDITION OF MY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR AMY 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.
)ITR TYPE OF INSURANCE INER WSO POLICY NUMBER SUBRT POLICYErr
IMNLIICOIYYY E, U.I.
A X COMMERCIAL GENERAL LIABILITY X 02SBMRB0509 81052016081051201 =H-a_L /20010000
_ �%V,LE UT_LH 'yEII 11000.000
$10,000
11 11 .H. :2,000,000
-N• 11.1I...�MTa., -FILE u- F (JFGA [ {4,000.000 . .
z FR_
, - LCL .- ,,,—T'-- ya,DOD,000
[,TI s I d
A AUTOMOBILE LIABILITY 02SBMRBO509 810572016087051201 72,000,000
Ee
Go oiU E
LVe ED,. L. BO n Jo T 1
Ir X FI VJ - % J .rrE FPrerFI ,F, _....__
1
A % UMBRELLA U4S X owdR X 02SBMRB0509 8105201608105!201 s FPH.cE 111,000000
E,mEss HAS
emu=Le Fen,E s1000000
Y, I X[,, F. .sl000O _ T
A ANDWORKERS
EMPLYERSLSAn LN 02WECCR0745 6/052016 08!05201 X ', "AND EMPLOYERS LIABILnY
Llo1 rs'TNLP «T vrry - L' B,.o¢� S50Q000
SIC h tlR., _71LLII Y NIA
11, 1 1,uHl =L cIEEsE-E=,E,nPLorEe $500,000
DE'CP,IPT�'N F-OPElnTCNT Les, EI FIrFsF 11 11 VT 1500,000
i,
DCSC PnC °FOPEri ONSILOCATIONSIVEHICLES(ACORD101,Additional Rema SSCbeWit.mWbeeeaaReEamort.P.oe IxrtpWmCi
Columbia Gas of Ma is an additional insured on the General Liability and Umbrella LIablllty Coverage per
written contract or agreement,
CERTFICATE HOLDER CANCELLATION
Columbia Gas Of Me 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 PROWe1ONS.
Westborough, MA 01581
AIRHOMZED REPRESENTODW
61998-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) 1 all The ACORD name and logo are registered marks ofACORD
#SB434491M843422 FCAJL
i' Ofce of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 178401
Type: Individual
E=lra0on: 7/282018 Tr/f 419291
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE --
SOUTHINGTON, CT 06489
Update Address and ectnn card.Mark reason for change.
[] Address ❑ Renewal ❑ Employment I— Lost Card
.u.n, , oocann
Once of Coosa our AOuirs&Business Regnhdoo License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expintion date. Iffound Yemen to:
Registration: 179401 Type: Office of Consumer Affairs and Business Regulation
Expiration: 712812018 Individual 10 Park Plara-8uae 51]0
NICHOLAS MEISTER /
NICHOLAS MEISTER
4 D QUEEN TERRACE _--
SOUTHINGTON,CT06489
Undersecrenn' Not valid without signature
lassac s� ^:;v
ooard
_c CSFA-106184
NICHOLAS MEISTER
4D QUEEN TERRACE -
Southington CT 06489
-
-_..........a . . 04/27/2019