38B-070 237 SOUTH ST-UNIT A BP-2017-0936
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-070 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c 142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0936
Project# JS-2017-001598
Est.Cost: $1254.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sg. ft.): Owner: DENNIS DONNA M
Zoning:URB(t00V Applicant: POTENTIAL ENERGY LLC
AT: 237 SOUTH ST- UNIT A
Applicant Address: Phone: Insurance:
61 EAST MAIN ST (860)620-4433 WC
BRISTOLCT06489 ISSUED ON:2110/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:OPEN BLOW INSULATION, VENT BATH FAN
THRU GABLE WALL, AIRSEALING, 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:
FeeType: Date Paid: Amount:
Building 2/10/20170:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck- Building Commissioner
File p BP-2017-0936
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 61 EAST MAIN ST BRISTOL (860)620-4433
PROPERTY LOCATION 237 SOUTH ST-UNIT A
MAP 38B PARCEL 070 000 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
FERMI ION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid U
Building Permit Filled out
Fee Paid
lypeof Construction: OPEN BLOW INS - ON,VENT BATH FAN THRU GABLE WALL,AIRSEALING
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
INFORMATION PRESENTED:
/proved 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
Demo'. :n Del.
- /d
Signa ore 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.
OlDepartmentuse only
City of Northampton Status of Permit
/ * ./ Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
CO
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
tt phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
..�APPKICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Ad-drress:�q j7_ '` + ,1 This section to be completed by office
•
237 SOU+{'15treel Uh! 14- Map Lot Unit
NOHJI0mh fo/ MA OiQ p0 Zone _ Oveday District
J� Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NirmIo. Dennls 237SCUM Si.- Unit/ , NCH-hampthn, A A
Name(Prinn/t)��>> YN.c /� /� n��1 �-n �er1 Current Mali s 0100
to ourncr emfh0)17Ao t{tNI Telephonel � � 1Lli
Signature
2.2 Authorized Agent:
NicholosM€rte,Y/P6te'r'na Lr9I9 lal EMai oSt) RYisthl ,CTolo010
Name(Print) Current Mailing
SOle 42.to
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildin (a)Building Permit Fee
InctIAMIIr ) 25U —
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection I1 /q( yyo6b� /
6. Total=(1 +2+3+4+5) 3E12-5Y Check Number fy(/ia fli0e7
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks fO Siding jol Other Itj
;t�SUIa hnvt,
Brief Description of Pro o
work:OffrrowInSl) non vevitba+(1 TIM thoul(abletoc \1a1reeal nC),weathengcchon
Alteration of existing bedroom Yes Y No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing.complete the following:
a. Use of building n0 a 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? Flreps orWoodstoves Number of each
g. Energy Conservation Compliance. i, Masscheck Energy fiance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. Po lain Yes No
j. Depth of basementnrcellar floor below finished grade
k. Will buil i 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. — set attach OW,YIEK as Owner of the subject
property 1 n /1 -Fr�r
hereby authorize OM I 'f t Kt j/t fi O K. l V Km,
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature�loffOwner Date
,1 L (� v }p y�} /� �,^ Date
111111
I, I v)Q11,lli/\� I�t4.IC+L�rJ 'Pater � R E-reyv/v��11 ,as Owner/Authorized
Agent hereby declare that the statem is and information on the foregoing appliceelliion are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and,penalties of perjury.
(ill ChoiCS J-, lbtQX
Print Name ,
/ c 2 7- 17
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:� Not Applicable/�❑
Name of License Holder: N(Ch()I VIS I Y T, bI Y (W1A IO\ (1,'4
License Number
L1 \ utiVTerr cVy i ngkOYI CT I/,o` R �2l
op
AddressewleDAre
3Lo - l2C - 4y33
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
MPXi1ONe,YN / Nich010S 'MelSiev Flg401
Company Name Registration Number
uDCv1(EW -) 11(490Uihiv><� v C7 (J�Ug� � I2g �
� zc �
Address Expiration Da
Telephonacp-(12t-0"li14.,u
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 34 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)ofthc 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: 231 SO\at Y l S\Yeet " 1),Y1 I t A
The debris will be transported by: Potential EneYlt�
The debris will be received by: PaAkt,rSOin TVI"€YpYIStS - ris-to I I CT
Building permit number:
Name of Permit Applicant N1(-,H h\as Me st€,1 E1-en tI Q Eller( Li
2-1- 1 l •
.
Date Signature of Permit Applicant
The Commonwealth of Manachusetts
p� Department of Industrial Accidents
Ikm'_'till-( Office of Investigations
I s 1 Congress Street,Suite 100
`'' 4—• ` Boston,MA 02114-2017
. ci' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name(Business/Organization/Individual): PO Y r[t I VL I r �'„I{y 0 i I1 L L ('/NI ,i
k�' t�) ��i-cL�)Iti
Address: � E i�'I Li l In, i r't,e I
H
City/State/Z.: LT �lu Phone#: -.,� __- �i�(
Are ou an employer?Check the appropriate box: Type of project(required):
I, I am a employer with 4. ❑ I am a general contractor and 1
employees (Poll and/or part-time).* have hired the sub-contractors G. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
comp. insurance.; Y. 9 Building addition
[No workers' comp. insurance
required.] 5. 9 We arca corporation and its 10.9 Electrical repairs or additions
3.❑ 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 MCL
insurance required,] t c. 152, §1(4),and we have no 12.❑ Roof repairs .L.
employees. [No workers' 13.�Other]]a]`�l,(I Q o 0
comp. insurance required.]
'Any applicant that checks box/II must also fill out the section below showing their workers'compeosatial policy infometion.
t Homeowners who submit his affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
tfontractors that check this box must attached an additional shed shoving the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors haveonployees,they must provide their workers'eanp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polky and job site
Information. + r T ,�n
Insurance Company Name: Ho,r ford DiSkAYtcyLCe G I CU r
Policy#or Self-ins. Lie. #: R2. W C C
C, K 1-15 Expiration Date: RS/2G1 -I
Sob Site Address:237 South St. -Un)l A City/State/Zip:NU mpun MA OOcO
+
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 tine
of up In$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 certify undfr the pains and penalties of perjury that the information provhled above is true and correct.
c--�_�... -7
Signature: �_�_.. �.... ' Date; 2- I - I 7
Phone g: S CC SCtl! 42uu -
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 me):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
G.Other
Contact Person: Phone#:
Owner Authorization Form
Donna Dennis
(Owner's Name)
Owner of the property located at:
237 South 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.
^M lid.
(Owner's Signature)
2-3-17
(Date)
ClientAt 82429 MEISTNIC
A COROT. CERTIFICATE OF LIABILITY INSURANCE DATE
NMIDDD Y)
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 INSURERIS),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the cenlflcate holder Is an ADDITIONAL INSURED,the pollcy(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 NAME: Audrey Lamontagne
Fradette Carlson Agency PHONEplc ,RiI 860 583-0943 FAXNo 860585-0038
PO Box 2456 ADDRESS: alamontagneistarshep.com
Bristol,CT 06011-2456 INSURER(S)AFFORDING COVERAGE I NAIL*
860583-0993 INSURER A.:Hartford Ins Group 119682
INSURED INSURER B.
Nicholas Meister DBA ' ---- - - - --- —
Potential Energy LLC INSURER C:
4 D Queen Terrace INSURER o: -
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. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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.
INSR ADDLSUBR POLICY EFF POLICY EXP
LIR TYPE OF INSURANCE INSR TWD POLICY NUMBER (MMIDOiVWYI IMMNORWYI LIMITS
A X COMMERCIAL GENERALL LIABILITY X 02SBMRB0509 08/05/2016 08/05/2017 EACH .r PENCE$2,000,000
rF r IE E art„el L81,000000
cE r r'Mn 0,000
e . PT r 81$2,000,000
=ENS E -ur E
EENERAL AGGREGATE £4,000,000
XF J*�'l � ._ IPP c r .apron_,v 84,000,000
A AUTOMOBILE LIABILITY 02SBMRBO509 08105/2016 08/0512017l V.31121,1Te1nS'thGLELIMIT £2000000
Ulu. I eoa:viIPT(Perpersor $
L WV¢ ED:BEL Ewe JL n11 S
o rEr PPOPEPr -:raU
XI ¢encs X IT, - 'IEEEacciI 8 _ . --
8
A X UMBRELLA DAB x -j, i X 02$BMRB0509 08/052016 08/05/2017 EACH OQJRRE NCE I st 000000
EXCESS LIAR rErrEAS MAD[' y.PEEATE ®1.000,000
r :, XTETIDN sI0000 YN _ I
s
AWORKERS TION 02WECCR0745 08/0512016 06105/2017 X ° I
EMPLOYERS'LIABILITY
. ,EEPEE- ai.E E. E - A¢IDer.T IE500,000
=m r N '.e LJom y Irvin -_...__._
enEMaryln EL DFe'E-FP EMPLOYEE fSDD,D6G
:Eye. ,lescribe
under
b
'E L DISEASE-Plalsv LIMIT ra500,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached emote apace le required)
Columbia Gas of Ma is an additional insured on the General Liability and Umbrella Liability Coverage per
written contract or agreement.
CERTIFICATE HOLDER CANCELLATION
Columbia Gas of Ma SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEIVERED IN
4 Technology Drive Suite 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough,MA 01581
AUTHORIZED REPRESENTATIVE
1....e- t3 4-2
I
ID 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S843449/M843422 FCAJL
`t:r)11/J1 e,rrrr e(f/7A r/ /7as.,rre> rrj elf.:
Office of Consumer Affairs and Business Regulation
10 Park Plaice - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 179401
Type: Individual
Expiraton: 7/2W2018 TrA 419291
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE
SOUTHINGTON, CT 06489 — - - ------ ---
Update Address and return card.Mark reason for change.
sen: _�..:.n.,, CJ Address I"] Renewal ❑ Employment E Lost Card
omit of-Consumer Aaiusd Badness Regmninn License or registration valid for ind reuse only
HOME IMPROVEMENT CONTRACTOR before the expiration date. if found reproturn to:
Registration; 1/9401 Type: Office of Consumer Affairs and Business Regulation
- Expiration: 7/28/2016 Individual 10 Park Plaza-Suite 5170
Boston.MA,Zt t6
NICHOLAS MEISTER f--s• r---TTu• -
NICHOLAS MEISTER
40 QUEEN TERRACE ..__.
SOUTHINGTON.CT 06489 U...
UoderaecreunNot valid without signature
ttli itassaa S s t,l ... S.]`r^.,
Basra rs .o:B os.;:aa't-.
cnn t ,4,r'
CSEA-106184 •,
NICHOLASMEISTER
4D QUEEN TERRACE
Southington CT 06489 -
... 04/27!2019