24A-204 (3) 37 MURPHY TER BP-2017-0925
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-204 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-2017-0925
Project# JS-2017-001575
Est. Cost: $2440.00
Fee:56500 PERMISSION IS HEREBY GRANTED TO:
nit Contractor: License:
Use Group POTENTIAL ENERGY LLC 106184
Lot Size(sq. ft.): 9713.88 Owner: NORTONSMITH HEIDI&GINA M NORTONSMITH
'Lovina:URBtloot.' Applicant: POTENTIAL ENERGY LLC
AT: 37 MURPHY TER
Applicant Address: Phone: Insurance:
61 EAST MAIN ST (860) 620-4433 WC
BRISTOLCT06489 ISSUED ON:2J6I2017 0:00:00
TO PERFORM THE FOLLOWING WORK:OPEN BLOW CELLULOSE, FIBERGLASS
BATTING, VENT BATH FAN THRU FOOF 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 2/6/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck -Building Commissioner
File 0 BP-2017-0925
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 61 EAST MAIN ST BRISTOL (860)620-4433
PROPERTY LOCATION 37 MURPHY TER
MAP 24A PARCEL 204 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY;
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid I -
Building Permit Filled out
t(�(�
Fee Paid
TvoeofConstruction: OPEN BLOW CELLULOSE. FIBERGLASS BATTING,VENT BATH FAN THRU FOOF
AIRSEALING& WEATHERIZA ION
New Construction
Nan Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106184
3 sets of Plans/Plot Pian
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
VASproved 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 Pennit 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
Dem lition Delay
a 3.17
Sign' N e 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 MOL 40A.Contact Office of
Planning&Development for more information.
Department use only
City of Northampton Status of Permit
4\ Building Department Curb Cut/Driveway Permit
,V 3 212 Main Street Sewer/Septic Availability
0 - Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
Ki,
. 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
This section to be completed by office
1.1 Property Address:
37 N urrhli Terrace_ Map Lot Unit
1(\V/ ri Wirt f n l M 4 01 0 Zone Overlay District
Vv Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Heidi Norferso1i+h 3-7 Murri�rr.
Te ,NorthamrtrylM
Name(Pant) !��� �1 /7 (��n Currep4laiing tUgij; -5J533 0j� D(�
-SU ol�rcraM\icyv ythVrt �t)rvn— Telephone �S SLf V
Signature
2.2 Authorized Agent:
Ni cm\aSM61Sfi-'1' A1'�'raitic . E-ne,r1` ,oICMGii15k., Eivi i,CIDuctr)
Name(Print) J_J Current Mailing Address:
�� - _- WU -SOLO-Li2U1i
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
It 1t31A At1CIA- $ 2, 440 -
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) S2, WA0 Check Number /3` ' 4/(a
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) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p , ' Siding 10] Other'71
BWork: escriptionTf Proa�rW2 �nsl- IiYYg. BOSS U� 1 ale t L�bat h •I a Thai voc- .
PcCIIUI�Sv
aivseaiJnc weafihenrtow
Alteration of existing bedroom Yes No Adding new bedroom Yes No jr
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
61 ew hou:e and or addition to existi • housin• corn•tete the followin•:
a. Use of b•' •ing :One Family Two Family Other
b. Number of rooms -.ch family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru I. Dimensions
e. Number of stories?
f. Method of heating? Fire. -s or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck En' : Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of we - ds? Yes No. Is construction within 100 yr. O.••• :' Yes No
j. Depth of basement or . .r floor below finished grade
k. Will buildin. : .rm to the Building and Zoning regulations? Yes No.
I. S•. c Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
I, — See, a orhbo Cl/Meas Owner of the subject
property )J�y /� 'n -Teri/14
}� v ��/�
hereby authorize Lal HiC hen I V/ il' t
to act on my behalf,in all matters relative to work uthorized by this building permit application.
Signature of Owner Date
1, 1\1) 1,h ti C1,c MCI ICI I/ / ftt j cd M VC �� ,as Owner/Authorized
Agent hereby declare that the statements d information on the foregoing applicatio are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
N hChO1 QS N1€15-tee
Print Name
V51 /I7
Signature of Owner/Agent te
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �/ p p Not Applicable 0 p
Name of License Holder: Niche) as IY i,1s- ev WRA - p‘ 0Li
j �jj�� Q �{� y� --(� CT �q p License Number /�
Address 4J/ SUCk.V1TXY./.SA of Ur , V�Mggq Expiration
Zo1q
l r ' • g� 0—W2D- 4433 cess A
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
NOniial cnerN i ici 24 o i
Com an Name Registration Number
LAD u eeyikrr,Sor+th1n9---UM CTOsugq 7/2 2-CI IZ
Address,f (;(� 1^ j� Expiration to
Telephoneb l('�OIVjU-`Iq3,
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.
il
Signed Affidavit Attached Yes I No 0
11. - Home Ow/ ner 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 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 Slate 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: AU g err M40)0(00
The debris will be transported by: 1) -ea 1 Cl\ EHe-yc1 (,1
The debris will be received by:1C K On ,ntt Yrvi Stc - ,�Y1S-ci) GI- C(9010
Building permit number
•
Name of Permit Applicant PatinflalEY1eY09/NchoKS MSte
i/ .
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
17 (t Office of hi vest/gallons
Y =24�.,•, n
d!- 16 1 Congress Street,Suite 100
'•
' Boston,MA 02114-2017
'etiE..-. www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lecibiv
Name(Business/Organizatiion/Individual): ,it� ii
f;�1 [ � B.,i Fy 'i1-.1'(�Ii ;�� ti N Li _i I 1 �� "• .
Address: Q1 L Murk tit, - tie-et
City/State/Zip: - ' ,C. t UvOtO _ Phone N: ' -�l,i2 __
Are ou an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6. ❑New constniction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 9 Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P b'. 9. 9 Building addition
[No workers' comp, insurance comp. insurance.:
required.] 5. 9 We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12.9 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13. Other ]i�51,(I a ti (7,,in
1 comp. insurance required.]
'Any applicant that cheeks box d I must also fill out the section below showing their workers compensation policy information.
t Haneownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit'Skating such.
IC.ontractors that check Nis box must attached an additional skeet silo ing the name of the sub-contractor.and stale whether or not those entities have
employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polky and job site
information. } l �7�/
Insurance Company Name: //'`�} Or fire �1,[��r-a Le (a YOU r _ / 7
Policy it orSelf-ins. Lie. #: yJ LW C L N, / 1 . / Expiration Date: :2111 Gl..': 1 �v n
Job Site Address:32 Murphy 1 €r c-e City/State/Zip:NOVI-harnpih.M4 VIC(Le
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 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 of the DIA for insurance coverage verification.
Ho hereby certify under the pais and penalties of perjury that the information provided above is true and correct.
=`t!
Signature: r Date: i / 3 V 17__
Phone#. 'RL,IC 5C� - 4 �htv ( /
Official use only. Do not write in Ihts area,to he 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#:
Owner Authorization Form
Heidi Nortonsmith
(Owner's Name)
Owner of the property located at:
37 Murphy Terrace
(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.
(Owner's Signature)
1-30-17
(Date)
ClienNY. 82429 MEISTNIC
ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MMm;RYYYJ
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 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT:It the certificate holder is an ADDITIONAL INSURED,the policy(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 endorsemenNs).
PRODUCER r`uAOti° Audrey Lamontagne
Fradette Carlson Agency PHONB 860583-0943 f t) . 860-585-0038
(A.LAIL En: (A.C,No).
PO Box 2456 ADDRESS: alamontagne@stalshep.com
Bristol,CI 0601 1-2456 INSUREWSI AFFORDING COVERAGE NAICS
860583-0943 INSURER A:Hartford Ins Group 19682
INSURED INSURER B:
Nicholas Meister DBA
Potential Energy LLC INSURER C:
INSURER o:
4 D Queen Terrace
Southington. CT 06489 INSU suRER RE_
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY NAT 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 SHONN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADOLSUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR VIVO POLICY NUMBER IMM2OMRY) IMM20/YYYY) LIMITS
A
COMMERCIAL GENERAL LIABILITY X X 02SBMRB0509 08105@076 08105/2017 r 52,000,000
.. Aro- [ DAMAGEr LaF _ {1,000,000
vi U L /anyJra peiscm410000 _
IN!JP)P, 12,000,000
$4,000,000
X r'0i I,.. cDuc �>.^c R.Gs 14,000,000
JTUEP
A AUTOMOBILE LIABILITY 02SBMRB0509 08/05/201608(05/2017:gra aeEqrj AN0I-E $2,000,000
Eoc-INuUR CE.Jar CiI: ¢
LO N_D s HEE-LE_ - YJ L.-ilu ma cmri $
X ED ._r<. % tNNLU - FFPT AVII $
uv
A XI UMBRELLA Lue xR X 02SBMRB0509 08/05/2076 08/05/2017H .ErI 41 0001_ 0-
-
EXCESS LIARI
•:=wrDE 41,000,000
XL kbrENr N<10a000 s
A WORMERS COMPENSATION 02WECCR0745 08105/2076 08705/2077 X ,rtr IFR
AND EMPLOYERS LIABILITY T
cLrr�Yy NIA
-r CAD:Aosta $500,000
Eo-
(M��m±duorY m NH) sL DISEASE-Et EMPLOYE 3500,000
DESCkIPTOa ort'>PERAnour ow -I -Po rr-e IT s500,000
cRPTIDN OF OPERATIONS r LOCATIONS r VEHICLES IACORD 101,Additional Remarks Schedule.may be attached it more space is 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 DEIIVERED M
4 Technology Drive Suite 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough, MA 01581
AUTHORIZED
REPRESENTATIVE
/
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) 1 Of 1 The ACORD name and logo are registered marks of ACORD
#S843449/M843422 FCAJL
(714 re oirrixnlr(pea/ r�/C/f2f �rfluJeUi
• EOffice of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 179401
Type: Individual
Expiration: 7/28/2018 Tri 419297
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE
SOUTHINGTON, CT 06489 ---
Update Address and return card.Mark reason for change.
s.nr 0 010-Q 11 Li Address (';] Renewal i..'J Employment El Lost Card
sL, t,term etta.n/il y /1.
Office
Office of Ceasamn Affairs&Borates Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
▪ Registration: 179401 Type: Office of Consumer Affairs and Business Regulation
- Expiration: 7/26/2018 Individual 19/Ark Plaza Suite 5170
Boston,MANILA
NICHOLAS MEISTER ,
NICHOLAS MEISTER
4D QUEEN TERRACE
SOOTHINGrot,CT 06489 Undersecreaarr Not valid without signature
ttassac
sits Moar; %._^
Basra Ot :.und:ng Reed,a,sto-s ar d Standards
( n:ru Srltril,rrur a :-.”11.,‘
:o-s, CSEA.108784 �
NICHOLAS MEISTER ti
4D QUEEN TERRACE
Southington CT 06189
-4.e.,.J�iStlF•
..._. ......,.. _ 04/272014