38A-002 (2) 26 BURTS PIT RD BP-2017-1152
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:3M-002 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit BP-2017-1152
Projects JS-2017-001952
Est.Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq.ft.): 18817.92 Owner: DAN JEFFREY
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 26 BURTS PIT RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
H O L Y O K E M A 0104 0 ISSUED ON:4/13/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE CARPET FROM FRONT KNEEWALL
AREA, INSTALL RIGID BOARD KNEE WALL
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 k 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 4/13/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1152
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 26 BURTS PIT RD
MAP 38A PARCEL 002 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TvpeofConstruction: REMOVE CARPET FROM FRONT KNEEWALL AREA. INSTALL RIGID BOARD
KNEE WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 92540
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 fromElmStreet Commission Permit DPW Storm Water Management
Ili ..ilio' e' l^
Y19 V7
Si_glirreofBuildin• 0 'c'. 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.
�����1 City of Northampton Status oftaeenfi: ' t
DeB
< - Building Department Curb Cuunv
Deway Permit— 212 Main Street Sewer/Septic Availability
Room 100 Wate/Xtattiwaslb no n » = .7.
Northampton, MA 01060 Two SelsMS 'PJanS `'-�
phone 413-587-1240 Fax 413-587-1272 PIOf/Sde 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: QQ/T��.Fthtis section to be completed by office
W ?DO rt::) p,-\ PiQ. Map 3S' ` Lot 00z Unit
-10YtnLC, (AMI 01DlyL Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5PF4yn� 7io P—)cls PN P,d . flt)rentk . Mtn0002
(Print) Current Mailing Address:
SG� q&eAi I I t ta 41 1432
Y Telephone
Signature
2.2 Authorized Ment:
Thomas RQszmost'r 21-12. 5.3FQn\K. gt tt \ IOU Mi9 01040
Name(Print) Current Mailing Address:
YR-3/2-g/,
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 21 000 00 (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) 2,000. 0° Check Number 4943 46
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 in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:- L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
N of Parking Spaces
__.
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 O DONT 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 O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part of a common plan
that will disturb over I acre? YES O NO O
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) n Roofing n
Or Doors ❑ /
Accessory Bldg. ❑ Demolition D New Signs [O] Decks [q Siding[o] Other[
iNS(]( rl-,or)
Brief Description of Pro..sed
Work: LL• C• s w kr v_nePt iX1 .0 l'�{S.S,\(1CM to Y\ -00ard K.Y\fe
Alteration of existing bedroom Yes No Adding new bedroom Yes N�
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sit 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
,as Owner of the subject
property nn..
hereby authorize -TY1OrnOL YI osS mc3SSLQc
to act on my behalf,�,hin all matters relative to work authorized by this building permit application.
s5: ,"C, '4'(T 4(7,ro y � / 7
Signatureauof Owner Date
I, l r crvtals PmoSSryv 1 s e C ,as Owner/Authorized
Agent hereby declare that the statements 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.
Thornes • osSmastsler
Print Name
Signature of wner/Agent Dater/ 4
SECTION 8-CONSTRUCTION SERVICES
8.1 licensed Construction Supervisor: Not
Applicable 0
Name of License Holder:ThOMCaS S(y ICU Sh`ltaSSl Ec 9 ZplU U
License Number
212 SotQolk S-t yote 1 Af\ O1oLkc-) 9/ti it
Address Expiration Date
4f3- 37_2- 31k1
Si atu Telephone
9.Reaistered Home Improvement Contractor: Not Applicable 0
6k}e (a lig LLL 1 (oS L(p9
Company Name Registration Number
2-UO. ?C-t . -rk() \ DU VAft Oto--(c> iiltl (�
Address [vitiation Date
Telephone U 13322'3 i I I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi 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 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: 7i4 C7�1Y S, ?ct Sir. . -F%0( ent
The debris will be transported by: 1'r\ e C txflStC
The debris will be received by: esA\\f CL t txs$tC
Building permit number:
Name of Permit Applicant ,lefce 'Y\a �C3 Nl
V07
Date Signature of Permit Applicant
City of Northampton
rip
Massachusetts A./ �- `es
DEPARTMENT OF BUILDING INSPECTIONS i .0
212 Main Street • Municipal Building 06 aCt
Northampton, MA 01060
Property Address: V(Q bc)rCS ?lrt 9)rk . }tnrf1VI(C , yl/Ilel
Contractor •
Name: Tomas 9n1sm/ v?
\ �Y1 cr9i I i ( A C
Address: 1 S,Veinvn R \
City, State: 1-f 01\1 0'( R M W pl OU
Phone: v l3 3ZZ I I I
Property Owner
Name: �f f'(-P jCV, c' c n
Address: 7,1 9 ;) YS Ql Qt C' .
City, State: 1()Y fXl I k M 1f\ (nl(9 La Z
1, IAM'S QIOS` wIsSIC C (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
7 //
RISE 60 Shawmut Road,Unit 21 Canton,MA 02021 1339-502-6335
ENGINEERING www.RlSEengineering.co m
OWNER AUTHORIZATION FORM
I. C1C- el
(Owners Name)
owner of the property located at:
' t
(Property Address)
w„ fr.) cf� // ti- (NC ht),
Property Add
hereby authorize athKC`�4"
(Sub ntractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.This form is only valid with a signed contract.
a ir
Or
XIS rlZ
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
io_ 600 Washington Street
• ="1'1=, Boston,MA 02111
s*t www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Energia, LLC.
Address: 242 Suffolk Street
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer?Check the appropriate box:
contractor and I Type of project(required):
I.[ I a employer with 24 4. ❑ I am a general
employees(full and/or part-time).* have hired the sub-contractors 6. ❑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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.t 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 In Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152,§I(4),and we have no
employees. [No workers' 13.® Other Insulation
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the 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 policy and job site
information.
Insurance Company Name: HDI - Ceding America Insurance Company
Policy#or Self-ins.Lic.#: EWGCR000186816 Expiration Date: 7/1/2017
Job Site Address: 210 r t' Qck Ptd.- City/State/zip: -Fl Ore of o 4th 6 010/Q1.
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 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.
I do hereby cent&unde the pains and penalties of perjury that the information provided ye is ue and correct.
Signature: Date: l /
Phone#: 413- 22-3111
Official use only. Do not write in this area,to be completed by city or town official
City or Town: . . Permit/License 6_
IssuingAuthority(circle one):
I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
,,,,,,,,,,,,,e&orir r,,.r,
eR.-\ Office fConsumer Affairs&Business Regulation License or registration valid for individul use only
NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
£��'2e9istration: 165169 Type: Office of Consumer Affairs and Business Regulation •
res Expiration: 1/11/2018 LW 10 Park Plays-Suite 5170
$?' Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE.MA 01040 Undersecretary Not valid without signature
0Massachusetts Department of Public Safety
�� Board of Building Regulations and Standards
License: CS-092540
Construction Supervisor
•
THOMAS B ROSSMASSLER •
100 MAIN STREET *
HATFIELD MA 0104 'e =
1r----177r Cc. Expiration:
Commissioner 09/02/2017
eft CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD'YYYY)
7/5/2016
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. N 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 poacy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
Certificate holder In lieu of such endorsemenfe).
PRODUCER LON TALI
James J. Dowd and Sons InsuranceAME: Mary Conray
Agency Inc.IRC. NAME: SAX
14 Bonnie Road -�A,IyC�NP,ExN:41T-538-7444 IA¢.No):
Holyoke MA 01040 Ad'OREtBs�c.QRcenrovgdowd,COM
-Were eR IDs:ENERLLC-01
INSURERI8)AFFORDING COVERAGE MICR
INSURED _INSURER A:)IDT-GSr1 inp America InsUrance Corolla
Ehex<JSa, LTC
INSURER s:Tonle National Insurance Company 25496
242 Rut£oAk street
Holyoke MA 01040 INSURERS:
INSURER E: _
' INSURER F:
COVERAGES CERTIFICATE NUMBER:2034052479 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOWHICCHOTHIS CERTIFICATE MAY SE ISSUED ANYNG R REQUIREMENT,
PERTAIN.THE INSURAERM OR N
CE AFFORDED BY ON OF ANY CONTRACT
POLICIIES DESOR CRIBED HEREIN IS SUBJEWITH CT T TO
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDDPBY PAID CLAIMS,
IOR TYPEOF INSURANCE —XliaraDR POLICY NUMBER IMM/ 1 IragieD Cnl WAITS
A GWERALLN&LITy T Y SQ3CR000184316 113(20ib u)1/20H
EAtliOCuURRENCE 51.000.000
X COMMERCIAL GENERAL SIABIOTT PREMISES VNENIm!PREMISES E BOO,GCC
RAMAL-
CWMS•MADE X OCCUR MED EX0(My One Arson) $
PERSONAL B AW INJURY Si.000,000
_ GENERAL AGGREGATE S2,000.000
GENt AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMPX)P ASS $2.000.000
I POLICY Ix I ErT LOC $
A AUTOMOBILEIJABILITY Y Y BACCROOOS A6816 9/1/20115 7/1/2017 COMBINED SINGLE LIMIT $1,000.000
l aamdmtl
ANY AUTO
ALL OWPoFt)NITOS BODILY INJURY(Por Oction) S
ALLOW ED AUTOS
BODLY INJURY Per Late))) S
al PROPERTY DAMAGE S
HIREDAUTOG IPeraccident)
NON-OWNED ANTICS S
S
e R UIMEREf.t4LIAB I cocuR Y Y 8529mriscaLI oft/21nE 71112017 RADA QCCLRMENGE S1.000.00c
EXCESSLIAB CLAIMS,MADE' AGGREGATE $1.000,000
DEDUCTIBLE S
X RETENTION 510.000 S
A WORKERS COMPENSATION V ynECR00o18881671112036 71ij2912 'C WO JIATU% OTPo
AND EMPLOYERS'WBUTS YfN TORY tJMITS ER
ANY PROPRIETORMARMERF_XEOITIVEu A,IA EL EACH ACCIDENT 51.000.000
OFFICERMEMBER EXCLUDED'
NMIdeory In NMI E.L.DISEASE•EA EMPLOYEE 51.000.000
NI&jRIPTIONOFer
4CSCRIPTION°F GPFMTONS below ( E.L.DISEASE•POLICY LIMIT S1,000.000
•
DESCRIPTION OF OPEMTONS ILOCATONSI VEHICLES mho ACORD101,AdBRlOnMR'marki SytadoiAAmore'payola tetlolroM
CERTIFtCATE HOLDER CANCELLATION 30
SHOULD ANY OPTHE IONABOVE DESCRIBED,PoLICIEBEPICS WILL
CANCELLED
IN ACCORDANCE
WITH
THE DATETIEROOTIOE WILL BE DELIVERED
- IN WITH TIE POLICY PROVISIONS,
AUTHOR¢En REPRESENTATIVE
O 49882009 ACORD CORPORATION. All rights reserved,
ACORD 25(2059105) The ACORD name and logo are registered marks of ACORD