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32A-216 (6) 73 POMEROY TER BP-2017-1209 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-215 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-2017-1209 Project# JS-2017-002037 Est.Cost: $2000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq.ft.): Owner: FISHER TIM zoning: URC Applicant: ENERGIA LLC AT: 73 POMEROY TER Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:4/25/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION -ATTIC FLOOR OPEN BLOW CELLULOSE 4" TO R49 WALLS DENSE PACK CELLULOSE 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 it 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 4/25/2017 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File 4 BP-2017-1209 APPLICANT/CONTACT PERSON ENERGIA LLC _ ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 73 POMEROY TER MAP 32A PARCEL 216 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST LOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid t°Sl /1l Building Permit Filled out �" Fee Paid Tvpeof Construction: INSULATION-ATTIC FLS e t S ' BLOW CELLULOSE 4" TO R49 WALLS DENSE PACK CELLULOSE 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 from Elm Street Commission Permit DPW Storm Water Management Signature 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. Version!.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability \ , Room 100 Water/Well Availability rthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address. Thiiss section to be completed by office 73 Pomeroy Tern Map 3at/7 Lot 01,(a Unit Northampton, MA 01060 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 7.1 Owner of Record: Tim Fisher 73 Pomeroy Terr. Northampton, MA 01060 Name(Pent) Current Mailing Address ' (413)210-1959 Signature S// 4lq— pto Telephone 2.2 Authorized Aaent: Tom Rossmassler/Energia LLC 242 Suffolk St. Holyoke, MA 01040 Name(Pnnt) Current Mailing Address. (413) 322-3111 Signature Telephone SECTION 3-ES ATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $2.000.00 (a) Building Permit Fee 2 Electrical $000 (b) Estimated Total Cost of Construction from(6) 3. Plumbing some Building Permit Fee 4. Mechanical(HVAC) $0 00 5. Fire Protection �}� 6. Total =(1 +2+3+4+5) Check Number2./.741.01e[/VV This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Version!.?Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs 0 Demolition 0 Repairs Additions 0 Accessory Building Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing Change of Use❑ Other 0 Brief Description Insulation-Attic Floor Open Blow Cellulose 4" to R49 Walls Dense Pack Cellulose Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 El A-2 ❑ A-3 ❑ 1A I ❑ A-4 ❑ A-5 0 1B 0 B Business 0 2A 0 E Educational 0 28 I ❑ F Factory 0 F-1 ❑ F-2 ❑ 2C 0 H High Hazard 0 3A 0 I Institutional 0 1-1 0 1-2 0 1-3 ❑ 3B 0 M Mercantile 0 4 5 R Residential 0 R-1 ❑ R-2 0 R-3 ❑ 5A ❑ S Storage 0 S-1 ❑ S-2 0 56 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1" 2"a 2" 3rd 3'° 4m 4m Total Area (sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private 0 Zone Outside Flood Zone]] Municipal 0 On site disposal system Version 1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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 (tot area minus bldg&paved parkins) of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wettands? 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 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial Building Permit May 15.2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: N/A Not Applicable I Name(Registrant): N/A Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): N/A Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Tom Rossmassler Not Applicable ❑ Company Name: Energia LLC Responsible In Charge of Construction Torn Rossmassler Address (413) 322-3111 Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No Q SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Tim Fisher ,as Owner of the subject property hereby authorize Tom Rossmassler/Energia LLC to act on my behalf, in all matters relative to work authorized by this building permit application. 5__E� ~MT kG .Z64O 04/21/2017 Signature of Owner Date 1111111111111111r- Tom Rossmassler 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. Tom Rossmassler Print Name 04/21/2017 Signatur of er/Agent 1 Date SECTI N 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Roller: Tom Rossmassler 92540 License Number 242 Suffolk St. Holyoke, MA 01040 09/02/2017 Address Expiration Date (413) 322-3111 Signature Telephone SECTION 13-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 O No 0 Ener is Your In ,e • . . 'inner ann.nom BUILDING PERMIT AUTHORIZATION FORM 1 fv1 1- - I ^,(-r ,owner of the property located at: (Owner's Name,printed) ry nn ) �--3 V'O1,e/Yo� 1 e C rrU Nv GC 4/ 1 on Mir (Property Street Address) (City/Town) hereby authorize Thomas Rossmassler of Energia. LLC. to act on my behalf and obtain a building pennit to perform insulation/wearherization work on the above named property. y /3 - 6 �IS= ]f73 Owner's Signature Telephone Number Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations `-.S.1114-"÷: -4 600 Washington Street • Ig - Boston,MA 02111 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: Type of project(required): 1.1i1 I am a employer with 24 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ 1 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' . insurance< 9. ❑ Building addition cam [No workers' comp.insurance P required.] 5. ❑ We are a corporation and its 10.❑ 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 MGL 12.D Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.E 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 - Gerlinq America Insurance Company Policy#or Self-ins. Lie. EWGCR000186816 Expiration Date: 7/1/2017 Job Site Address: 13 Porrcn c3 T-C-.a-Y • City/State/Zip: NOY1'h0.mptotlLTA e Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 0(0(a O 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 fonn 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. Ido hereby certify and the pains and penalties of perjury that the information provided above ' true and correct. Signature: Date: !./ 2f !7 Phone#: 413-322-3111 ]] 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 one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACO tI CERTIFICATE OF LIABILITY INSURANCE TATE MM ONVW /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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)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 endoreement(s). PRODUCER NAME Mary Conroy James J. Dowd and Sons Insurance Agency Inc. PHONE FAX 19 Bobala Road "t IAm L/9.E tI:41R-538-7949 (MG NMI: Holyoke MA 01090 ADDRESS:jnconyoviOcIoNd.COM PRODUCER CUSTOMER ID e;ENERLLC-01 INOURER(S)AFFORDING COVERAGE NAICY INSURED INSURER A:IIITI-Geri inq America Insurance Coruna Energia, LLC INsuRER Is:Torus National Insurance Company 25996 292 Suffolk Street Holyoke MA 01090 INSURER C: INSURER D: INSURER E INSURERF: COVERAGES CERTIFICATE NUMBER:2034052979 REVISION NUMBER: THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING MY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY HE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT Xry TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN ILjq MAYHAVEBEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE x JSR,WDOL VD POOCY NUMBER 011la fl fMW ; OMITS A GENERAL LNBNTY Y Y ECGCR00012.6816 7/2/2016 1/1/2017 _ EACH OCCURRENCE E1,000,000 X COMMERCIAL GENERAL UPBILITY PREM ES(Ea occurrence) S100,000 CLAMS-MADE X OCCUR MED EX?(My nne MINIM 5 • PERSONAL&ACVINJURY $1,000.000 GENERAL AGGREGATE $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000.000 IA 7 POLICYIJFCOT fLoc 5 A AUTOMOBILE LUABIUIY • Y Y EAGCR0001e6e16 7/2/2016 7/1/2017 COMBINED SINGLE LIMIT $1,000.000 ANY AUTO (fa accldenrl BODILY INJURY(Per person) 5 _ ALL OWNED AUTOS % SCHEDULED AUTOS BODILY INJURY(Per eaWmU S PROPERTY DAMAGE X HIRED AUTOS IPenaldent) X NON.OWNED AUTOS $ 8 % UMBRELLA LIAB OCCUR Y Y 85393N15OAL1 7/1/2016 7/1/2017 EACH OCCURRENCE SE,000,000 EXCESS LIAB CLAMS.MADE AGGREGATE 51.000,000 _ DEDUCTIBLE X RETENTION 510.000 A WORHERO COMPENSATION Y BHGCR000106616 7/1/2016 7/1/2017 X WC ORYUATLL O IH. AND EMPLOYERS'UABILITY y N TORY UNITS ER ANY PROPRIETORPAWTER,EXEPITIVE❑ NIA EL.EACH ACCIDENT 51,000.000 O,Me,RINEM EREXGWOED7 ( ry n NH) E.L.DISEASE.EA EMPLOYEE 51,000,000 II ducme under OEegRIPTION OF OPERATIONS below EL.DISEASE•POLICY LIMIT 61,000,000 DESCRIPTION OF OPERA11ONS I LOCATTORSI VEHICLES (AItIFh ACORD 101,Additional Remarks Schedule,11 mon space Is required) • • CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED • IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE X] REY l ®1988.2009 ACORD CORPORATION. AU rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD pi --r- a II LIn- ) your Lo Efficenry Ener ..co,n April 18, 2017 Commissioner Hasbrouck RE: Request for Waiver I request that you grant a modification to waive the requirement for control construction for 69-79 Pomeroy Terrace in Northampton because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Please feel free to contact me by telephone at (413) 326-1860 or by email at tomr©EnergiaUS.com. Respectfully, Tom Rossmassler President & CEO • run - 1 r u o treet, 'o o e ' , 1.10 , e ner•laI .com a r-17-r• , i/A ; 7( i,,jr -' Office of Consumer Affrs&Bess Regulation License or registration valid for individul use only O - OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 165159 Type: Office of Consumer Affairs and Business Regulation Expiration: 1/11/2018 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 • ENERGIA LLC THOMAS ROSSMASSLER 242 SUFFOLK STREET \.c.._ `„,,-._ HOLYOKE.MA 01040 Undersecretary Not valid without signature Massachusetts Department of Public Safety \ Board of Building Regulations and Standards License: CS-092540 Construction Supervisor THOMAS B ROSSMASSLER 100 MAIN STREET HATFIELD MA 01004 = Nti..,s. 1 Expiration: Commissioner 09/02/2017