23A-093 (18) 17 FAIRFIELD AVE BP-2018-0984
GIs#: COMMONWEALTH OF MASSACHUSETTS
M=Block: 23A-093 CITY OF NORTHAMPTON
Lot:.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeon: INSULATION BUILDING PERMIT
Permit # BP-2018-09B4
Project# JS-2018-001792
Est.Cost:$800.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor. License:
Use Group: ENERGIA LLC 92540
Lot Size(so ft.): 13242.24 Owner: GOTTLIEB SETH G&JENNIFER N
Zoning:URB(100)/ Applicant: ENERGIA LLC
AT: 17 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:4/3/2018 0:00:00
TO PERFORM THE FOLLOWING WORK INSULATION - 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# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Dcoartment 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 4/3/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
rph',ne4l3-587-1240
City of Northampton Status ofPennit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well AvailabilityNorthampton, MA 01060 Two Sets of Structural Plans
Fax 413-687-1272 PlotnSlte Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION e)p 19- "// P (✓
1.1 Prooerlv Atltlresa:
This section to be completed by office
V9 . Map Lot 06731.1nit
�/ /T 1d`Jnl�ir�CCC�rl A O/U / 2— Zone Overlay District
lP Elm SL 0I81diA ce Dlama
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Crew of Record:
Name(Pnnt) Current Mail n Address
SSG-/566tif r r u_Zl Telepho
Signature
22 Authorized AaeM: / �J ^-
Name(Print)J/ Cunent Malting Address:
�/,�
Signa Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
com leted by bermitapplicant
1. Building 6O (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+q+5) C eck Number 3�
This Section For Official se Onl
Building Permit Number: Dale
Issued'.
Signature:
Building Commissionedlnspector 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 Shad m by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage ab
Open Space Footage
(Lot ares minus bldg&paved
parkag)
q ofParking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IFYES: enter Book Page and/or Docurni
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 csnstmction sobvity disturb(clearing,grading excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Pennil from the DPW is required.
SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ED Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs. [O] DeeW [p Siding[C31 Othel
Brief Description of Proposed
Work: =A1SK(.�T/o
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes ---_--No
Plans Attached Roll -Sheet
ss.If New house and or addition toistin housin complete the following:
a. Use of building:One Family Two Famiy 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?
It. 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
1, �vr v A/� GK Qt�,/ /G��� as Owner of the subject
property
hereby authorize !J/�GLc—cr�l/T
to act on my behalf,m all matters relative to war autherzed by this building permit application.
S 3 zP
Signature of Owner Data
1, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
�
Print Name
3
SignaN (Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: �'' �o Not Applicable ❑
Nem.of License Holder: �/% S5 4 SJR--�-�
License Numb
ZfZsl��,�a si �yo�Yor�G ,tf.�
Address Expiration L� to
Signature Telephone
9.Registered Home Improvement Contractor Not Applicable ❑
Company Name Registration Number
,-q 7, Sur-��1 k S7lfDLYOK� �L�
Address 1' Expirati�.te
Telephone YL.)-6/. 317
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be c
aonpleted and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building per
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 o engage an individual for hire who does not possess a license,provided that the owner acts
as suuervisor.CMR 780, Sixth Edition Section 1083.51.
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 on.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 be/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,Stale 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: I? ¢/a2_P/ L(� A-VC—
The debris will be transported by: 1 /--fG-4 wAS-�t -
The debris will be received by: A-Lt-(6-6 Lc gg c,,-
Building permit number:
Name of Permit Applicant �4�1 QD SS�I�SSGE�
3�� I
Date Signature of Permit Applicant
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
V41;
www.massgov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organintiongndividual): Energia LLC.
Address: 242 Suffolk Street
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer?Check the appropriate box:
. 1 am a general contractor and I Type of project(required):
1. 24 4 ❑ g
I am a employer with
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. E] Building addition
[No workers' comp. icomp.P'
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] ! a 152, §1(4), and we have no
employees. [No workers' 13.®Other Insulation
coml insurance reuired.]
'Any applicant that checks box#1 omA also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contactors that checkthis box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide her workers'comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is are policy and job site
information.
❑surance Company Name: HDI - Gerling America Insurance Company
Policy#or Self-ins. Lia #: E�WGCR000186816 Expiration Date: 7/1/2018
Job Site Address: 17 r-- / r(2F7lee:3Lb City/State/Zip: r--6,4tgeyey ,, /t /�-
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.
Ido hereby certify on er dee pains and penalties of perjury that the information provided above is true nd carr t.
Si tures Dae:
Phone#: 41 3�22_31 11
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#:
`tcorrd CERTIFICATE OF LIABILITY INSURANCE6/3eP0/0/20117
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 policy(las) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the polity,certain policies may require an andamement A statement on this certificate do"not confer rights to the
certificate holder in lieu of such enaomement(s).
PgopVEPA NAMEMarr, Conroy
James J. DOWd 6 Sons Ins ...a FAA
14 Bobala Road x - - xP:
Holyoke MA 01040 gWREs3'e
P
cus ID : ELL
INSURER AFFORDINICWERAGE NAICI
eumeO O..UREP
HD1-Gerlin ori a I surdnce C 0 a
Energia, LLC 242 Suffolk Street
MA 01040
COVERAGES CERTIFICATE NUMBER:825622400 REVISION NUMBER:
THIS IB TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIODINDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH 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.
IIm ME OF INSURANCEP WVE POLICY X
OLICY NUMBEM1 MWDDM/YV LIMIib
GENERAL LNRIUTY occou000106916 7/1/2017 71112010
EACH CCLLWRENCE 51.000.000
COMMERCIAL GENERAL LIgeILITT
P E$ 5100.000
CI-MME-MADE a OCCUR MED EXP wo MaRs $0
PERSONAL A ADV INJURY $1IGOJA00
GENERALAGGREWTE 52.0001000
GEN L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPCPAGG 55.000,000
POLICY X PRP LOL 5
AUTOMOBILE LIABILITY QAoca)00186.16 7/1/2017 7/1/2018 COMPANEO SINGIE LIMIT 51,000.C00
ANY AUTO (FB ecekBM)
BODILY INJURY(Per Pereon) 5
ALL OWNED AUr05
BODILY INJURY IPe&CBBEnl) 5
SCHEDULED AUTOS
PROPERTY DAMAGE
HIREDAUTOS IPer...0 $
X NON-0WNEOAUTOS 5
5
VMBRELIAWB OCCUR EACHOCCURRENCE s
EXC F—U CLAIMS Be
AGGREGATE 5
DEDUCTIBLE
R MION 5
A AND EMP3 YEBUR SATIONABIUTP EIVOCR0001S6816 7/1/2017 7/1/5018 X L'IC6TATLL OTR
AND EMPLOVORIPARTNERI YIN
ANY CERIM EErOR EXCLUDED?
EL,EACHACCIOEM $1,000,000
OFFICERMFMBER E%CWOE07 ❑ NIP
(Marm.yln NN) E.L.DISEASE-EA EMPLOYE $1,000.000
DESCRIPTION OF OPERATIONS errow
E L.OIBEASE,POLICY UHIi 51,000,000
IDESCRl"ONOFOPEM ONSI LOCATION$I VEHICLES(ANh ACORD 101,Addldonel ROMMB SOAeEUN,limon ep ce l$Mqulreal
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
TO Whom It May Concern BEFORE THE EXPIRATION DATE THEREOF,ROME WILL BE DELIVE RED
Y IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORI2EDREPRESENTATNE
®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
® Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-092540 Expires:09/02/2019
THOMAS B ROSSMASSLER
100 MAIN STREET -
HATFIELD MA 01038
Commissioner
O(fic of Conium rArt n&Business Reg Ianan License or registration valid for individul use only
t44OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Registraf on 165169 Type: Office of Consumer Affairs and Business Regulation
Expiration: 1/11M18 LLC 10Park Plaea-Suite5170
Boston,MA 02116
ENERGIA LLC �/ZO
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE, MA 01090 Undeneeretary Not valid without signature
RISE60 Shawmut Road, Unit 2 Canton, MA 02021
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Jennifer Gottlieb
(Owner's Name)
owner of the property located at:
17 Fairfield Avenue
(Street)
Florence, MA 01062
(Town, State, zip)
hereby authorize 0000G�G�
(Subcontractor)
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.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
Cutmer Signature
Sign Date
2/1/2018