34-006 (14) 276 TURKEY HILL RD BP-2018-1204
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:34-006 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeom INSULATION BUILDING PERMIT
Permit# BP-2018-1204
Project# JS-2018-002151
Es[ Cost, $688.00
Fee,$65.00 PERMISSIONIS HEREBY GRANTED TO.-
Const.
O:Const Class: Contractor. License:
Use Group: THE ENERGY STORE 106082
Lot Size(so.ft.): 131072.04 Owner. NEVEJANS JOEL
zonine: Applicant: THE ENERGY STORE
AT. 276 TURKEY HILL RD
Applicant Address: Phone: Insurance:
17 B EAST ST WC
EASTHAMPTONMA01027 ISSUED ON:5/16/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.KNEEWALL SLOPE - 2" THERMAL BARRIER
POLYISO
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 N Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Qil: 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 Sienature•
FeeTvpe: Date Paid: Amount:
Building 5/16/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
-T-
City
City of No Still ton Shhfl('eltdA6tRldk '
MAY 1 B it D artent
I �-w
2 ain Stre d �.�. �
Room 00 woo
DEPT OF A 11060 YJb:$)IgYri'1#4Bdvc4Ya PiMni.
13-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAARLY DWELLING
O- I D - � -0 L
SECTION 1 •SITE INFOATION .
Th
1.1 Property AddressThissection to be completed by oRlce
�11v TurVu�+ll\1 Map3�1 Lot unit
Nora-».r'np{w. ma olaLZ Zone Overlay District
Elm St.DlsMct CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZE AGENT
2.1 Owner of Record:
SpP1 Nc�c �rAnS 2�e Turd 11. IL '8 01OU2
Name(Print) Curte�t Mailing rep:
G'a X10 titf . 9?45r
Telephone
Signature
2.2 Authorized Anent:
Name(Pant) Cumml Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed bV permitapplicant
1. Building 3 FU \.7 2a (a)Building Permit Fee
2. Electrical W O U (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit I"
4. Mechanical(HVAC) O
5. Fire Protection
6. Total=(1 -2+3+4+5) Check Number
This Section For Official Use Only
Da e
Building Permit Number Issued:
Signature: l
Building mis.ionadlnapector of Buildings Oat.
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Al(Information Abat Be Completed. Permit Can Be Defied Due To Incomplete Information
Existing Proposed Required by Zoning
This column in be filled m by
Building Department
Lot Size
Frontage
Setbacks Front
Side L_.. R:.. . . L: R:I.
Rear
Building Height
Bldg, Square Footage
Open Space Footage %
(Loc arca minus bldg&paved I.
kin
#of Parking Spaces
volume&location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW OD YES O
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO O 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 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK ticheck all applicable)
New House ❑ Addlaon ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs l0I Decks IM Siding]0] Other l
) 1.1.0. CACI
Brief Description of Propos e
Work: V4lU, W 51—2 '1`11.,m 1. hisy'u" PnIr IISb kom..
Alteration of existing bedroom_Yes_. A No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement _Yes --K—No
Plans Attached Roll -Sheet
ea.If New house and or addhion to exlating housing,complete the following:
a. Use of building:One Family Two Famity 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?
I. Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. 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
I, J& l�T...c 1 1.J .as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature M Owner Date
I,�,YIYI d,✓ f}�� e !l , as Owner/Authorized
Agent hereby deal re that Me statements and mformalion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print me
n, ( gal 18
Signature of OwnarlAgent Date
SECTION S•CONSTRUCTION SERVICES
81 Licenser)ConstruelionnS�up'"e'rvisor: Not Applicable
Name of License Holder: 4�fA&C 1—W 4:)n y «L (fibOTLL
License Number
, .( s I Y1.4 31151ab
Address Expiration Date
1'�,_� {y Li j I • LJSSS =n5�1 a�e
Signature Telephone
9 Re IstemdN Improvenrnt Contractor. Not Applicable ❑
)-,4 'S9.1
Company Name Registration Number
Ty
' \p enexin t'{u 1q
Address Expiration Date
Yl Y1 �2 N �' w Lam. [,�{'{�lephone Sfi6•RlDlolaU�
SECTION 1d WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,1 25C(S))
Workers Compensation Insurance afficavit 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....... No...... ❑
City of Northampton
Massachusetts
_ s
D1iPAR0T1BnT OF BpILDING INSPECTIONS
212 Main Street o Municipal Building Jy pC
Northampton, MA 01060
AFFmAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation, repair,modernization, conversion,
improvement, removal, demolition,or construction of an addition to any preoxisfing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which ars adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: =�-A i 0-7k C(1 Est. Cost: [p 19
Address of Work: ol�(O_ "T pY 4-l.c.�l 126 M M amckr n rYlA
Date of Permit Application: 4 1 3LA 1g
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
1C Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building pennit as the agent of the owner:
Date Contractor Naule HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
Permit Authorization
t118S5 S Form
Site 1D�3339988919 Customer: JOEL NEVEIANS
I, "S �-( / " l �t'�Ati/ er of the property located at:
l0wrw.N.M pdKed)
ZDV turkey Hill Rd Northampton,MA 01062
lrreo.nrsveelsddiv.l lord
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/orweatheritation
work an my property.
Owner's%mitu a'
Date: Q U
emcee osem eee se eeueuoueoeseeee.oeoeemmeesa eoeeemoaueee easuueoee
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractorto the
above referenced project:
Participating or Date
Name:CLEAResuh
Phone: 800480-7472
Email:
_ rwotneeu.eWv
ga.302015
Scanned by CamScanner
ACO CERTIFICATE OF LIABILITY INSURANCE a"oamv ol"a"
THIS CERTIFICATE IS ISSUED J S AMATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,UTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSITTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the tartifltate holder Is an ADDITIONAL INSURED,the yoliry(ke)must have ADDITIONAL INSURED PreNtalom or be endorsed.
N SUBROGATION IS WANED,subject to the terms and conditions of the Polity,certain panties may require an endmaemen. A statementen
this coAllicate does net confer dghte to the certificate holder in lieu of such andoreement(s).
PRODUCER NALIE. Wendy Fllim,CIC
Venbrook Insurance Sa1Wms,CA Uc,0080832 Pan'
AR xe:
0320 Canoga Ave..12M Floor � �. vAim®wnbmecoom
JmmR BAPFORONOCOYEMGE NAPA
Woemand Hllle CA 8135] MSURERA: CIUm&Forster Spadelly 60.520
INSURED INSURERB: We9CO heti—Com,my
The Energy Smre,LLC MSURM c:
3 Slmm Lane INSURER o:
Whe 1C INSURER E:
Novae n CT 00470 INSURER F:
COVERAGES CERTIFICATE NUMBER: 18-19MASTER REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NJWEDABOVE FORTHE POLICY PERIOD
INDICATED. NOTWITHSTANDINOANY RECUIREMENT TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
OR ME OF INSNUNCE Y
L Yn4
Cg1ME0.LULBENEML WBWIY FACH OCCURRENCE S 1.".000
CWMSAIPDE ®OCCUR PREMISES i "'"D
MFD EVµnv ane-^I S 5."
A EPK121944 0312712018 "12](1019 IRGCNMLADVNJURY S 1'oBo'M
GENLACGREWTE UMITIXYUES PER: GENERALAOGREWTE S 2'000'0"
X POLICY EJET �LOC FRCOI1CiS-COMMPAGG f 2'000'"D
CHR:
ADroMONLE tIAaenr mMaINED SINC1E UMR f 1,0"."0
ea
ANYAUTO aCdLY INLNIVRV IPeM0 f
B MHED SCHEDULED WPP1606061-00 0312]11010 0312]2019 aCmLVIWURr IPer.o:aeml E
AUTOSONLY AUTOS q(OPERIYOAMAGE
Hi REO NONOWNEO S
PWam]ml
AUTOSONLY AU-S ONLY
undemmumni mOlFn9 s
_...,_...__.....tl_....... s,Bao,D"
X [IUMRREIJALW "CUR EACX CCCURR[NCE i
A ExcE99 UAe UAlMS.E EFX-110328 0312]2018 032]12019 AGGREGATE f 5.000,000
DED RETEN110N i S
WORNERS COMPENBATpX FER OM
AND...LARRUDY YIN STATNE EN
ANY RI"'Po'"N % CV ❑ EGIDENT S
OFC�ENCLVE
� nm
ELOISFASE-FA EMPLOYEE f
D,AFla DN FI T— ELOISEME-PGLIGYUMn S
DESCRIPTION OFOPEPATONS e&c'�'
DEADm,lpaeFOPEMTYNISIUDDMNYa1VEI Um IACDnBfe1,yryeo,yl0. SOwJUN.Rory MaWtliMN—P M,puFM
-30 Days NoYce o1 Cancellation,except 10 days for non-mylmnt of premium.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEU ED BEFORE
THE EXPIRATION DATE THEREOF,ROME WILL BE DELNEItE01N
Proof a InsumOm ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPREeEMAYSIE
.AL ur.,r`fa L<i.
®1988-2015 ACORD CORPORATION. AR rights reserved.
ACORD 25(2016103) The ACORD Rome and logo am registerml mama of ACORD
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: LLC
THE-ENERGY STORE, LLC Registration: 178392
3 SIMM LANE STE 1C Expiration: 04/09/2020
NEWTOWN, CT 06470
Update Address and Return Card.
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
178392 04/09/2020 One Ashburton Place-Suite 1301
THE-ENERGY STORE, LLC Boston,MA 02108
ROBERT NEAL GQ�---
3 SIMM LANE STE 1C
NEWTOWN, CT 06470 Undersecretary Not valid without signature
The Commonwealth ofMassachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,t$IA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Orgmivz[ion/Individual): The Energy StoreLLC _ -
Address: 3 Simm Lane
City/State/Zip: Newtown,CT 06470 Phone It: 888-840-6641
Are you an employer?Check the appropriate box: Type of project(required):
LZ I am a employer with 3 4. ❑ 1 am a general contractor and I
6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contrnctors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contracmrs have 8, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers'comp.insurance comp.insurance.:
required] 5. ❑ Weare a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l LE] Plumbing repairs or additions
myself[No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no Weatherization
employees.[No workers' 13.® Other
comp.insurance required.]
*Any applicant thatchecks box it mustalso fill out Ne section below showing their workers'compensation policy int rmrtion.
I Homeowners who submit this affidavit indicating they are doing all work and from hire outside conaan..most submit a new affidavit mthentng such.
'M.ontracton thin check this box most attached on additional shect,howing the none of the sub-contracwrs mid state whether or not those entities have
employces. If the sub-contrectrs have employees,they most 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 she
Information.
Insurance Company Name: Venbrook Insurance Services
Policy 4 or Self-ins.Lia 4: EPK121944 Expiration Date: 3/27/2019
Job Site Address: T"ilrl(.. Wl 2d City/State/Zip: " F14+ MA 6101/2
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 r�rt�under the pains and penalties of perjury than the information provided above is true and correct
Signature%/t/Jflq�t,dC(� Dag N/.telI�
Phone 4: 475-2044585 Cell 888-840-6641 Office
Ojftcfaf use only. Do not write in this area,to be completed by city or town offaiat
City or Town: PermittLicense h
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#:
City of Northampton
=' Massachusetts
z
` DaeARTlBM' OF BUILDING Z SPBCTIORS
212 win Stn t oN icipal Ruildinq
Northampton, M 03060 'y yPa
Debris 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.
The debris from construction work being performed at:
1-1 to 'T-(;, � N111 'C'
(Please print house nu r and street name)
Is to be disposed of at:
- - 1"� tcs�s�, IQs+ho-mPttx, fY1q�loa}
(Please print naive and location or taciiity)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
l��Frw �, A, �I13D1(�
Signature of Pe It Applicant or OwnerDate�
If,for any reason, the debris will not be disposed of as indicated,the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.