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29-599 (5) 42 STONE RIDGE DR BP-2018-1267 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 29-599 CITY OF NORTHAMPTON Lot: .001 PERSONS CONTRACTMG WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category INSULATION BUILDING PERMIT Pertnit4 BP-2018-1267 Proiect# JS-2018-002253 Est.Cost: $3000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group ENERGIA LLC 92540 Lot Size(sp ft.): 81021.60 Owner: DIBRINDISI ERIC P&SUSAN M Zoon : Applicant• ENERGIA LLC AT. 42 STONE RIDGE DR Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:6/4/2018 0.00:00 TO PERFORM THE FOLLOWING WORK:INSULATE TO KNEE WALL SLOPE 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 6/4/20180:00:00 565.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED s ' y66 toy -kN-- � .z T7"&AJ SAY 29 h ' nt use only City of orth mpton Status ofPelmh: Buildi et) rtment Curb CugDdwwAy Pamd OF B iNG INS I n $ reef .S•awAN$sp4C AvageMliry OPTHAMPTON.MAOI Watatyy)all AMil•""- Northampton, MA 01060 TWO Ssis of SmxY.'val Plans phone 413-587-1240 Fax 413-587-1272 PWg'.iaN PNna ,. .-,--- Other 8peci APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING / SECTION 7 -SITE INFORMATION / /..;1`/(' 7 1A Procerty Address: This section to be Com�pleette'd by officeYiJ 7�1DCC > - Map 60Lot J�Unit ll�r�J/ w/v2/VGI�I� G Zone Overlay District G� 1. Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: «/G Y2 -'5 bWE72IDGE 721 . Name(Print) Cureni Mailin Atldress' 5Ec-- l-2cr4e Q UT4omr • s8(o -%3/S Teleph ne Signature 2.2 Authorized Agent: Name(Print) CCur ent Mailing Address: qt3 - .422 - �le� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bPermit applicant 1. Building aU (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) 00 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: �°'uOV'-'"-�- S 31 I(uj Building Commissionedinspector of Buildings Date �•V�ucG— ra Ctc/E�C-/.q u5 • CO,K EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER R CONTRACTOR 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) #ofParking Spaces Fill: volume&tucntion A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW © 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 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 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 Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Atterationfis) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D] Deeks [p Siding[0] Other[Wj-� Brief Description of Proposed Work: / 6C-- YJP — � Alteration of existing bedroom_Yes No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement _Yes Plans Attached Roll -Sheet 5a. If New house and or addition to 2.x1WWg 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? I. 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.ofwetlands?_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 F�OR/ BUILDING PERMIT I, ERIC v✓IBu`�!V �IS ` as Owner of the subject property , ' `p hereby authorize !/C to act on my behalf, in all matters relative to work aly orized by this building/�permit application. Ott 4µ(kd / Signattuum off Owner D I, / ;Ae 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. Print Name Signature ofOwner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Appli le r❑0 /} Neme of License Holder: // 2 ] Vr/ ��r ass-44"45e license Number y Skc= L S IP 12,11 Adbress Expiration Dat S,rrat Telephone 9 Raplaterad Nome Improvement Gonad : Not Applicable✓❑/ Comoanv Name Registra— timber L#zSuc--Edk4< ST. N0LYOX6 AA, Address r Expiratio ate Telephone 1l( .3� -3Z? 91 SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8(( Workers Compensation Insurance affidavit must b pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building p Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts m=ss rrOvc z `' DEPART.�'NT OF BUILDING INSPECTIONS � Z+ 212 Min 8ttwt • aunicipal Building yJy Cs Nottheapton, !a 01060 AFFIDAVIT 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 constmction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must he registered Type of Work: ZA/$(4C.cA-7/d 1✓ Est.Cost Address of Work: /e`(f(\ C_c /ZD Date of Permit Application: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): —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.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION. Signed under the penalties of perjury: 1 hereby �apppplfor a building permit as the agent of the owner: `41,yf1" -722,/RaSc,44S5cc�/OV6tO,14 /�isI& Dad Contractor Name 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 GolurnNa Gas of MassYchusetts 60 Shawmut Road, Unit 2 Canton, MA 02021 A Nl8 .Company OWNER AUTHORIZATION FORM 1, Eric Dibrindisi (Owner's Name) owner of the property located at: 42 Stone Ridge Road (Street) Florence, MA 01062 (Town, State, Zip) hereby authorize (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. customer Signature aUlC<oq 19 -Sign Dale 4/17/2018 The Commonwealth ofMassaehusens, Department oflndustrialAccidents li Office oflnvestigations - 600 Washington Street Boston, MA 02111 a y' . Tsr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organisation/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). 1.1Z 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. E] 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 S. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. Building addition required.] 5. E] Weare a corporation and its I0.❑ Electrical repairs or additions 3. officers have exercised their 1 am a homeowner doing all work 11.❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12 ❑ Roof repairs insurance required.]° c. 152, §1(4),and we have no employees. [No workers' 13.® Other Insulation comp. insurance required.] 'Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. ,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 most attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: HDI - Gerling America Insurance Company Policy #or Self-ins.[Liicc.#: EWGC/R000186816 Expiration Date: 7/1/2018 //1/2O1 8 �"A Job Site Address: y.� �G .C.l �1�� f21� City/State/ZipAZ4&(/CE ^+ OAZZ 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and the pains and penalties of perjury that the information provided abov 's true and correct. Si ature: Date: Phone#: 41 Y3122-31 11 Official use only. Do not write in this area,to be completed by city or town ofj Bial City or Town; Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector 6.Other Contact Person: Phone#: acoad® CERTIFICATE OF LIABILITY INSURANCE �� s/3oizan THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the coni0eate holds Is an ADDITIONAL INSURED,the policy(lee) meet be andomed. If SUBROGATION IS WAIVED,subject No the terms and condition.of the Policy,Cental.pCHOICE may require an endorsement. A statement on this certificate does not corder rights to the certificate holder in lieu of such endorsement(s), PROUDER CCNTACTMCO O FAX James S. Dowd & SOILS Ins p ONE 14 Bobala Road - - ACNw: Holyoke MA 01090 A Dias$: C XTON P ENE L INSURE SAFFOFOING COVERAGE NpICp INSURED INSURERA:HDI-Gerli A ori 2 In BULauce Comes Energia, LLC 242 Suffolk Street INSURER B: Holyoke PEA 01040 INSURER C: INSURER D: INSURER.: INSURER F: COVERAGES CERTIFICATE NUMBER:825622400 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INT TYPE OF INSURANCEMUM- IC EE POLICY. P POLICY NVMBE0. MM ° MMm LIMITS A mNERALLIABHItt ECGCR000186... i/1/201] 1/1/2018 FACX CCCURgENCE 51,000,000 % COMMERCIALGENFRAL LMBILIry Jmm PR USES q • 5100,000 CWNSMIX E %❑OCCUR MEO EXP(My a0B 08nm) 50 PERBONALaADVINJURY SI,000,000 GENERAL AGGREGATE 52.000,000 OEN L AGORE MLIMIT APPI161 PER: PRODUCTS-COMPIOPAGG 52,000,000 POLICY . PRO" LOC S A AUTOEBILE LIABILITY EAGCR000186816 7/1/2011 7/1/2018 COMBINED SINGLE LIMIT s1,00Q 00° ANY AUTO (E9 ocGtlean EMILY INJURY rSr penin) 8 ALL OWNED AUTOS % SCHEDULED AUTOS BODILY INJURY(Px&CERIl) s PROPERTY DAMAGE 5 HIRED MENS )PeraccMenN % NON-OWNED AUTOS 3 E UMBRELLA LWe OCCUR FACHOCCURgENCE S EXCESS OAB CW MS.MA°E AGGREGATE 5 OEWOTUU1 RETENTION A MUORNERSCOMP COMPENSATION VSTTLL AND E M PLOYERSLIABILITry YIN ENGCR000186816 1/1/2011 7/1/2018 % AOTR ANY pgOPflIETOR MCLUDgJF%ECUTIVE OFFICERWFMBER FXCWOEDi ❑ N/A .L..ACX ACCIDENT 51,000,000 IMFlpelory In NH) EL.DISEASE-EA EMPLOYE 51,000,000 DES CRI ION OF OGERATIONS MIow EL.DISEASE POLICY LIMIT 51 A00,000 DEBCRIPTOH°F OPERATONSI LOCATIONS/VEHICLES Ipmpll pCORD 101,Atltllllonal Ranuhe SOM1eGUIp 11 mom epsoe lS nVulnm CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED To Whom It Ha COntern BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Y IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPMMNTATNE r�� O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009108) 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 B0ER 100 MAIN STREET HATFIELD MAA 0101038(9'8/n y� Commissioner ... Offrvn fCovs rAfnin&Bunaeaa Regulation License or registration valid for individul use only NOME IMPROVEMENT CONTRACTOR before the expiration date. Iffound return to: '.Y.rj ,�Registretion: 165169 Type: Office of Consumer Affairs and Business Regulation Expiration: 1111/2018 LLC 10 Park Plau-Suite 5170 Boston,MA 02116 ENERGIA LLC 0/ZO THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE,MA 07040 ❑vdeneere4ry Not valid without signature