17C-263 (7) 88 NORTH MAIN ST BP-2019-0122
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 17C-263 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeorv. 1NSULATION BUILDING PERMIT
Permit# BP-2019-0122
Proiect# JS-2019-000200
Est Cost$2400.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: ENERGIA LLC 92540
Lot Size(sa. ft.): 10890.00 Owner: JENSEN KRISTIN
zonin%URB(100) Applicant: ENERGIA LLC
AT: 88 NORTH MAIN ST
Applicant Address: Phone. Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:7/3112018 0:00.00
TO PERFORM THE FOLLOWING WORK INSULATION TO ADDITIONAL ROOM SPRAY
FOAM CLOSED CELL 3'
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 sienature:
FeeType: Date Paid: Amount:
Building 7/31/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
only
RECEIVED Ci of Northampton �,sofpermit D'a°m" e"
Bu lding Department Curb CWDAvewey Poem*
JUL 9 0 2018 12 Main Street SawWlSspftAvaaeMMY
Room 100 Wan(/Wall Ava*W**y
ort mpton, MA01060 Two, of Structural Pnero
dA Eiatl*BalB 5 7-1240 Faz413-587-1272 PIaUS*ePlans
NomRAMProN.MAmaes Ottw specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR—TWO
_FFAMILY
DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
� . #X
Overlay
/u fS77Map�_ Lot Unit
()�O,9FYce, Ayowol� Zone CDiDistrict
Elm St.D4tdd CB Dlemcl
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
915%/41 "SE�GSEN 8g/� �l�/•r/ S KE ¢
Name(Prim) /J�® �y /� .�•� Current l
SEC�F��i / /!�//1V Tele y
Signature
2.2 Authorized Anent: /, L
Name(Prim) CurrentMailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by parmut applicant
1. Building �J DD , do
(a)Building Permit Fee
2. Electrical G' (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee )n
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 -2+3+ 6,0 Check Number
This Section For Official Use Only
Dale
Building Permit Number. Uwe.
r
Signature: 7k5 / 114
Building Com loner/Inspector of Buildings Dale
Section 4. ZONING Alt Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tbis column to be filled in by
Building Depadmear
Lot Size
Frontage
Setbacks Front
Side L . R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lor ares minus bldg&pend
#ofParlsing Spaces
Fill:
volume&Lacafian
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 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(deanng,grading, oavalion,or filling)over 1 acts or is it part of a common plan
that will disturb over 1 acre? YES O NO
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 Alteratlon(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signa [C7] Deeks [0 . -81dir Other
Brief Descnption of Pro sed 7V [I7]
Work: 5;,v .46h-r," ,Z.VJ4 Soft.p 4K ccasElB CEL„-
Alteration of existing bedroom�Ves o Adding new bedroom Yes ✓No
Attached Narrative Renovating unfinished basement _Yes
Plans Attached Roll -Shast
Oa.If Now house and or addition to no housinig. complete the followin :
a. Use of building.One FamilyTwo 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 stones?
I. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is constructionwithin 100 ft.of we0ands?_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 AUTHORVATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILD�IING�P/_ IT
1, �( S ZZA/ -,as Owner of the Subject
property .r '/�J �+
hereby authorize [! SS�`iL a L
to act on my behalf,in all matters rela0ve to work authorized by this building rmit apPli tion.
Fjmt"—
Si,natu..f Owner Date
I, " / (/lf FL/ /kit as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the bestof my knowledge
and belief.
Signed under the pains and penalties of perjury.
19A/ S f}SS
Print Name
Signatureof erlAgent Date
SECTIONS-CONSTRUCTION SERVICES
6.1 Licensed Construction Supervise Not Applicable 11 /�/t
Nam.of Licen..Holder: / (�� KOSS� « G 4 _l v✓
License Number
Address Z Expiration ate
� yi3 .322.3r�L
Signa—tujr' Telephone
8 Ri alaterl Nome Improvement Contmi Not Applicable ❑
Company Name Reg�slr�ion u or
� �
Address Ezpiratiq a
Telephonay/r•32 <
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 buildiRy permit.
Signed Affidavit AXached Yes...._. No...... ❑
11. - Home Owner ExemiWon
The current exemption for"homeowners"was extended to include Owner-occupied Dwelling 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 whoConstructs more than home in a two-year d 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 b 'Idi ¢pernift.
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 m Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General taws Annotated,von may be liable for persons)
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 c40, 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:
The debris will be transported by: �GL/a
The debris will be received by:
Building permit number:
Name of Permit Applicant �l�.4�QdSS.tf fSSLE2
Z'A - 4t.---
D to Sig Lure of Permit Applicant
��■ ito '
BUILDING PERMIT AUTHORIZATION FORM
owner of the property located at:
(Ow ''. Nfame, pr
(Property Street Address) (City/Town)
hereby authorize Thomas Rossmassler of Energia, LLC. to act on my behalf and obtain a building
permit to perform insulation/weatherization work on the above named property.
n r s S ature ]� Telephone Number
Dat U
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-092540 Expires: 09/02/2019
THOMAS BBSLER _ aII
100 MAIN STREET
HATFIELD MAA 0103801038
Commissioner CZ
: .., Office of Co m Ariain&Basis.,Reguiatlon License or registration valid for individul use only
� ''NOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
I:rlt.1'k gistration: 165169 Type; Office of Consumer Affairs and Business Regulation
Expiration: 1112018 LLC 10Psrk PIs=-Suite5170
ENERGIA LLC �11D\'�'� Boston,MA 01116
THOMAS ROSSMASSLER
242 SUFFOLK STREET �Py ,
HOLYOKE,1401040 -Undersecretary Not valid without signature
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
wil 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leelbly
Name (Business/Organiration/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:
24 Type of project(required):
1.5a 4.I am a employer with ❑ I am a general contractor and 1
employees(full and/or pall-time).* have hired the sub-contractors 6. EJ 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'
[No workers' camp.insurance comp. insurance.:
9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their 11.❑ 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
employees. fNo workers' 13.® Other Insulation
comp.insurance required.]
*Any applicant that checks box AI must also fill out the section below showing Itch workers'compensation policy information.
t homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new amdavit indicating such.
1Conuacbm,that check this box most attached an additional sheet showing the name of the sub-Oontractors and state whether usual those entities have
employees. If the sub-connectors have emplayem,they must provide their workers'comp.policy number.
]am 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.Lic.#: EWGCR000186816 Expiration Date: 7/1/2011
Job Site Address: 7"- le" S'7 City/State/Zip: �-+1/� .(fjf- 6;2d,��
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage m 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 w 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 u der the pains and penalties of perjury that the information provided above is true and correct.
Simt re: ate: 712,711
Phone
Offlcial 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#:
ac Ro o® CERTIFICATE OF LIABILITY INSURANCE
renD1e
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: N the certificate holder IS an ADDITIONAL INSURED,the pollcy(les)must b°endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the Policy,certain policies may require an endorsement A statement on this certNlcate does not confer rights to the
Cert caC holder In Ileu of such sodonsame sI.
PRODUCER pM .TACTMB Conor
James J. Dowd&Sans Ins
14 Bobala Road PxoxEam 413-538-]444 EAxNI
Holyoke MA 01040 E+nnit
na°ucsa . ENELL
INSUREJUS)AFFORDING COVEMOE NAICA
INEUEneIs,LLC um INSURER A:Evanston Insurance Company353]8
242 SrtJuffolk Street INSURER s:Commerce Insurance Company 34754
Holyoke MA 01040 INSURER c:StarStone National Insurance Company 25498
INSURER o:Guard Insurance Group 8281
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1841818189 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.
INSRWNE of INSURANCE A POLICY EFF POLJCY P
POIJCY NUMBER D LIMITS
A GENERAL LMML 3OB9C% ]/IQme 71114019 EACHOCCURRENCE $201
X COMMERCIAL GENERAL LNBILIN
R MISE SIMI
CIARAS-MAOE O OCCUR MEDEXPJAI SU
PERSONALBAOVINJURY 12000,010
GENERALAGGREGATE Ez..
GENL AGGREG4TE LIMIT APPLIES PER PRODUCTS-COMP/GP AGG 12,DXM
POLICY FX PPP LOC S
B AUTCLpMLEUUAsS ( MAFCAU WIMIa 7I1p019 COMBINEDSINGLE LIMIT Si WOpN
ANYALTO (Eeaudnn
ALLOVVNEOAUT05 BOOLYINJVRY(PHpeRM) S
DUDILY INJURY P01adwl) E
X SCHEDULEOAVTOS PROPERTY pAMAGE
X HIREDAUTOS IPereWMnp 1
X NON-OVINED AUTOS S
S
C UMBRELLA WB X q:CUR ]5]SOH180AU ]11rzm9 ]/14019 EACH OCCURRENCE 51,MAX0
X EXCESS LIAR CLAIMS-MADE AGGREGATE S
°EOUCTISI£ S
RETENTION S S
O WORKERS COMPENSATION TBWUARD LI4019 ]/14019 X VA ST OTH-
ANO MPLOYERS UNIEUTY YIN
Al PROPNsTO9RAmNERIEXELUPVE NN EL FACH ACCIDENT $1.OW.000
Me1 � MEXCLUDED] N/A
( 9I11 1 ELOISEASE-EA EMPLOYE $1'cO0
r dercnp'WWa
OESCRIPTIONOEOPE TIONS.— E.L.OSFASE-P000YU.1T I s
DESCRIPTION OP OPEMT°NSILOCRTONS/VEHICLE8 MNec11 ACRD i°1.AEEIBoIul ftMr*ScM ule,Kmon aptp Is ngWndl
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
To Mom It May Concern
AUT1oR1ZED REPRESENTATIVE
®1988-2009 ACORD CORPORATION. All rights reserved.
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