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23D-085 (4) 41 WARNER ST BP-2019-0364 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D-085 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-2019-0364 Proiect# JS-2019-000591 Est.Cost: $4500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. lass: Contractor: License: Use Group: POTENTIAL ENERGY LLC 106184 Lot Size(sq.ft.): 24524.28 Owner: BERCUVITZ DEBRA&KRIS THOMSON Zoning: URB(100)/ Applicant: POTENTIAL ENERGY LLC AT. 41 WARNER ST Applicant Address: Phone: Insurance: 4 D QUEEN TER �860Z506-42660 WC SOUTH I NGTONCT06489 ISSUED ON.9/24/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.ADD 10" CELLULOSE IN ATTIC, INSULATE WOOD SIDED WALLS W 4" DENSE PACK 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: Mouse# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: "Fire 2 e-art,,�„ment 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 ftnature: ture: FeeType: Daft Paid: Amount: Building 9/24/2018 0:00:00 $65.00 212 Main Street,Pbone(413)587.1240,Fax:(413)587-1272 Louis Hasbrouck Building Commissioner File#BP-2019-0364 14Sa "ap APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC ADDRESS/PHONE 4 D QUEEN TER SOUTHINGTON (860)506-4266 Q PROPERTY LOCATION 41 WARNER ST MAP 23D PARCEL 085 001 ZONE URB000) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OU Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: ADD 10"CELLULOSE IN ATTIC. INSULATE WOOD SIDED WALLS W 4"DENSE PACK New Construction Non Structural interior renovations Addition to Existiniz Accessory Structure Building Plans Included: Owner/Statement or License 106184 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 Demolition Delay �' ?IZ4 tj F 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. Department use only City of Northampton R EC E rmit: ..- Building Departme t klul ivewe y Permit 212 Main Street Sewer/Sep is AvE ilability i Room 100 SEP 2 1 V"BWell Avail bility Northampton, MA 01 60 Two Sets Stru ural Plans _ phone 413-587-1240 Fax 41 -58 ns DEPT OF BUILDIN PE TION, NORTHAMPTO 1 cI� APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Y/wl Map Lot OSS_ Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: // ( ft &;?WvLrt Yl JAW SrWrr /V4(nfA-MPrnA),1 N' Name(Print) Cutr'rent Mailing Address: 13 ti 14JTI Z7}rL.a roam— Telephone 6y8 f Signature 2.2 Authorized Agent: /1�icrfoc r/LIB-�sr i AO eVnf-c, MRf�0 SQ-$Ox , , iRtr�-,�J,C;0605Z Name(Print) Current Mailing Address: oe t;e't�� �/3 2gS02773 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building //;M_ (a)Building Permit Fee 2. Electrical "�✓vV (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) OD 5. Fire Protection 6. Total= 0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date IIJFo@ Por�nr�l�Nr,;���s.eo� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) i ._. _...Z w J - _.._._..........� E i w� ' �i�� � r�it�r �' i �... r' � � ,., ' % ...,. n ...w. Y f.}. .............. .. .. .......... .......... .....�.. .,.,...r-n... .e.r.�.1 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 L C_ Side L: L:�.-� � R:° 0 Rear Building Heigh Bldg.Square Fo e % -� Open Space Foot e (Lot area minus bldg a ed arkin #of Parkin Sac Fill: volume&Location A. Has a Specia Pe mit/ riance/Fin ing ever been issued for/on the site? NO O DON NOW ES O IF YES, date issued: IF YES: Was the pe it ecorded at gistry of Deeds? NO O ONT KNOW O YES O IF YES: enter B k Page and/or Document# B. Does the site contain a broo 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 © 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 Alteration(s) Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding[p] Other[rA �AISoL*TlpP-) Brief De cription of Proposed Work: UU /O�� ('GLL44z3e AfTlC, WluwPit�' woo✓J JI�G"D t,M_GL$ w/d"A';LAAG�,1fc4t- Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing 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? f. 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.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 I, �('m - , as Owner of the subject property ,,// hereby authorize I�, OL+1 Mn-ra to act on my behalf, in all matters relative to work authorized by this building permit application. _W�J►9 d 4�pAJ 4A Signature of Owner Date / L*S �(s� 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. �,C*0('a�, Mara Print Name Ze�� /°v !8 Signatur f Owner/Agent Date • e .� .. ... <.^, SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor::A Not Applicable El Name of License Holder:/ C(SMk lj 61lI/ License Number 1 AkUF90 SO.0-or C•6CY 2E, �W Aeirrla, Cr o(.002 4/27�iy Address Expiration Date Signat a Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ _PorcA)n A-t. Company Name v Registration Number 11440E i�J Sc ku - 40K rfWO,Cr 06o62- (0/2,1 /ZOZO Address Expiration Date Telephone goo 620 qq?s SECTION 10-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....... No...... ❑ � �l� � r �:�..� .. The Commonwealth of Massachusetts Department of Industrial Accidents ;f Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/individual):PQ U4/I ygoLAS r-ISM Address: ZQUEE't� �ERRACE City/State/Zip:L -_A , C Phone#: O •g2_(oG Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with r. 4. F1 I 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 g, E] Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.T 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.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other /'/ A LTU(.-A -lod 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:§MIA-EQRSDINSURAIACC, 002 Policy#or Self-ins.Lic.#: 02WEClZt ��J� Expiration Date: QB wozol'i Job Site Address: 41 Warner Street City/State/Zip: Northampton,MA 01062 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 U r thepains andpenalties ofperjury that the information provided above is true and correct. Sip-nature: `' "' } Date: '71i8 f Phone#• 86n'�O� 'yZG6 Official use only. Do not write in this area,to be completed by city or town off ciaL 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#: 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: q I WM re SoZ15r The debris will be transported by: ?Vxwrlp'� ;&aed The debris will be received by: �"CQLANxKlb Building permit number: Name of Permit Applicant � 1(49ukA4i5-re�, 1,11 . Date Signature of Permit Applicant Owner Authorization Form I, Debra Bercuvitz , (Owner's Name) Owner of the property located at: 41 Warner Street (Property Address) Northampton, MA 01062 , (Property Address) hereby authorize Potential Energy, LLC , a certified Mass Save Home Performance Contractor, to act on my behalf to obtain a building permit and to perform work on my property. AV (Owner's Signature) (Date) A�--� JDTDATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE R004 872o/2ols THIS CERTIFICATEIS 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(ies)must have ADDITIONAL INSURED provisions or 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 endorsement(s). CONTACT NAME: STARKWEATHER & SHEPLEY INS BK/PHS (n//CCri,Ext): (866) 467-8730 (AAi'a,nw): (888) 443-6112 090570 P: (866) 467-8730 F: (888) 443-6112 oIESS: 301 WOODS PARK DRIVE INSURER(S)AFFORDING COVERAGE NAlca CLINTON NY 13323 INSURER A: Sentinel Ins Co LTD 11000 INSURED INSURER B: Hartford Fire and Its P&C Affiliates 00914 INSURER C: POTENTIAL ENERGY LLC. INSURER D: 4 D QUEEN TER INSURER E: SOUTHINGTON CT 06489 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR TYPEOFINSURANCE ADDL SUBR POLICYNUMBER POM IDCYYE.FF POLICYEXP LIMITS LTR LNSR WVD (MCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s2, 000, 000 CLAIMS-MADEa OCCUR DAMAGE TO RENTED $1, 000, 000 PREMISES(Ea occurrence) A X General Liab 02 SBM RB0509 08/05/2018 08/05/2019 MED EXP(Any--Person) $10, 000 PERSONAL&ADV INJURY s2, 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s4, 000, 000 POLICYa JE O- X❑LOC PRODUCTS-COMP/OP AGGs4, 000, 000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) s2, 000, 000 ANY AUTO BODILY INJURY(Per person) $ A OWNEDSCHEDULED AUTOS ONLY AUTOS 02 SBM RB0509 08/05/2018 08/05/2019 BODILY INJURY(Par accident) X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA L X OCCUR EACH OCCURRENCE $1, 000, 000 A EXCESS LIAB CLAIMS-MADE 02 SBM RB0509 08/05/2018 08/05/2019 AGGREGATE $1, 000, 000 DED X RETENTION$10,000 WORKERS COMPENSATION PER I XOTH- ANDEMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $500, 000 OFFICER/MEMBER EXCLUDED? B (Mandatory In NH) N/A 02 WEC CR0745 08/05/2018 08/05/2019 E.L.DISEASE-EA EMPLOYEE $500, 000 If yes,describe under E.L.DISEASE-POLICY LIMIT 1'500, 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Those usual to the Insured' s Operations.Columbia Gas of Ma is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Columbia Gas of Ma AUTHORIZED REPRESENTATIVE 4 TECHNOLOGY DR STE 250 e—,Faea-,?Of WESTBOROUGH, MA 01581 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office t- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 192284 POTENTIAL ENERGY LLC 1 HARTFORD SQUARE Expiration: 06/21/2020 BOX 2-E NEW BRITAIN,CT 06052 Update Address and Return Card. SCA 1 v 20M-05x17 / Office of Consumer Affairs&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 192284 06/21/2020 1000 Washington Street-Suite 710 POTENTIAL ENERGY LLC Boston,MA 02118 NICHOLAS MEISTER c.0 1 HARTFORD SQUARE DOOR 65 SUITE 216 Undersecretary Not valid without signature NEW BRITAIN,CT 06052 %lassacnusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supra iv3r 1 &- '- 3:1raih -Icense� CSFA-106184 ,; in NICHOLAS MEISTER 4D QUEEN TERRACE s Southington CT 06489 Exp;ratior Commissioner 04/27/2019 1' Nordia City Of Louis Hasbrouck<Iasbrouck@northamptonma.gov> Imo/ Wlen 41 Warner St Northampton 1 message Louis Hasbrouck<Iasbrouck@northamptonma.gov> Fri, Sep 21, 2018 at 1:41 PM To:info@potentialenergyus.com Hi, The house at 41 Warner Street in Northampton was built before 1900 and may have knob and tube wiring. Please provide an affidavit that the knob and tube wiring has been replaced.See attached or provide other information. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413)587-1240 office (413)587-1272 fax Affidavit Regarding Knob and Tube Wiring.pdf 94K City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street * Municipal Building � C Northampton, MA 01060 too, Property Address: t to f {t%Q '�'€PZCT`. Contractor Name: I&Oncy t' tST" #' t tt�t kL r'qa('� Address: ')ewc City, State: Int Phone: i(lp0 ao LN?3 Property Own,t Name: C.I Address: Snk 161ew or City, State: t , mftI D I In z I, l 14Ot i}-5 (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date Z