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42-043 (11)
669 WESTHAMPTON RD BP-2019-0313 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block:42-043 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2019-0313 Project# JS-2019-000507 Est.Cost: $2894.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THE ENERGY STORE 106082 Lot Size(sa.1): 25047.00 Owner: JOHNSON FRANCIS&LUCY HARTRY Zoning: Applicant. THE ENERGY STORE AT: 669 WESTHAMPTON RD Applicant Address: Phone: Insurance: 3 SWIM LANE WC NEWTONCT06470 ISSUED ON.9/16/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE AND WINTERIZE HOME- 9 INCH FIBERGLASS BATTING CRAWLSPACE 2" THERMAL POYISCO 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: FeeTyne: Date Paid: Amount: Building 9/16/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED �SUL ?�d�t/ Department use only SEP 1 0 @ft�%f Northampton Status of Permit: Building epartment Curb Cut/Driveway Permit r of auil Dwc IN n S reet Sewer/Septic Availability ORTHAMPTON.PAA 0tkRg0rr 1 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Iq^;'>I -.�' 1.1 Property Address. This section to be completed by office Map � Lot t/ 3 Unit N\a Zone Overlay District tv Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: phone Signature 2.2 Authorized Agent: ELeLa 1 4�� Wit- n'r c-4' Name(Prin) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (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) Check Number This Section For Official Use Only BuildingPermit Number: Date Issued: Signature: 7 lir (. Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) r t"• ...� .. .._ Section 4. ZONING Ali 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) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW (.J YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW ® YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ,a DONT KNOW O YES 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-,0 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 © NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. I SECTION 5-DESCRIPTION OF PROPOSED WORK[check all applicable► New House ❑ Addition F-1Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[p] Other[CIO Brief Description of Proposed Work: I Y'1� \C IVe «i-6 V ;h 2 C� 7ZC l-lc�- -S `FLP2c = Alteration of existing bedroom Yes 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? j h. Type of construction I i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. Floodplain Yes No Depth of basement or cellar floor below finished grade I 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 as Owner of the subject property c. hereby authorize � _ �C�`� , �J`�- ; LLC to act on my behalf, in all matters relative to wo horized by this building permit application. Signature of Owner Date Ul._.._-- as Owner/Authorized Agent hereby declare that the statements and informlation on the foregoing appli6ation are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. V�rl Print Name Ij nature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed ConstructionStuuRerviiso�r.: l Not Applicable ❑ Name of License Holder. t 1(1� 1 C ]A \�;� 'rs� License Num Address Expirat n Da Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company{Name � Registration umber ' J ) 1 ` Address � r�_LExpiratioh Dat Ma\a Te ephone 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...... ❑ Permit Authorization mass save Form Site ID: 3438669 Customer: FRANCIS JOHNSON 7 O147iJ5<f�V �-1-aCY W*T owner of the property located at: (Owner's Name,printed) 669 Westhampton Rd Northampton, MA 01062 (Pruperty Street Address) (edy) 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/or weatherization work on my property. Owner's Signature: — Date: 7—/ "/ l FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date i I Name: CLEAResult Phone: 800-480-7472 Email: For Office Use Crty Rev,102015 RCS PLANVIEW DIAGRAM 0 iCustomer: r Home Phone Address: (0411 t.�'Q.S�Qc�� Work Phone: Town: Cell Phone: Any Mmrtations for access by large tnxi,7 No Yes d yes describe Any spe[dlc dvectlons or landfnatksi No Yes It yrs,dewrAx. Site ID: Energy Specialist: Reviewed by: $CA U O U i� (�3 dGcf tr•��S,.,ei�5 CY� 0�0 0"tom• i.' 3�S For Office use Only �• a Bushes Ladder Neighbor Proximity- Pocket Doors Insert Radiators # Fence(s) Existing Conditions X=Access ❑=Vents Note Inside Square R=Roof S=Soffit G=Gable RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Dnp Edge T=Triangle Install �O=New Access Note in Circle C=Ceiling W=Wail S=Sheathing Temp Unless Noted Otherwise -Vents Note in Triangle R=8"Roof S=Soffit G=gable M=12'Mushroom For Access 2200-10-1J1! H,. AREA I SUPPORTING MATH TOTAL i a 35 Recommended �� Ventilation Calculation N Recommended _ Ventilation Calculation , AIR SEALING WORK HOURS _ Air Sealing Work Hour _ Calculation Work Hours 4 6 B 10 12 14 �16 ._......_ t+2 Attic Sq.Footage _<500 501-800 801-1100 1101-1400 1401-1700 1701-2000 2001-2300 Every= Exceptional AFL Hours Primarily Floored Attics Chimney or BF=i Hour Multiple Chimney/BF=2 Hou Prefab/Modular Hours No Chimney=4 Hours Chimney=6 Hours _ Exceptional KW Hours X<20 feet=1 Hour 20 ft<X<40 ft=2 Hours X>40 ft=4 Hours i Rim Joist Only Hours RJ>150 ft=2 Hours BMT Ceiling Only Hours C ing Area< ,000 sq ft=1 Hour Ceiling Area>2,000 sq ft=2 Hours —NOTE:You MUST be ltSULATINC,,RJ or Basement Ceiling to specify RJ or BMT Ceiling ONLY Air Sealing Hours- 0 © >6"Loose Insulation Cross Batt Insulation Multipliers ❑ >6"Mix Batt 8 Loose Insulation �^ Truss Construction For Office Use Only Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 R Boston, Massachusetts 02108 Horne Improvement Contractor Registration Type: LLC THE-ENERGY STORE, LLC Registration: 178392 Expiration: 04/09/2020 3 SIMM LANE STE 1C 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 3 SIMM LANE STE 1C NEWTOWN, CT 06470 Undersecretary O i without signature The Commonwealth of Massachusetts T Department of Industrial Accidents I Congress Street,Suite 100 Boston,M.4 02114-2017 'V www.massaovIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER.ry11TTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/lndividual): The Energy Store, LLC Address: 3 Simm Lane City/State/Zip: Newtown, CT 06470 Phone#: 888-840-6641 Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 3 employees(full and/or pan-tine).- 7. p New construction 2.O I am a sole proprietor or partnership and have no employees working for me in 8. F�Remodeling any capacity.(No workers'comp_insurance required.] 9. El Demolition 3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I LM Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.F-1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.[a'Other Weatherization 6.r-1we are a corporation and its officers have exercised their right of exemption per MGL c. 152,$1(4),and the have no employees.[No workers'comp.insurance required.] *Arty applicant that checks box gl must also fill out the section bclor.,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 ann an employer that is providing workers'compensation insurance fur my employees. Below is the policy and job site information. Insurance Company Name: BNC Insurance Agency, Inc Policy#or Self-ins.Lic.#: BNUWC0131379 Expiration Date: 4/15/2019 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§§'25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperiury that the information provided above is trite and correct. Signature: Date: _ Phone#: 475-204-4585 Cell 888-840-6641 Office 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#: ACORO0 DATE(M M/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/30/2018 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(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). PRODUCER CONTACT Joseph E.Salvatore,AAI NAME: BNC Insurance Agency,Inc HONo Ext): (914)937-1230 Aic,No: (914)937-1124 90 South Ridge Street E-MAIL enc jsalvatore@ bncag y.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Rye Brook NY 10573 If A: StarNet Insurance Company 40045 INSURED INSURER B Energy PRZ LLC INSURER C: DBA The Energy Store INSURER D: 3 Simm Lane,Suite 1C INSURER E: Newtown CT 06470 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1842482992 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. IFF POLICY EXP LTR AUULbUBK TYPE OF INSURANCE INSD WVD POLICY NUMBER MMLICY E /DDIYYYY MM/DDfYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s DAMAGE CLAIMS-MADE F]OCCUR PREMISES Ea occurrence) S MED EXP(Any one person) S N/A PERSONALS ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F—IJECT JECT LOC PRODUCTS-COMP/OP AGG 5 OTHER. S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) S OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident b UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE 5 E=I RETENTION S $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER YIN 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA BNUWC0131379 04/15/2018 04/15/2019 EL EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN -—SAMPLE...... ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC"R" CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 044/02/2102/20,8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 014LY 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 NOTICONSTITUTE 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(les)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). I PRODUCER CONTACT Wendy Filice,CIC t NAME: Venbrook Insurance Services,CA Lic OD80832 I PHONE FAX I (AJC.No Exit: __ �(AIC,No):_ _ 1 6320 Canoga Ave..12th Floor EMAIL dice@venbrook.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 Woodland Hills CA 91367 INSURERA: Crum BForster Specialty 44520 INSURED INSURER B: Wesco Insurance Company The Energy Store.LLC INSURER C: 3 Simm Lane INSURER D: Suite 1C INSURER E: _ Newtown CT 06470 1INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEDiBELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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- TY POLICY EFF POLICY EX LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYY MMIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000'000 CLAIMS-MADE FX OCCUR DAMAGE TO ff N 50,000 PREMISES occurrence S _ MED EXP(Any one person) S 5.000 A EPK121944 03/27/2018 03/27/2019 "PERSONAL BADV INJURY S 1,000,000 GEN'L AGGREGATE LIMJTAPPLIES PER, GENERAL AGGREGATE S 2'000'000 X POLICY ❑JEC E LOC PRODUCTS-COMP/OP AGG S 2.000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMITS 1,000,000 Ea acadeni X ANY AUTO BODILY INJURY(Per person) S B OWNED SCHEDULED WPPI604061-01) 03/27/2018 03/27/2019 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED P I I I NON-OWNED PROPFRdZOAMAGE 5 AUTOS ONLY AUTOS ONLY Per 2 Mdent Underinsured motorist 5 X UMBRELLAUAB RREN'"""' 5,000,000 X OCCUR � EACH OCCURRENCE S A EXCESS LIAR EFX-11AGGREGATE 5 328 03/27/2018 03/27/2019 5,000,000 I _ DED RETENTION$ $ I WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER - ANY PROPRIETORIPARTNERIEXECUTIVE ❑ NIA EL EACH ACCIDENT S OFFICERlMEMBER EXCLUDED? (Mandatory In NH) E.L DISEASE-EA EMPLOYEE S If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached it more space is required) `30 Days Notice of Cancellation,except 10 days for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. ( AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD