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11-003 (3) 79 COUNTRY WAY BP-2019-0484 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11 -003 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-2019-0484 Project# JS-2019-000781 Est.Cost: $9948.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Groin THE ENERGY STORE 106082 Lot size(sa. ft.): 23391.72 Owner. Nina Shraver Zoning: Applicant: THE ENERGY STORE AT. 79 COUNTRY WAY Applicant Address: Phone: Insurance: 3 SIMM LANE WC NEV TONCT06470 ISSUED ON:10/19/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:WEATHERIZATION, INSULATE ATTIC FLOOR, DAMMING PROPAVENT, AIR SEALING 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 10/19/2018 0:00:00 $70.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 'r-eseG L Department use only City of Northampton Status of Permit: Building Department Curb CutfDriveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability_ Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify- APPLICATION pecify-APPLICATION TO CONSTRUCT,A LISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION �j O•J Z O 7 1.1 Property Address: OCT 18 7Q1$ his section to be completed by office �Q�� � Map Lot O 0 3 Unit t DEPT.OF BUILDING INSPECTIONS NORTHAMPTON,M�Ine� Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �,r M nm(n\w, Name(Print) Q Current Mailing Ad ss: l/ Telephone — Signature 3h3 ►� 2.2 Authorized A en : nw� Name(Prinft) Current Mailing Address: /-"4 01T.0 v i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item 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. Totai=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: CO/!S/ls Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR 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) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained a , Date Issued: C. Do any signs exist on the property? YES O NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO La 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 0 NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check ail applicable) t New House Addition [7 Replacement Windows Alteration(s) ❑ Roofing ED Or Doors ❑ 1 Accessory Bldg. ❑ Demolition ❑ New Signs [1:3] Decks [(3 Siding[L7] Other[CK Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No `1 } Attached Narrative Renovating unfinished basement Yes No I Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the foiiowina: - a. Use of building:One Family %z, ' 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. 1. 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 1, �i 1� �1('��C _.� as Owner of the subject property hereby authorize CACVzl Pf\\-e r\ 'tl ' to act on my behalf,in all matters relative to worW authorized by this buildin ll application. Signature of Owner Date that ,as Owner/Authorized Agent hereby declare t at 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 Mame itign)OUre of OwnedAgent Date � c 3.`. Permit Authorization mass sage Form Site ID: 3439557 Customer: NINA SHARAYER owner of the property located at: (OwneA Name,printed) 79 Country Way Northampton, MA 01062 (Property street Address) (aty) 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: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResuit Phone: 800-480-7472 Email: For Office Use Only Rev.102015 Page 1 of 4 CLEAResult CONTRACT CLEAResult 5o Washington Street, Customer Name:NINA SHARAYER Westborough,MA,01381 EmaU:nIrmshrayerpgmaH.com Phone:207-319-2004 Premise Address:78 Country Way,Northampton,MA 01062 Project ID:3439557 Date:JtAy 18,2018 Applicable Customer Required Actions: Notes: Flooring Removal Customer must remove flooring from attic2 prior to contractor's arrival. Job Description Contractor will perform or cause to be performed the following work on these"Premises"In a professional manner and in accordance with the terms of this Contract,including the attached recommendationstwork order describing the work in detail(the"Work")which are incorporated herein by reference. AAeasurta__.tesot)plkin. sv> tity _ .l�nl Total cost itrtar moist Attic Floor-8"Open Blow Cellulose 952 SF $1,675.52 $418.88 Cut and Finish Access 1 each $124.53 $31.13 Hatch-2"Thermal Barrier Polyiso 1 each $4628 $11,57 Damming 78 each $186.42 $46.60 Propavent 42 each $174.72 $43.68 Kneewall Wall-2"Thermal Barrier Polyiso 66 SF $315.48 $78.87 Walls-Clapboard-3"Dense Pack Cellulose 1885 SF $4,354.35 $1,088.59 Garage Ceiling-10"Dense Pack Cellulose 528 SF $1,742.40 $435.60 Air Sealing at Estimated 62.5 CFM50 Per Hour 8 hr $740.64 $0.00 Attic Stair Cover w/Carpentry(with AS hrs) 1 each $289.31 $0.00 Whole House Fan Box-2'Thermal Barrier Polyiso(with AS hrs) 1 each $187.70 $0.00 Exterior Door Weather Stripping(with AS hrs) 2 each $60.14 $0.00 Door Sweep(with AS hrs) 2 each $50.62 $0.00 Total: $9,948.11 Program Incentive. -$7,793.19 Customer Total: $2,154.92 Page 2 of 4 Payment Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#11:$700.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResult,50 Washington Street,,Westborough,MA,01581.Final Payment:$1,454.92 as the final payment for the Work shall be payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(I1C)upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of $7,793.19.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Dispute Resolution The IIC and Customer hereby mutualty agree In advance that in the event thal the IIC has a dispute concerning this Contract,the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in MAL c 142A. , You may cancel this agreement if it has been signed by a parry at a place other than an address of the seller,provided you notify the seller In writing by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.DO NOT SIGN THIS CONTRAC IF THERE ARE ANY BLANK SPACES. Customer Signature Date Indicate your selected IIC here,if applicable Initial here if you want the Program to assign a Participating Contractor CLEAResuft Signature Date Name of CLEAResult Representative The Coninionwealth of Hassachiisetty T Department of Industrial Accidents ;x I Congress Street,Smite 100 r Boston,M.9 02114-2017 www.nmssgovIdta Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): 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 I am a employer with 3 employees(full and/or pan-tune).' 7. 0 New construction 2.0 I alit a sole proprietor or partnership and have no employees workine for me in 8. []Remodeling any capacity.(No workers'comp.insurance required.) 9. ❑Demolition 3.0 I am a homeowner doing all worts myself(No workers'comp.insurance required.)° 10 Q Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attacht:d sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.EjOther Weatherization 6.0 We are a corporation and its officers have exercised their right of exemption per NIGL c. 152,$1(4),and we have no cmpluvices.(No workers comp.insurance required.) "Any applicant that checks box€I must also fill out the section beloh^showing their workers'compensation policy information. I 1-lomeowners 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 o f the sub-contractors and state whether or not those cmitir..c 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: BNC Insurance Agency, Inc Policy 4 or Self-ins.Lic.#: BNUWC0131379 Expiration Date: 4/15/2019 Job Site Address: 7Y calm A/CY/ City/State/Zip:�t� `/ ojo Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex Yatton 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 tender t/r pal andpenal o 'perjury that the information provided above is true and correct. Signature: Date: Phone n: 475-204-4585 Cell 888-840-6641 Office Official ase only. Do not write in this area,to be completed by city or town offrciaL City or Town: PermitlLicense# 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#: THEENER-01 GP17ARR CERTIFICATE OF LIABILITY INSURANCE 0$120 8 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 endomement(s). PRODUCER Brown S Brown of New York Inc. PHONE ;(914)337-1833 Ac Nd;(914)337-1596 800 Westchester Avenue,N311 Rye Brook,NY 10573 L .cerrificates@bbinsny.com INSURERS)AFFORDING COVERAGE NAIC 0 INSURERA_Crum&Forster Specialty Insurance Co. 44520 INSURED wwRER B.AMTrust Insurance Company of Kansas Inc. 15954 Energy PRZ LLC Dba The Energy Store INSURER C:StarNet Insurance Company 40045 3 Simm Lane Suite 1C INSURERD: Newtown,CT 06470 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION UMBER: j 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 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. INSR TYPE OF INSURANCE ASL SUB WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �X OCCUR X EPK-121944 03/27/2018 03127/2019 PDRAMAGE TO RENTED $ 50,000 MED EXP fAny one S 5,000 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2'000'000 POLICY�JEL�i' DX LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE UA131 RY COMBINED SINGLE LIMIT 4 1,000,000 X ANY AUTO X KPP1051229 00 03/27/2018 03/27/2019 BODILY INJURY Per $ OWNED SCHEDULED AUTOS ONLY AUTOS SSWN BODILY INJURY Per accident S AUTOS ONLY AUTOS Ot�l� AOec P ade DAMAGE $ A UMBRELLA LIAB I X I OCCUR EACH OCCURRENCE $ 5'000'000 X EXCESS LIAB ` CLAIMS-MADE EFX-110328 03/27/2018 03/27/2019 AGGREGATE $ 5,000,000 DED J—TREMNT10N S $ C WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY TA_UTE FR ANY tPR�OlPMRIIETBOERIPARTNEWEXECUTIVE YIN BNUWC0131379 04115/2018 0411512019 E.L.EACH ACCIDENT S 1,000,000 (MarMatOry In NH)EXCLUDED? a N r A E.L.DISEASE-EAEMPLOYE S 11000'000 1f yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1'000'000 A Polution Liability EPK421944 03/27/2018 03/27/2019 Each Condition 1,000,000 A Errors&Omissions EPK-121944 0312712018 03/27/2019 Each Wrongful Act 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES CACORD 101,Addiliaml Remarks Schedule rray be attached It more spaceis requw ;Action Inc and National Grid USA its direct and indirect parents subsidiaries and atniiates shall be named as additional insured on Commercial!General Liability and Automobile Liability policies as required by written contract or agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BCAC,INC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1531 East Street ACCORDANCE WITH THE POLICY PROVISIONS. Pittsfield,MA 01201 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) / ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and Logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Horne Improvement Contractor Registration Type: LLC THE-ENERGY STORE, LLC Registration: 178392 3 SIMM LANE STE 1C Expiration: 0410912020 NEWTOWN, CT 06470 Update Address and Return Card. 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 178392 04/09/2020 One Ashburton Place -Suite 1301 THE-ENERGY STORE, LLC Boston, MA 02108 ROBERT NEAL ,Q„Cc"""� 3 SIMM LANE STE 1C NEWTOWN, CT 06470 Undersecretary i without signature