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24A-242 21 TERRACE LN BP-2019-0819 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A-242 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-2019-0819 Project# JS-2019-001353 Est.Cost: $3900.00 Fee:$65.00 PERMISSION IS HEREB Y GRANTED TO: Const. Class: Contractor: License: Use Group: POTENTIAL ENERGY LLC 106184 Lot Size(sq ft.): 13939.20 Owner: ST MARTIN DEVON Zoning:URB(100)/ Applicant. POTENTIAL ENERGY LLC AT. 21 TERRACE LN Applicant Address: Phone: Insurance: 4 D QUEEN TER (860) 506-4266 O WC SOUTHINGTONCT06489 ISSUED ON:1/18/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD CELLULOSE TO ATTIC FLAT, INSTALL ROOF VENTS, VENT BATH FAN 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 1/18/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner use only City of Northar iptoj 0f, Building Department utta; Frit 212 Main St eet JAN 1 7 20 Room 10 W +N^ wipl Northampton, M 01 of can ni'x iris Pfar# phone 413-587-1240 F APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Q 9"' I f`/ 1.1 Property Address: This section to be completed by office ll�/� 2 �� L � Map—ate�� Lot 0��� Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: )5� Lgym na .21 l�� +Ale- ame(Print) Current Mailing Address: _ WS 'b 9328 cSGc.,c�V7 N�1'�'T14�/"r'�� Telephone Signature 2.2 Authorized A ent: lGlct4s/�G�ls? � d(� I<WAl 1k1 Name Z CCurrent Mailing Address: f0 /-1"273 Sign re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Q (a)Building Permit Fee 2. Electrical cJ (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee (� 4. Mechanical(HVAC) �v 5. Fire Protection 6. Total=0 +2+3+4+5) / Check Number Ce This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of BuildingsDate 14C) @ I✓//��OTw'r1&i,CKJg-.0G`�US. C 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 LR: L: R: Rear Building He' ht Bldg. Sq ootage Open Spaj, F otage (Lot area mi s b g&paved 00 arkin #of Parkin S ces Fill: volume& a�on A. Ha a ial Permit/Variance/F ding ever n issued f r n e site? NO DONT KNOW YES IF YES, d e 'ssu IF YES: the rmit recorded at th Registry of D eds? NO DONT KNOW YES IF YES: nt r Book Page and/or Document B. Does the sit co tain a b ook, body of wate or wetlands. NO © DONT KNOW O ES O IF YES, ha a p rmit bee or need to be o ained from a Conservation Commission? Needs to b ob ained Obtal ed O , Date Issued: C. Do any signs ex t n the property? S 0 IF YES, describe 1 e, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © 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 © 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 Alteration(s) El Roofing El Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[p] Other[0] Brief Deiptisan of-Proposed �C.�9-� lit►� L. Grp �f�iJ/�f f��',U9— ��iJ Work: 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 existinta housinsa.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, as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I 1CA0(W l�r(,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. S ig ed under the pains and penalties of perjury. ZlG 5 &&d Print Name rby Signatbfe of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su a isor: NotApplicable ❑ Name of License Holder: IG /MS lST�� !,*6!g/ License Number �CRYIt3GT0/L1, C-4- O(o,eSg J�b 7111 Address Expiration Date /38027 Sig Telephone 9.Relalstered Home ImorovemeW Contracts. Not Applicable ❑ ''oT-brjuT*L, 1922-8Y ComDany Name Registration Number / r�k�'FD `-'�U(� ��c 2�, �cfco gR► � Cr—o("oSZ 2/A Z) Address Expiratio Date 4111 Telephone 42 007?3 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...... ❑ City of Northampton Massachusetts J ;G t DEPARTMWT OF BUILDING INSPECTIONS at 212 Main Street • Municipal Building r-', Northampton, MA 01060 sf ... 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("RIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation, repair, modernization, conversion, improvement removal, demolition, or construction 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: 1 syu4 nyd Est.Cost: Address of Work: 2 Ace- 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 y 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 PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Dlato Contractor Nam 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 City of Northampton -'' Massachusetts li�c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 9Jb„ Cn1°a Northampton, MA 01060 Debris 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. The debris from construction work being performed at: f c ZAA�e- (Please brint house number and street name) Is to be disposed of at: A & M46 &AIIU14Ge) el- (Please print name and location of facili y) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 11"Al Signature of Permit Applicant or Owner Dat If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts ` = Department of Industrial Accidents Office of Investigations ' l 600 Washington Street YN, Boston,MA 02111 t-- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Q-( t.AT'!(AYL�C INIC14oLAZ MFt57 R Address: D Quad 1 ERRAL'z City/State/Zip:"4&rot4lPhone#:_6O_50(o•g2GG Are you an employer?Check the appropriate box: Type of project(required): 1.% I am a employer with r 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. EJ New construction 2.r-1I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. F1 Demolition workingfor me in an capacity. employees and have workers' y p �'• f 9. ❑ Building addition [No workers' comp.insurance comp.insurance.; 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.E] Roof repairs insurance required.] c. 152, §1(4),and we have no / employees. [No workers' 13.[4 Other� LTU(-AnOnt 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. lContractors 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. n Insurance Company Name:§ATA-EPRI) SURIft 99.6 GRoy2 Policy#or Self-ins. Lic.#: j2r2)A[C: '� aF r?q5 Expiration Date: O O Q Job Site Address: 21 Terrace Lane City/State/Zip:Northampton,MA 01060 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 u3*r the pains and penalties of perjury that the information provided above is true and correct. Signature: ""' Date: Phone#: $fin 5C4 'yZ&G 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#: DocuSign Envelope ID:65DI FD4F-9662-439D-A77F-98C1 BD25EB9A Page 1 of 4 CLEAResult' CONTRACT CLEAResult 50 Washington Street, Customer Name:DEVON ST MARTIN Westborough,MA,01581 Email:devonstmartin@gmail.com Phone:413-588-7328 Premise Address:21 Terrace Ln,Northampton,MA 01060 Project ID:3426550 Date:June 18,2018 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 recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference. x fro+ Air Sealing at Estimated 62.5 CFM50 Per Hour 12 hr $1,110.96 $0.00 Exterior Door Weather Stripping(with AS hrs) 3 each $90.21 $0.00 Door Sweep(with AS hrs) 1 each $25.31 $0.00 Attic Floor-6"Open Blow Cellulose 1122 SF $1,817.64 $454.42 Roof Vent-12" 2 each $300.12 $75.03 Roof Vent-8" 1 each $109.30 $27.32 Bath Fan-Vent to Roof 1 each $141.30 $35.32 Damming 24 each $57.36 $14.34 Door-2"Thermal Barrier Polyiso 1 each $90.44 $22.61 Attic Floor-9"Fiberglass Batting 24 SF $59.04 $14.76 Kneewall Wall-2"Thermal Barrier Polyiso 36 SF $172.08 $43.02 Total: $3,973.76 Program Incentive: -$3,286.94 Customer Total: $686.82 Payment Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$225.00 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:$461.82 as the final payment for the Work shall be payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC) upon satisfactory completion of the DocuSign Envelope ID:65D1FD4F-9662-439D-A77F-98C1BD25E89A Page 2 of 4 Work. Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of $3,286.94.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 mutually agree in advance that in the event that 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 M.G.L.c 142A. You may cancel this agreement if it has been signed by a party 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 CONTRACT IF THERE ARE ANY BLANK SPACES. LDSo«�spna by:tAvv St M4r-rN 10/8/2018 112:03 EDT Customer Signa �°�'BFZr�aF°_ u� Date Indicate your selected IIC here, if applicable Initial here if you want the Program to assign a Participating Contractor Shannon McKeon 10/4/18 Shannon McKeon CLEAResult Signature Date Name of CLEAResult Representative