18C-055 (4) 51.5 HATFIELD ST 22 BP-2019-0906
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 18C-055 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
PemUt: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit 4 BP-2019-0906
Proiect 4 JS-2019-001510
Est. Cost:$900.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: ENERGIA LLC 92540
Lot Size(sa.R.): Owner. DAVISROXY
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT. 51.5 HATFIELD ST 22
ApplicantAddress: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:2/19/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION
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 4 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 2/19/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 -
Louis Hasbrouck—Building Commissioner
Deparbnent we only
City of North mpt of P mtk.
Building Dep rtmert curb veway PenDQ
212 Main S reef.i FEB 1 9 201 r cAve lebldy
Room 1 0 W al Availability
Northampton, A 01 Structural Plans
r, ir, 'is>
phone 413-587-1240 Fax 413-5137-)' � re PIInti-
APPLICATION
ro
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
_ }}/ Map Lot 0 S� Unit
\ IL "Ok `�-\r^\y L' r n` ` Zone Overlay District
Elm SL District CS DlsMct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of RecorO:
�xu L I �1 ; 51112 "Whekd a PST- 2-7
Name(Print) Curren Mailing Address-
Telephone
Signature
2.2 Authorized Agent: y 2_1-\1
7` ` �k � ((�'( 1' C' 11^
2 42 �-7\)�1 C)Ny-' ` 1T A A 1\)Vt
Name(Print) Current Mailing Address:
Signature telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Coal(Dollars)to be Official Use Only
completed by permit applicant
1. Building �(� V\J (a)Building Permit Fee
2. Electrical �1 M (b)Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical(HVAC) V' cc
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissionerlinspector of Buildings Date
LV&L,(cC-- (a ea2P ;n us. co-j'_
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
$PCt100 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
nis column to bo filled in by
Building Department
Lot Sire
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage as
(Lm arw minus bldg&paved
ranking)
4 o Parking Spaces
Fill:
volume&Location
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. Wit the construction activity disturb(clearing, grading,excavation, or filling)over t acre or is it part of a common plan
that dl disturb over 1 acre? YES O NO O
IF YES,then a Northampton Stoll Water Management Permit from the DPW is required.
SECTiONDESCRIPTION OF PROPOSED WORK(check all II
New House ❑ Addition ❑ Replacement WindowsAlteraflon(s) ❑ Roofing E]or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding[O] Other
Brief Description of Proposed
Work. )11.V.1r,��
Alteration of e.isting bedroom_Yes X, No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement 76S-41—
Plans Attached Roll -Sheet
Ga. If New house and or addition to existing housing complete the followlna:
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 n.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
T S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
It roperlI, 9Py _ X � TV\S as Owner of the subject
hereby authorize 7n'C`(� Y`l worka \ 'k_1db QJ�I.\
to act on my behalf, in all matters rel.ive to work authorized by this building permit application.
SFS. /JFaP Ci(T Ao(. jI Ld
Signature of Owner Date
I, ���� �PC as Owner/Authorized
Agent hereby declare that a statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed u r th pains and penalties of perjury.
Prin ame
/4
Signature or Ownerl ent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not tA'ppplicabblle ❑
Name of License Holder:
License Number
2-y) (SufjfoI k, S} 11r>1� MA okoHo oq tai [?.o\c\
Atldres Expiration Date
/ lu��l�zz-�i\�
Si stirs TelephN
8.RwIstered Home Improvement Contractor: Not Applicable ❑
Ex rQjCa (J-C . IclS16pll,
Company Name Registration Number
LO 0\()(-c
- 1 I(O hri
Address Expira ion D to
Telephone (A1 -,3221311
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted vnih this application. Failure to provide this affidavit unit result
in the denial of the issuance of the building peimit.
Signed Affidavit Attached Yes....... 4No...... ❑
City of Northampton
•:�' ' Massachusetts �'.'•' ,r�4
\ D&PART T OF BUILDING INSPECTIONS
213 Nam Street 11 Building
Nonthaapton, M MA 0101060
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("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any preexisting 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:Ijthe homeowner has contracted/with a corporation or LLC,that entity must be reregistered
Type of Work: y("L�Aa , ,0^1, I(' ` A Est.Cost:�co
Address of Work:5I 1h7 7-L)A \-�,1 `tt M 7
Date of Permit Application:
I hereby certify that: "T
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
_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:
2_/P)J201q Ir�m F S�I�nS��f�EC�_ mica llf_ ,HIC tCNP
Date Contractor Name Registration�SNo.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
empMassachusetts
® c
11 z
DEPARTNENT OF BUILDING INSPECTZONS
212 neon Street Municipal Building
Q� \
Nostnton,on, M, M1 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:
51 I J - NAAfkCVA St . AFT 2-9
(Please print house number and street name)
Is to be disposed of at:
m\e6 Wo,-rte. 1�1 ►��e S1 . SaY (�iFtC'b MR 01 `
(Please print name and location of facility) ,�
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signal a of Permit Applicant or Owner Date
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.
,ac itcl` CERTIFICATE OF LIABILITY INSURANCE PATERMMLIDMYVI
8112018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES HOT 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 DERTIFIGATE HOLDER.
IMPORTANT: If the ceWNoats holder is an ADDITIONAL INSURED,(ba pol"Isa)must be Redotsed. B SUBROGATION IS WAIVED,aubl A to
the terms and conditions of the policy,certaM policles may roquim an endoraemsnt. A statement on We cert111Gam does not comer rights to the
udRbata healer N Neu of such endorsement a.
"=Can Mary Cum
T _he Dowd Agamies,LLC P E .41a.63S-]944 �—
14 Bobala Road .-�..
Holyoke MA 01040
ucER ENELL _
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Ener
LLC
In uREn4-Evanston insurance Cmn an 35378
EnUf
242t u%olk Street w uaeae Commcroe Ins rants Co. an 34784
Hoyoke MA 01040 c:StarStaste Nattanat 4caurance O a zss96
NSURER ;GUem ImWall G1011b 62N}
MEURER,
URER
COVERAGES CERTIFICATE NUMBER:1131630225 REVISION NUMBER:
THS{S TO CERTIt-Y THAT THE P0,1C1ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE F'aN;Y
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 IB SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPEOOkI waWcE F CYNII BER ILI Y P Y UNITS
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ANY Akoo
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ALL OWNED AMOS ECMIV IMAMY iP6t rRman} S
x SCNEWLEDAVI,pS pObILY INJURY 1P9raoddVI) 5
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MIRED MITOS FROfft- 'Imp
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C x VMBflELlA LIAR X wCUR 78>6pXi6ppU 7/1fl0iR YliR019 EADHOCCURRENC£ 51, OM
lonut"I" CWMS NAPE
AC uREGgT£ 8T,0.Ualp
DEDUCTIBLE
a
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o iMRRERSMWELIAINU FNYWVSzt?E d
MY PROoRI ER6'LIABILIIY Y1ry 7rIlM)8 ]){Y(pt9 T STATV- Dit}
ANY PR=Naaa,oX,LUDEul CWNE LEA
OFFKaRM.IN W,IXG,'JOEOr 11 .JI H/q E.L.EACH ACGIDEM E1,DIp,fb
(AORddealt qty E.C.DISEASE.
I( dovMew4e EA ENMOYE ROW p
CR1 NOE W.RA Mmx EL.OISEA,E ��
PQLIGY LIMIT S ��
OE4CRIPhON aV ePERAnnNal I LOCATONS I VRJICLE.(ANud,aepRo tv},pddXlanal Remarxe Heludulq Ilmon apban Ia np4lhdl
C iFICATE HOLDER CAN LLATION30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE F1tP1RATlON OAtE THEREOF,NOTICE"LL BE DELNERED
IN ACCORDANCE VJITM THE POLICY PROVISIONS.
To Whom it May concern
AUTH p6EO flEppynE'6EMATVE
®196&2009 ACORD CORPORATION. AN tights resnrved.
ACOft423(20139!09} The ACORD name and Iogo are ragixtared mark,of ACORD
commonwealth of Massachuselta
Division of Professional Licensure
Board of Sodding Regulations and Standards
Conetrudien Supervisor
CS-092540 Expires:09!0212019
THOMAS 6TRE ET SSLER
107 MAIN STREET
HATFIELD MA alaae
Commissioner
O{p¢¢of Cons Affaks&6 5 s li& fano License or registration valid for individul use only
'''HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ftwonnatbn: 165169 Type: Office of Consumer Affairs and Business Regulufidn
Expiration: V1112018 LLC 10 Part,Plazu-Suit.$170
Boston,MA 0211G
ENERG1A LLC �o/Zo
THOMAS ROSSMASSLER
242SUFFOLK STREET
HOLYOKE,MA 01040 ^Undersecretary 1Votvalid withoutslgnature
il
The Commonwealth of Massachusetts
Val",
Department of lndnstrirslAccidenis
Office of Investigations
600 Washington Street
Boston,MA 02111
ivww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Yrint Legibly
Name (OusinessiOrganizationlindividual)t EneLgia LLC.
Address: 242 Suffolk St.
Ci /State/Zi ; Holyoke, MA 01040 Phone#: 413-322-3111
At you an employer?Check the appropriate box: 77.,tt�,.m
Type of project(required):
1.�1 am a employer with _ 4. ❑ [am a gcontractor and I 6. ❑ New consaud"memp4oyees(fullandlor part-time).* havehisub-connactors2.❑ I amasole proprietor or partner- listed oached sheet. 7. ❑ Remodelingship and have no employees These stractors have S. ❑Demolitionworking formeianycapacity. employhave workers' 9 ❑ Building addition[No workers' comp.insurance comp.ice.tequired.] 5. ❑ We areoration and its ME] Electrical repairs or additions3.❑ I am a homeowner doing all work officersxercised theta I I,❑ Plumbing repairs or additionsmyself[No workers'comp, right otion per MGL 12.❑ Roof repairs
insurance required.]i C. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required]
"Any apptkantabat checks bol al nmsl also fill out du section below slwwing tlmic wads'mnspensation policy iafomtation.
I tlomeuwnerz who submit mis hffki It indicming they we doing all Wart and inch biro ounids v=nazicis must submit anew atIldavit indkating sor1,.
tConlrawors that chick this box muss attached an additional sbcet showing lliename of the sub-connazmrs and stale wlsdher or nal arose entities have
employees. If rhe sub-contractors have eniplvyeas,they must provide their workers'comp.policy n.a,ber
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Group
Policy#or Self-ins.Lic.#: ENWC952172 Expiration Date: 7/001/2019 l
Job Site Address: 511—"& � City/StatelZip: �/� o l d ee d
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 andior 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 ven ification.
I do hereby terrify in at pni s and panNries ojperjury that the hrformadmo provided above "/Inw oadty/�rrnel.
Signature, Date: �!
Phone#: 413-322-3111
Official use only. Do not write In rids area,to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority(circle one):
].Board ofBeeith 2.Building Department 3. City/Town Clerk 4, Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Permit Authorization
47T rik
mass save Form
Site ID: 35889755 Customer: ROXY L DAVIS
I, 2xlj �� .JlJPS ,owner of the property located at:
(Owners Nam%primed)
51 1/2 Hatfield St APT 22 Northampton, MA 01060
(pmperty5treat Address) (chy)
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. n
Owner's Signature: WfJ-)I,
Date:
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractorto the
above referenced project:
Nee-G-/
Participating Contractor Date
Name: CLEAResult
Phone: 800480-7472
Email:
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