31B-207 (2) 98 STATE ST BP-2019-1162
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mar,:Block:31 B-207 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categom INSULATION BUILDING PERMIT
Permit# BP-2019-1162
Proiect# JS-2019-001883
Est.Cost: $1300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grow ENERGIA LLC 92540
Lot Size(sq. ft.): 5924.16 Owner. KITTO ANDREW
Zoning, URCn00v Applicant. ENERGIA LLC
AT. 98 STATE ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON.•411912019 0:00:00
TO PERFORM THE FOLLOWING WORILATTIC DAMMING AND ATTIC FLAT
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 Fio l:
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 Slenature:
FeeType: Date Paid: Amount:
Building 4/19/20190:00:00 $000
312 Alain Street,I'boce(.113))87-1240- Fax: (413)587-1272
Louie Hasbrouck- Building Commissioner
TORCity of Nort am on D
,r Building De artr�lent
212 Main Strut APR i 8 2019 SULATION
. � Room 100 1
Northampton My
„oFrT
phone 413587-1240_Fax 413 5�'�-TlT2" .. ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Atltlresa.
Thissectionto be completed by ofitp 07
Map LotUnit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Arc�i t o C Fa X10 e 5 �� Nnrtham�l�c j M
Name(Print) -c Q�"[Aail � orsp,\q
`PP IYt7 \i {� \Yl Ly tY� Tlekphon`
Signature
2.2 Authorized Agent:
2 2 SvFf \W, aV N \u V-£ m ) p
Name(Print) Current Mailing Address:
lye L-3\\\
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permita licant
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 '-'7ceb
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerllnspector of Buildings Date
/j/'G1jP @ e�IDX A0. US• Coate__
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisoror:�c Not cApplicable 11
Name of License Holi���� Y'�l.La 1 �1` 1 l UG
License Number
M 0 /2rwcs'
Address Expiration Oate
22-311
SI lure lepho e
8.Reaistered HomeImprovement Contractor: Not Applicable ElEr�ran l LC 16-)I�a
Company fill Registration Number
2`IZ 1 A 11 V-31 Zo
Address 1 Expiration Dale
Telephanp
SECTION 5-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....... A No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONL Y
\cam€ - Mtge. Losrmin- T - i3 V\CeiC)��
I, 1c�n--\ 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.
Print No
Sign of OwnerlAgent Date
I, 'KY-ii Y&�) --�) Ifl\'F'tn as Owner of the subject
property
hereby authorize lord
to act on my behalf, in all matters relative to work authorized by this building permit application.
\ MA0 sth =C> fl �-f 111 )7�1�
Signature of Oa ner Date
City of Northampton
/ .> Massachusetts
.A DEPANTNENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building °sc
Northad,ton, IM 01060
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 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:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work:T.MU\_Q LCm Est. Cost: t,Wo oo
Address of Work:CIS �)Awe aYecA-
Date of Permit Application:
I hereby certify that:
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:
q III 12&1G FrPrC�in, llC ' 1��1P,q
Date Contrac Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
yL�LIZG171
Date Owner Name and Signature
City of Northampton
Massachusetts
c
L
DEPANT T9 OF BUILDING INSPECTIONS
212 Mem the ipsl Building J�, C
Nor[hampton,on, M!A 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:
CB �)1Cti,� Sifce
(Please print house number and street name)
Is to be disposed of at:
A\ref\ Ao0 Ac 4UF1S` s! �DrfYaFie�d,MH of o<\
(Please print name and location of facility) ' j
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signaty a of Permit Applicant or Own e 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.
City of Northampton
Massachusetts i
I
\ DEPARTMENT OF BUILDING INSPECTIONS SJ
212 MainS[reet • Nunicipel Builtling
Northampton, I 01060 �✓SyH'.37 aC
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 9118
Contractor
Name: TC"cr �1O�stYY�� ,AE(
Address.
City, State: K O%C�LA
Phone: �i-33) \\\
Property Owner
Name: A\YL\Ye o Y AAK-
Address: qt `StC2 P
City, State: hl.cv VAD,!LLO(-)f) I M1Z
I,
at.do es �U_�1/A SS (contractor) attest and affirm that the building I intend to
insuldonot have any open air(kl)ob 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
Ac D' CERTIFICATE OF LIABILITY INSURANCE DATE 1W2018 "1
812/2018
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 .DEB NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),RER(S), AUTHORIZE.
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may mqulre an endorsement. A statement on this certlfloate does not confer rights to the
cartlgcate holder In lieu of such endoreeme s
PRODUCERPyUN p Ma Can.
The Dowd Agencies,LLC .413.538-7444 Na Ne:
14 Bobala Road
Holyoke MA 01040 EMpIt
P uc R ENELL
INSURER S AFFORDINO COVERAGE NAICA
INSURED
wsu ERA:Evanston Insurance Company 35378
Energla, LLC
242 Suffolk Street INSURER e:Commerce Insurance Company 34754
Hdyake MA 01040 RSURERC:SIar3tana Nallon Ins ranc9Com an 25496
USURER o:Guam Insurance Group 8281
INSURERS:
INSU F:
COVERAGES CERTIFICATE NUMBER:1131830225 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, NOTUITHSTANDING 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.
ILN0. TYPE OF INSURANCE A PO CYNUMB MANUMI P LIOYEFF PM CYD� LIMITS
A DENERALUNILay' 2DB4466 MOVE i11R019 EACH OCCURRENCE sLOW.Wo
X COMMERCIALGENERALLA ILITY SSOAW
CLAIMS-MACE O OCCUR MEOEXPLA Mrp..a)) S'Jus
PERSONALSADVINJURY SLD OW
GENERALAGGRE ATE S2,0 DW
..'AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPMPAGG 52. .D10
P0.1CY X F", LOC S
B
TM.R
DURLIArr"" BHOP9J )/12010 )/12018 COMBINED SINGLE LIMIT51000Aa0
ALTOEesola WlWNED AUTOS BODILY INJURY(Par apron) S
CULEOA_.. DILY INJURYIPrraddeal S
U AUT05 PERTY DAMAGEOWNEOgUTpS j
G X UMBRELLA LIAR X OCCUR ]6)50HIBWLI 7/12016 7/1RmB EACH OCCURRENCE $IAO.OW
EXCE55 LM0 CLAIMS DADS
AGGREGATE j1.W0OW
DEDUCTIBLE
RETENTION S
D WORNER6 COMPENBATOX ENMORI172 ]/12018 ]/1/2019 STATU- DTH.
Al.EM=MI.'LIAMUTY YI NIA X
L.EACH ACCIDENT ANYPROPRIETORAPARTNERE/%ECUTIVE SLDDU OW
IMenEe ory In Nea s' 'U0e0] F.
II ,tloeulbe OMer E.I. DISEASE-EA EMPLOYEE SLODO.CW
LflIPION OP TONS a. E1.DEEMS E-POLICY.IMT S
DESORVTDH OF OPEMTONSILOCATGNS I VEXI4E5 (ARNM ACORD 101 Atlalllonal RomaMv 5[M1eavlo,Irma�o tato la RCulmtll
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS,
To Whom It May Concern AUTHORRED REPRESENTA¶VE
®1988.2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD
Commonwealth of Massachusetts
Division of Professional Licensure
Boafd of Building Regulalions and Standard$
Construod.n Supervisor
CS.092540 Expires: 0910212019
' .,THOMAS B ROSSMASSLER i
100 MAIN STREET
HATFIELD01 MA O1d3B v�
Commissioner
................ N......f.,.,,,;�, m.. ..
.Oram or Coasunnr&"'vs&&usiuess Regulnton License or registration valid for individul use on ly
'HOME IMPROVEMENT CONTRACTOR Wave the ezpirnti0n data. If found return to:
II- + Registration: 165169 Type: OtFGeofCentumer Affftrsand Businass Regulattan
' . Expiration: VIV2018 LLC lO Parl<Plazn-Suite 5170
uostan'MA 02116
ENEMA LLC
THOMAS ROSBNIASSLER
242 SUFFOLK STREET l
HOLYOKE,NA 01040 ^pnaersceretnrq Not valid without signsAtrn
a
The Commonwealth of Massachusetts
Depnr[aleat of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MAI 02111
rvww.niass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Laaibly
Name (13usincss/Organization/Individual): Ef1BfQl2 LLr.+
Address: 242 Suffolk St.
City/StatelZip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer?Check the appropriate box: Type of project(required):
l.�l am a employer with 1-�— 4. Q (am a general contractor and I 6. ❑New construction
employees(foil ondlor part-time)." have hired the sub-contractors
2.❑ 1 not a sole proprietor or patfier_ listed nn the attached sheet, 7. Remodeling
ship and have no employees These soh-corttractoes have g, Demolition
.aakin for me in an ca au ' employees and have wor•Icers' 9
g Y P �ty. C] Building addition
(No workers' comp. insurance comp. iusmance3
5. We are a corporation
and its 10.❑ Electrical repairs or additions
required.] p
3,0 1 am a homeowner doing all work officers have exercised their I I.Q Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t C. 152,§I(4),and we have no
employees. iNo workers' 13.0 Other
comp, insurance required.]
'Any apptieanl dmtdudcs box Q I must nae fill out dm section bubo,bowing rbeir.mrkcrs'eompenvuion policy iufemvid.o.
r Flomcmrnrrs who n�bmit n.is nlntlav44ailcadng Ihey ace doing nil work and rlwn bAc outside comwctn¢nmeL submi[a law affidavit iodicutiug such.
rCeinu etars the chock Ibis hos man annened an i ddietion A el ahmving obe nanw ortlm sub,conUnctors and state whelhtt or not Ilwsc entities a.i,
employees IRhe sub-cowmadn have enrpioyees,nay must provide(heir workers'comp.policy number.
nm mr empioyeY drrtt is providing workers'cottrpeamYimr insurance far my er+rpioyees, Below is the policy acrd job site
information,
Insurance Company Name; Guard Insurance Group
policy#or Self-m,
pfL��ia#: ENWC952172 Expiration Date: 7/01/2019 r,,�`�,
lob Site Address: ICD J �r ._ City/StarelZip:NC`)V}'t'p,YY�T>rj{\, C)SCCA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Faiiure 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 Cne
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify rtl 'r the pains and penattles of perjury!/rat the information pro virhad hate,.S t ''and correct.
Si nffiure Date
Phone#' 416-322-3111
Official roe a/dy. 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 Cleric 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Andrew Kitto
(Owners Name)
owner of the property located at:
98 State Street
(Property Address)
Northampton MA 01060 ,
(Property/ esA�d�dresss)) /A1
hereby authorize IE' V Gly l�/A
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.This form is only valid with a signed contract.
Owner's ignaf
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 i Canton, MA 02021 1 339-502-6335
www.RiSEengineering.com