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38B-084 (6) 134 SOUTH ST BP-2020-0096 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B-084 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2020-0096 Proiect# JS-2020-000164 Est.Cost:$3500.00 Fee:$77.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sa.ft.): Owner: GILLIAM THEORA Zoning: URB(100)/ Applicant. ENERGIA LLC AT. 134 SOUTH ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON.7/25/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE WALL WOOD SIDED 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 7/25/2019 0:00:00 $77.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Nort amp E C E I V '" Building Department I A , 212 Main tre5 Room '00 ��� 2 2019 / SULATION Northampton, MA 1060 s- phone 413-587-1240 +Fax _ - �Ir 1 NA'SPFc Ns �NL Y NOFiTHAk1P?ON.FAAnin APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address. ^�This section to be completed by office Map O D.1 Lot U C Unit j �h 5-t�e - Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) � [� Current Mailing Addres r\ Y Mkk P `U� k y m. Telephone It „�7 �\ X \ Signature 2.2 Authorized Agent: Name(P nt Current Mailing Address: Signature l elepho e SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building J (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 = 0 +2+3 +4 + 5) Check Number This Section For Official Use Only Building Permit Numbe Date Issued: Signature: -"ZS 201Cl Building Commissioner/Inspector of Buildings / Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) v ii+U1,'•. tll@;f.. ..y.>'Ait:r, 14' ;,g.:;,.O Vi,.>d r:l�w"p• �iA:• �.«�iar�r`i.y't„T 4FA.:.uhf". _ . .._ n.�w_..,.ir... w •.vplr:nw. s, .�p..w.a•ed'.M.... .wJ«.i .w..4.r,..ar wJ..... ,,,r,�..an:W .s,'j++r•.«. _._. .., ..,..w.n«..+.y,r ....�s•�y.....,. +..a-wrf . 4 1 s- • , }: :,. .. .�:.a:�r•.,... ..«.,�+ ... � ,4,•.wyr':._.,,t�•a»..,.r, r .- ♦ ..,w.le,,,y„•.,.du• ave +. ...> •rt�+M.• ....y4:.:.,m ,w+rd« �t 4krj � xf"-"' x�1w,"�`'YN":P+�..fit e ��, :�, t• 'fr •nw•^+<^'R ,+;: p . t 1 h' t _�ir ., .. ?i ii.. rt• - ;M' F .w r i �.qr -+;e J•+. ' „ i - +. 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SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:` Not tAApplicable l ❑ Name of License Holder.. m C1i �rY�� �f� lJ"► `�� License Number Address Expiration Date y - Sig t re Telephone Not Applicable ❑ Company NaAe Registration Number 2y2 5v c�� �1 r°\ okoyc) \ I \0 12-0 Address Expiration Date Telephone yk3'?31-2-D t\ 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....... N, No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY 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. om V-C�-�� Print N e 16 Signature of Owner/Agent Date I, C-M�\O.m as Owner of the subject property herebyauthorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date f,? .. .E%l't t�}•{1�.f�i:. 3'J t o+:. � I.. /J1A 'Y' :�.�i s N" � 'tiCrt .. a ol. jAR �. _....... .,,w, -.. _ .... .. rclwl�� .rulY�w ♦ w _,.y,•— r � n .. _-... -r .... y.4q..�. ♦ p}�; .,. .� �n�angn...,......i`�./`. �i�+'.x.^:... _ lyt��+rru,a4 t � ti,» ` � ����i4�-•:�..�� '!I y':?\.L S '�•�?�M�.�■ cis��• - •. 'MI�5t1"'7P 3y7�. '1'. •.,� "f: _;i' hi, :"9�...� "C•s'e y ,ii}/4... ;fir(. ea ,k,. $.. :;"tl•._ {.c' `'� ;$i ,v' r7,VC " (I fit("Is k+v r' ¢ l .,.��. t. Yt^�,1L.��.y .til�2 .r T.•+ EC�ar 1. - � -c'- Vii., I >< �1«l�:�6 !, - .. + ' City of Northampton zif Massachusetts t �a< DEPARTMENT OF BUILDING INSPECTIONS �• z: 212 Main Street •Municipal Building Js OD Northampton, MA 01060 rsdly ��� 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: Icy ��-fi1 �tY�t (Please print house number and street name) Is to be disposed of at: (Please print name and loca ion of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature 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. City of Northampton Massachusetts Y' <<� DEPARTMENT OF BUILDING INSPECTIONS _ 212 Main Street • Municipal Building p 0 Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: \S--A �k}�h_ Contractor Name: jC�(`� Address: City, State: kO\UCO 17_' 01\0V4d Phone: Property Owner Name: Address: City, State: �1,C,Y1r7T \ L —� I,Torn 1V-C'ln rrcAf W r (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob 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 �] I / z��q DocuSign Envelope ID:FC9B25C5-C4F9-4B01-B1BC-7B20CD0536AF RISE 8 ENGINEERING- OWNER AUTHORIZATION FORM 1, Theora Gilliam (Owner's Name) owner of the property located at: 134 South Street _ (Property Address) Northampton, MA 01060 (Property Address) hereby authorize IL�n Ift (Subcontr tor) 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. LDocuSignby: Gi�iawl r�-S*ature 7/15/2019 12:45 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 02021 1339-502-6335 www.RISEengineering.com f� S. Keyes Electric, Inc. 5 State Rd. South Deerfield, MA 01373 (413) 695-4968 MA Master License # 21213A May 30, 2017 Theora Gilliam 134 South Street Northampton, MA 01060 Dear Ms. Gilliam, We have removed all the Knob & Tube Wiring at 134 South Street in Northampton, Massachusetts. Any remaining Knob & Tube Wiring has been rendered unusable. Sincerely, Steven R. Keyes President JUL 1 1 2017 ENERLLC-01 CHRISTINE A�oRo CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 6//26/226/2019 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 endorsements. PRODUCER CNTACT Christine Sullivan Phillips Insurance Agency,Inc. P HONE nlc,No:(413)592-8499 97 Center Street Arc,No,Ext):(413)594-5984 Chicopee,MA 01013 E-MAI .christine phillipsinsurance.com INSURERS AFFORDING COVERAGE NAIC p INSURER A:State Automobile Mutual Ins CO INSURED INSURER B:Guard Insurance Group Energia LLC INSURER C: 242 Suffolk Street INSURER D; Holyoke,MA 01040 INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: 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. ILTR NSR TYPE OF INSURANCE AODL SUBR POLICY EFF POLICY EXP POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAVAS-MADE a OCCUR XPBP2870943 7/1/2019 7/1/2020 DAMAGE TO RENTED 100,000 MISES(Ea occurrence) 5 MED EXP(Any oneperson) 51,11,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY�JECT FILOC 2,000,000 PRODUCTS-COMP/OP AGG S OTHER: g A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 a_acr5 X ANY AUTO BAP2477206 7/1/2019 7/1/2020 BODILY INJURY Perperson) 5 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BODILY INJURY Per accident 5 AUTOS ONLY ASTOS ONLY PPe�accR ent AMAGE S A Xs UMBRELLA LIAR X OCCUR EACH OCCURRENCE g 1,000,000 EXCESS LIAB i CLAIMS-MADE PBP2870943 7/1/2019 7/1/2020 AGGREGATE 1,000,000 DED X RETENTION S 0 B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN ENWC989225 7/1/2019 7/1/2020 1,000 000 %pFICER,11 R EXCLUDED? NIA E.L,EACH ACCIDENT g i ,Ile T In NH) E.L.DISEASE-EA EMPLOYE 1,000,000 It yes,RIP 1 be under 1,000 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a t ;.1 • t�:.7" „l: ltytr5'' ,'.fe,'.4 t' f,aF"' sfi�('S g .��$'C:'t..s,s3`` � " s _ • .u .4 a lire? f :,tt`•^:,g•!r' �i.ri,.,j � t., ;;f '�;2'.a, b.�6N j+' '", „t�,... t f , ' .PT,say-:' :' .�1 ,.�.�,t As �' k�. -f kit .�, t _� P ;•.._ .�+t,�,j@ f �+ �.c r - i_ ':,,Ca'w�'"t ti''rR '"W d -q i h.�• � ^�` •t, .. ,. .�. r rt r7;; ., +a' v� a � �m-ary' f t e9' , 1• _ ^ i - .rqf ' },•i a{°t�' 'f1f � � '•lar t �-.ty . Y:'. � _ x t 5� tr s� x.. k}tt`��if r�, e 'X.'"l.u^c.af#i k� ..l At `t ..7.2 ..t"}'} �. +i.• „,' :a k. _ r,£r� t f cr 4 i`i �.' s'th .'tc. 1`, +� j{ # Gtr y,S, .k? ..... _ _ .. _ ... _. ... .. .. .. 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C Commonwealth of Massachusetts Division of Professional Licensure Board of BUilding Regulations and Standards Construc{ion Supervisor CS-092540 Expires: 09/02/2019 THOMAS B ROSS 100 MAIN STREE MASSL R HATFIGLO MA 01038 L Commissioner l� .i Or@cc orCoasumcr `! /(n,•••/�;„ri, HOME IMPROVEMEff�irs&Business Regulation Registration: NT CONTRACTOR License or registration valid Expiration: 165169 before the ex for individul 1/11/2018 Type: Pirltion date, use only LLC �fficc of Consumer 1f found return to: ENERGIA LLC �12 0 10 Paric plaza_ Affairs and Business Re Boston Suite$)170 gulation MA 02116 THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE,MA 01040 Undersecretary _ —. / Not valid without sig'- ' gnature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Energia, L L C Address: 242 Suffolk St. City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111 Are you an employer? Check the appropriate box: Type of project(required): 1.[1I am a employer with fig_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. E] Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. =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 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.#: ENWC989225 Expiration Date: 7/01/2020 Job Site Address:Q)-A City/State/Zip:NpY ('a1Y\�)Ac-)" "P,01oc, 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 under the pains and penalties of perjury that the information provided above is true and correct. Sip-nature: Date: Phone#: 413-322-3111 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#: