23A-040 (27) 52 MAPLE ST BP-2020-0758
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-040 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-2020-0758
Project# JS-2020-001302
Est.Cost: $2200.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group ENERGIA LLC 92540
Lot Size(sa.ft.): 20603.88_ Owner: GHISELIN ALEXANDER D
Zoning:GB(100)/ Applicant: ENERGIA LLC
AT. 52 MAPLE ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413)322-3111 WC
HOLYOKEMA01040 ISSUED ON.12/26/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE 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 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:
FeeTvpe: Date Paid: Amount:
Building 12x26/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
F __--.�`•_ Dep
OR
r`- City oflNort
._ Building Der�rtr ehY�... V E0—__
�, ,•,. 212;Mair� S
}trTerei;t
Room' 1094
G�K
INSULATION
Northampton, �CI0aad3 2019
. 413-58phone 413-587-120 . ONLY
NO
APPLICATION FOR INSULATION FOR A ONE OR TWO-FAMII-Y_DW LLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
Map_ Lot D Unit
bZ V0V V I • Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LAL-C
NCame�(�Print) Current Mailing Addres
JAS._.. X�1 1 1`� � fl� t t 1 Telephone
Signature
2.2 Authorized Agent:
2y2 Sy F f�1 IF, �t Ye�.�
Name(Print) Current Mailing Address:
Signatur �elep ��,7
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 1100.0c) (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) 2, Check Number
This Section For Official Use Only
/.• —7`�j'
Building Permit Number: DateIssued:
Signature: 12Z 9 3
A 9
VU I
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable
Name of License Holder:T�1 5r(���icr 2 s, 1-n
License Number
vim= Mf10ok-0 M�jC52
1?�21
Address Expiration Date
1
Sig ture elepho e
9.Realstered Home Improvement Contractor: Not Applicable ❑
Company tWnhe Registration Number
O 01 j kOJZOZG
Address Expiration Date
Telephon k
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....... x No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
I, T(-,m 1 Tc�opcxmcr 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.
IV� � I
Print Name
Signatur of caner/Agent Date
=�C�;r1 as Owner of the subject
property C
hereby authorize ��� )W( S5 tc r
to act on my behalf, in all matters relative to work authorized by this building permit application.
a MA 6Jyh a r-) tZ 1A 1701 S31
Signature of Owner Date
City of Northampton
Massachusetts
c
Ire
—A w '�
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street •Municipal Building
\ Northampton, MA 01060 ssN�y �7�11
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:
S2 maz\c I .
(Please print hodse number and street name)
Is to be disposed of at:
-R 1 i�f'c� vel�'►���
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
\,f`lr��V-C qq f?, t . SAY end N1, 0`r01-��
(Company Name and Address)
/,&� 1z/9 �
Signa re of Permit Applicant or 94nerbate
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
.S��
1
Massachusetts
W.
. / DEPARTMENT OF BUILDING INSPECTIONS
y'•.
' I�r 212 Main Street • Municipal Building
Northampton, MA 01060 b .. �
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 52—
Contractor _
Name:
Address:
City, State: C�\l1bY
Phone:
Property Owner A X
Name: _
Address: ZG�� r
City, State: F� t( ,�� \ OtM
I, �P ���,G(�{-S,S��� (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
4
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
ConstruC116rl Supervisor
CS-092540 i .., E*pires:09/02/2021
THOMAS B ROSSM SL
100 MAIN STREET
HATFIELD MM 0103
Commissioner
...........
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:
Realstration Expiration Office of Consumer Affairs and Business Regulation
165169 1 01/10/2022 1000 Washington Street -Suite 710
ENERGIA LLC Boston,MA 02118
THOMAS ROSSMASSLER �I
242 SUFFOLK STREET w(C.(%aGli.Gc' V—tL.--
HOLYOKE,MA 01040 Undersecretary Not valid without signature
Th a Common wealth of Massach usetts
Department of Industrial Accidents
Office of investigations
c ' 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, LLC
Address: 242 Suffolk St.
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer? Check the appropriate box:
1. I am a employer with 19 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. E] 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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.T 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.[:1 Electrical repairs or•additions
3.❑ 1 am a homeowner doing all work officers have exercised their II-El Plumbing repairs or additions
myself. [No workers' cornp. right of exemption per MGL
insurance required.] t c. 152, §1(4), and we have no 12.❑ Roof repairs
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
a new affidavit IndicIng such.
t Homeowners who submit this affidavit indicating they tire doing all work and then hire outside contractors must submit
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether not those die s have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
am an employer that is providing worker s'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:-SZy City/State/Zip: )l'
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.
1 do hereby certify undo the pains and penalties of perjury that the information provided above is rite az l correct.
Simature- Z
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#:
DocuSign Envelope ID:E4A355A2-5B1E-469E-A5A1-1F17CM685E2
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Alex Ghiselin
(Owner's Name)
owner of the property located at:
52 Maple Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize rqo2GIA
(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.
LaDocuSipned by:
u;?" A istLv,
Owners igna ure
12/3/2019 1 1:37 PM EST
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.Rl5Eengineering.com
r
Invoice
James Maillaux Electric
ELECTRICAL d GENERAL CONTRACTOR -- --
221 Pine St. Suite 160 Date Invoice#
Florence, MA 01062 12/2/2019 6290
Phone: 413-585-1592
Fax: 413-584-3976
Matllouxelearic a gmall.com
Bill To
52 Maple Place,LLC —
164 Riverside Dr.
Florence,MA 01062
i
i
P.O. No. _Terms Job Re:
Due on receipt K&T
Quantity Description Rate Amount
Electrical Service: 11/202/19-Verify knob and tube wiring inactive 125.00 125.00
I �
I
I
i
I
I ;
i
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Thank you for your business,please remit to the above address
iTotal s125.00
Invoice
James Maillaux Electric-
ELECTRICAL I GENERAL CONTRACTDIP
221 Pine St. Suite 160 Date--� —Invoice#
Florence, MA 01062 1212/2019 6290
Phone: 413-585-1592
Fax: 413-584-3976
Malliouxelectric(P)gmail.com
Bill TO
52 Mapic Place,LLC
164 Riverside Dr.
Florence,MA 01062
P.O.No. Terms Job Re:
Due on receipt K&T
Quantity Description Rate Amount
Electrical Service: 11/202/19-Verify knob and tube wiring inactive 125.00 125.00
Thank you for your business,please remit to the above address
Total $125.00