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30A-001 (3) 228 FLORENCE RD BP-2020-0810 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30A-001 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-2020-0810 Proiect# JS-2020-001398 Est.Cost: $6000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq.ft.): 20211.84 Owner: BROOKS JOSEPH Zoning. URA(100)/WSP(100)/ Applicant. ENERGIA LLC AT. 228 FLORENCE RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:1/16/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE CRAWLSPACE CEILING 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 1/16/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dep OR .=<, City of Nort "atton rte ° Buildin� Department 212 Main00 NVINSULATION Room 100 � s Northampton, MA 01 , phone 413-587-1240 Fax 41 ONLY APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: This section to be completed by office Map Lot Unit ZZ81 L 1 O `r en cc V\ 1 Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ya3 Iq'7Q Name(Print) rte Current ail�NTdress: ``e r t 1 1�� y �Y M Telephone —� ✓�� J� Signature 2.2 Authorized Agent: Name(Print Current Mailing Address: Signa re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee _ 4. Mechanical (HVAC) to� 5. Fire Protection 6. Total=(1 +2 +3 +4+5) 00 1 Check Number This Section For Official Use Only Building Permit Number: —aU Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) ?_r.P�yt!' 'i t�'�L:'y'� �[''1.°r.i.�'• C•a�.:r��xi� :�l...k,''t,.;�+CE. -'�'+�e-'{ i�17"Sj'f�;�l,�,Y 1,�4 ...... .... .< •.....e...ao.«... . .«..+..-c�c..,,,e.:toa.r it.c�,ar:.... .s*.uc.,,:_..e..._.w....,,..cm...-,,. .r... ...,.\.... ....•-,►..--.,. . .w•e...,.n.k.•w..e•.p:..c --.:, T W.i Fv..r..,-.:p•♦ .. . ..+. .v,we.y.. _. .. •YM . �.. .v �Attes v,.,,v<•rrr.+Nc.- v,_..... ..Frw•w.:,t.{e.'e. ,.., _set. t`. I V1 - ."Ld��,.-r••�a' t¢All" ;;yl. .1 A} ...:5c1•. .\ { _ . '... .. ,....-�-.._..._-�._...._-,.. _.tom...,_.--�--.__. .-. ...� r y .t:4tib; , { \fit. I! t%�..',VT{� ... .•.� S� .. r e ! .4 i .. ., Ys - a p�M♦. '�� b ..! 4//°��`''r �f t, x+u^ ' � .ry. ! ,gr � r..D, .. li d r 1r t 1� t >r- ., �1y t� 777• . i s Sk �Y tr' >: iii}1-• y-rYi - F' I t SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not \5�-`Applicable 1❑ Name of License Holder: 1(�(�I� �JJS� ,� V" O License Number fl 00 ()q I RL 17 021 Address Expiration Date I - 322 - 3i� 1 Sigrofure Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ IFrrrava t � C S Ql�N�q Company N e Registration Number 2w,? suko v : yr wot i� n iaA o G\ I 1 Q 1 ?-02 Address J Expirat not Da et Telephone 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....... No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY cje-\\\n9 -CV Vk"�9a% iE�\N eros�Spa�. Ce:�\�c�� -Z�►-�-�-�c rte. �� r �� ►�\yi� I, Tori Fmwaa5r-r 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. y � Print Name � a Signatu of Owner/Agent Date I,- ,`L,Q Y1 , as Owner of the subject property hereby authorize Tcm- to act on my behalf, in all matters relative to work authorized by this building permit application. :W, M MA NAh V�pr n-) I lc � 120zG Signature of Owber Date ♦' �� .. ♦�; .i. y21 F..;. , r. .t If,1�'Y\7�1t �:.\ �j Y (.1� .. °3. l '1 !�M :: K rJ+t' ; � e* ,•j ,".,. - f c \ - ft »� - ''mss `S`" E s r 1 , •. - 1 �\. A.Y". 1., -'�Y. .. .. is,. �,�. , •� 'Y' } ,' r :;� ?f�:. .11;w: N�°1�' � U .. .. ,rR.^?-,c:+ttxt:l'S,'LE';'G a.'\ ' y¢:. Y '��'t i�• :�,�Y ;t..'�,� ,4 y_.. ,JY' �'Li,e�'�.�. �` ?'.Lw�' �Y'.a. , 1 . . � 1>... ,y_'__ .�__. __ ..�.- .v., ... ... __. q 1 rY.^S ` TAcalk uAl,;,. r ti;,r •! R ij City of Northampton X E Massachusetts G 'I DEPARTMENT OF BUILDING INSPECTIONS � (� 212 Main Street •Municipal Building \ 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: Vint yl(� (Please print house number and street name) Is to be disposed of at: H NOCAt, U1 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 1-2,v Sig ure of Permit Applicant or O ner 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 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: Type of project(required): l.&/I am a employer with_J q 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 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 12.0Roof repairs insurance required.] t c. 152, §1(4), and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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; _ n I City/State/Zip:W)X-OLDO=O f AOO1M, 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 un the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 41 3-!G-31 11 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#: ENERLLC-01 CHRISTINE A�R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/26/2019 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 endorsement(s). PRODUCER C NTACT Christine Sullivan Phillips Insurance Agency,Inc. PHONE 97 Center Street AIC,No,E.1):(413)594-5984 (A/C,No):(413)592-8499 Chicopee,MA 01013 E-MAIL ,christine@phillipsinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:State Automobile Mutual Ins Co INSURER 8:Guard Insurance Grou Energia LLC 242 Suffolk Street INSURER C Holyoke,MA 01040 INSURER D, 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X OCCUR EACH OCCURRENCE $ 1,000,000 X PBP2870943 7/1/2019 711/2020 PUAMA REMI ETORENTED S 100,000 MED EXP(Any oneperson) $ 5,000 GEN'L AGGREGATE LIMIT APPLIES PERPERSONAL&ADV INJURY $ 1,000,000 : 2,000,000 POLICY FX JE o O LOC GENERAL AGGREGATE OTHER: PRODUCTS-COMP/OP AGG 2,000,000 A AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO $ BAP2477206 7/112019 7/1/2020 OWNED SCHEDULED BODILY INJURY Perperson) S AUTOS ONLY AUTOS EE BODILY INJURY Peraccidenl S AUTp�ONLY AO Q�VYNED (P'L)H cRdenl AMAGE OIV $ A X UMBRELLA LIAB X OCCUR $ EXCESS LIAB CLAIMS-MADE PBP28709437/1/2019 7/1/2020 EACH OCCURRENCE 1,000,000 DED I X I RETENTION$ O AGGREGATE 1,000,000 B WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE YIN ENWC989225 7/1/2019 7/1/2020 rt 1,000,000 ER QFFICER y9MBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 DocuSignEnvelo e ID 52FBCB4D-AEC2-43FF-9104-13E3EDB26031 Permit Authorization mass save Form SiY{iY5}i TpitC.csgh tbrYetSiy 6'!S`iP.t@nr': Site ID: 3724915 Customer: JOESPH BROOKS l� Joseph Brooks , owner of the property located at: (Owner's Name,printed) 228 Florence Rd Northampton, MA 01062 (Property Street Address) (City) 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. DocuSigned by: Owner's Signature:CbSt t 47F 400 7EBOE9mk C947F8400_. Date: 11/11/2019 12:32 PM EST FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: fou c:- /A Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only Rev. 102015