17A-025 45 HASTINGS HGTS BP-2020-0861
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-025 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-2020-0861
Proiect# JS-2020-001471
Est.Cost:$2700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BAYSTATE ENERGY REDUCTION LLC 102811
Lot Size(sq.ft.): 12371.04 Owner: KOLBJORNSEN PAUL H
Zoning: RI(100)/URA(100)/ Applicant: BAYSTATE ENERGY REDUCTION LLC
AT. 45 HASTINGS HGTS
Applicant Address: Phone: Insurance:
83 MORSE ST UNIT 4E (401) 523-6805 WC
NORWOODMA02062 ISSUED ON.1/28/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND WALL 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# 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 Sisnature:
FeeType: Date I'aid: Amount:
Building 1/28/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
( 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans_
O :.. Cify—
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE O DEM -A"ONE OR TWO F+LY •WELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to beounpfeWd;by office
—7 At -F .t n
Map [ �'ot` /Unit
Lfs fk5-fi/ujsh
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
`I J
(,e o I'.'rnyn '-Y
Name(Print) Current Mailing Addr s
Telephone ,
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
4o I •5-a,3 �8
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building d 760. 0 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) �,(' V V
5. Fire Protection
6. Total = (1 + 2+3+4+5) Check Number LA
This Section For Official Use Only
Building Permit Number:1:?-P-v' �fl Date
Issued:
Signature: 6& a
Building Commissioner/inspector of Buildings Date
hA @
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [p] Other[C]
Brief Description of Propge] , n I�d (/ateA( J6
Work: (.(, �*-[e� �(/J�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the followinq:
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 ft.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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1. V as Owner/Authorized
Agent hereby de re 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 perju
Print
Signature'of Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: '( I^LL Not Applicable ❑
Name of License Holder: OV l_ssv —
License Number
93 orae. s EnVWQ0d, M 91131�d
Address /�-7O/ Expiration Dat
Signature Telephone
9. Registered Home Irniorovement Contractor: Not Applicable E3
6 / 91
Com an Name Registration NumbLC-2
X33 t'�'1 d��C s 4# �-� � 10
Address [''''') Expiration D e
V W Telephon /-6d-3
SECTION 10-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...... ❑
City of Northampton
Massachusetts ' r�
E }}f•�'
14^ Ti
;4 DEPARTMENT OF BUILDING INSPECTIONS
a: p
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:
(Please print house num er and street namA)
Is to be disposed of at:
gr t4)
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
ik" ayl_d
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
a d I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/OrganizatiotiAndividual): Iry 1 1,0 �
Address:
C7__7
�D
City/State/Zip: w Phone#: "� ',50?3. �0 W
Ll
Are you an employer?Check the appropriate box: Type of project(required):
1. � 1 am a employer with_employees(full and/or part-time).* 7. [:]New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
I[]I am a homeowner doing all work myself.[No workers'comp.insurance required.I t
10 E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compcnsation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.[3 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.'
6.❑We are a corporation and its officers have exercised their right of exemption per MGL C.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I must also till 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 subcontractors and state whether or not those entities have
employees. Tf 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 andjob site
information. ..1�
Insurance Company Name: s�� 9dbaoaLW--
QQ�� If
Policy#or Self-ins.Lie.#: Vr7 k)0-D 54403 Expiration Date: ;;?Oao
Job Site Address: 145 S h City/State/Zip:
'
Attach a copy of the workers'compensa on policy de ration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains avid penalties of perjury that the information provided abov,is trite and correct.
Signature: Date: /
WIL_Phone#: Wil• f zs - Ce'4
Oficial use only. Do not write in this area, m he 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#:
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type. Supplement Card
184541
SAYSTATE ENERGY REDUCTION LLC
Registration: 02/01/
83 MORSE STREET UNIT 4E Expiratic>n. 021fltt'2fl20
NORWOOD,MA 02062
Update Addreea and Return Card.
$C:AI t? 23&MIT
011400 of cansurner Affehe d ausineaa Reputation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:5uWemeni Card before the expiration date. if found return to:
falratlon Office of Consumer Affairs and Business Regulation
184541 0zV120P0 10 Pad(lUza-Suite 5170
OAYSTATE ENERGY REDUCTION LLC Bost ,f A 02118
ROGER OUELLETTE �' C ---
83 M09SE STREET UNIT 4E
NORWOOD,MA 02062 undersecretary Not v'al lid Ullthout signature Comrrionweatlh of Massachusetts
Division of Professional Licensure
Board of Balding Regulations and Standards
Con*fructio 't}4ivwqr specialty
SQL 142811 amperes:0911312020
ROGER A 0*
83 MQRSE O�OS� t
NORWD
Commissioner
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): Baystate Energy Reduction
Address: 83 Morse St
City/State/Zip: Norwood, MA 02062 Phone #: 401-523-6805
Are you an employer? Check the appropriate box: Type of project(required):
LE I am a employer with 8 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
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions
eq ]
3.❑ I am a homeowner doing all work officers have exercised their 1 I.E] 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.❑X Other Attic Insulation
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: Berkshire Hathaway Guard
Policy#or Self-ins. Lic.#: BAWC054403 Expiration Date: 3/2020
4
Job Site Address: - .S wtmhis City/State/Zip: s9"teN-IMAII ''_~
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.
Ido hereby certify u der the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 10/28/19
Phone#: 401-523-6805
Official use only. Do not write in this area, to he 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 S. Plumbing Inspector
6.Other
Contact Person: Phone#:
ACo CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY)
01/06/2020
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 CONTACT Keiko Gianfriddo
NAME:
Southeast Agency,LLC PAH/ONnE Ext (860)376-2535 A/C,No: (860)376-8505
108 Main Street h-MAIL keikog@seagencies.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Jewett City CT 06351 INSURERA: Arch Specialty Insurance Company 21199
INSURED INSURER B: Utica National Ins.Company Of Texas 43478
Baystate Energy Reduction LLC INSURER C: Nautilus Ins Co 17370
83 Morse Street,Unit 4E INSURER D: Berkshire Hathaway Homestate 20044
INSURER E:
Norwood MA 02062 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL196708023 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.
INR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY Y EFF POLICY EXP
(MMIDD/YYYY) (MMIDDIYYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE ]OCCUR PREMISES Ea occurrence $F; DAMAUE TO RENTED 100,000
MED EXP(Any one person) $ 10,000
A AGL0052287-01 03/01/2019 03/01/2020 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000
X POLICY ❑PRO/ECT ❑ 2,000,000
LOC PRODUCTS-COM P/OPAGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED 4941834 03/14/2019 03/14/2020 BODILY INJURY(Per accident) $
AUTOS ONLYX AUTOS
X HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY X AUTOS ONLY Per accident
X UMBRELLA LIABX OCCUR EACH OCCURRENCE $ 2,000,000
C EXCESS LIAB CLAIMS-MADE AN063957 03/01/2019 03/01/2020 AGGREGATE $ 2,000,000
DED I X1 RETENTION$ 10,000 $
WORKERS COMPENSATION X SPERTATUTE EORH
AND EMPLOYERS'LIABILITY Y/N 500,000
D ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA BAWC054403 03/01/2019 03/01/2020 E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Homeworks Energy is named as Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Homeworks Energy ACCORDANCE WITH THE POLICY PROVISIONS.
101 Station Landing
AUTHORIZED REPRESENTATIVE
Medford MA 02155 �!
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
.
.
Insulation/Air Sealing Permit Authorization
Specialist: Benjamin Anton Company: HomeYVnrksEnmqgy
Email: berjamin.aotnn@homewnrksener0.cnm Address' 101Station Landing
Cell: 802'236'5104 Medford,xxoOZ155
Phone: 781-305-3319
........... -_ -----
Customer- Pau|Nn0#mrnmen Address: 45 Hastings Heights
Email: pkxray@cnmcast.net Florence,MA,01062
Site ID: 0 Phone: 413-320-3275
1,the owner of the property identified above hereby authorize HomeWorks Energy Inc.,or their Partner
toact onmybehalf inobtaining any building permit that maybe required to
perform insulation and/or Weatherization work on my property and all matters related to the work authorized
bysaid permit|fone bobtained. Any related permit application cost will come a¢nuadditional charge'provided
that the agreed VVea<hehzationwork iscompleted.
Customer
Signature: _ _\�_�^� °°=. 11/28/2019
����
pau| Ko|bjornued
/ . ,
HomeWorks Energy
101 Station Landing,Medford,MA 02155
CONTRACT - AUDIT
�A/ r��
781-3053319 FAX
HOmeftrks Page 1
PROGRAM
CMA-HPC
OUSTOMER PHONE A L CLIENT 0 WORKORDFA
Paul Kolbjomsen (413)320-3275 11/19/2019 492212 00001
SE"CE STREET MUNG STRUT PROPOSED BY:
45 Hastings Heights 45 Hastings Heights HomeWorks Energy
Florence, MA 01062 Florence,MA 01062
DESCRIPTION QTY COST INCENTIVE TOTAL
ATTIC DAMMING-R-38 FIBERGLASS 40 $82.00 $61.50 $20.50
Provide labor and materials to install a 12"layer of R-38 unfaced
fiberglass batts for damming purposes.
ATTIC FLAT-8"OPEN R-30 CELLULOSE 1,120 $1,612.80 $1,209.60 $403.20
Provide labor and materials to install an 8"layer of R-30 Class I
Cellulose to open attic space.
ATTIC HATCH:SEAL&INSULATE 1 $60.00 $45.00 $15.00
Provide labor and materials to insulate the back of an attic hatch with
2"rigid insulation board.Weatherstrip the perimeter.
VENTILATION CHUTES 60 $150.00 $112.50 $37.50
Provide labor and materials to install ventilation chutes in the rafter
bays to maintain air flow.
HOME AIR SEALING 10 $850.00 $850.00
Provide labor and materials to seal areas of your home against
wasteful,excess air leakage. Materials to be used to seal your home
can include caulks,foams and other products. Primary areas for
sealing include air leakage to attics,basements,attached garages
and other unheated areas(windows are not generally addressed.) A
reduction in cubic feet per minute(cfm)of air infiltration will occur,but
the actual number of cfm is not guaranteed.
At the completion of the weathenzation work, and at no additional cost
to the homeowner,a final blower door and/or combustion safety
analysis will be conducted by the sub-contractor.
HomeWorks Energy
b9c
` 101 Station Landing,Medford,MA 02155 - DIT
CONTRACT AU
781063319 FAX 0
HorMworics Page 2
Ene-9v.Inc PROGRAM
CMA-HPC
-CUSTOMER PHONE-- 0
Paul Kolbjomsen (413)320-3275 11/19/2019 492212 00001
-SFAVICE STREET BILLING STREET PROPOSED BY:
45 Hastings Heights 45 Hastings Heights HomeWorks Energy
SERMCE CITY,STATE,ZIP
Florence, MA 01062 Florence,MA 01062
DESCRIPTION QTY COST INCENTIVE TOTAL
Total: $2,754.80
Program Incentive: $2,278.60
Customer Total: $476.20
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
*"Four Hundred Seventy-Six&20/100 Dollars $476.20
NOTE:TM CONTRACT WAY BE VATHDRAWN BY USIF NOT EXECUTEDYJTHIN DATE OF ACCEPTANCE '�" t