24C-141 (6) 90 FRANKLIN ST BP-2020-0922
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24C- 141 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-2020-0922
Proiect# JS-2020-001571
Est.Cost:$6000.00
Fee:$104.00 PERMISSION IS HEREB Y GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sa:ft.): 9452.52 Owner: GOODMAN IAN
Zoning: URB(100)/ Applicant. ENERGIA LLC
AT. 90 FRANKLIN ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:2/13/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE WALLS
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 Sip-nature:
FeeTvpe: Date Paid: Amount:
Building 2/13/2020 0:00:00 $104.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
DepEy
I-ORV
City of Northampton
s1�` Building Departme 'e
�» 212 MaiOttreet 1
Room 1;Q4,, �
INSULATION
Northampton, MA'fffY�
phone 413-587-1240 Fax 1". ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY-DOWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address This section to be completed by office
Map Lot `S�l Unit
qZone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LLIL�
Lac c ;� 0 vc�,n►�,1 5� Nc�r�h�0�� t"ll C
Name(Print)" Current Mailin Address:
LCV 1bY�\1 1 t Telephone
1S
Signature
2.2 Authorized Agent:
2ti2 517 -�C3�Il��t-�tOlu►a►�,e t�1�010y0
Name(Print) Current Mailing Address:
y1 L - X111
Signature, Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 000 (a) Building Permit Fee
•��
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 0 Jy
5. Fire Protection
6. Total=0 +2+3+4+5) c) Check Number
/y 1 This Section For Official Use Only
Building Permit Number: 16Q— o r! P Date
Issued:
Signature: VU
c�0
Building Commissioner/Inspector of Buildings Date
�✓�� @@Eie��"S • CS • C ,
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: C (� c ✓ Not Applicable ❑ l
Name of License Holder:
License Number
oft Q)9fOU ZOO�
Address Expiration ate
Si ature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
F ray CX WC, I C�S 1 GC�
Company Na;he Registration Nuber
Address Expi tion ate
Telephone��1� ���-�- �\
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
I, TO M E'_( , 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.
6
Print Name
2 20
Signater/Agent Dat
I, �(� r7 t r.�1 ► as Owner of the subject
property
hereby authorize ]Dm I�b�5 pYX'A55
to act on my behalf, in all matters relative to work authorized by this building permit application.
� Y YYN&40`1Y m 211 (Z,02-0
Signature of O ner Date
i
City of Northampton
�tir_r.�.sr r
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJ '`•..«......�OC`
Northampton, MA 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered:
Type of Work:-T--nS�l�,� O f-\ Est. Cost: G Wo
Address of Work:��
Date of Permit Application: (3Z 0-1 '2_0Z�
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:
n2,'�012-02C) _YC>M �r(�i� Cr Oct (0Z/2F21
Date Contractor Name HIC gegistrafion No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and ignature
i
ii
i
City of Northampton
Massachusetts
'A w
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building v OD
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:
Go TY ayVl\\("\ �-
(Please print house number and street name)
Is to be disposed of at:
(PTease print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Sigrfature of Permit Applicant r O er 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
fi
Massachusetts '~�'`<rG
x DEPARTMENT OF BUILDING INSPECTIONS y�
212 Main Street • Municipal Building
-�� Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: CIC) +YQ.'(1�r-�`
Contractor _��
Name: `!�
Address:
City, State: 4A(D\UAn --e-
Phone:
Property Owner
Name: =-\N Good Cll
Address: C-1O VVCxnV-'k
City, State:
I, C�Y�S1 1`�C�SSrr55� (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 2 /] 1220
Tower FJecbic, LLC Invoice
5�'* NwlriYVra
I ccSof IIA►.M A(A 0110
lll- W41 It
Gllti .DiX•
V10}VIN 9156
Ott TO
ball GX)dfluml
90 l:mkliI);1'C
Norlharnplon l`IaU1060
If RIA
90 Franklin St
ItLiMt Ilortw for any Acti%c or inactive Knob and 150.00
Tube Wiring
Checked hast-iicnt,exterior altic space cra%%l
space.
There is No Knob aml Tula Nlring wt thin Ih.Ilonlc
Sala flax 6.25°. 0.01)
141a. Uc= 18067.A
CT. Lwz 192267-1:I Total Su IM)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UF
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le ibl
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.VI am a employer with 1_q 4. ❑ I am a general contractor and I Type of project(required):
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
working for me in any capacity. employees and have workers' g' ❑ Demolition
[No workers' comp. insurance comp. insurance.: 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11-El Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §1(4), and we have no 12.❑ Roof repairs
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.
lContractors 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.
r 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. Li,. #: ENWC989225 Expiration Date: 7/01/2020
Job Site Address: M
. `''1, , Fr
City/State/Zip:_tA()X-W MOtCjfl vlp, wc)(A
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 under the pains and penalties of perjury that the information provided above is true and correct.
i nature: &�� 2 2
Date:
Phone#: 4103"-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#:
A�ORU" ENERLLC-01 CHR ST E
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYy)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.HIS
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(les)must have ADDITIONAL INSURED prov --
isions or 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
Phillips Insurance Agency,Inc. c Nracr Christine Sullivan
97 Center Street PHONE
Chicopee,MA 01013 (AIC,No.Exc:(413)594-5984 aAc,Ne:(413)592-8499
E-MAI .christine phillipsinsurance.com
INSURER S AFFOR"GE COVERAGE
INSURED INSURER A:State Automobile MEnergia LLC INSURER a:Guard Insurance G
242 Suffolk Street INSURER C:
Holyoke,MA 01040 INSUR R D:
INSURER E
COVERAGES INSURER F:
CERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
NAMED ABOVION E FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 7XrPBP2870943
A X COMMERCIAL GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICY EXP
_ LIMITS
CLAIMS-MADE a OCCUR EACH OCCURR NCE 1,000,000
7/1/2019 7/1/2020 DAMAGE TO RENTED
100,000
MED EXP(Any one person) S 5,000
EN'L AGGREGATE LIMIT APPLIES PER:PERSONAL&ADV INJURY S 11000,000
POLICY a JE T EILOC GENERAL AG R T 2,000,000
TA
PRODUCTS-COMPIOPAG 2,000,000
LIABILITY
COMBINED SINGLE LIMIT 5
BAP2477206 s 11000,000
NLY SCHEDULED 7/1/2019 7/1/2020
AUTOS BODILY INJURY Per erson S
NLY q�65 OI p BOOIIY INJURY Peraccitlenl S
P�OPERTY AMAGE
er accidanl S
A X UMBRELLA LIAB X OCCUR
$
EXCESS LIAR CLAIMS-MADE 2870943 EACH OCCURRENCE 1,000,000
DEO X RETENTIONS D 7/1/2019 7/1/2020 AGGREGATE 1,000,000
B WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY S
.pQ4NppY cPROPRCIETOER/PAR7NER/EXECITENWC989225::::: PER OTH-
lalmitla�0V In0 EXCLUDED9 7/1/2019 7/1/2020UTFJAIIJIF PR
II Yes,describe under ,L.EACH ACC D NT1,000,p00DESCRIPTION OF OPERATIONS b .L.DISEASE-EA EMP OYE 11000,000
E.L.DISEASE-POLICY LIMIT c 1,000,000
DESCRIPTION OF OPERATIONS I 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)
The ACORD name and logo are registered marrks9of ACORDCORD CORPORATION. All rights reserved.
DocuSign Envelope ID:A1CB07BF-5COD-4C1B-9AD8-331AFD7E48DA
54Y Permit Authorization
:.
mass save Form
Site ID: 3965842 Customer: IAN GOODMAN
IAN GOODMAN
owner of the property located at:
(Owner's Name,printed)
90 Franklin St Northampton, MA 01060
(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: (QN LoLnWN
Date: 1/23/2020 4:24 PM EST
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 Fr-4 Office Use only
Rev. 102015