16A-020 104 FAIRWAY VLG BP-2020-1045
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-020 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-2020-1045
Proiect# JS-2020-001773
Est.Cost: $300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME ENERGY SOLUTIONS INC 106188
Lot Size(ssg. ft.): Owner: SAVAGE FRANCIS
Zoning: URA(102)/WP(17)/WSP(15)/ Applicant: HOME ENERGY SOLUTIONS INC
AT. 104 FAIRWAY VLG
Applicant Address: Phone: Insurance:
68 RUSELLVILLE RD (413) 203-2454 WC
SOUTHAMPTONMA01073 ISSUED ON:4/1/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.•INSULATION/WEATHERIZTION
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 4/1/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
..1 •.`.``�. Dep
-OR
City of Northampton ,,
Building Departme�n�
r ! 212 Main Str tO
'r `'�
SULATION
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-11
2,"�S�< ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address: T�s section to be completed by office
� Map Lot Unit
I Zone Overlay District
UElm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Re ord:
or,r1C cJG 16 0 N
Name(Print) Current MailinVddres_
Telephone 33o - Jill
Signature
2.2 Authorized Agent:
nor of utio '' 033 Ce le+e Aqhwtq, So u4-ks &h
Name(Print) j' Current Mailing Ad ess: p� 33
mow' L z��
C///3) a03 - ay5�
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (,G (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) 773 09 Check Number
This Section For Official Use Only
Building Permit Number: �'l�7 Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Survis/�'-or: Not Applicable ❑
Name of License Holder Crt
A W1� I �( CID
License Number
sse �� 0�3 ,a I a K 1�3
Address /,/ Expiration Date
// 9
Signature.j� one
h"" ('
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Nam! Registration Number
doa,�s InC. 1,-�? /y lido _
A dress Expiration Date
?3 CO � � Q/ n
Telephone ' 203-�l(
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...... ❑
` Permit Authorization
T M11 ,
ass save Form
Site ID: 3961566 Customer: FRANCIS SAVAGE
I, Francis Savage , owner of the property located at:
(Owner's Name,printed)
104 Fairway Village Northampton, MA 01053
(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.
Owner's Signature:
1/8/20
Date:
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 For Office Use Only
Rev. 102015
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The C"tttt monwea th of Massachusetts
Department of Industrial Accidents
Office of Investigadons
Lafayette City Center
2Awnue de Lafayette, Boston, ,MA 02111-1750
»v Mass g rvIdia
Workers'Com ensatfen Insurance Affidavit:General Businesses
Applicant Information Please Print Lekibly
Business/Organization Narrle:borne Energy Solutions Inc.
Address:233 College Hwy
City/State/Zip:Southampton MA 01073 Phone#:` 13-203-2454
Are you an employer'Cheek the appropriate box: Business Type(required): j
j'X l am a employer with 5 employees (full ands 5. 0 Retail l
or part-dire)." 6. Q Restaurant/Bar/Eating Establishment
2.Q a I a sole proprietor or partnership and have no 7. Q Office and or Sales(incl, real estate, auto,etc.) t
employees working for m: in any capacity,
[No workers' comp. insurance required] S. 0 Non-profit
�1.Q We are a corporation and its officershave exercised q. Q Entertainment
their right of exemption per c. 152., §1(411,andwe have 1 tl.Q Manufacturing
no employees. (No workers' comp, insurance requiredl 1 l..Q Health Care
a.Q We are anon-profit organization,staffed by volunteers,
with no employees. [No workers' comp, insurance req] 12.0 tither
*Any applicant thA, cocks box*3 mu&l also fill ow the, ctisxn below showing their policy infery ation.
*"If the,corpomteofflices have exempted tftcmselvos.tart the c€rpomton hm other omployem a workers"compensation policy is required and such aft
trrprz ration shoWA check box#I.
I ural an employer that is providing orkerws'compenwdon insuranerjor my employees. Below is the policy information.
tnsurance Company Name:AmGUARD Insurance Company
Insurer's A�ddress:l5 Scutt' liver Dr
CltylStat `zip: Wilkes-Barre PA 18703
Policy#or SeV-ins. I.,ic.#HOWC140654_. _ _ Fxpiratioon Date:1/4121
Attach a copy of the wormers' rompeosathin policy declarat oa page(shting the pelt," number and expiration date).
Failure to secure coverage as required under 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up
to S1,500M and/or one-year imprisonment, as well as civil penalties in the farm of STOP WORK ORDER and a fine of up to
S250,00 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 i suran e coverage verification.
I do hereky certify, under tJh ander e*; hat thein rmation prt�vided ahcvve is t'rtre.tctrd correct.
M
nr �
rzitattdr�, � gate,
413-203-2454
Official use only. Do not write in this area,to be completed by'dty or town official
i 0ty or Town: Permitll,heeast
Issuing Authority, icherk one):
IQBoard of Health 2.0 Building Depart ent 300ty/Town Clerk 41hicensing Board
505rlectrnen's Office 6.[]Other
t C:`ontact Person: phone