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30A-023 (10) n r E 7p- l q-5 to � CE1VE� S�Q /Z Department use only city of Nortam on St us of Permit: Building De aft entOCT 2 4 2018 Cu b Cu Driveway Permit �-�t 212 Main Stre t Se er/S ptic Availability Room 100 - �N er/ II Availability Northampton, r''+� Wh.MA-ot wo Set bf Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY D�W^ELLING SECTION 1 -SITE INFORMATION �� `� VLt�+ l� 1.1 Property Address: �This section to be completed by office Map SCJ A Lot Unit A\4 c'- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) jCurrent ailin Addr f\l AD� Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature 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 �J 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) QQ Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: wilding Commissioner/Inspector of Buildings Date tt'k' Ar -T-KE446:5 @ ez47d.0'-(?1a-US - r272L, �u EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage - Setbacks Front Side L: R: --` L: � R:77 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW Q YES 0 IF YES, date issued: IF YES: Ws the permit recorded at the Registry of Deeds? NO DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO kA DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO y`Y IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q = Sidin [0] Other[ Brief Description of Proposed Work: SOC6 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 following: a. Use of building :One FamilyTwo 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 _ (3m to act on my behalf, in all matters relative to work authorized by this building permit application. �ee, M MA P��rh Tc�r m K) I n 110\ Signature o Owner Date I, Tc(VN-N � 1�1 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. Print Name GI Signatur O er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �om � Y^1 h)��� )q]) Sq0 License Number Addres S/nhme=�—aExpiration Date S' nat e T hone 9.Realstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number - Lql M(roko4o k /►o)eo Address F— Expiration ate Telephone kA - 1O 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 buildi g permit. Signed Affidavit Attached Yes....... V No...... ❑ City of Northampton Massachusetts tt !4. DEPARTMENT OF BUILDING INSPECTIONS �'• \ 212 Main Street •Municipal Building yJs.., cam ,. 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 n ber and street name) Is to be disposed of at: LA \ Yc . 5�Y kE\c\,\Aa,01 kcm - print name and location of facility) (Please P Y) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Sigu4turetof Permit Applicant or Own r 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 Common wealth of Massachusetts Department of Industrial Accidents Office of Investigations 10 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Leeibly 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): 1.QI am a employer with 1() _ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 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' insurance.$ 9• ❑ Building addition comp.[No workers'comp. insurance P• required.] 5. ❑ We are a corporation and its 10.E:1 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.❑ Roof repairs insurance required.]t c. 152, §](4),and we have no employees. [No workers' 13.0 Other comp, insurance required.] *Any applicant that checks box#I 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. #Contractors 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.#: ENWC952172 Expiration Date: 7/01/2019 Job Site Address: (1 City/State/Zip:FXOVe' "Ce. "O G Z Attach a copy of the workers'comp sation 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 2A for insurance coverage verification. I do hereby certify nder the pains and penalties of perjury that the information provided abo is true d correct. Si ature: 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#: A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/2/2018 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 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 The Dowd Agencies, LLC NAME: Mary Conroy 14 Bobala Road PHONENo. 413-538-7444 FAX Holyoke MA 01040 E-MAIL ac No ADDRESS: CRODuCER D ENELL INSURED INSURERS AFFORDING COVERAGE NAIC q Energia, LLC INSURER A:Evanston Insurance Company 35378 242 Suffolk Street INSURER B:Commerce Insurance Comeany 34754 Holyoke MA 01040 INSURER C:StarStone National Insurance Company 25496 INSURER D:Guard Insurance Grou 8281 INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: 1131630225 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 ADD SUB LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YWYMM/DD/YYYY LIMITS POLICY EFF POLICY EXP A GENERAL LIABILITY 2DB4466 7/1/2018 7/1/2019 EACH OCCURRENCE X S 1,000.000 COMMERCIAL GENERAL LIABILITY AMA EN PREMISES Ea occurrence S50,000 CLAIMS•MADE X OCCUR MED EXP(Any one person) $1.000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S2.000.000 POLICY EXI PRO- LOC PRODUCTS-COMP/OP AGG S 2.000,000 B AUTOMOBILE LIABILITY S BHOPBJ 7/1/2018 7/1/2019 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S1,000,000 ALL OWNED AUTOS BODILY INJURY(Per per S X SCHEDULED AUTOS BODILY INJURY(Per accident) S X HIREDAUTOS PROPERTY DAMAGE S X NON-OWNED AUTOS (Per accident) S =DEDUCTIBLE S CUR 75750H180ALI 7/1/2018 7/1/2019 EACH OCCURRENCE AIMS-MADE S 1,000,000 AGGREGATE S 1,000,000 S COMPENSATION ENVJC952172 $ AND EMPLOYERS'LIABILITY 7/1/2018 711/2019 X WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT 51,000,000 (Mandatory In NH) If es,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. To Whom It May Concern AUTHORIZED REPRESENTATIVE ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD RD CORPORATION. All rights reserved. commonwealth of Massachusetts Division of Professional Licensure Board Of BUilding Regulations and Standards Construction Supervisor CS-092540 Expires: 09/02/2019 THOMAS B ROSSMASSLER . 100 MAIN STREET HATFIELD MA 01038 Commissioner Office Of Consumer Affairs&Bus/ iness/Regulation r/' j :I'iOME IMPROVEMENT CONTRACTOR .License or registration valid for individul use only before the expiration date. ound return to: Registration: 165169 y Expiration: 1/11/2018 Type: Office of Consumer Affai LLC rs and Business Regulation 10 Park Plaza-Suite 5170 ENERGIA LLC !ZO Boston,MA 02116 THOMAS ROSSMASSLER i 242 SUFFOLK STREET HOLYOKE,MA 01040 Undersecretary _. Not valid without signature