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22D-108 (6) 25 AVIS CIR BP-2021-0063 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22D- 108 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2021-0063 Proiect# JS-2021-000091 Est.Cost: $2500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME ENERGY SOLUTIONS INC 106188 Lot Size(sq.ft.): 22520.52 Owner: LEONARD ANDREW Zoning: URA(100)/WSP(100)/ Applicant. HOME ENERGY SOLUTIONS INC AT. 25 AVIS CIR Applicant Address: Phone: Insurance: 233 COLLEGE HWY (413) 203-2454 O WC SOUTHAMPTON MAO 1073 ISSUED ON.7/20/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.I NSULATIONNVEATH ERIZATION 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 7/20/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner m --- 3 `— City of Northampton Building Department 212 Main Street " Room 100y o© Northampton, MA 01060r 0 phone 413-587-1240 Fax 413-587-1272 ° APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY j SECTION 1 -SITE INFORMATION INS ULA TION PERMIT i 1.1 Property Address: Ibisseetim to beompleted tsy office V I r Asap Lot Unit -- (f ✓ kaf'1� 01 u(p�- Zone Ove€�rDistrict Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 14 "OvI1018 Name(Print) Curr nt Ma" g dress: g 4' -AcA ed `�� Telephone Signature 12.2 Authorized Agent: r>`er of ufio 3L33 G l Q lhqh SoqAAnlOkn geL Name(Print) Current Mailing Ad ess: -.3 Signature Teleph'orre SECTION 3-ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be Oficial Use Only completed by permit applicant 1. Building (a)Building Permit Fee ;i 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2+3+4 +5) Q Check Number I This Section For Official Use Only BuildingPermit Number: Date �/�2�Z���"� Issued: Signature: -/ -7 zo I 1 Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction S rvisor: �l� I ( Not l al4 le�� Name of License Holder: G�/ JI 1 License Number Ig l a n �3 Address Expiration Date Signature / one jiiNot Applicable ❑ g ::4 193a � Company Nam C I }} Registration Number G �nrcc/ 11(ll�vt` I��. { -C-) /q ) Q 0 Address �I_tn Expiration Date (folyo"��®73Telephon&-.13 SECTION 10-WORKERS'COMPENSATION INSiTR/k#1 MAFFIDA T(PA-G-E.a.152,4 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resul in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ r;. w G )IumN a Gas­ of Massk.hUSCUS 60 Shawmut Read; Unit 2 Canton, MA 02021 A NF5ource Company OWNER AUTHORIZATION FORM 1, Andrew Leonard _._..__.....__........ __._......................_....__ ___ ....__..._.__. __._ _.____._ .___....._......______.___._.__ ___....___..__...._.._ _ (Owner's Name) owner of the property located at: 25 Avis Circle , (Street) Florence, MA 01062 , _.._._..._......_................... _................_.._._......_......_....__.__,._....___...___._..__..........___ _.__.__.__.µ_.________.__. ., (Town, State, Zip) hereby authorize _ ..._...... ....... _............_.._.....__..._____ .___.__.._..__._ (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It ir homeowner's responsibility to close out this permit by contacting their muni ipal' y at th comp#' tion of this work. P -customer Signature Zg Date s ( :"'+ ._ 0610512018 r►Comwonwe4 ttlt ofMassuchuseas Department of Industrial Accidents Wice of Invesdgtrtinns Lafayette City Center / 2,Avenue rte Lafayette, Boston,MA 02111-1750 www rrtassgovfa Workers' Compensation Insurance Affidavit: General Businesses Amphrant information Please Print Udbly Bus]ness/Organization Name:Hoge Enemy Solutions Inc. Address:233 College Hwy City! tate/Zip:Southampton MA 01073 Phone#:413-20 -2454 :ire you;an employer? Check the appropriate box: Businesrt Type(required): i. 1 am a employer with. _._ employees (full and, 5- D Retail or pari-tirne).* b. [] Restaurant/Bar/Eating Establishment 2. ] 1 am a sole proprietor or portntiship and have no 7. Office andlor Sales(incl, real estate,auto,etc. employees working for me in any capacity, [No workers' carp. insi rance required] � [�Non-profit .D We are a corporation and its officers have exercised 9. [ Entertainment their right of exemption per c. 1,5 2.§](4),and we have 10.01Manufacturing no cmployews. No workers' cornp. insurance required]" 13,Q Health Care 4.,7 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' coma. insurance req.] 12.0 Other *A"alvylicattt that checks box#1 rnust also fill out the wction below showirg thtir w deers'compewsittion policy infortuati . "If the corporuate officers have exempted themselves],but the ccvpo atirsr,has cAher antiloyees,a w€rkers'competuation policy is required and such an orgartrrationshouAd check hox#I I am an etmplayer that is pro villin workers'compensation insurance jor my employees. Below is the policy information. Insurance Company Na e:AmGUARD Insurance Company Insurer's Address:16 South River lir C:'ity'Statc"tip: ilkes- erre, PA 18703 Policy##or Self-ins. Lic. #HOWC140654 Expiration Date:1/4121 Attach a copy of the w orkers' compensation poly declaration page(showing the policy 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 S 1,5M.00 aadfor one-yoar imprisonmeatt> as well as civil penalties in the form of a STOP WtJfi2K ORDER and a fine of up to 2 50.0O a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t1w DIA fear insunance coverage verification. I do Isere yrt1�, under th and I at the in�ormation protiderl o vc is true ttn�corrf3c� C a I"hc ire : 413-203-2454 official use only. Do not write in this area,tw be completed by t'or yrs official. l City or Town: PermJVUcense Issuing Authority (,cheek rine): I oBoard of Health 2,I Building Department 30 Clty[Tow n Clerk 4.0I:icensfng Board 5 Selectmen's Oflice 6.[]{Rarer i Contact Person-- Phone�: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructiom t plisor Specialty CSSL-106188 E�pires 1212812023 SHAWN B MITCHELL 68 RUSSELLVILLE RD � r SOUTHAMPTON MA ti Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Nome lmprovemerA.Contractor Registration < ..y Type: Corporation r „ ' Registration: 193885 HOME ENERGY SOLUTIONS INC �> � xpiration: 1210412020 ; 58 RUSSELLVILLE Rn SOUTHAMPTON,MA 01073 .4" a Update Address and Return Card. SCA, 2oM t y� omce of Consumer Affairs 8 Business Regulation HOLE IMPROVEMENT CONTRACTOR RogisbiNion valid for individual use only TYPE,Ctxooration before the expiration data. tf found return to: Req3sj'gn Expir-Mion Office of Consumer Affairs and Business Regulation 12104!2020 1000 Washington Street-Suite 710 HOME ENERGY SOLUTKMINC Boston,MA 02118 SHAWN MITCHELL. tab RUSSELLVILLE'RI3 SOUTHAMPTON,MA 01073 Undersecretary , Mot Vaud without signature