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17A-034 (3) 250 NORTH MAPLE ST BP-2021-1480 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-034 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-2021-1480 Project# JS-2021-002460 Est.Cost: $3700.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MODERN ENERGY LLC 106112 Lot Size(sq. ft.): 14766.84 Owner: YOUNG CHRISTINE E Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: MODERN ENERGY LLC AT: 250 NORTH MAPLE ST Applicant Address: Phone: Insurance: 12 HYCREST RD (508) 449-0449 WC CHARLTONMA01507 ISSUED ON:6/11/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION 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 6/11/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner / �i o 14 The Commonwealth of Massachusetts A'ro ��1 O Board of Building Regulations and Standar.L'c Massachusetts State Building Code, 780 CMR )1;/4g1,„.0,,G <D�MUNI IPALITY ro n, USE/ Building Permit Application To Construct, Repair,Renovate Or De.8► ' ' ised tll&r 2011 One- or Two-Family Dwelling q\oorio%' This Section For Official Use Only Building P rmit Number: —J 1'' id go Date A lied: ///rvJJJ �5� II zvzI Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 250 u • Maple. St I ? 3v 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? _ Municipal 0 On site disposal system ❑ I Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Chr1S-Vine Young Noc-t-inac-c )1 l , iv 010 (Q2 Name(Print) City,State,ZIP 250 N . Maple S- . - Li13- S103- -WM ( wil44secom(ast • ne-k- No. and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) �❑ Alteration(s) 0 Addition 0 Demolition El Accessory Bldg. 0 Number of Units Other 'B pecify: S`OS U\ci- o n Brief Description of Proposed Work': `t n S U I Q-e (iV Q l\S w I t v) C e 1 t U 1 o SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 , -too 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Lheck Amount Cash Amount: 6.Total Project Cost: $ 3 i 1 0 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 2 512LALOI 3 .e.Cc ce.U License Number Ex iration Date Name of CSL Holder L�Q St d List CSL Type(see below) C SS L No.and Strut Type Description n+^ n^ y� U Unrestricted(Buildings up to 35,000 Cu.ft.) l.1 ,a 1� '"1 �I Q d R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry 0 -I L. LI o L I L (� RC Roofing Covering I WS Window and Siding FuF Solid j e cc v erne d e r� e n e r a r'. - co SI Insulation a l Burning Appliances Telephone Ema address D Demolition 5.2 Registered Home Improvement Contractor(HIC) V( 90 5 a 10Z I Mode ran Enf rq L L c_ HIC Registration Number Ex iration Date Mc Company Name or HIC Rt ant Name 1 H Cs(—e '-c\ �e CCvemoc\cx enevT,.\now=tom No.and Stroel Email address MOof itbn , 'A 015 0-1 5A—Li q q—OU y q City/Town,State,ZIP Telephone SECTION 6: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 113 No .0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize -1-e V \ to act on my behalf,in all matters relative to work authorized by this bu'1$ing permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. �eCcr-e-v)VIK- 5j2-1120Z Print Owner's o uthorized Agent's e(Electronic Signature) I Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton r s`s...°' siC Massachusetts ��?'. '<< �; * i G wi Ri ; DEPARTMENT OF BUILDING INSPECTIONS a l; 0,� 212 Main Street • Municipal Building xJP• �D� Northampton, MA 01060 sf °� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: (9 ciS, 1-3\00-\`n 'n V_Ca1 , (iv-eT umu 1n P4- The debris will be transported by: Name of Hauler: i_ L Ha ive Signature of Applicant: ?j7r--- Date: S J 2-7 (a2 i CLEAResult CONTRACT I r CLEAResu,r i 50 s:boWashingtonoh, 4A,Str 01 Customer Mane:Christine'c tiVasrbarvugh,hf4,pr581 n9 Email:cyo,ing1443@ccvncastnet 1 Phone:4?3-563-4644 3 Promise Address:250 N Ma pie St.Nmnamotcr•MA Malting Address:250N Mapze St,Norther:pot M A: J `. Project ID:3991,724 Date:Feb,Zee,2020 i i i Job Description I Contractor will perform or cause to be performed the following work on these'Premises'in a professional manner and in accordance with the terms of this Contract.including the attached recornmendationswork order describing the wont in detail ithe'Work whicr are incorporated herein by reference, 1 Measure Description Location Quantity Unlit Total Cost Customer Cost Walls Wood Shingle 3` Dense Pack Cellulose 632 SF $3.574.OS $393,52 IBlower Door Test . each $72'5 57 Total: $33.646.63 Program Incentive: -_2,735.17 Customer Total: $911.71 Payment 9 Customer agrees to pay Contractor for the Work.the Customer Share of the Contract Price as follows:Payment*1:$0.00 as a Depos;t payable to CLEAResult upon signing the Contract not to exceed 1 i3 of the total retail costs).Mail check&contract to CLEAResur;. 50 Washington Street, ,Westborough.MA,01581,Final Payment:$911.71 as the final payment for the Work shall be payable to Me Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work. Custor"e• understands that heishe will not be required to pay the Utility incentive Share of the Contract price in the amount of$2.735.12. Changes to individual line items and'or previous incentives may increase or decrease the size of the Utility Incentive Share. Dispute Resolution The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract.the;IC may submit suz;^ dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be required to submit to such arbitration as provided in M.C.L,c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller,provided you notify the seller in writing by ordinary mail posted.by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. DC NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Page 1 of 4 y/ / r y; /u'/ r �/j r r y / r/ r �j/� � / /i/' /jam/�//4,� i�%/r /y r/r /s �� � � /' r �%// �%/i./�$����J�� / �r�/%/ %/psi ,r F 6 ;4171)2/0 (17/"2P/ Customer Signature D e Indicate your selected IIC here,if applicable Initial here if you want the Program to assign a Participating Contractor �� i�i (,4h 19Pl �h 212612020 Noam Perirnutter CLEAResutt Signature Date Name of CLEAResult Representative 4 / y yrr;: i�/iir Page 2 of 4 Permit Authorization mass save Form Site ID: 3991724 Customer: Christine Young CA►►rr 5-7f yl G D 4 h ,owner of the property located at: (Owner's Name,printe e._/ 250 N Maple St Northampton, MA 01062 (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 bui ing permit to perform insulation and/or weatherization work on my property. Owner's Signature: /V/ Date: ; ‘ 2,6 lJ 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 I Fcr Office Use Or'i Rev.102015 The Commonwealth of Massachusetts _ Department of Industrial Accidents a ' Office of Investigations ==�1= \ Lafayette City Center =�4 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):MODERN ENERGY LLC Address: 12 HYCREST ROAD City/State/Zip: CHARLTON, MA 01507 Phone #:508-449-0449 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ 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 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no INSULATION employees. [No workers' 13.Q Other comp. insurance required.] *My 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. 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: TRAVELERS Policy#or Self-ins. Lic. #: 1 K07706-5 Expiration Date:1 2/06/2021 Job Site Address: 2 5 0 N M a p I t - City/State/Zip: N oh e no-n fl t M Y 0 1 O(o, 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. I do hereby certiffyy under the pains and penalties of perjury that the information provided above is true and correct. Signature: [/ Date: / 2. 1 J 2 0 2- 1 Phone#: 508-449-0449 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 51:1Plumbing Inspector 6.0Other Contact Person: Phone#: 1 DATE(MMIDD/YYYY) ACON R ® CERTIFICATE OF LIABILITY INSURANCE �..---- 12/03/2020 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 Melissa Lotter NAME: Hometown Insurance Center,LLC PHONE (508)347-9394 FAX (508)461-2035 (A/C,No,Ext): (A/C,No): 590 Main Street E-MAIL mlotter@htownins.com ADDRESS: PO Box 541 INSURER(S)AFFORDING COVERAGE NAIC# Sturbridge MA 01566 INSURER A: Maxum Indemnity Company INSURED INSURER B: Preferred Mutual Insurance Co. 15024 Modern Energy LLC INSURER c: Nautilus Insurance Company P 0 Box 88 INSURER D: Travelers Prop.Casualty Group TPC001 INSURER E: Northborough MA 01532 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2012203975 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A BDG 3024078 12/06/2020 12/06/2021 PERSONAL a ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ 20,000 B OWNED SCHEDULED PCA0100300844 09/01/2020 09/01/2021 BODILY INJURY(Per accident) $ 40,000 AUTOS ONLY AUTOS XHIRED �/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /-• AUTOS ONLY (Per accident) Underinsured motorist BI $ 1,000,000 X UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ 5'000'000 C EXCESS LIAB CLAIMS-MADE AN077914 12/06/2020 12/06/2021 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION J PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN- 1 D ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A 7PJUB-1K07706-5-19 12/06/2020 12/06/2021 E.L.EACH ACCIDENT $ , , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CLEAResult,Eversource and National Grid are listed as additional insureds on a primary and non-contributory basis,when required by written contract Jeffrey Vlk is exempt from Work Comp coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CLEAResultAttn:Contractor Services Dept ACCORDANCE WITH THE POLICY PROVISIONS. 50 Washington St AUTHORIZED REPRESENTATIVE p U Westborough MA 01581 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r /PWo/m/MrIMI/90a n f'#a dltdioea Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration . Type LLC t * Registration: 188905 MODERN ENERGY LLC = +� - Expiration: 09/14/2021 12 HYCREST RD t CHARLTON, MA 01507 �` 4 — — 4=-----. at,' ec y it `O III Update Address and Return Card. . 'QM-o5;17 '!, !, ..,i,ni-.•.=.�fd n( J/rrivr.ytri.:r=//; Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. It found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 188905 09 14r2021 1000 Washington Street -Suite 710 MODERN ENERGY LLC Boston,MA 02118 JEFF VLK q7-7 12 HYCREST RD .e1ur•C , =<//r,r' CHARLTON MA 01507 Undersecretary No lid without signature Commonwealth of Massachusetts Z®� Division of Professional Licensure Board of Building Regulations and Standards Constructipost}iil4i+/iBpr Specialty CSSL-106112 6L/pires:03/20/2023 JEFFREY VIi i 12 HYCRESTRD CHARLTON M9 01 Commissioner .)•