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44-097 (2) BP-2021-2061 418 ROCKY HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 44-097-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2021-2061 PERMISSION IS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 5000 ENERGIA LLC 92540 Const.Class: Exp.Date:09/02/2023 Use Group: Owner: KIRVIN JOHN P& ANN M Lot Size (sq.ft.) Zoning: SR Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-31 1 1 ENWC 162970 HOLYOKE, MA 01040 ISSUED ON:10/22/2021 TO PERFORM THE FOLLOWING WORK: ATTIC INSULATION 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. Signature: I • • O cr, 1 • � , • yQ ( I Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIVED F The Commonwealth of Massachusett OCT 1 5 � OR W Board of Building Regulations and Stan ds full TNi 1P i ITY Massachusetts State Building Code, 780 MREPT.OF BUILDING INSPECTIONVSE NORTHAMP ON,MA•,060 Building Permit Application To Construct,Repair,Renovate • •- . -•• ,-• 2011 One-or Two-Family Dwelling 11 This Section For Official Use Only uillling Permit Number: 6 0- ex t-.I0((i, Date Applied: el - Z- A cu,� � Kos �/� 10 2 2ou V Building Official(Print Name) Signature Date 0 / C4?C4IaZ (sors QI IATION .1 Property Address: Map&Parcel Numbers 416 ROCKY HILL RD 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 CI Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ANN KIRVIN NORTHAMPTON, MA 01062 Name(Print) City, State,ZIP 416 ROCKY HILL RD 413-584-3564 amkirvin@comcast,net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:insulation Brief Description of Proposed Work2:INSULATION ATTIC FLOOR OPEN BLOW CELLULOSE 11" DAMMING SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $5000.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $Suppression) Total All Fees: $ Check No.13 heck Amoun 4. Cash Amount: 6.Total Project Cost: $5000.00 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 92540 9/2/23 Tom Rossmassler License Number Expiration Date Name of CSL Holder 242 SUFFOLK List CSL Type(see below) U No.and Street Type Description HOLYOKE MA 01040 U Unrestricted(Buildings up to 35,000 cu. ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-322-3111 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Energia LLC 165169 1/10/22 g HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 242 SUFFOLK ST ivelice@energiaus.com No.and Street Email address HOLYOKE MA 01040 413-322-3111 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 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 Tom Rossmassler/Energia LLC to act on my beh ,in all matters relative to work authorized by this building permit application. S.-iZe471 -6 10/7/2 Print er's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my n e below,I hereby attest under the pains and penalties of perjury that all of the information contained in ' application is true and accurate to the best of my knowledge and understanding. 10/7/21 Pri Owner's or Authorized Agent's Name(Electronic Signature) 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 SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton 00.Y82,MN)p\. 1 .," " 4'-'\ Massachusetts ,S‘s_.. ' s, ` F`i l � ' DEPARTMENT OF BUILDING INSPECTIONS a,.'`��, A° 212 Main Street • Municipal Building 9 \� Y " Northampton, MA 01060 sstly ‘'‘ac 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: Rose st Springfield MA The debris will be transported by: Allied waste Name of Hauler: Signature of Applicant: r,Z . Date: 10/7/21 Permit Authorization mass save Form Site ID: 4234784 Customer: ANN KIRVIN Ann M Kirvin , owner of the property located at: (Owner's Name,printed) 416 Rocky Hill Rd 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 building permit to perform insulation and/or weatherization work on my property. Owner's Signature: 440 H. 1'( Date: 08/ 31 /2021 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: EJ tJ6C-/4- Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 Fcr Office Use Orly Document Ref:C9ZFM-BJF8F-WOPJQ-WBHKB Page 2 of 8 ENERLLC-01 JOCELYN '4C-4SPRO. CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 6/4/2021 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(les)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 NAME cT Jocelyn M Douglas Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (A/C,No,Ext): I(A/C,No): Chicopee,MA 01013 nkss:jocelyn@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:Guard Insurance Group Energia LLC INSURER C: 242 Suffolk Street INSURER D: Holyoke,MA 01040 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE 'ADDL.SUER POLICY NUMBER POLICY EFF POUCYM/D /EXP LIMITS JNSD WVD, (MM/DD/YYYYI,(MWDD/YYYY1 A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/1/2021 7/1/2022 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Ma aBccliiden SINGLE LIMB $ 1,000,000 ) X ANY AUTO BAP2477206 7/1/2021 7/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOSp �� pp BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOSWONLY PROPERTY ardent)DAMAGE A X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LAB CLAIMS-MADE PBP2870943 7/1/2021 7/1/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ B WORKERS COMPENSATION X PER AND EMPLOYERS'LABILITY STATUTE E A R ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ENWC203063 7/1/2021 7/1/2022 E.L.EACH ACCIDENT $ 1,000,000 FFICER/MEMBgEER EXCLUDED? N N/A ,Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 Energia LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards €?t tE vicar CS-092540 Elyptres:09/02/2023 THOMAS B ROSS 100 MAIN STREET _ mire TFIELD MA, 01,. , r �. _ . 1SSiOfWf tt .."j.ta_ ati ✓// ` 'i/Nr ee,eweli r/./1,(i.JJrrt/rr,Jr//3 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 165169 01/10/2022 1000 Washington Street -Suite 710 ENERGIA LLC Boston,MA 02118 falcuL , L,,....„. THOMAS ROSSMASSLER ? .� 242 SUFFOLK STREETCG•ia . HOLYOKE,MA 01040 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents fs Office of Investigations ( - Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 =, _ _„=� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ENERGIA LLC Address: 242 SUFFOLK ST. City/State/Zip: HOLYOKE, MA 01040 Phone#: 413-322-3111 Are you an employer? Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 16 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. n Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. E Non-profit 3.❑ We are a corporation and its officers have exercised 9. n Entertainment their right of exemption per c. 152, §1(4),and we have 10.11 Manufacturing no employees. [No workers' comp. insurance required]** 11.17 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.. Other Insulation *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **[f the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: GUARD INSURANCE GROUP Insurer's Address:416 ROCKY HILL RD City/State/Zip: NORTHAMPTON MA Policy#or Self-ins. Lic. # ENWC203063 Expiration Date:7/01/2022 Attach a copy of the workers' compensation policy 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$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 coy- .Le verification. I do hereby certify, un' ' the pains and penalties of perjury that the information provided above is true and correct Si a ature: Date: 10/8/21 Phone#: 413-3 -3111 Ext 122 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 2.0 Building Department 30 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia