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19-011 (4)
BP-202 1-2098 32 INDUSTRIAL DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 19-011-001 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-2021-2098 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 30000 ENERGIA LLC 92540 Const.Class: Exp.Date:09/02/2023 Use Group: Owner: FUGU THE GROUP LLC Lot Size (sq.ft.) Zoning: GI Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-31 1 1 ENWC162970 HOLYOKE, MA 01040 ISSUED ON:11/01/2021 TO PERFORM THE FOLLOWING WORK: 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: 4 . • 11 Fees Paid: $210.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner /31c _ �� Versionl.7 Commercial Building Permit May 15, 2000 Department use only OCT 2 •ity of Northampton Status of Permit: 6 �0( , :uilding Department Curb Cut/Driveway Permit • pT•OF / 212 Main Street Sewer/Septic Availability Nq,t7n � ,� Room 100 Water/Well Availability oAT eU/toin TCN•r4gp0F0�lnNS ;/Northampton, MA 01060 Two Sets of Structural Plans •hone413-587-1240 Fax 413-587-1272 Plot/Site Plans r Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 32 INDUSTRIAL DR. Map Lot Unit NORTHAMPTON MA 01060 IZone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: FUGU GROUP LLC [32 INDUSTRIAL DR EAST Name(Print) Current Mailing Address: _ (413)297-1094 Signature J,F.C_ - -- Telephone 2.2 Authorized Agent: [TOM ROSSMASSLER/ENRGIA LLC 242 SUFFOLK ST HOLYOKE MA 01040 Name(Print) Current Mailing Address: (413) 322-3111 Signature Telephone SECTION 3-E TIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee $30,000.0- 2. Electrical (b) Estimated Total Cost of $0.00 Construction from (6) 3. Plumbing $0.00 Building Permit Fee 4. Mechanical(HVAC) — 5. Fire Protection _ $0.001 6. Total=(1 +2 + 3+4+ 5) Check Number This Section For Official Use Only Building Permit Number � Date Aa'al I d ®� Issued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations Eric isting Wall Signs El Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs El Roofing❑ Change of Use❑ Other❑ Brief Description INSULATION TO WALLS CELLULOSE DENSE PACK-NO CONSTRUCTION Of Proposed Work: ti j a S--rkit 7'u 2,4-(.. (�( A 6--6,S 1 SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly CIA-1 ElA-2 0 A-3 ❑ 1A I CI A-4 ❑ A-5 ❑ 16 ❑ B Business ❑ 2A ❑ E Educational 0 26 I 0 F Factory 0 F-1 ❑ F-2 0 2C 0 H High Hazard ❑ 3A 0 I Institutional ❑ I-1 0 1-2 ❑ 1-3 ❑ 3B 0 M Mercantile ❑ 4 ❑ R Residential El R-1 ❑ R-2 ❑ R-3 El 5A 0 S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: I S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: I Proposed Use Group: I Existing Hazard Index 780 CMR 34): , Proposed Hazard Index 780 CMR 34): _ SECTION SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st _...._._1 1st 2nd 2nd 1 3rd 3`d I_ 4th 4tn Total Area (sf) Total Proposed New Construction(sf) Total Height(ft) I._,_ i Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system El Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: ', Not Applicable E Name(Registrant): . Registration Number Address L ' 1 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): n/a Name Area of Responsibility I Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Re ion Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor TOM ROSSMASSLER Not Applicable ❑ Company Name: ENERGIA Responsible In Charge of Construction 242 SUFFOLK ST HOLYOKE 01040 Address (413)322-3111 Signatur Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No ®/ SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT jDAVID SHELTON as Owner of the subject property hereby authorize;TOM ROSSMASSLER/ENERGIA LLC to act on my behalf, in all matters relative to work authorized by this building permit application. & c11-04, 1- C ail [10/20/2021 Signature of Owner Date TOM ROSSMASSLER _ __ , 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. !TOM ROSSMASSLER 1 Print Name 10/20/2021 Signat of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:jTOM ROSSMASSLER 1925_40 License Number 242 SUFF LK ST HOLYOKE MA 01040 09/02/2023 Address Expiration Date [(413) 322-3111 Sign re Telephone SECTION 13-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 0 No 0 /...14 ENERLLC-01 JOCELYN '`�`�R� 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(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 Jocelyn M Douglas Phillips Insurance Agency,Inc. I PHONE FAX 97 Center Street (A/C,No,Ext): I(A/C,No): Chicopee,MA 01013 ADDDDRIIESS:jocelyn@philiipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD.WVD (MM/DDM'YY) (MM/DD/YYYYI A X COMMERCIAL GENERAL LABILITY 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 i PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY (Ea COMBINED t SINGLE LIMIT $ 1,000,000 X ANY AUTO BAP2477206 7/1/2021 7/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ $ 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 OTH- AND EMPLOYERS'LABILnY ENWC203063 7/1/2021 7/1/2022 STATUTE ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N �FFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ Aandatory in NH) 1,000,000 E.L.DISEASE-EA EMPLOYEE $ 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 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 4 Division of Professional Licensure Board of Building Regoiations and Standards ConStwCttrfti5t]pervf sor CS-092540 Expires.09102/2023 THOMAS B RDSSMA$$ 100 MAIN STREET L HATFIELD MA 0103.$ . tjr tf r��'>flL1`‘s ;ommissioner ,/ fi c Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Pegistration Expiration Office of Consumer Affairs and Business Regulation 165189 01/10/2022 1000 Washington Street -Suite 710 ENERGIA LLC Boston,MA 02118 THOMAS ROSSMASSLER 242 SUFFOLK STREET f�N✓/L 'tGfir.>t HOLYOKE,MA 01040 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents _= i' Office of Investigations Lafayette City Center T "��-ty 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.❑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. ❑ Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** l l ❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.1 Other Insulation *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If 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. 1 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: 32 INDUSTRIAL DR E 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 coverage verification. I do hereby certify, and r the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 10/8/21 Phone#: 413-3223111 Ext 122 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1.0Board of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5.0 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia