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30A-053 (9) BP-2021-2235 56 LIBERTY ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 30A-053-001 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-2021-2235 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 6000 ENERGIA LLC 92540 Const.Class: Exp.Date:09/02/2023 Use Group: Owner: BOURNE ALDEN &KATE BAILEY Lot Size (sq.ft.) Zoning: URB Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 ENWC162970 HOLYOKE, MA 01040 ISSUED ON:11/30/2021 TO PERFORM THE FOLLO WING 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. Signature: Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEI I/ 214 The Commonwealth of Massachus tts N /o 1,00 Board of Building Regulations and St ndards V 2 9 202 y FORCIPALITY Massachusetts State Building Cpde,,7 ar R USE Building Permit Application To Construct,Repair;Rerf3tratepi De • Remised Mar 2011 One-or Two-Family Dwelling _" ,,, -ripn�� This Section For Official Use Only c`-`--1 Buildin/ Permit Number:a:n.5 V-,)I ' . a Date Applied: l5rvi �/ /i 36 2ozl Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 A s ors Map&Parcel Numbers 56 LIBERTY ST f�' 0� 3 l.la 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 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: ALDEN BOURNE FLORENCE MA 01062 Name(Print) City,State,ZIP 56 LIBERTY ST 917-816-2437 acbourne@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ 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 Shed Spray Foam Closed Cell floor,walls, gables, slopes 6 mil poly Crawispace Crawl Wall Spray Foam Closed Cell SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $6,000.00 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 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: $ j,� Check NoO/ Check Amount /: l i / Cash Amount: 6.Total Project Cost: $6,000.00 0 Paid in Full 0 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 List CSL Type(see below) u 242 SUFFOLK ST No.and Street Type Description Holyoke MA 01040 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413 322 3111 ivelice@energiaus.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165169 1/10/22 ENERGIA LLC 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 A1414 DAVIT(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 Vaf No .❑ 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 Energia LLC Thomas Rossmassler to act on my behalf,in all matters relative to work authorized by this building permit application. see autho attached 11/15/21 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name be,. I hereby attest under the pains and penalties of perjury that all of the information contained in this appl> on is true and accurate to the best of my knowledge and understanding. `L 11/15/21 Print Owner's • 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" ne a _ Your Local Energy Efficiency Experts EnergiaUS.com BUILDING PERMIT AUTHORIZATION FORM I, ,k L_DEAIRo-R1JE , owner of the property located at: (Owner's Name, printed) 57 4/8 Ty sT /(ra.T6,¢a ePioiv ,a,4- (Property Street Address) (City/Town) hereby authorize Thomas Rossmassler of Energia, LLC. to act on my behalf and obtain a building permit to perform insulation/weatherization work on the above named property. 7'%e'-- q(147/6-2437 Owner's Signature Telephone Number /0724/2-/ Date The Commonwealth of Massachusetts j Department of Industrial Accidents 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. ❑ 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.1 Other Insulation *Any 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. 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:56 LIBERTY ST City/State/Zip: FLORENCE MA 01062 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,under the ins and penalties of perjury that the information provided abov is tr and correct. Signature: Date: Phone#: 413-322-3 1 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): 1.0Board of Health 2.1=I Building Department 3.0 City/Town Clerk 4.0Licensing Board 5.0 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia Commonwealth of Massachusetts Division of Professional Licensure If Board of Building Regulationsat`� and Standards ConstwetPt�nt t'+pfrvisor CS-092540 ;> :' itfpires:09/02/2023 THOMAS B ROSSMA i 100 MAIN STREET HATFIELD MA 010,E .% Commissioner OS- eerni.14k, 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 185169 01/10/2022 1000 Washington Street -Suite 710 ENERGIA LLC Boston,MA 02118 THOMAS ROSSMASSLER 242 SUFFOLK STREET Not valid without signature HOLYOKE,MA 01040 Undersecretary ENERLLC-01 JOCELYN ACORO CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DD YYYV) 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 NAME: Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (A/C,No,Bet): (A/C,No): Chicopee,MA 01013 At,DaEss:jocelyn@phillipsinsurance.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 LTRINSD WVD (MM/DD/YYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY 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&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PE8T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accidenu X ANY AUTO BAP2477206 7/1/2021 7/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AURTEOS ONLY _ AUUTNOSWN BODILY INJURY(Per accident) $ A _ AY HIED ONLY UTOOS ONLY (Peer accident�AMAGE $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB 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'LIABILITY STATUTE ER EN W C 203063 7/1/2021 7/1/2022 1,000,000 ANY AFFICER/MEMBEREXCLUDED PROPRIETOR/PARTNER/EXECUTIVE N N/A E.L.EACH ACCIDENT $ (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 I 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 i I, 1� ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. 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