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44-053 (2)
BP-2021-2242 1114 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 44-053-001 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-2021-2242 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 3408 COZY HOME PERFORMANCE 102169 Const.Class: Exp.Date: 12/10/2022 Use Group: Owner: DION DAVID &ADRIAN Lot Size (sq.ft.) Zoning: SR Applicant: COZY HOME PERFORMANCE Applicant Address Phone: Insurance: 180 PLEASANT ST#200 4135290200 46-845373-01 EASTHAMPTON, MA 01027 ISSUED ON:12/01/2021 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. Signature: `, 0 1' • itrrijtiAk- yQ • Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner , / '''''‘d9A'" A The Commonwealth of Massachusetts W Board of Building Regulations and Standards'/ '0k \ 4 Massachusetts State Building Code, 780 C c 9 M 1✓IPAi f1TY r 0 USE/ Building Permit Application To Construct, Repair, Renovatec,'De lish a ��Rev sed Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only , I Buildin Permit Number: - a 1 I . "a.) 41).. Date Applied: \ Eu11._), 1Z-,, // - 1/-30-26Z( Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers ///y Floreoict RA Nor-l .rpfoh 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 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Adricih Dial Nn(AGAIN pfOn MA- Olblo;t Name(Print) City,State,ZIP' MI F/erutct kci 03-2 YN- 977 7 ctdrian Mien e \rysoul•Um No.and Street Telephone Email Mdress 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 cl Specify: hi sk lava, Brief Description of Proposed Work' vt. n it air rr,Ze, ' - 41-4 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 1/08 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: IL Check No.;&37 Check AmouiS ifh Cash Amount: 6. Total Project Cost: $ 31 tog 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C55 L l Od i o 1 t 0\ 0. rn A R K 4.14 A 7.Z. License Number Expiration Date Name of CSL Holder L 1 a O P1�q s 4n-I' s i- ¢d O Q List CSL Type(see below) No.and Street Type Description /y ,�, U Unrestricted(Buildings up to 35,000 Cu.ft.) f A 5T r A NO im\; !fl T OI O a.'1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding /� SF Solid Fuel Burning Appliances 1113"sat U&)Q MAF\Q my co y Want.0h'I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement/� Contractor(HIC) ` a.�-� y 15 I v13 Cozy u,Om F. Perrot m 6/ C.L HIC Registration Number Expiration Date I Co pan Name or HIC Registrant Name I 0 pie4i,Ant St h0i00 AlchtkCr+�ycd2�horh42..CgM No.and Str et Email address c,415 ANdir pkc* ('l% OW 11 413', ..ca.0 , City/Town,Stat ,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. SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN CONTRACTOR OR OWNER'S AGENT APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize CO2 1+3mt. Q .c ku('t'nk c.i to act on my behalf.in all matters relative to work authorized by this building permit application. I- Permit 4,A• Fir,. ma_ It/Aa.Icy Owner's Signature Date t ' SECTION 7b: APPLICANT 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 isJtrue and accurate to the best of my knowledge and understanding. 41/Xe ja... ///ba lei Contractor//Owner s Agent/Owner ignature Date 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 ttwl 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%oc:t Information on the Construction Supervisor License can be found at www.mass.gov/dp 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" Permit Authorization mass save Form Site ID: 4198797 Customer: ADRIAN B DION Adrian Dion , owner of the property located at: (Owner's Name,printed) 1114 Florence 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: Adriaa Dion Date: 10 / 26 / ... ••••••••••••••••*w+ •••••••••••••••••••••••••••••••••••••••••••••••••• FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: c /C r e�'�c�fK!H !/ o-,2- Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Only Document Ref:FPPH2-ETGUA-TOMIR-PZ4VT Page 5 of 5 City of Northampton r 1 Massachusetts 4�SNs Y s;Qrc i w * IJ C3 :� DEPARTMENT OF BUILDING INSPECTIONS y I ►r• 4 212 Main Street • Municipal Building Q a Northampton, MA 01060 P" '%, 3+'J'' 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: DA ,s4.e2 e /gc P/eAs4<,r sT , Ecs lfn- M' c-/c.27 The debris will be transported by: Name of Hauler: (02i /�ame 4-62- kKec_ Signature of Applicant: ..: ji,_/__ Date: ri/•) /� The Commonwealth of Massachusetts —o Department of Industrial Accidents 14 IP '_._ ►1@( . Office of Investigations i Lafayette City Center 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): C., 2 I kkbrne. Per kc(`mCi.vtC'.e _ Address: 1$0 P 1po.sc- - $Y u-1e. Zoo City/State/Zip: s#Lc Y- m - C' (e a.7 Phone#: \3 - 5 2 l -0 2-o U Are you an employer?Check the appropriate box: Type of project(required): 1.© I am a employer with 7 4. 0 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. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 10.❑ 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.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.1=I Other employees. [No workers' comp. insurance required.] *Any 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: COn4AV -(\i tvlcernnii-Y CO Policy#or Self-ins. Lic.#: L to - ' 45?,1,3 •-01 -07 Expiration Date: i i 102/ 2'2.Z Job Site Address: /i/y F/creme-e PA City/State/Zip: der-i-Ltbp-tan /tiA- 0/06Z- 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 certi under the pains an penalties of perjury that the information provided above is true and correct. Signature: L Date: V22/2( Phone#: 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 3.DCity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: A 1) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 11/11/2021 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 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 NAME: Berkshire Insurance Group Inc PHONE 877)234-4420 FAX 877)234-4421 43 East St (A/C,No,Ext): (AIC,No): Pittsfield, MA 01201 EMAIL ADDRESS: PRODUCER (413)447-7376 CUSTOMER ID INSURER(S)AFFORDING COVERAGE NAIC I INSURED INSURERA Continental Indemnity Co. 28258 INSURER B: Cozy Home Performance, LLC - 180 Pleasant St INSURER C: Easthampton, MA 01027-1287 INSURERD: CTL 1273 1679258 INSURER ET 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Fa occurrence) $ CLAIMS MADE L OCCUR MED EXP(ern/one Denton) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 7 POLICY JECT LOC $ AUTOMOBILE LIABILITI' ANY AUTO (Sc aBccidentINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS PROPERTY DAMAGE (Per accident) S NON-OWNED AUTOS : $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE t DEDUCTIBLE S RETENTION $ $ WORKERS COMPENSATION X WC I IMRS W- AN D EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE❑N/A 4 6—8 4 5 3 7 3—01—17 11/02/2021 11/02/2022 E.L.EACH ACCIDENT S 1,000,000 A OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) E.L.DISEASE-EAEMPLOYEE S 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 1,0 0 0,00 0 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach Atord 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Cozy Herne Performance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Mill 180 180 Pleasant Street BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Easthampton, MA 01027 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNT /-J 1 1783118 ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved 1 ® DATE(MM/DD/YYYY) A o CERTIFICATE OF LIABILITY INSURANCE 4/22/2021 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 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 NAME: Diane LaFleche The Dowd Agencies, LLC PHONE FAX 14 Bobala Road (A/c,No Ed):413 437-1062 I(A/C,No):413-437-1462 E-MAIL Holyoke MA 01040 ADDRESS: d(afIeche@dowd.com PRODUCER _ USTOMERIDs:COZYHOM-01 INSURER(S)AFFORDING COVERAGE L NAIC Y INSURED INSURER A:Selective Insurance of South Carolina ) 19259 Cozy Home Performance LLC 180 Pleasant St. ,INSURER B: Easthampton MA 01027 INSURER C: INSURER O: I INSURER E: _INSURER F: ' COVERAGES CERTIFICATE NUMBER:620509354 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 i TYPE OF INSURANCE ADDLISUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY S 2206979 4/17/2021 4/17/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISESIEa occurrence) $500,000 CLAIMS-MADE ,OCCUR MED EXP(Any one person) $15,000 I PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: • PRODUCTS-COMP/OP AGG $3,000000 POLICY X i 1I9 X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS I BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE • HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ A X UMBRELLA LIAB X OCCUR S 2208979 4/17/2021 4/17/2022 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DEDUCTIBLE __ $ X RETENTION $0 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN __ I TORY LIMIT_ ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � j N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE,$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. To Whom It May Concern AUTHORIZEDORIZED REPRESENTATIVE ` ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC COZY HOME PERFORMANCE, LLC. Registration: 162770 180 PLEASANT STREET Expiration: 04/05/2023 EASTHAMPTON, MA 01027 Update Address and Return Card. 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 162770 04/05/2023 1000 Washington Street -Suite 710 COZY HOME PERFORMANCE,LLC. Boston,MA 02118 MARK LANTZ 180 PLEASANT STREET ifa.404 .. EASTHAMPTON, MA 01027 No Va11CI Without s' lure Undersecret ary carariGnweAtih Pi PAA$Ea tiiSSetts Division ai Ptotasslonat La:ensure Spew„of auilding tuOi$ations aliN Stanaara4 144411$11V CS*...'Y1j-trail • VIM!1211GO:122 MARK M LANTZ 180 P-.EASANT STREET, EASTHAMPTON MA alas y 1. uric Construction supervisor specialty Restriosod to: OSSL-10-htsoloticn cortraatar Failure to possess a current edition of the t'lassachusetts state Building Corte'IS cause for revocation of this license. For information about this license Call(SIT)7 2F- 200 or visit www.rmass.SSovlcipl