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29-563 BP-2021-2318 70 BIRCH HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-563-001 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-2021-2318 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 4000 ENERGY PROTECTORS INC 101143 Const.Class: Exp.Date:06/16/2022 KEVIN EMILE BOUCHER & MARY YE-YU WANG Use Group: Owner: BOUCHER Lot Size (sq.ft.) Zoning: WSP Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6562UB0G29826021 Spencer, MA 01562 ISSUED ON:12/17/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON 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: • if y9 - Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner TAiiiE[VEi1J DEC 1 6 2021 Co onwealth of Massachusetts ►EPT.OF BUILDING INSPECT' FOR 1, ; rIOrkTHAMPToN rnAd d�fl3uilding Regulations and Standards MUNICIPALITY tti — Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: f 0-d 1'a7 3 I Date Applied: IEun-)<s� / 1Z-n.20z1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Je clri ecs.s:Ctel l+: \, Eic 1.2 Asse 4Map& Parcel Numbers/ 3 1.1a 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 Check ifyes❑'Lone? Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: KCvin BOv C-her 1C-vti C-C t in,Pi- 0 i oC a- Name(Print) City, State,ZIP 70 (3 a r c(� H.-• 1 l exk' e.., 6 C. c,,Z r- 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 I*YSpecity: �-�j 1,4.11,0 . Brief Description�V(`� -s sc cription of Proposed Work': Pi.-\sr"" S t✓C cin 4 i VL S u 1 C. k"C r1 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ L i i p CYO 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: S Suppression) _ A_11 Check No. Check Amount: Cash Amount: 6.Total Project Cost: SA--I) (�U 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-101143 6/16/22 Joshua Dada License Number Expiration Date Name of CSL Holder -- jJ 64 Paxton Rd List CSL Type(see below) No.and Street Type Description Spencer,MA 01562 U Unrestricted(Buildings up to 35,000 cu.ft.) Restricted l&2 Family Dwelling City Town.State,ZIP M Masonry RC Roofing Covering -- --- WS Window and Siding 7 SF Solid Fuel Burning Appliances 74-253-0277 jdada79@hotmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 172960 8/19/22 Energy Protectors Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 64 Paxton Rd — _ jdada79@hotmail.com No.and Street 774-253-0277 Entail address Spencer,MA 01562 City-frown,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 Issuanc 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 to act on my behalf,in all matters relative to work authorized by this building 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. ` Zl Print O\u ner'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 ala 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.uoyroca Information on the Construction Supervisor License can be found at www.mass.gov/cap; 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 � "' Massachusetts �„. • "'; l A y S DEPARTMENT OF BUILDING INSPECTIONS r \ t :,1014/ 212 Main street • Municipal Building %r `D�; �.� Northampton, MA 01060 Slay .;,,10 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: S P�'n c cn e 'M' °t4 6 a.— The debris will be transported by: Name of Hauler: it 0� +-e_ c- f` S ti c___ Signature of Applicant: Date: ti Z ( I �1 ^2-1 The Commonwealth of Massachusetts l —yam gl. Department of Industrial Accidents _;M�__ 0 1 Congress Street,Suite 100 =lit{_ Boston,MA 02114-2017 ,41 wrv►tt mass.gov/dia 11-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization'Individual):Energy Protectors Inc Address:64 Paxton Rd City/State/Zip:Spencer,MA 01562 Phone#:774-253-0277 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 11 __employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.1:3 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 0 Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 51:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t ©OterInsulation 6.0 We are a corporation and its officers have exercised their right of exemption per NIGL c. 14 152,§1(4),and we have no 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. 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:Ace American Insurance Co Policy#or Self-ins.Lic.#:6S62UB0G29826021 Expiration Date:9/01/22 Job Site Address: O (3i 'r`C i'� 4 L rc-k,'t' City/State/Zip: \°'f 4''1'Le't Y A- C I'ti6 2- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 pains and penalties of perjury that the information provided above is true and correct Signature: ')C_01Date: 11-11 ( A—1, 2( Phone#: b.)0a4-1,'1 y~a- —U a-- ?) Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City'/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACOR1J CERTIFICATE OF LIABILITY INSURANCE DATE(NMUDD/YYYY) ili....----- 08/30/21 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 pollcy(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 AcT HAIM: Nina Arroyo ���7t Coonan Insurance Agency,Inc. PHONE Exu: 508.987-7122 L�A(G.Not; 508-987-7152 267 Main Street AppD' `Ess; Nina©coonaninsurancs.com Oxford,MA 01540 INSURERMAFFOROING COVERAGE NAIL a INSURER A: AIX Specialty INSURED INSURER B; Safety , Energy Protectors,Inc. INSURER C: Century Surety Insurance , 64 Paxton Road INSURER 0: Spencer,MA 01562 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. ��R OWCILWlaR -LTR TYPE OF INSURANCE BAD WVD POLICY NUMBER zamm LASTS COMMERCIAL GENERAL UA ILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RbN r tO CLAIMS•MADE El OCCUR PREMISES(Er ocomencol ,$ 100,000 MED EXP(Any one person) $ 5,000 a ^ y L1 N-H714840-00 08/31/21 08/31122 PERSONAL S ADV INJURY $ 1,000,000 — _AFL GENERAL AGGREGATE f 2,000,000 L AGGREGATE LIMIT APPLIES PER. 2r p00,000 LOC PRODUCTS•COMP/OP AGO S X POLICY❑Ter OTHER S AUTOMOBILE LIABILITY /EA accidennt31NOLE LIMIT • $ 1,000,000 ^'ANY AUTO BODILY INJURY(Per person) S a AUTOB ONLY X SCHEDULED y 6236519 12/23/20 12/23/21 BODILY INJURY(Per ecddent) $ ' HIRED X NONE QED PROPERTY DAMAGE $ AUTOS ONLY L er sodden!) S X UMIIMILLALIAs X OCCUR EACH OCCURRENCE $ 3,000,000 c EXCEU$LLAB CLAIMS-MADE y CCP1005749 08/31/21 08/31/22 AGGREGATE $ 3,000,000 DED RETENTION I i�pp pT ' $ IO pp WORKERS COMPENSATIO N I STATUTE 1 I ERR- AND EMPLOYERS'UABa.ITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ N 1 A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED?(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE,S N yes IFTIO OF E.L.DISEASE•POLICY LIMIT $ — DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space I.moulted) Workers Compensation Insurance certificate to follow under separate cover. Action Inc.and National Grid USA Its direct and indirect parents subsidiaries and affiliates shall be named as additional insured on Commercial General Liability and Automobile Liability policies CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. Worcester Community Action Council 484 Main St.ste.200 AUTHORIZED REPRESENTATIVE Worcester,MA 01608 I Litie414#144ft° 1988.2015 ACORD CORPORATION. All rights(2C44143 ed. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MINDO/YYYY) kel.....-' 08/31/2021 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: Nina Arroyo _ COONAN INSURANCE AGENCY `N"E°E"`)` (508)987-7122 I two.Not; ADQRtEsB: Ninae000naninsurance.com 267 MAIN ST _._ _.._INSUR_ER(S)AfFORDIN000VERAGE NAIC Y OXFORD MA 01540 musts A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: ENERGY PROTECTOR INC INSURER C: 84 PAXTON RD 1NSRER C: SPENCER MA 01562 INSURER P: COVERAGES CERTIFICATE NUMBER: 690758 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 ,ADDL,SUER POLICY EFP POLICY EXP LTR TYPE OF INSURANCE 'wsD;INVIS POLICY NUMBER mwooY rin fMM/ N YY) LMIAS • COMMERCIAL GENERAL LIABILITY 1 j EACH OCCURRENCE $ 1 . DAMAGE TO RENTED •CLAI1+S•'1A0E -._ - OCCUR M 9ES(Ee oc vrrMa) $ MED EXP(Any one Ir1on) S I N/A i PERSONAL 6 ADV INJURY S GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE I 1 POLICY Li J jE-- f_]LOC . PRODUCTS_COMP/OP AGO I . __� OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 1 ANY AUTO [BODILY INJURY(Per person) $ flALL OWNED "SCHEDULED AUTOS AUTOS I N/A 1 BODILY INJURY(Par accident) S HIRED AU'OS �...I N P PROP—MY ON•OWNED , j ROP Y DAMAGE $ ^AUTOS i (Per acctdenl) J S ULL/1 LIAR __• OCCUR EACH OCCURRENCE $ UXCU$LIAR 1 CLAIMS•MADE N/A H AGGREGATE S DED I RETENTIONS S WORKERS COMPENSATION X p AND EMPLOYERS'LIABILITY Y/N . $A I ER A 0 CER/ /40EREXCLUDED,ECUTIVE NIA N/A N/A 6S62UB0G29826021 09/0'/2021 09/01/2022 E.L.FACHACCIOENT $ 500,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE 8 500,000 'If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMB $ 500,000 NA l DESCRIPTION Of OPERATIONS/LOCATIONS/VEHICLES(ACM lei,Additional Remarks Schedule,may be attached If more space I.required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 8,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the Insured hires.or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigationsi, Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Eversource National Grid ClearResult ACCORDANCE WITH THE POLICY PROVISIONS. 120 Turnpike Rd Suite 200 AUTHORIZED REPRESENTATIVE Southborough MA 01772 Daniel M.Crowley,CPCU.Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD fit} to I ;. A . ,... .... t 1 It.; --: • te 1r -a is ,,,- „iti. it' C - V. a a i tk•-1 • Office of Consumer Air and Business Regulation 1000 Washington Swat M eulte 710 Boston, Maseadmits 02118 Homo Improvement Contractor Reglsb&1on M caligron INC. M PAXTON N D. MA 01e.a ,.,. ...__ • Updide Adam tad Moho Oat I. Who dOoNsamagaltrinisamMINI 12=1:1611114f012MatiMbi • Irate 0111seelasiesswPassatillisliess IMO �• 11 i1 PAXT�ONMD. o'il,� �M MA O valid withatiOingium DocuSgn Envelope ID:566BE460.5C49-47E5-AB6D-E3B011E64F 14 RISE ENGINEERING OWNER AUTHORIZATION FORM -_ . -- Kevin Boucher (Owner's Name) owner of the property located at: 70 Birch Hill Ext , (Property Address) Florence, MA 01062 , (Property Address) hereby authorize iii/rti c Aki!.71) Subcontradtor(to be filled in by office) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. --Uoco5 g,cd by. Ow'`3i e''°'gitthattre 4/25/2021 15:57 AM PDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com