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38C-030 (3) BP-2022-0032 322 SOUTH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38C-030-00I 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-2022-0032 PERMISSIONISHEREBYGRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 3000 JOSHUA DADA 101143 Const.Class: Exp. Date:06/16/2022 Use Group: Owner: SCHULMAN, JOSHUA Lot Size (sq.ft.) Zoning: URB Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6S621JB0G29826021 Spencer, MA 01562 • ISSUED ON:01/12/2022 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: Gas: , Final: Final: - Rough Frame: Rough: - Fire Department Driveway Final: Fireplace/Chimney: Final: - Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i s.2 Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner - , -1 ,_!; jq q j.47r LT-If-1, The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR o 'f J `� Massachusetts State Building Code, 780 CMR MUNICIPALITY s . USE s ,' Butl ing Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 J 0 � J One-or Two-Family Dwelling — 1''1 This Section For Official Use'Only i'. " ' Buis mitC er �uinber:�P .a �.Z'`� — Date Ap lied: f • .. /.: -12= 2z Building Official(Print Name) ' Signature I Date" SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Ass sso Map&Parcel Numbers_ 4-4-A, ssuiA C4' ; sc, U D 1.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 Onl site disposal system CICheck if yes❑ ' • ,'SECTION;2 PROPERTY OWNERSHIP' ' 2.1 Ow er'of Rec d: Sb5truck VtAAr&ctr kvf tW OM 1 J/1.ft' 0 i 66 Name(Print) City,State.ZIP 1 -' . SoLA- ��C S+ cokt6-- -7"34- 6 No.and Street Telephone Email Address SECTION'3:DESCRIPTION OF CVO (check, .• 1P,ROPOSED RfC2,. 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 'tC' pecify: Brief Description of Proposed Work2: inc U C 'e_... i- C ‘, CAX\ G eic-\-e( tOf' c,,ki45 1 I SECTION 4 ESTIMATEDVCONSTRUCTION;C,OSTS Estimated Costs: ` Item ' Official Use.Only ' (Labor and Materials) 1.Building $ 13 p c J 1 Building Permit Fee $, Indicate how fee is determined:` I El Standard,City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x:multiplier. - x 3.Plumbing $ 2: Other Fees: $ 1 , ' 4. Mechanical (HVAC) $ List a , 5.Mechanical (Fire Suppression) $ Total All Fees:$ 4 , Check No3J3/Theck Amount: U5 Cash Amount:. 6.Total Project Cost: $ —1 O 0 ❑Paid in Full 'Cl Outstanding Balance Due 1 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 List CSL Type(see below)_ 64 Paxton Rd No.and Street Type , Description Spencer,MA 01562 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted I&'2 Family Dwelling City Town.State,ZIP M Masonry RC Roofing Covering WS Window and Siding 774-253-0277 SF Solid Fuel Burning Appliances j dada79@h otma il.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 hotmail.com No.and Street 774-253-0277 Email address Spencer,MA 01562 Cityfrown,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 ❑ 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 ap lication is true and accurate to the best of my knowledge and understanding. Print Owner's or uthorized 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.cov/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 • Massachusetts y t!'!:10' "' DEPARTMENT OF BUILDING INSPECTIONS isI5 ++� 'r 212 Main Street • Municipal Buildings b� It • Northampton, MA 01060 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 1150A. The debris will be disposed of in: Location of Facility: VIe-er ' 'M& 0 ISM The debris will be transported by: E. 1(\ei-z3y 06.2 c-- s SAC, Name of Hauler: Signature of Applicant: Date: dam' The Commonwealth of Massachusetts v: 1. Department of Industrial Accidents 1 Congress Street,Suite 100 _'��= Boston,MA 02114-2017 solr www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Leiibly 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): I.�✓ I am a employer with 1 1 employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself. No workers'comp.insurance required.] 9. Demolition 10 Building addition 4.❑I 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.[}Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.DRoof repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are a corporation and its officers have exercised their right of exemption per hIGL c. 14. ]other Insulation 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 andjob site information. Insurance Company Name:Ace American insurance Co Policy#or Self-ins.Lic.#:6S62UB0G29826021-L Expiration Date:9/01/22 �,,p Job Site Address: �� 1 City/State/Zip NJ O(% e' t t Ai A- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date) 0�®66 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: Date: = III i' Phone#: ') "I ' -� 1=Y) 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#: RDA CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 08/30121 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(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 ATICT Nina Arroyo Coonan Insurance Agency,Inc, Ph ONE Exit: 608.887.7122 I I .No); 508.987.7152 287 Main Street ADDREDS; Nina@coonanlneurance.com Oxford,MA 01840 INSURERS)AFFORDING COVERAGE NATO I INSURER A; AIX Specialty INSURED INSURER B: Safety Energy Protectors,Inc. INSURER C: Century Surety Insurance 64 Paxton Road INSURER D: I Spencer,MA 01682 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, EXCLUSIONSE AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED D�B�Ypp PAID pCLAIMS. TV TYPE OF INSURANCE BOO µyD POLICY NUMBER (maw Oy[tuDp/y YY� LIMITS COMMERCIAL.GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE El OCCUR DAMAGE TO R ocourD PREMISES(BP oWrlorxol S 100,000 MED EXP(My ono person) S 5,000 — a y L1N•H714840-00 08/31121 08/31/22 PERSONAL a ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPL ES PER: GENERAL AGGREGATE S 2,000,000 �� PRODUCTS-COMP/OP AGO S 2,000,000 �I POLICY JeCT LI LOC 9 �11 OTHER: CLIMITAUTOMOBILE LIABILITY O aBIN0Oeeld oSINGLE LIT S 1,000,000 ANY AUTO ;BODIL),INJURY(Per poraon) S —' OWNED X SCHEDULED 8238519 12/23120 12/23/21 ,BODILY INJURY(Per accident) S B AUTOS ONLY AUTOS y PatOPERtY DAMAGE S X HIRED AUT08 x AUTOS ONELYY t or Rcc)dann ONLY I S X UMBRELLA LIAR X OCCUR 'EACH OCCURRENCE .S 3,000,000 c EXCESS LIAO CLAIMS-MADE y CCP1005749 08131/21 08/31/22 'AGGREGATE , $ 3,000,000 DED 1 RETENTION S MUTE S WORKERS COMPENSATION I 1 8TA7UTE 1 17 AND EMPLOYERS'LIABILITY Y I N ANY PROPCER(M ETORIEXCLUDRIEXECUTIVE❑ N I A E.L.EACH SCEA9EaEA EMPLOYEE,S (Mandatory n EXCLUDED? gESGtRIPTIOnNn NH)OF OPERATIONS below I E.L.DISEASE•POLICY LIMIT 3 DESCRIPTION OP OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remake Schedule,may be attached N more space Is ngtllrod) Workers Compensation Insurance certificate to follow under eeperate cover. Action Inc.and National Grlc USA Its direct and Indirect parents subsidiaries and affiliates shall be named as additional Insured on Commercial General Liability and Automobile Liability policies I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Worcester Community Action ACCORDANCE WITH THE POLICY PROVISIONS, Council 484 Main St.ate,200 AUTHORIZED REPRESENTATIVE Worcester,MA 01808 ' 4, _ , ( ., ktiotsfttitt 988.2015 ACORD CORPORATION. All rights'�ed. ACORD 25(2018/03) - The ACORD name and logo aro registered marks of ACORD ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMILIDA YY) 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(les)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(&), PRODUCER ACT NAME: Nina Arroyo ! COONAN INSURANCE AGENCY �P�HcON Q ), (508)987-7122 I i r`c y,t: _� -MAIL legs; Nina@coonaninsurance.com 267 MAIN ST INSURERISLAFFORDING COVERAGE ! __ NAICII _—_ OXFORD MA 01540 INSURER A: ACE AMERICAN INSURANCE CO r 22687 INSURED INSURER B; ..._ _... 4-- 1 — — — ENERGY PROTECTOR INC INSURERc:---... . .._---__.. —.._.....-__.---__--- .. -----..._....-...-- INSURER D _..__....__ . ._._IL.... — _._....._-T 64 PAXTON RD INSURER E!_—__,-__„—_—_ SPENCER MA 01562 _INSURER F: 1 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 DESCRIBED1 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iLTRR I TYPE OF INSURANCE Imo'L SUER! POLICY NUMBER I IMMIUDUIYYYY)1(MMMILI�DIYYYY)Y EXP ! LIMITS INS() vivo COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S tt i ';6 v77-A1;TORENTED` I f CLAiMS•MADE !!OCCUR I I I : 'ree PREMISES(Ea cc l S MED EXP(Any one person) —.S__-.-_ __ _ , I N/A I PERSONAL S ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: •i j i 'GENERAL AGGREGATE S t ! I POLICYI j JEOT ,LOC i PRODUCTS•COMP/OP AGO $ ,OTHER: I I I f $ ( COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY I ' (ga exaen:y--•----- __.-----------. 1 ANY AUTO j 1 ) BODILY INJURY(Per person) $ —" ALL OWNED 1,SCHEDULED _ AUTOS AUTOS ! I NiA BODILY INJURY(Per Strident) $ NON-OWNED ' ' I PROPERTY DAMAGE $ 1 HIRED AUTOS I `AUTOS (Per accident) illl i I $ 1 UMBRELLALIAB j OCCUR j i, EACH OCCURRENCE $ EXCESS UPS CLAIMS-MADE N/A AGGREGATE S i ! ' $ 1 DED i RETENTIONS WORKERS COMPENSATION i I 1X' STATUTE i 1 EOTTH. AND EMPLOYERS'LIABILITY ANYPROPRIETOR1PARTNER EXECUTIVE Y/N ; E.L.EACH ACCIDENT $ 500,000 A IOFFICEWMEMBEREXCLUOED? NIA NIA N/A 6S62UBOG29826021 09/01/2021 ;09/01/2022 j i I I E,L.DISEASE•EA EMPLOYEE $ 500,000 {Mantlatory In NH) i I I I I-- -- — I It yes,describe under 1 1 EL DISEASE-POLICY LIMIT $ 500,000 'DESCRIPTION OF OPERATIONS beioA 1 ( 1 i i 1 N/A ; j li DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may bo attached If more apace is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,nb 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 o-i 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.govrIvid/workers-cornpensationfinvestigations/, 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.CroVey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • -'wl:a Ws 1 1 tir o int 1 514'If W • ram« • lit �� O • I , J � • • • • 1 , • • Oil of Consumer fairs and u Regulation 1000 Weehingtan Street« Sub 710 Boston, Me 0211$ Homo Impuvament Contactor RegistreNon • Fremei maracas INC. Irfr +u✓/i1 Oalifiloge fNA01 P Oillee,_of r7�diAR1bf�� `�� `�7 t ',I : `S r�Y ' ` + 41_ �. ffaltifirgiventi los • aNait ceigrosesorAffebselsoillosbuisaittescitas IBMIRA• PROISUMR0 III• 7� JOSHUA DADA v 1 fd ) DocuSign Envelope ID:0D4493FA-B729-4F23-9BE6-6C9ADBBB93AE \Wit RISE ENGINEERING' OWNER AUTHORIZATION FORM Joshua Schulman (Owner's Name) owner of the property located at: 322 South Street (Property Address) Northampton, MA 01060 (Property Address) hereby authorize Subcontractor(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. LDocuSigned by: )e0SLAZt, SdUttAtuit, Ownel" niiM ii9re 12/7/2021 1 10:52 AM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com