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38B-258 (6) BP-2022-1099 61 OLIVE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38B-258-001 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-2022-1099 PERMISSIONISHEREBYGRANTED TO: Project# insulation Contractor: License: Est. Cost: 8000 ENERGIA LLC CSL92540 Const.Class: Exp.Date:09/02/2023 Use Group: Owner: SLOANE PETERSON KATHERINE Lot Size (sq.ft.) Zoning: URB Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2022A HOLYOKE, MA 01040 ISSUED ON:09/08/2022 TO PERFORM THE FOLLOWING WORK: INSULATI ON/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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: enti*AL. - C417 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner I Ilk",L! I i i cNV �,o),7- )8Z7 ' r The Commonwealth of Massachusetts a' I .-f Board of Building Regulations and Standards FOR MUNICIPALITY wi, (NJMassachusetts State Building Code, 780 CMR USE ca I ...:(BuildingPermit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 M" 'I i'`-`1 One-or Two-Family Dwelling V ryry�� Thiss on For Official Use Only Building Permit Numbe A. OM''Q_i . )ate Applied: p$/24/2.02y Kevh) gsT j/4 9-'7-Zp it.— Building Official(Print Name) Signature Date Th SECTION 1:SITE INFORMATION (7.-- p"""""`" saa.ov a' 1.2 Assessors Map&Parcel Numbers b1 ° C.Q ( 0"'14 21/6- O/S ao Z /i.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zo ing Information: 1.4 Property Dimensions: uRBWr . Zq8 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: KATHERINE PETERSON NORTHAMPTON MA 01060 Name(Print) City,State,ZIP 61 OLIVE ST 734-709-2774 none provided No.and Street Telephone Email Address SECTION 3:DESCRIPTION� / OF PROPOSED WORK2(check all that apply) New Construction CI Existing Building Owner-Occupied 0 Repairs(s) 0 Alteration(s) Cl Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:INSULATION Brief Description of Proposed Work2: INSULATION INSULATION ATTIC SPRAY FOAM CLOSED CELL TO SLOPES AND DORMERS SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $8000.00 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; �] Check No.j! heck Amount: ,u Cash Amount: 6.Total Project Cost: $8000.00 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 92540 9/2/23 THOMAS ROSSMASSLER License Number Expiration Date Name of CSL Holder 242 SUFFOLK ST List CSL Type(see below) U 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 2/16/2024 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 242 SUFFOLK ST HOLYOKE MA 01040 413-322-3111 City/Town,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 Tom Rossmassler& Energia LLC to act on my behalf,in all matters relative to work authorized by this building permit application. See Permit Autho 8/12/22 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' s application is true and accurate to the best of my knowledge and understanding. 8/12/22 Print Owner'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 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 halFbaths 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 M O / �•. r Massachusetts e Of,: ilk DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building `/: Northampton, MA 01060 44., *0 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 dispos•d 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: BOSTON RD WILBRAHAM MA The debris will be transported by: Name of Hauler: USA WASTE Signature of Applicant: Date: 8/12/22 BUILDING PERMIT AUTHORIZATION FORM I, K0,44,e.sit,e. Pe 4:e.vs v►1 ,owner of the property located at. (Owner's Name,printed) (Property Street Address) (City/Town) hereby authorize Thomas Rossmassler of Energia, LLC. to act on my behalf and obtain a b 4lding permit to perform insulation/weatherization work on my property. 34/ - ? off - 2 - er's Signature Telephone Number 8/ z /22 Date T,, City of Northampton Massachusetts ('7àI1 � /1 04,tV/ , DEPARTMENT OF BUILDING INSPECTIONS y spy „ 212 Main Street • Municipal Building 0C` ". Northampton, MA 01060 .1/4 Property Address: 61 OLIVE ST Contractor Tom Rossmassler & Energia LLC Name: Address: 242 SUFFOLK ST City, State: HOLYOKE MA 01040 Phone: 413-322-3111 Property Owner Name: KATHERINE PETERSON Address: 61 OLIVE ST City, State: NORTHAMPTON MA 01060 I, Tom Rossmassler (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature ,4------------ Date 8/12/22 ___......IN ENERLLC-01 JOCELYN A�ORO CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) I 7/5/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAITE 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 INSUREI (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 NAME CT Jocelyn M Douglas - --_ Phillips Insurance Agency,Inc. PHONE -FAX 97 Center Street (A/C,No,Ext): _ (A/C,NM: Chicopee, MA 01013 miss, INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:A.I.M. Mutual Insurance Company Energia LLC INSURER C:Markel Insurance Company _ 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 SUBRI POLICY NUMBER i POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/1/2022 7/1/2023 DAMAGETORENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY , $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 7118,, X LOC PRODUCTS-COMP/OP AGE, $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BAP2477206 7/1/2022 7/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED i AUTOS ONLY _ AUTOS pBOO�DILYINJUDDRY(Peraccidert) $ AURTOSONLY _ NON-OWNED (Pera�ltlent)AMAGE $ $ A X UMBRELLA LIAB l X OCCUR EACH OCCURRENCE _ $ 2,000,000 EXCESS LIAB CLAIMS-MADE PBP2870943 7/1/2022 7/1/2023 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS LIABILITY YIN WMZ-800-8008072-2022A 7/1/2022 7/1/2023 STATUTE ER 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N FFICER/MEMBER EXCLUDED? NIA 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 $ A Equipment Floater PBP2870943 7/1/2022 7/1/2023 ,Leased/Rented 35,000 C Pollution Liability CPLMOL106305 4/19/2021 4/19/2023 Pollution 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE , EPRE,SENTATI VE y ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center -4 a. 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 1 l.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑• 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: A.I.M. Mutual Insurance Insurer's Address: (9( 01.106 ST'. City/State/Zip: 0 9.7 K /4 A Policy#or Self-ins. Lic. #WMZ-800-8008072-2022A Expiration Date:7/01/2023 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 Invlestigations of the DIA for insurance coverage verification. I do hereby certify,and the pains and penalties of perjury that the information provided above is true and coirect. Signature: Date: / 2 Phone#: 413- 22-3111 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.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.1=1Licensing Board 5.1:1 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia t prnmonweatth of Htassac huSetes Of Professional Lrcensure Q Butttting Regulations and Standards Con*h 041104 Sup.rvtsor CS-092540 f apues O9/UZI/023 THOMAS a FOSS t." 100 MAIN STREET # +iAYRELD MA a, 'd SS Ofl0f K. I7mt w._ . THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:LLC Registration valid for individual use only before the expiration date. If round return to: Registration Expiration 165169 02/i612024 Office of Consumer Affairs and Business Regu'ation ENERGIA LLC 1000 Washington Street -Suite 710 Boston,MA 02118 THOMAS ROSSMASSLER �' 242 SUFFOLK STREET i, HOLYOKE,MA 01040 `� Not valid without signature Undersecretary I • I