30B-032 (15) BP-2023-1636
12 NORWOOD AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-032-001 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-2023-1636 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
Est. Cost: 3500 ENERGIA LLC 108421
Const.Class: Exp.Date: 02/19/2025
Use Group: Owner: NICHOLS GREGORY D&REBECCA J FLETCHER
Lot Size (sq.ft.)
Zoning: URB Applicant: ENERGIA LLC
Applicant Address Phone: Insurance:
242 SUFFOLK ST (413)322-31 1 1 WMZ-800-8008072-2022A
HOLYOKE, MA 01040
ISSUED ON: 11/20/2023
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:
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:
• 1• y2 1�
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Buildine Commissioner
R_E__________
b -N City of Northa ,pton _7 DeppO
' a Building Departmen NOV
212 Main Street %C^23
y, . - Room 1 opp SULA TION
6 Northampton. .„.... .
, MA-0106Q�H 4�nn;NG,Ns. ^Y I
_ phone 413-587-1240 Fax 413-5874272'2 ONLY
_________ .
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address This section to be completed by office
14 NORWOOD AVE NORTHAMPTON Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
14 NORWOOD AVE NORTHAMPTON SAME
Name(Print) Current Mailing Address: 413-584-6148
ATTACHED FIND PERMIT AUTHO Telephone
Signature
2.2 Authorized Agent:
BENJAMIN BORDEN/ENERGIA LLC 242 SUFFOLK ST HOLYOKE MA 01040
Name(Print) Current Mailing Address:
413-322-3111
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3500.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee Cif 6
4. Mechanical(HVAC)
5. Fire Protection
6. Total= (1 +2+ 3+4+5) 3500.00 Check Number arch
Q /i This Section For Official Use Only
Building Permit Number: �` --3.0 Date
Issued:
Signature: / /� //' 20 - 20Z,
Building Commissioner/Inspector of Buildings Date
ivelice @ energiaus.com (Cep7tii--44 .74:0,0
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: BENJAMIN BORDEN 108421
License Number
242 SUFFOLK ST HOLYOKE MA 01040 2/19/25
Address Expiration Date
II��
�r`Svr — 413-322-3111
Signature Telephone
9.Registered Home improvement Contractor: Not Applicable 0
ENERGIA LLC 165169
Company Name Registration Number
242 SUFFOLK ST HOLYOKE MA 01040 2/16/24
Address Expiration Date
Telephone 413-322-3111
SECTION 5-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 C� No 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
INSULATION TO WALLS SPARY FOAM CLOSED CELL - FG BATT TO CEILING.
l BENJAMIN BORDEN/ENERGIA LLC , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
BENJAMIN BORDEN
Print Name
Sir 11/12/23
Signature of ner/Agent Date
REBECCA FLETCHER as Owner of the subject
property
hereby authorize BENJAMIN BORDEN/ENERGIA LLC
to act on my behalf, in all matters relative to work authorized by this building permit application.
SEE ATTACHED PERMIT AUTHO 11/12/23
Signature of Owner Date
City of Northampton
cT Massachusetts h .L� (5' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building j
.'0 Northampton, MA 01060 4:fr,y. 7t"° A
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
14 NORWOOD AVE NORTHAMPTON
(Please print house number and street name)
Is to be disposed of at:
USA WASTE - WILBRAHAM MA
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
11/12/23
Sig�of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
�t.4ti.mr,4., City of Northampton Sys '.,.`.,
I. F \,* Massachusetts iwf �' %\rc
t c
>r r ;G
DEPARTMENT OF BUILDING INSPECTIONS `l
" elr s 212 Main Street • Municipal Building
Northampton, MA 01060 �^
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 14 NORWOOD AVE NORTHAMPTON
Contractor ENERGIA LLC
Name:
Address: 242 SUFFOLK ST
City, State: HOLYOKE MA 01040
Phone: 413-322-3111
Property Owner
Name: REBECCA FLETCHER
Address: 14 NORWOOD AVE
City, State: NORTHAMPTON MA
1, BENJAMIN BORDEN (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
Date
11/12/23
N., The Commonwealth of Massachusetts
' Department of Industrial Accidents
-' Office of Investigations
Lafayette City Center
�- ," ,t,� 2 Avenue de Lafayette. Boston,MA 02111-1750
"= :s,- 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):
I.0 I am a employer with 16 employees (full and/ 5. 0 Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl. real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 3. 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]**
4.❑ We are a non-profit organization,staffed by volunteers, 1 1.❑Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other INSULATION
*Any applicant that checks box 41 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: /y 4/AeWoo6 A V G
City/State/Zip: 4j/1/L7/f,4Ar '7i'/ ,/L/,/¢
Policy#or Self-ins. Lic.#WMZ-800-8008072-2023A Expiration Date:7/01/2024
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 pains and penalties of perjury that the information provided above is true and correct.
Signature: v j ant a&�2�2 Date: 7/19/2023
Phone#; 413-322-3111 Ext 122
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
t Issuing Authority(check one):
1°Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.OLicensing Board
5.0 Selectmen's Office 6.0Other
____'"1 ENERLLC-01 ALYSSA
A�oRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY)
6/20/2023
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 �AME•Cr Alyssa Perusse
Phillips Insurance Agency,Inc. PHONE 1 FAX
97 Center Street (A/C,No,Eat): (NC,No):
Chicopee,MA 01013 EAlniet OS
-MNL ,alyssal@phiilipsinsurance.com
INSURERS)AFFORDING COVERAGE NAIC#
INSURER A:State Automobile Mutual Ins Co
INSURED INSURER El:A.I.M.Mutual Insurance Company 33758
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 USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE 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 ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMIf3
LTR ,1NSO INVD (MMIDDIYYYYI (MM/DD/YYYY)
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR PBP2870943 7/1/2023 7/1/2024 PREMISESlEaoccccurrrrencel $ 500,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY X SEC X LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILE LIABILITY ( axidenD SINGLE LIMIT $ 1,000,000
X ANY AUTO _ BAP2477206 7/1/2023 7/1/2024 BODILY INJURY LPerperson) $
OWNED SCHEDULED
_ AURTEO�S ONLY _ AUTOS BODILY
BODILY INJURY(Par accident)_$
AUTOS ONLY ,_. AUTOS ONLY (Per acid DAMAGE $
$
A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000
EXCESS UAB CLAIMS-MADE PBP2870943 7/1/2023 7/1/2024 AGGREGATE $ 2,000,000
DED I X RETENTION S 0 $
14wpp "°ggLYRSti�� 18Y X I raTUTE I ER
WMZ-800-8008072-2023A 7/1/2023 7/1/2024 1,000,000
ANY PROPRIIETgORRIPARTNER(EXECUTIVE E.L,EACH ACCIDENT $
OFFIC R/M EH)EXCLUDED? N N/A 1,000,000
EL DISEASE-EA EMPLOYEE $
If yea,describe under 1,000,000
DESCRIPTION OF OPERATIONS below _ - El.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AGGRO 101,Additional Remarks Schedule,may be attached if more apace is requlred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPRATION DATE Energla LLC ACCORDANCE WITH THE POLICYRPROV NOTICE WILL BE DELIVERED IN
PROVISIONS.
242 Suffolk St.
Holyoke,MA 1040
AUTHORIZED REPRESENTATIVE
I
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re{'gguftlations1 and Standards
_ .
Clan_L :�Ir,r 79 5!,
CS-1011421 , t 02l19/2025
REMAIMIN 4
242 SUET OL' t` is
HOLYOKE MfS, 1 :,t
•Ur�ditO�
Cow gage ff. atmi::0-
M ya
Registration# 165169
Registrant ENERGIA LLC
Name Benjamin Borden
Address 242 SUFFOLK STREET
City, State Zip HOLYOKE, MA 01040
Expiration Date 02/16/2024
1 a Id
Your Local Energy Efficiency Experts* EnergiaUS.con,
BUILDING PERMIT AUTHORIZATION FORM
I, R M CA , owner of the property located at:
(Owner's Name, printed)
/V/I/ORWoo.6 A YE . voicrif-AAiP roc/
(Property Street Address) (City/Town)
hereby authorize Energia, LLC. to act on my behalf and obtain a building permit to perform
insulation/weatherization work on the above named property.
Re/eCibGbecca J Lcca etcher(N7 etcG�eT) y r3 5ge/— l�if cS
Owner's Signature Telephone Number