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17C-175 (11)
BP-2024-0114 26 FAIRFIELD AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-175-001 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-2024-0114 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 3000 ENERGIA LLC 108421 Const.Class: Exp.Date: 02/19/2025 Use Group: Owner: TRUSTEE BARR DOROTHY J 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: 02/05/2024 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: a' Tit 1 II Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner i °` Dep i se / : T 1 a-ri4.'* City of No tham¢tory rx. \_ i' Buildin Dep ment B QINSULA TION ,', Northampton. MA Oi�6Q't,� ..,.. __ , ONLY phone 413-587-1240 Fax 413-587,1 r�,✓ .. ,nb, I APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWILLING ONLY i SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address This section to be completed by office 26 FAIRFIELD AVE. Map Lot Unit FLORENCE MA Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DOROTHY BARR 26 FAIRFIELD AVE. FLORENCE MA Name(Print) Current Mailing Address. 617-651-0559 PLEASE SEE PERMIT AUTH ATTACHED Telephone Signature 2.2 Authorized Agent: ENERGIA LLC- BENJAMIN BORDEN 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 3000.00 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee / 4. Mechanical(HVAC) C11/ U S 5. Fire Protection lll��J"` 6 Total=(1 +2+3+4+5) 3000.00 Check Number Qa1L_ /y,ff / This Section For Official Use Only �� Building Permit Number. 0/"''��!` q I Date / Issued. Signature: / /i�G-- 2- Z- 2DZ`i Budding Commissioner/Inspector of Buildings Date IVELICE @ ENERGIAUS.COM EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ BENJAMIN BORDEN 108421 Name of License Holder License Number 242 SUFFOLK ST HOLYOKE MA 01040 2/19/25 Addres<. Expiration Date 413-322-3111 Signature 1 elephone 9. Registered Home Improvement Contractor: Not Applicable 0 ENERGIA LLC 165169 Company Name Registration Number 242 SUFFOLK ST HOLYOKE MA 01040 2/16/24 Addre2_4„,y Expiration Date Telephone413-322-3111 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 No... .. ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY INSULATION TO ATTIC FLAT CELLULOSE OPEN BLOW- FG DAMMING - HATCH THERMAL BARRIER POLYISO KNEEWALL 2"THERMAL BARRIER POLYISO 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 1/30/24 Signature of Own , nt Date DOROTHY BARR as Owner of the subject property hereby authorize ENERGIA LLC- BENJAMIN BORDEN to act on my behalf, in all matters relative to work authorized by this building permit application. SEE PERMIT AUTHO 1/30/24 Signature of Owner Date City of Northampton ' Massachusetts 3 ' DEPARTMENN thOaF pBtUonIL:MAIN G 0INSPECTION S 212 Main Street •M a Buildang 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: BOSTON RD WILBRAHAM MA (Please print house number and street name) Is to be disposed of at: BOSTON RD WILBRAHAM MA (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USA WASTE (Company Name and Address) —1S,11.-------1-130/24 Signatur 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. City of Northampton ir• h r; Massachusetts � A t DEPARTMENT OF BUILDING INSPECTIONS f ,� • .r"' 212 Main Street • Municipal Building Northampton, MA 010E+0 a MANDATORY FOR HOUSES BUILT BEFORE 1945 26 FAIRFIELD AVE. Property Address FI ORFNCF_MA Contractor ENERGIA LLC Name Address: 242 SUFFOLK ST City. State: HOLYOKE MA 01040 Phone: 413-322-3111 Property Owner DOROTHY BARR Name 26 FAIRFIELD AVE. Address City, State FLORENCE MA 01062 I BENJAMIN BORDEN/ENERGIA LLC (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 c./161.4rt.at____ Date 1/30/24 mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Cheryl Kiras owner of the property located at: (Owner's Name) 209 Mosier Street South Hadley (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization 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. Owner's Signature tit 2 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date IN The Commonwealth of Massachusetts f— Department of Industrial Accidents Office of Investigations r fir►'_ ii'A, Lafayette City Center �' — F�' 2 Avenue de Lafayette, Boston,MA 02III-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): I.it 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. ❑ Office and/or Sales(incl.real estate,auto,etc,) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Nop-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.©Other Insulation Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. '^°if the corporate officers have exempted themselves.but the evrporation has other employees.a%torkers compensation policy is required and such an prganization should check box#I. am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. k" Mnsurance Company Name: A.I.M. Mutual Insurance !� n Insurer's Address: 2 A 1. t� } sG City/State/Zip: 'FM t sJC. A 010CD2 'olicy#or Self-ins. Lic. #WMZ-800-8008072-2023A Expiration Date:7/01/2024 L►ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). toailure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up $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. $ignature: Date: 12/1/23 phone#: 413-322-3111 xt 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.❑Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther_ __ Contact Person: Phone#: www.mass.gov/dia ENERLLC-01 ALYSSA ,d►coRoA CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 CONTACT Alyssa Perusse NAME: Phillips Insurance Agency,Inc. PHONE I FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 nooAkss:ayssa@phlllipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:AIM.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 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP UMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/1/2023 7/1/2024 PAMAGE TO RENTED 500,000 PREMISES(Ee occurrencel $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PEO- X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) X ANY AUTO BAP2477206 7/1/2023 7/1/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRREE�� ONLY AUTOS BODILY p BODILY INJURYD (Per accident) $ AITOS ONLY roam Y (Peer ardent)DAMAGE A X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE PBP2870943 7/1/2023 7/1/2024 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B AND EMPL OYERS LNJABILIITNY Y/N X STATUTE R ERA ANY PROPFRIETOR/PARTNER/EXECUTIVE WM2-800-8008072-2023A 7/1/2023 7/1/2024 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (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 $ DESCRIPTION OF OPERATIONS I LOCATIONS/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 Ener la LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE � T7 ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD V Commonwealth of Massachusetts Division of Occupational Lkansure Board of BuiMing Reculations and Standards Cdnntip ttii 131I v'ser ?+ d cS-108421 .� t-._ !Vim:0211 W2025 B'ENJAIMI N <. 7A2 SUR O S 1E HOLYOKE `*/O/ COmrlSa]Oti£r l d �i}17•�:..'.i, .:. Registration# 165169 Registrant ENERGIA LLC Name Benjamin Borden Address 242 SUFFOLK STREET City, State Zip HOLYOKE,MA 01040 Expiration Date 02/16/2024