36-163 (5) BP-2024-0253
1078 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
36-163-001 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-2024-0253 PERMISSION IS HEREBY GRANTED TO:
Project# • INSULATION 2024 Contractor: License:
Est. Cost: 2000 ENERGIA LLC 108421
Const.Class: Exp.Date: 02/19/2025
Use Group: Owner: JR CRUZ COURTNEY S& BILLY CRUZ
Lot Size (sq.ft.)
Zoning: WSP Applicant: ENERGIA LLC
Applicant Address Phone: Insurance:
242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2022A
HOLYOKE, MA 01040
ISSUED ON: 03/07/2024
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:
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
ram _ G �
3/ t Dep
FoR
City of Northarnptort' MAR
tcy..44, ' • Building Department 2024
1NSULA TION
A ,., f 212 Main Street• r
4, Room 100 uiti) ciNsp
�� Northampton. MA 01060
7- phone 413-587-1240 Fax 413-587-1272 QfJL
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address. This section to be completed by office
1078 BURTS PIT RD Map Lot Unit
FLORENCE Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
COURTNEY CRUZ 1078 BURTS PIT RD FLORENCE
Name(Print) Current Mailing Address
SEE PERMIT AUTHO 413-320-3748
Telephone
3ignatui e
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 (a)Building Permit Fee
2,000.00
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ii6e6
5. Fire Protection
6. Total=(1 +2+3+4+5) 2,000.00 Check Number I3o
This Section For Official Use Only
Building Permit Number:6' ` g"4?53 Date
/ Issued:
Signature: I_i�`
Building llnspecto6ligs Date
ivelice @ energiaus.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
The Commonwealth of Massachusetts
Department of Industrial Accidents
9_ (.11 Office of Investigations
I '=1
__?��- Lafayette City Center
"_,,117 / 2 Avenue de Lafayette, Boston, MA 02111-1750
'''4- wwx.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):
l.111 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.❑ 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 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: 1078 BURTS PIT RD
City/State/Zip: FLORENCE MA 01062
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: Date: 3/05/24
Phone#: 413-322-3 11 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):
1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board
5.0 Selectmen's Office 6.❑Other
Contact Person: Phone#:
www.mass.gov/dia
mass save
Savings through energy efficiency
PERMIT AUTHORIZATION FORM
I, Courtney Cruz owner of the property located at:
(Owner's Name)
1078 Burts Pit Road Florence
(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.
Courhrcey Crue
Owner's Signature
02-14-2024
Date
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor
to the above referenced project:
3/0 ti
Participating Contractor Date
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