24B-022 4 w e Zr/n8 "t!"0 Of ,
m.:.,
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 153287
Expiration: 11/14/2010 Tr# 290494
.._
Type: Individual
THE ENERGY SPECIALISTS
MIKE GRENWOOD
55 CIRCLE VIEW DRIVE
HAMPDEN, MA 01036 Undersecretary
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"---- Construc Suz,er. Specialty Lcers .:
Llcense: CS SL 99381
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_THAE_ CREENWOOD
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7- 99381
PATRONS MUTUAL INSURANCE COlvIPANY OF CONNECTICUT
GLASTONBURY, CONNECTICUT
ARTISAN CONTRACTORS POLICY DECLARATIONS
Policy Number: CTR0011514 NEW Effective date: 10/14/09
NAMED INSURED AGENT 7680
MICHAEL GREENWOOD RICHARD R GREEN INSURANC AGENCY INC
DBA THE ENERGY SPECIALISTS 11 ALLEN ST
55 CIRCLE VIEW DRIVE HAMPDEN, MA 01036
HAMPDEN, MA 01036 (413)566-0028
Policy Period: from 10/14/09 to 10/14/10 12:01 a m. Standard Time at your mailing address shown above.
Insured is: INDIVIDUAL
Business Classification: CARPENTRY - RESIDENTIAL Code: 10030
LIABILITY COVERAGE
COVERAGES LIMITS OF INSURANCE
L. Bodily Injury and Property Damage Liability $1,000,000 Per Occurrence $2,000,000 Aggregate
M. Medical Payments $5,000 Per Person
N. Products /Completed Work $1,000,000 Per Occurrence $2,000.000 Aggregate
0. Fire Legal Liability $50,000 Per Occurrence
P. Personal and Advertising Injury Liability $1,000,000 Per Occurrence
• PROPERTY COVERAGE
DESCRIPTION AND LOCATION OF PROPERTY
Loc. 1: 55 CIRCLE VIEW DRIVE HAMPDEN, MA 01036
COVERAGES LIMITS OF INSURANCE
Loc. # Building 4 Limit ACV _
A. Building
B. Business Personal Property 1 1 $2,500
C. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS
Increased Property Off Premises: Automatic Increase — Coverages A & B: 0% ANNUALLY
Property Deductible: $500
SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS -
AP -100 Ed. 2.0 AP 0611 01 99 AP 0643 12 99 AP 0432 12 03 AP -222 Ed. 2.0 GL -895 Ed. 2.0
PG 5521 06 05 AP 0700 01 08 AP 0688 06 02 AP 0690 06 02 AP 0692 06 02 AP 0365 10 06
AP 0233 01 08
PREMIUM AND BILLING INFORMATIOIN'
ANNUAL POLICY PREMIUM: $917 5650 Minimum Earned Premium Regardless of Term
ENDORSEMENT PREMIUM: BILL TO: Direct Bill To The Insured
TERRORISM PREMIUM: $20
MORTGAGEES
7i,./
PRINTED: 10/20/09
INSURED COPY THIS IS NOT A BILL
V Lai' A V
i
„TEE WORKERS RS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S6OUB- 9955L97 -A -09 )
NEW -09
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1.
NCCI CO CODE: 80411
INSURED: PRODUCER:
GREENWOOD. MICHAEL DBA RICHARD R GREEN INS AGCY
THE ENERGY SPECIALISTS 11 ALLEN ST
55 CIRCLE VIEW DRIVE HAMPDEN MA 01036
HAMPDEN MA 01036
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 10 -1 6 -09 to i 0 -1 6 -10 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 1 0 -27 -09 CL ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: RICHARD R GREEN INS AGCY ^ //' 76YMT
152 { _f
,Y; n The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 ti 'ashinaton Street
..r %' Boston. CIA 02111
www.mass.goi' dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization /Individual): J < f .5
Address: - ' • i
City!State /Zip: /yc, 11, ; ic. ; Phone .. G�i 3) S
Are you an employer? Check the appropriate box: j
Type of project (required):
I. I am a employer with 4. ] I am a general contractor and I
have hired the sub-contractors
6. -{ New construction
h
employees (full and/or part- time).' - I Remodeling
2.7 I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These s': :b- contractors have 8. Demolition
working for me in any capacit}. employees and have workers' 9. Building addition
[No workers' comp. insurance comp.:nsurarce_>
required.] 5. ! We are a corporation and its 10_i Electrical repairs or additions
3.1 1 I am a homeowner doing all work officers have exercised their ; l .I V Plumbing repairs or additions
myself. [No workers' comp. _ right of exemption per . fGL
insurance required.] - c. 152, § 1(4). and we have no 12. Roof repairs
employees. [No workers' 1 3 -1 !Other
comp. insurance required.]
'.Any applicant that checks box T1 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 and job site
information.
Insurance Company Name: !�? r' , r cf. ; i -fir , G c ��
- i
Policy = o r Self - ins. Lic Z. 5� 7 ` - -
. ! r; L F i " s�- _ Expiration Date: /=`' - - iL
Job Site Address: 02 4rn. r 3. (/'. _ _ City /State /Zip:A ,,,,94,..,. k C,�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 81,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 8250.00 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 pg s and pet !ties of perjury that the information provided above is true and correct.
Signature: Date:
/ L '
Phone 4: t e ii. ) 5 - 4 7 .=' s
•
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 CIerk t. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: ��
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i `ie .4 4 , / ( /,i'i „.. ,e3 e.4 , 5 93 4- / j
License Number
Address Expiration Date
Signature Telephone
9 ltet is ,atilt I .'' '','' ti , Chit .cfti t ,_ M a ,`' 2, 4 ` 3 Not Applicable ❑
Co f n panv Name // Registration Number
C r c / c/, - . - € /✓,p. '� e , ,•ral. // ,' Lo
Address Expiration Date
Telephone , . - 7 ' /
SECTION 10- 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 17 )72 / No ❑
S
The current exemption for "homeowners” was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
-
New House D Addition 0 Replacement Windows Alterations) ❑ Roofing n
Or Doors 0
Accessory Bldg. El Demolition El New Signs [O] Decks ED Siding [0] Other[j "
Work: Descrigtio f Propy�ed f ? 4/ /I j
Work: ��� /t -3 o <'�/ . �, .cam � � � / �
Alteration of existing bedroom Yes X No Adding new bedroom _ Yes X' No
Attached Narrative Renovating unfinished basement Yes Jr No
Plans Attached Roll - Sheet
saw I91ew a is 'ii l 4 d of tir & t 'r dili t &A+ i ifcvr`I ISC
a. Use of building : One Family x Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
............. ............................... .
SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Al/ 1 /I 4 , as Owner of the subject
property
hereby authorize / 74.. r•, ., u r4- 9/%.1/
to act on beh If, in all Matters lative to wwfkA uthorizdd by this building permit application.
' lL air, - t'"
9
S i nature f O wner Date
I 7i/ — ...,, yam„ s/5-,e- , 4 /.-.5,€' r , as Owner /Authorized
Agent hereby declare that't estatemerlts 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.
eel
" 4,-/ 6:1.-,-..,,,e...) O.-%
Print Name ,
6 ^/C
Signature of Owner • : -nt Date
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
si
` Lot Size i ! i _. _
Frontage ---- -
Setbacks Front
Side L:t ! R:. L: R:' '' 1 `.,_,..
Rear = # I
'
Building Height } i
i ,
Bldg. Square Footage f—I I % I L i i
Open Space Footage
(Lot area minus bldg & paved I i
parking)
I I # of Parking Spaces ._...._...
Fill: , , N _w
(volume & Location) i ;
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW P YES 0
IF YES, date issued:; 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book , Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO Z
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO J"''
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ° � - 7
Building Department e
212 Main Street s d ., $ 1,,
V
Room 100 � ������
Northampton, MA 01060 ` i . g ,,L t . tt ,.
Fax 413 587 27 ;4
phone 413-587-1240 Fa K
APPLICATION TO CONSTRUCT, ALTER, REPAIR; RENC OR pEMOLISH A ONE OR TWO FAMILY DWELLING
/ CTION 1 -SITE INFORMATION
��� r rO
tJ This section to be completed by office
I Property A��j dress:
c •r....,; ..fie. C T Map = Lot Unit
ti c, i t ` / ,4 , "'IT "} Zone Overlay District
Elm St District C13 District
iECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
t.1 Owner of Record: /
/yam •;3 /,� - QZ. r ��... : J e %
N ) J Current Mailing Address:
''3 s f - 7 S ' >- i
Telephone
Signature
2.2 Authorized � utt �r ' Agent: �J /- / �"
✓ /;i ? / � nr e` ti Cs) C") e . 5 i 6,,:,..,,..-/- e:/ : `e° h, . 06/ �- r4./.4 -+ h A
Name (Print) / ,+ A J i Current Mailing Address:
SigrnaTOfe 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
- /�
s
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5) Check Number � j ' �/'•'
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
- 2010 -1214
ANT /CONTACT PERSON THE ENERGY SPECIALISTS
,SS/PHONE 55 CIRCLE VIEW DR HAMPDEN (413) 566 -1058
,RTY LOCATION 25 DENISE CT
4B PARCEL 022 001 ZONE HB(2)/URB(98)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
NO FORM FILLED OUT
'aid
ling Permit Filled out 0 g%i 5
Paid �'�/
eof Construction: ADD R -30 CELLULOSE TO ATTIC FLAT
v Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
gilding Plans Included: F1IJati
Owner/ Statement or License 99381
3 sets of Plans / Plot Plan Must flAV A UC, A GCfS S fog- 1 MS PccT lO ( I
A
CHE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
c-- 'Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
y fir`_ 7716
Signature of Buildin Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
BP -2010 -1214
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
BP -2010 -1214
JS- 2010- 001769
00.00
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
THE ENERGY SPECIALISTS 99381
ft.): 9626.76 Owner: WHEELER HOLLIS C
,(2)/URB(98)/ Applicant: THE ENERGY SPECIALISTS
AT: 25 DENISE CT
it Address: Phone: Insurance:
.LE VIEW DR (413) 566 - 1058 WC
) E N MA01036 ISSUED ON: 7 /7/2010 0:00:00
PERFORM THE FOLLOWING WORK:ADD R -30 CELLULOSE TO ATTIC FLAT - must
ittic access for final inspection
THIS CARD SO IT IS VISIBLE FROM THE STREET
tor of Plumbing Inspector of Wiring D.P.W. Building Inspector
rground: Service: Meter:
Footings:
h: Rough: House # Foundation:
Driveway Final:
Final:
Rough Frame:
Fire Department Fireplace /Chimney:
h: Oil: Insulation:
Smoke: Final:
S PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
' OF ITS RULES AND REGULATIONS.
ificate of Occupancy Signature:
Type: Date Paid: Amount:
ing 7/7/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo