30C-018 The Commonwealth of Massachusetts
Department of Industrial Accidents
t. ,_..
Office of Investigations
600 Washington Street
' Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Energia, LLC.
Address: 242 Suffolk Street
City /State /Zip: Holyoke, MA 01040 Phone #: 413- 322 -3111
Are you an employer? Check the appropriate box: Type of project (required):
1.21 I am a employer with 10 4. ❑ 1 am a general contractor and I
employees (full and/or part- time).* have hired the sub- contractors ❑New construction
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub- contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9, ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3 . ❑ I am a homeowner doing all work officers have exercised their 1 1 . 0 Plumbing repairs or additions
myself, [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13.1K Other Insulation
comp. insurance required.]
Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information.
I 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 has e
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: Guard Insurance Group
Policy # or Self -ins. Lie, #: ENWC319433 Expiration Date: 2/16/13
Job Site Address: 7, 5
.BWr/S � City/State /7_ip: 0/4'2_
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 S1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5250.00 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 u d t e pains and penalties of perjury Mat the information provided above is tr e and correct.
Signature: /" _. - Date: /. __
Phone #: 413- 322 -3111
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 Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
o 4wOr l
440
PARTICIPATING
mass save. CONTRACT P
PERMIT AUTHORIZATION FORM
I, C r ' ' (7 u t /i , owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and /or weatherization work on my property.
Owner's ignature
Se ar 7 .2614
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
&k_PA),c_i(?•—
Participating C tractor Date
Rev. 12132011
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder : j j s To 55 ntas s/ e r 2 54 0
License Nu ber
2 SAI 1. s. \ 1 G K e, MA10 v o q 2
p Addres Ex iration ate 113
/ _ �!/3 - 322 -3(1 1
Sign.t i Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
E��/w /l9 57109
Com Ndme , A /� Registration Number
242 S.A. ' 1 a- J4 ( j r /4 A 0 '0 lilt y
Address Expir ion ate
,>" Telephone ad3 - 322 ^3l (�
—
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 No ❑
11. Home Owner Exemption
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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D O her
Brief Des ri•tion of Pro•osed
Work: d . / L — i ,,i t • ' z : i GEL1.tl .5e_ TD Rze
Alteration of existing bedroom Yes / No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes c No
Plans Attached Roll - Sheet
6a. if New house and or addition to existing housing, complete the following:
a. Use of building : One Family 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, T .3 e,( - C-14 exit yv , as Owner of the subject
property
hereby authorize e ill
to act on my behalf, in all matte rel ive to work authorized b this building permit application.
See, Tee' c+ AL( r,M d. // 24' / 2
Signature of Owner Date
I, /� S ki055rx. 55 ler , 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.
a am S "R65S1'k a SS 1 -e_e`
Print Name
1 / 2S 1
Signature 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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Y - Department use only
City of Northampton Status of Permit:
2012 Building Department Curb Cut/Driveway Permit
3 212 Main Street Sewer /Septic Availability
pr�sioNS Room 100 Water/Well Availability
p� NURtHAMFTON'A "'Q6 Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
IS ur+ � _ _t Map Lot Unit
if6
� -- T � l /�
� '1 Zone Overlay District
/�l
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
R o 4 n
e.r (u e 4i ? CA/C6
Nam Pint) Current Mailing Addr ss
l se z, -e ALCA \ v Jed., V Telephone J g - 0tA
Signature
2.2 Authorized Agent: ��)) 4.6.ie7/5 hOntas .d Snfassler y2 3k- o 1 k S-t•
Name (Print) Current Mailing Address:
Signature Telepf /.3223,JI
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building '/.2000 . 6 6 (a) Building Permit Fee
2. Electrical L (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �! -ow"' 6. Total = (1 + 2 + 3 + 4 + 5) 2 2 00, O 0 Check Number /J�Q D j
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0619
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 495 BURTS PIT RD
MAP 30C PARCEL 018 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / r i 6 /
Fee Paid JJ� c
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 92540
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOZMATION PRESENTED:
✓✓ 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
De solition Delay
, ,/ 7 ';>- '
Sig : 4000
g e of uilding 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.
495 BURTS PIT RD BP- 2013 -0619
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C - 018 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0619
Project # JS- 2013 - 001000
Est. Cost: $2200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 40118.76 Owner: GUERTIN SHIRLEY & ROGER
Zoning: SR(100)/ Applicant: ENERGIA LLC
AT: 495 BURTS PIT RD
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:12/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner