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24D-088 IM11 HOcNEYWELL CUSTOMER CONTRACT ,Zs 1 �b One Hartford Square Suite 16-206 a PARTICIPATING New Britain, CT 06052 ( "T4 O; Vii' CONTRACTOR 877.306.4483 Office '-~`^"` ' "a.`..rot's: 860.357.5691 Fax HIC # 167827 info @victoryenergysolutions.com Representative: Stan John Frey 60 North St. Northampton,MA 01060 Customer ID:213589 Contract ID:213589_WORK Site ID:213589 inwavisetat Measures Improvement i Drsuiptios d Qeaati i Quantity Cost Foist Insulation Basement Rim Joist 11100 sqft S14430 Sub Total: $144.30 Energy Efficiency Incentive $108.23 Net Sales Tax After Incentive $0.00 Total $36.07 TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the above described work,furnishing the material and labor specified above for the total price listed above. Payment of the full amount of Total is expected by cash or check upon completion of contracted work.If paying by credit card a 3%service charge will be added.Deposit may not exceed one-third of total balance. Deposit Amount 02r Deposit Date ' Final Balance 7 A t,•Gel Balance Due Upon Completion of Work Scope. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the above described work,furnishing the material and labor specified above for the total price listed above Payment of the full amount of Total is d.expected by cash or check upon completion of contracted work.If paying by credit card a 3%service charge will be added. The custo - agr.-s to the ba a of the cost above upon completion of the job. DO • o THIS CON CT IF THERE ARE • k Y BLANK SPACES•Customer Signature: e , Date: 9-3' — / e 3 Contractor Signature: ' . <... _ - ' .,; y _ Date: 7-''7i–I3 LIMITED TIME OFFER:The prices and incentives offered in this Contract are subject to change in accordance with the Mass Save Home Energy Services Program offers. 146tern Massachusetts C:aslzarnhi.a(;as, Electric c u �SS'ists*�,"�f""kl s"L�t„` k N04 r,a..44 I as r,(.sfa,o A Wow* w, Y The Commonwealth of Massachusetts =v._,= Department of Industrial Accidents �' le-= � Office of Investigations _ 5 600 Washington Street i:— Boston,MA 02111 www masxgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 4,c k.tx j f ne 3,1 S o∎‘.16�Cz Address: (� , 4Oc r fr 1 1 City/State/Zip: Phone#: - c: -4`l S�S Are you an employer?Check the appropriate box: Type of project(required): 1.Qri am a employer with aQ 4. ❑ I am a general contractor and I employees(full and/or part-time).** have hired the sub-contractors 6. ❑New construction 2.❑ I 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' 9. ❑ addition [No workers'comp.insurance comp.insurance:: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11. Plumb' mg ❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 rust also fill out the section below showing their wot7c rs'compensation policy information. ' I t Homeowners who submit this affidavit indicating they are doing all wait and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the nano of the sub-oamactors 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. • I n s u r a n c e C o m p a n y Name: [,(.-}-:CO. AIL.1-;ci J t c u cnnne_ t p-v i Policy#or Self-ins.Lic.#: L+5.- ... 1q14/ Expiration Date: 4111 Lol Job Site Address: (F 0 C e \L Gla.a.tre- City/State/Zip: 4(2t"( i 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$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 c- - der the pains and penalties of perjury that the information provided above is true and correct Signature- Oid OZ .P Date: Q I..4d 1 15 Phone#: 111--c:(,- 41d a 3 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#: i..... SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: SA-01)ey IC 0,4 tJELVL.~ ':Lko CV-1y S t 4' 4,i0 ( License Number Address Expiration ate lam' £�> > 0 -� G ..4`S Sr3 Signa�y�r Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ J % cLkoc Cr\oss S 31,,._4 DINS ��� 1±2, Company Ndnfe / Registration Number Cr 010 0S 2 It/I f�'1 Address Expiration Efate Telephone 3))—D0(..4-/4-74D 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 buildi g 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 n Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [D] Other[D] Brief Description of Proposed Work: sr��►r � ... �o'��e1r \�.5...��:- fie∎ \0 S� h l� less� .t Alteration of existing bedroom Yes Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes ✓_No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following:nt a. Use of building : One Family ,/ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms 1. j c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions r,r�•� e. Number of stories? f. Method of heating? Fo dL ,c- Fireplaces or Woodstoves yip's Number of each l g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction \(-15"0.vtri.cc— i. Is construction within 100 ft. of wetlands? Yes ► 4Jo. Is construction within 100 yr. floodplain Yes ✓'No j. Depth of basement or cellar floor below finished grade •rl\'� 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, JtAv. , as Owner of the subject property hereby authorize \I,C_,�tocyy (r��/ S vex\ to act on my behalf, in all mattes relative'lolwork authorized by this building permit application. ci-24-13 Signature of Owner Date I, k \QQ„ Cam . i cO d — V;c*oryy Cr‘iii-c S 011-..4.rr, , as Owner/Authorized Agent hereby declare that the statements and information oraJthe foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. c7):rx1 +cl U C> Print Name Signature of&.'/Ag_..'� Date 555 Department use only _ - City of Northampton Status of Permit: r ��r ( :uilding Department Curb Cut/Driveway Permit � 212 Main Street Sewer/Septic Availability D ;J Room 100 Water/Weli Availability No hampton, MA 01060 Two Sets of Structural Plans 87-1240 Fax 413-587-1272 Plot/Site Plans rnping'&`MA 01060 Electric, �Mp�a Other Specify "PLICATION 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 Go 1J tsc-i'h . Map Lot Unit k)C p-toss, m Pr (..1,)oto rJ Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: dr.r� �rc ecA (p 0 .■ ©c-\\-, Jor' 0,,v.l -c,m A& of oG(� Name(Print) Current Mailing Address: Telephone gnature 2.2 Authorized Agent: Mi 4 G _ft I/o - • a Scv-d-- ALA-)'A3c Name(Print) . Current Mailing Address: 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 g' t a∎k :a0 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection �4 6. Total = (1 +2+3+4+5) SL %-t,'Jc Check Number oa73 1LYS5 This Section For Official Use Only ate Building Permit Number: D Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0407 APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN (877)206-4483 PROPERTY LOCATION 60 NORTH ST MAP 24D PARCEL 088 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out dal�� r Fee Paid d Typeof Construction: INSTALL BASEMENT RIM JOIST INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 93101 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9R14-ATION 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 'tion ela / 3—/S Signa e of Building 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. 60 NORTH ST BP-2014-0407 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D-088 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-2014-0407 Project# JS-2014-000697 Est.Cost: $145.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VICTORY ENERGY SOLUTIONS LLC 93101 Lot Size(sq.ft.): 8886.24 Owner: FREY JOHN D&JENNIFER K DIERINGER Zoning:URC(100)/ Applicant: VICTORY ENERGY SOLUTIONS LLC AT: 60 NORTH ST Applicant Address: Phone: Insurance: 1 HARTFORD SO SUITE 206 (877) 206-4483 WC NEW BRITAINCT06052 ISSUED ON:10/4/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL BASEMENT RIM JOIST 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 10/4/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner