31B-202 (8) The Commonwealth of Massachusetts
Department of Industrial Accidents
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 (BusinesslOrganization/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):
I.® I am a employer with_10 4. ❑ I am a general contractor and 1 6 ❑ Ne�x construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working or me in an capacity. employees and have workers' 9
g y p ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MG1. 12.❑ Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. iNo workers' 13.® Other (f1SUIatlO(1_ _
comp. insurance required.I
*Any applicant that checks box#1 must also till out the section Nokm showing their workers'compensation policy mtorniation
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor.,must submit a ne%k afiidacit 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 hase
employees. Ifthe sub-amtractors have employees.they must pro%ide their workers'comp.pohcy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual Insuranc2 _ _ _ _-
Policy r, or Self=ins. Lic. 4: __ WC5_31 S-389490-013 _ Expiration Date: 2/17/14
Job Site Address:a T ST City�State,Zip/WW(,177/0. 11� �iOLGI)
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 tine
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: /Z 3
Phone 1;: 413-322-3111
Official use only. Do not write in this area,to be completed by city or town ofciaL
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#:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 4 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
lZ ,x//71 G�- as Owner of the subject property
hereby authorize /T to
act on my beha n all matters relative to work authorized by this building permit application.
Signature of er Date
f
I, i�IS -1,7 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.
'�D"{.S IQ05SMAs5-t-E V-
Print Name
Sig natur caner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
d
Name of License Holder:
License Number
ZgZ SgFFot-K T- A61-YOKE , K4 � IOSO _ R1 ZI (5
Address Expirati n Dat
�t3 -,322
Signature Telephone
SECTION 13-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 bui Ang permit.
Signed Affidavit Attached Yes No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
2.`,t2 S u t+0 0 KC—,,,A< tk d t d g d
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be tilled 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 () DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES
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 Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other 'yf/S�G/�Tr�
Brief Description "Enter a brief description here. D&A15C- oQ4CK- CECrll GeS& 7'4 l0(+ is
Of Proposed Work: -Tv i243,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 36 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _ _ Proposed Use Group:
Existing Hazard Index 780 CMR 34):_ Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1 ac
_ _ 15f
2nd
2nd
3rd
3`d _
4cn
4th
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft) _
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone_Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ I Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[-]
Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curti CutfDriveway Permit -
DEC �P013 212 Main Street SewerlSeptic Availability
1 Room 100 Wator/Woll Avaitabilityi
EIe r4 /
- Northampton, MA 01060 Two Sets of Structural Plans
413-587-1240 Fax 413-587-1272 Plot/SitePlans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
/QoS�Ec T ST Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1/7t� TKtll 7�) LTI— f?'Er,
Name(Print) G!<= ra,� It A-%�j f ' 'c-c'`c.'�rv'je-t 1 Current Mailing Address:
Signature Telephone
2.2 Authoorzed Aaent:
T,�viK�s ` � iK f�5sLE2 2L(2-s uPPOi-k, s tf6L4 o
Name(Print) Current Mailing Address:
q (3 -3 22.-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /� �, p0 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) • O Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signatur
Buil Commissioner/Inspector of Buildings Date
10 PROSPECT ST BP-2014-0744
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-202 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-2014-0744
Project# JS-2014-001267
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sa. ft.): 37069.56 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: EU000)[URC(100)/ Applicant: ENERGIA LLC
AT. 10 PROSPECT ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:1212012013 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL 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 12/20/2013 0:00:00 $90.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner