32C-070 Federal ID#
Victory Energy Solutions WHPC RI Contactor Registration No
MA Contractor Registration No
Home Performance Contractor CT Contractor Registration No
1 Hartford Square,New Britain,CT 06053 CONTRACT
860-357-5590 FAX 401-123-1234
Page 1
PROGRAM
CMA-HPC
CUSTOMER PHONE DAYE CUEWS WWK ORDER
Mark Sayre (646)465-0400 09/02/2015 416042 00001
28 Maple Avenue 28 Maple Avenue
SERVICE CITY,SYA-115.11P BILUNG UTY,KfAfe.zip
Northampton,MA 01060 Northampton,MA 01060
JOB DESCRIPTION
AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be
performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of
air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary
areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally
addressed.) (8)working hours.A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm
is not guaranteed.
At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality.
$680.00
AIR SEALING:Provide labor and materials to install Q-Ion weatherstripping and a doorsweep to(1)door(s)to restrict air leakage.
$75.00
AIR SEALING:Provide labor and materials to install Q-Ion weatherstripping to(3)door(s)to restrict air leakage.
$174.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass baits to(200)square feet for damming
purposes.
$410.00
ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class I Cellulose added to(1036)square feet of open attic
space.
$1,522.92
VENTILATION:Provide labor and materials to install(4)12"diameter"mushroom"roof vents)to increase ventilation in attic
areas. The vent can be supplied in(circle color)black,brown,gray or mill finish.
$476.40
VENTILATION Provide labor and materials to install(1)insulated exhaust hose with roof mounted flapper vent to exhaust
existing bathroom fan(s).
$118.75
. ~
Federal ID 1$
RI Contractor Registration No
Victory Energy Solutions WHPC MA Contractor Registration No
N611-357-5590 FAX 401-123-1234
Page 2
PHONE DATE WENT 9 WORK OKUER
Niark Sa\re (6,10465-0400 09"02;2015 416042 00001
28 Nhplc A-,enut, 28 N-laple Avenue
Northampton.NIA 01060 Northanipton,MA 01060
JOB DESCRIPTION
Total: $3,457.07
Program Incentive: $2,680.01
Customer Total: $777.06
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF
***Seven Hundred Seventy-Seven &06/100 Dollars $777.06
NOTE tWS CONTRACT MAY BE WTHDRAWN BY LS Ir NOT EXECVTEO VATWN DATE OF ACCEPTANCE 'Z,
DAYS
Federal ID#
Victory Energy Solutions WHPC RI Contractor Registration No
MA Contractor Registration No
Home Performance Contractor CT Contractor Registration No
1 Hartford Square,New Britain,CT 06053 CONTRACT
860-357-5590 FAX 401-123-1234
Page 1
PROGRAM
CMA-HPC
P R
Mark Sayre (646)465-0400 09/02/2015 416042 00001
28 Maple Avenue 28 Maple Avenue
Northampton,MA 01060 Northampton,MA 01060
JOB DESCRIPTION
AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be
performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of
air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary
areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally
addressed.)(8)working hours.A reduction in cubic feet per minute(efm)of air infiltration will occur,but the actual number of cfm
is not guaranteed.
At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure the safety of the indoor air quality.
$680.00
AIR SEALING:Provide labor and materials to instal)Q-lon weatherstripping and a doorsweep to(1)door(s)to restrict air leakage.
$75.00
AIR SEALING:Provide labor and materials to install Q-Ion weatherstripping to(3)door(s)to restrict air leakage.
$174.00
DAMMING:Provide labor and materials to install a 12"layer of R-38 unlaced fiberglass batts to(200)square feet for damming
purposes.
$410.00
ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class I Cellulose added to(1036)square feet of open attic
space.
$1,522.92
VENTILATION:Provide labor and materials to instal)(4)12"diameter"mushroom"roof vents)to increase ventilation in attic
areas. The vent can be supplied in(circle color)black,brown,gray or mill finish.
$476.40
VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roof mounted flapper vent to exhaust
existing bathroom fan(s).
3118.75
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
s www.mass.gov/dia
\'i'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibly
Name (Business/Organization/Individual): mv ,
Address: Har4v-.8 ,
h P N e, Yl ��Phone#: %911- ac)(® - q Y9
Ci /State/Zi
,Are you an employer?Check the appropriate box: Type of project(required)
I.P I am a employer with 30 employees(full and/or part-time).* 7. E]New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp. insurance required.]
❑
3 El I am a homeowner doing all work myself[No workers'comp. insurance required.]' 9. Demolition
10 ❑Building addition
4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
I
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.: p
6❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14 OtherTn SL1 t i
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
y 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: 7-1 wo�f_ . JD A
C q
Policy#or Self-ins. Lic. #: ,?�(p(O 5 Expiration Date: i�
�' i
Job Site Address: 3 Maple AVEhut_ City/State/Zip: Nor }har,ne i'On.Ma
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 0ID1oD
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S 1500(V)
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250 110 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby eerti nder the pains penalties of perjury that the information provided above is true and correct.
Si Date: O v4 f
Phone#: 9
d
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
y
Name of License Holder: M\ch Q e.I G 10 r- r- 1 O1 O 2,12.
License Number
15 1 4mohlg Ave, WA+e-r*0wn , M2 o2y12 (0 ,120 tot$
Address Expiration Date
%-1-1- 3o ca- tiy03
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
►(0-1827
Company Name Registration Number
One. F4-ov-- gore Square \�1511l0
Address I Expiration Date
N e va +a, 1 C T 00 0 5 1 Telephone $11-%Wo- 4483
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....... W di 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.CM 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 C Se e. 0a10r ae h e d Co+n i'r oac'+- I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors (]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks IM Siding[O] Other
Brief Description of Proposed
Work: Se.e o""CkChea COn+mc-�
Alteration of existing bedroom Yes No Adding new bedroom Yes v-"'No
Attached Narrative Renovating unfinished basement Yes V"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, M o.r C e, as Owner of the subject
property
hereby authorize M c In a e t , O n IP r 010\O
to act on my behalf, in all matters relative to work authorized by this building permit application.
Se.e Q Conic c-4-
Signature of Owner Date to
I, Mac h o►e.1 G lO n F r 1, 4016 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.
Mlcinge 1 GlanFr �o�►�O
Print Name
Signature of Owner/Agent
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:
ear
Building Heig
Bldg. Square Fo tage
Open Space Foota e
(Lot area minus bldg& aved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Sp ial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:`
IF YES: Was e permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (i DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, exc ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
--- - t ity f Northampton Status of Permit:
• 2 ,ZQt{� uild g Department Curb Cut/Driveway Permit
NQ� 21 Main Street Sewer/Septic Availability
om 100 WaterNVell Availability
or-BIJILDINGINSPr- ross ton, MA 01060 Two Sets of Structural Plans
Dom' AMPTON,MA o
NoR ' one 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
This section to be completed by office
1.1 Property Address.
2$ M4PIe Ave"-kr- Map Lot Unit
P�or+} -Arn p i-OYl, M3 p 1 c)lv 0 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MgrK SgUr h 28 Male A-/e, 1-(or+kar,.,p'tbh MG
to cob
Name(Print) Current Mailin ddress:
(o�-I(o- q&5- 0 4 0 0
CSee attached Cor,- -ro,c-4�� Telephone
Signature
2.2 Authorized Agent: AP+%
M;c.V%ne.l GsonPrtjJO 15 NkohIS Avc � Wa, r -�pv,►n . ma oz L412-
Name(Print) qL 4k Current Mailing Address:
8-7"7 - 3b lo- Hy83
Sign Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building l ' . 0-7 (a)Building Permit Fee
2. Electrical 'I (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) 3 4 5-1 . D-1 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0616
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q
PROPERTY LOCATION 28 MAPLE AVE
MAP 32C PARCEL 070 001 ZONE URC(98)/WP(77,)/CCB(2)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108212
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,RMATION 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
Demolition Delay
Signature of Buil mg 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.
28 MAPLE AVE BP-2016-0616
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-070 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2016-0616
Project# JS-2016-001033
Est. Cost: $3457.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 108212
Lot Size(sq.ft.): 11020.68 Owner: SAYRB MARK
Zoning. URC(98)/WP 77 /CB(2)/ Applicant: VICTORY ENERGY SOLUTIONS LLC
AT. 28 MAPLE AVE
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 306-4483 () WC
NEW BRITAINCT06052 ISSUED ON.111412015 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 11/4/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner