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17C-117 (3) OWNER AUTHOR17ATION FORM JON (ms's ) 2p�� owner of the prop*fwd at —a 6q.,— (Property Address) (Properly Address) hereby a dwtee {Submd afto an auk subcontractor for RISE Errghmering,to act on my buff lo obtain a bukft paamb and to perform work on my properly. Y/4 �l l C, I.IIMT S Spgn duce A- 1 � DATE -wT11)DNr,-0 a RAM � ~ ~~...^.~`�.°=""="°=°"=,��u� �ru:mvm�oeomcrx�000mp*sn; -S MOLDEP.THIS GEFTIFICA== DOES MOT AFFIRMAIIWEL�!OR '�!EC-A VEI,'kr-AMEMD- Mlt'-ME) 0�ALTER I - COVERAGE AFFORDED IRY—ME POLICIES pormy(ies)must be endorsed. If SUB.R0r=A-nOhT IS IWAIVED,subjec�to he �IIO t9FMB End conditions el-the policy,certain pokies may require ar.Endorsement A sttement an Us certificate does not Iqhts 1"D U I CC com I IMSUFMR Co. [33-38 SUPER B SURER F THIS IS TO CERTIFY THAT THE rOLICIES OF INSUPANCE LISTED RGLOtAt'HAVE GEOj ISSUED TO T ME INSURED MAMED ABOVE POP-ME POLICY PERIOD INDICATED- i"10-11)VI-1 HSTANDING jVWY REQUIREN-5iEN�j.TERM OR CONDITION OF ANY CONIT PACT OR 0 MER DOCMIEM-i jkQTp RESPECT T 0 MICH THIS CEPTIFIGA.TE NIAY Be ISSUED OR NIAY PERTAIN. THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A.LL.T Vj-= EICLUSMS AND CONDIT IONS Or SUCH POLICIES LIMIT,3 SHOMW MAY HAVE Mal REDUCED By pAID CLAIijjS. EACH OCCURRE,ZE 1,000,000) 22-53542 3/2-1/2015 /27/2016 PERSORALZADVINJURY IS 1.,000,0001 Air.o !',533�2 /2V2015 .4127120i 53-9t- 1112712013 3/2712G16 00.GGO Wi= 20is 412, /2D26 22ERTIFICATE HOLDER w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: _ 9 1 Cola 9+ 7 City/State/Zip:&V i CT 0090 t Phone #: V_f 0— (Q t0 W Are Ydu an employer?Check the appropriate box: Type of project(required): i L 1 am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed an the attached sheet. 7. F-1 Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' q ❑ Building addition (No workers' comp. insurance comp. insurance.'. required.] 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions myself. o workers' corn right of exemption per MGL p. 12.❑ oofre a'rs insurance required.] ' c. 152, y 1(4), and we have no employees. [No workers' 13. Other comp, insurance required.] "Any applicant that checks box#1 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 emplovees,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: C✓ +t:. Policy#or Self-ins. Lic.#: N L1\N C,N � 1 3 _ Expiration Date: _ 4 15711 U 7 — Job Site Address: f� ��16 �r,,A/t�L.,, City/State/Zip 6r,6i ; 0(0(02, 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 ine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine �:)r 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 ce fyinder th p ins and pen flies of perjury that the information provided above is true and correct Si nature: Date: Phone# Official use only. Do not write in this area,to be completed by city or town offrciat 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#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, i acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: A /01 d, T--i►rmp' M— 01002- The debris will be transported by: ° 1lP_bri S The debris will be received by: Building permit number: Name of Permit Applicant ri In 11 Date Signature of Permit Applicant �------- ----- �� SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: ar& S 10 License Number Ad[j�� L17757 9-0-4515 Expiration Dateg I Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Com*pany Name Registration Number e ti Address Expiration Date Telephone968 910-1601 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 afficlavit will result in the denial of the issuance of the buileg permit. 11. - Home Owner Exempflon The current exemption for'1wmroxmom~was extended minclude one(1) or w,v(2)famdie, and m allow such homeowner m engage uoindividual for hire who does not possess olicense,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own u parcel of land oo which he/she resides m intends m reside,uo which there is.or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/u,farm structures. Such'Ymmoonncr'shall submit tu the Building Official,oua form acceptable m the Building Official, responsible for all such work performed under the buildinil perntit. As acting Construction Superviso your presence ou the job site will be required from time m time,during and upon completion of the work for which this permit isissued. ,Also hc advised that with,ure, noou`Chaptur |52(YVodum'Componsoioo) and Chapter |53(Liability of Employers tn Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable bopomvn(m) 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 uf 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 ! Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [[] Siding(0] Other[C j Brief Desr�i tips of Prop sed Work: W�UI-ticl.i(` t�_Rtr rj,��; , ri',�!'g�l �SS 6Y1� 11/ o j Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes J No y Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.if New house and or addition to existing housing, complete the following: i 4 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? i d. Proposed Square footage of new construction. Dimensions i e. Number of stories? j 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 as Owner of the subject property hereby authorize 1'`t t�121050S to act on my behalf,in all matters relative tolwork authorized by this building permit application. f [21295" Signature of Owner Date I as Owner/Authorized j Agent hereby declare that the staterTients and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 1 Signed under a pain and penalties perjury. Print Name - qt Signature of Owner/Agent Date Section 4. ZONING At(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 Rcar Building Height Bldg. Square Footage % Open Space Footage % 4 of Parking Spaces A. Has uSpecial ever been issued for/nn the site? NO �� YY�/ DONTKNO ^�� Y[5 \�/�� IF YES, date issued: IF YES: Was the permit recorded at the isLryofDeeds? NO ,~~��/ DON'T KNOW YES \�� IF YES: enter Book Page and/or Document# �� M �� B. Does the site contain a brook, body of water orvvetiands7 NO \_� DON7 KNOW �� YES \^~� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained \^�/-� Obtained /-�_~/� Date' ' C. Do any signs exist un the property? YES �~�� NO �_�� |FYES, 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( hng.gmUing vobnn.urfiU)ng)ovor1 acre oria!tpa�ofo common plan that wiUdisturb over 1 oom? YES < ) NO �� ) �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r Department use only City of Northampton status of Permit: Building Department Curb Cut/Driveway Permit � 212 Main Street Sewer/Septic Availability DEC Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans i h ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans _ P DO T C7, 13 o„rN; 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 pp jai Map Lot Unit s 1 Zone Overlay District Elm St.District CIS District i SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i i j 2.1 Owner of Record: �i i' Name(Print) Current A ailing Address: T elephone (sce 1 q775 20q-q58 Telephone Signature j 2.2 Authorized Agent: Vol 181 4k o Name(Pri Current Mailing Address: - H75 j.-Qq y585' i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS j item Estimated Cost(Dollars)to be Official Use Only —completed by ermit applicant 1. Building (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) , © , p'7 Check Number This Section For Official Use Only__ f Building Permit Number: Date Issued: i Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0841 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804(888)840-6641 PROPERTY LOCATION 27 SHEFFIELD LN MAP 17C PARCEL 117 001 ZONE URB(100)/ 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 KNEE WALL INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106024 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 4_1;�_P_Proved 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 Si of 4ki'l dmg O is al 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. 27 SHEFFIELD LN BP-2016-0841 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 117 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-2016-0841 Project# JS-2016-001426 Est. Cost: $1710.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq. ft.): 31711.68 Owner: BLANK RONALD J&FIDELA S J zoninsz: URB(100)/ Applicant: THE ENERGY STORE AT. 27 SHEFFIELD LN Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON.11512016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL KNEE 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 1/5/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner