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31B-134 122 STATE ST BP-2016-1488 GIS:a: COMMONWEALTH OF MASSACHUSETTS Map:Block:31B- 134 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-2016-1488 Project# JS-2016-002549 Est.Cost: $2100.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq.ft.): 4007.52 Owner: JENKINS BENJAMIN J Zoning:URC(100)/ Applicant: ENERGIA LLC AT: 122 STATE ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 Liability HOLYOKEMA01040 ISSUED ON::6/15/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSU LATION 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 6/15/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File F BP-2016-1488 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111 PROPERTY LOCATION 122 STATE ST MAP 31B PARCEL 134 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT ,[ Fee Paid Ca" '11381 r(16 Building Permit Filled out Fee Paid Tvpeof Construction: 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 FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 '� Sign -I wilding I-ficial 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. Deportment use only RECEI\ ED City of Northampton Status of Permit Building Department Curb Cut/DrivewayPermit ITN 14 -3r-'7212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability oil•..,.. Northampton, MA 01060 Two Sets of Structural Plans _ _ =on: 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 122 STATE ST Map Lot Unit NORTHAMPTON,MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2,1 Owner of Record: SARAH STOLWIJK 122 STATE STREET,NORTHAMPTON,MA 01060 Name(Print) Current Mailing Address347 419 7759 SFF ATTACHED PERMIT A[UTH FORM Telephone Signature 2.2 Authorized Agent: THOMAS ROSSMASSLER 242 SUFFOLK ST,HOLYOKE,MA 0W40 Name(Print) Current/ C1 -3111Address: 413-323-32 2-31111 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $2100.00 (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 'L //J� 6. Total=(1 +2+3+4+5) $21000 Y,/ 0 Check Number 9 4 �tts- This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings 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 DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES O IF YES: enter Book Page and/or Document It B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding[❑] Other[CO INSUI ATION Brief Description of Proposed INSULATION OPEN BLOW CELLULOSE 6" Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet se 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 SARAH STOLWIIK I, ,as Owner of the subject property hereby authorize THOMAS ROSSMASSLER to act on my behalf, in all matters relative to work authorized by this building permit application. SEE ATTACHED PERMIT AUTH.FORM 6/7/16 Signature of Owner Date 111111111 .111 THOMAS ROSSMASSLER-ENERGIA LLC 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. THOMAS ROSSMASSLER Print Name / "r-� 6/7/16 Signature of Ow r/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable C Name of License Holder_ THOMAS ROSSMASSLER 92540 License Number 242 SUFFOLK ST,HOLYOKE,MA 01040 9/2/17 Address Expiration Date 413-322-3111 Sig ture Telephone 9,Registered Nome ImorovemeM Contractor: Not Applicable ❑ ENERGIA LLC 165169 Company Name Registration Number 292 SUFFOLK S'I,HOLYOKE,MA 01040 1/11/18 Address Expiration Date Telephone 13-322-3111 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 TO No ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellins of one(I) 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 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: 122 STATE ST,NORTHAMPTON,MA 01060 The debris will be transported by: ALLIED WASTE The debris will be received by: ALLIED WASTE Building permit number: Name of Permit Applicant 6/7/16 Date Signa ure of Permit Applicant rresunkePermit Authorizationmass save Form swimstwaetn wap,~ay °AImCCONTRACTOR Site ID: 500050173024 Customer: SARAH STOLWIJK I, SARAH STOLWIJK ,owner of the property located at: (Owner's name,minted) • 122 State St Unit 2 NORTHAMPTON (Property Street Address) (On) 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. 44 _ Owner's Signature: Date: 3131 1 G0 00D0000000000000000000000000000000000000.00000000000000000000000000000 FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 4,vPwLoof Participating Contractor Date acal For Office Use Only Conservation Services Group a 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472 Rev.062015 The Commonwealth of Massachusetts • r=,., Department of Industrial Accidents 11 f1 Office of Investigations I Ltd -rl 600 Washington Street -' = tz, Boston,MA 02111 • www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leath'Y Name(Business/Orgnnirationllndividual): Energia, LLC. Address: 242 Suffolk Street Ci !State/Zia: Holyoke, MA 01040 Phone#: 413-322-3111 Are you an employer?Cheek the appropriate box: Type of project(required): 1.g' 1 am a employer with 24 4. D 1 am a general contractor and I 6. 0 New construction employees(full and/or part-time),' have hired the sub-contractors 2.0 I am a sole proprietor or partner- fisted on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.: 9. Building addition required-] 5- Q We are a=potation and its 76.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'camp. right of exemption per MOL, 12❑ Roof repairs insurance required.] c. 152,§l(4),and we have no employees. [No workers' 13.K Other InaulailOn comp.insurance required 'Any applicant that checks hog N I must also ail om the section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing all work and tan hire outside contractors onst submit a new affidavit indicating suck, tContradors that check dig box must attached an additional sheet showing the nand of the subcontractors and state whetter or not thane entities have employees. If the sub-canracmrs have employees,they mass provide their wod;ers'comppolicy numbcr- I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she information. Insurance Company Name: H01 - Gerling America Insurance Company Policy#or Self-ins.Lie.N: EWGCC00018S815 Expiration Date: 7111201E lob Site Address: 122 STATE STREET City/State/Zip: NORTHAMPTON, MA 01060 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 oftdGL c. i52 can lead to the imposition of criminal penalties of fine up to$1,50090 atdtor 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 certify der the pains and pens ' • perjury that the information provided above is true and correct. - Date: 617/16 $lE7,yIU[&; L _ Phone#; 413-327.3111 Official use omy. Do not write in this area,to be completed by city or town official - City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.Citytrowm Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: Crirlf,,,,in,,,,,,kwii grikuctektiefif Office of Consumer Attain&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Istratlon: 165169 Type: Office of Consumer Affairs and Business Regulation Expiration: 1/11/2018 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 ENERGIA LLC THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLVOKE,MA 01040 Undersecretary Not valid without signature i. ,® Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-092540 Construction Supervisor THOMAS B ROSSMASSCth ,. 100 MAIN STREBT HATFIELD MA 010 . Expiration: Commissioner 09102/2017 • ACORd CERTIFICATE OF LIABILITY INSURANCEDATE'e DNYYYI 4%•••••• 7 /71291. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(es)must ha endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may r.Ruire an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endoraemaM(s). urv� pcaoucea • neME; Mary Conroy James J. Dowd and Sons 'Rant-ammo Agency ICC, PRFAX --" 14 Bobala Road JWn.No_�At R-53B;S4a IIAiCNoI: Holyoke MA C1040 nwoo"Ilress: mcanroy@dowd.corn cUU$TNdER IPe.ENERLLC-kt_ _ .__ .......`—, _.. IN$URERIS}AFFORDINO COVERAGE I NAICI INSURED INSURER A:Hai iaQ_ x�ccInsurancee Con co i Fnergia. LLC 242 Suffolk StreetINSURERS:Tor $ atlot i Is Surat, CORoan __� Hoyouke HA 01040 wsvirEec: _..�_... WSUI5ER o. IxSDREREa _� �. NMMRERP I COVERAGES CERTIFICATE NUMBER:1282823167 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POLICY PERIOD INDICATED.NOTWiTHSTANDINGANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT OATH RESPECT TO TO ALC TNHE HISCERT EXCLUSIONS AND COE ISSUEU NDITIONS OR MAY F SUCH POLICIS.LIMITS SHOWNN MAT THE POLICIES REDUCED BY PAID CLAIMS SUBJECT INN '.DL-Ili: PCL ' E I arferliF L' TYPE OF NSURANCB t, POLI. roccR i&.n u. .,u» WITS AOENEtµUASRitt Y IEGGCC0001068t5 7/1/2015 1/1/2015 FACH-AVAIntralViOCCURRENCE 171000,000 X_ CiOMMERCIAL 3M GENERAL LIABILITYL MEOEXP SLUD:ODO �X�i put )�IsS.000 _....� , _. _ ill _^ r PERSONAL a ADV INJURY ISL,000.000 _, (I GENERAL AaoREGAT= 52,000,500_ GENTAGGREGATE LIMIT APP'JES PER: PRODUCTS•COMP/OP ACG 51.000,000 POLICY PROS LOC I 15 At3TOMn PURER/JOY Y -f -=0.CD60ka5815 EE/3iN15 177172018 j tOM NECSPYSLE UWT lEa 51“5511501) 151,000.000 ANY AUTO '3IXIILY INJURY(Pa moue 5 ALL W.NfDAUtOS L IBCORY INJURY(Per a:Sr S. EN SCHEDULED AUTOS PROPERTY DAMAGE $ ©HIRED nuns IPrSC4nt _..__._ ell NbFOV.N2UAlsOfi I _._. 5 g ©UMBREW LNB ' 5CCUR IY TORust"_3 j]ILIE015 "111:015 EAo occL RELE 52.000_000 EXCESS LIPS II CWMSIMDEI I r AGGREGATE 10,U00,000 • DEW^uTISLEI 5 X 510,003 , I I A WORKERSCQMPEN5A1ON I± 2% CCOCO1B5 B3 II]/1/2015 19/1/2016 x NCSuarr RN.' s I AND eMPLOIFAS'LJABLITY YI _ .Y1N11I5 FR _.. {}.NY P4OPRCTCPIPARTNEREXECUTWE� NiO rEL EM1CN tL'YpElt a-.000.]CJ 1(YFCERA REXCLtOOV I Damson In NH) IEC DISEASE.OA EMPLOYE. P_,000.100 ;OE-X solo Oes PERATIrNS LNox 1 EL.DISEASE.POLICY UMR 51.000.000 I DCSairrON OP W ERATONSILOCAT ONSI VGIICik3 HMCItACORO 1111,A<C1van.IRxn.M1S Xhd„e,V„mn spsca}S,eWNad} CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ASOVE DESCRIBED POLICIES BE CANCELLED IN ACCORDANCE WITHE THE OTHE POLICYN DATE E ROVISIONgCE WILL BE DELIVERED AUTHDRQED REPRESENTATIVE ®t9S8-2009 AGGRO CORPORATION, All rights reserved AGGRO 25(2009009) The ACORD name and logo are registered marks of ACORD -- City of Northampton oy ,,5 " s, Massachusetts ¢_ 1.-- °� L DEPA£TBENT OF BUILDING INSPECTIONS m '..0-3.'..-.*, 212 MainStreet • MuMAM01060 Municipal Building J Yµ `aCD Nor Property Address: 122 STATE ST, NORTHAMPTON,MA 01060 Contractor THOMAS ROSSMASSLER-ENERGIA LLC Name: Address: 242 SUFFOLK ST City, State: HOLYOKE,MA 01040 Phone: 413-322-3111 Property Owner Name: SARAH STOLWIJK Address: 122 STATE ST City, State: NORTHAMPTON, MA 01060 I, THOMAS ROSSMASSLER (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature //^/ Date 6/7/16 -