17C-300 (6) 40 LAKE ST BP-2017-0855
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-300 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-2017-0855
Project# JS-2017-001438
Est.Cost: $1200.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group ENERGIA LLC 92540
Lot Size(sq.ft.): 13068.00 Owner: BLOOM EVELYN
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 40 LAKE ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:I/13/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL A 14" LAYER OF CELLULOSE TO OPEN
ATTIC
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 1/13/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck- Building Commissioner
File#BP-2017-0855
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 40 LAKE ST
MAP 17C PARCEL 300 001 ZONE URB(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ry
Building Permit Filled outiti /h
Fee Paid V
Typeof Construction: INSTAL A 1 ER OF CELLULOSE TO OPEN ATTIC
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR TION 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
Demoliti s•
Si_ fBuild gY'rcial 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.
` " ' Department use only
\rL��\ \laity of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
\\\ 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
\j phone 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
y O tote cry Map Lot Unit
-\ oYtnLCtMt Ol OCOa Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ffJr Mn b��o 90 Lave S-t . - ini•rnCr , nnvi nlnroa
Name(Print) Current Mailing Address:
' I'` 13-3'74 -
gyp. 14oL1
Ste PEK.k1T r \� i4-lo Telephone
Signature
2.2 Authorized Anent:
l. . ,. • 0.o SStnas1:1 r . 4a SUt-Ft\It_ &t. tltl\ynt.r tM14
Name(Print)/ Current Mailing Address: oio41O
413-asci-a) 1t
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building V qi 1 i aoo .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 /�
6. Total=(1 +2+3+4+5) Check Number . /r�% 4 S
This Section For Official Use Only 7
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt 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 Depadment
Lot Size
Frontage
Setbacks Front
Side L: It: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot arta 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 O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q
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$-DESCRIPTION OF PROPOSED WORK(Check all applicable)
New House ❑ Addition 0 Replacement Windows Atteration(s) 0 Roofing ❑
Or Doors
Accessory Bldg. 0 Demolition ❑ New Signs (DI Decks [C Siding(p](nOther!`wsj "
Brief Description of Proposed
Work to&tali n iW` inytt tri crikA0V -To open nx-riC. f�
Alteration of existing bedroom Yes No Adding new bedroom Yes ( --No
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet TT��
ea. If New house and or addition o 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
It Will building conform to the Building and Zoning regulations? Yes No
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Eve tyn bloom , as Owner of the subject
property
hereby authorize -1IIOYnOS .oSSrnrtsSt, r
to act on my behalf,in all matters relative to work authorized by this building permit application.
E6 ecehf cc- 6T+to ! //0"7
Signature of Owner Date
Thorn yg RoS.S rnaSSIRr ,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.
U / N.e r. • Ue Slur'
Print Name "//0
7
•
Signature of er/Agent Date
SECTION 8-CONSTRUCTION SERVICES
§.1 Licensed Construction
v�Supervisor: Not Applicable 0
Nameot L,cent.HddarttiA: MFYI0S- nAp
A«tl' r . 'iaz `go
License Number
tt0Klatt' , Wit n (nkik 4/al
Address Expiration Date
Signa .re Telephone
p.Registered Home Improvement Contractor: Not Applicable 0
EN ..... ..+ � (pStW9
Company Name u Registration Number
wr. - week S*. e.e.l+' icr y Quit OkOLIO I I tt I
Address Expiration Date
_Telephone, 4l3-%aa)-A III
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15$§25C(efl
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 thebuildinermit.
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings 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 135.5.5.1.
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-veal 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 ad 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: 440 LO `C SA . -F\ DVtX\t_( , `MW (Mao
The debris will be transported by: \t f d i,if1R1-e
The debris will be received by: fr1U ed tAIfAS-i-e
Building permit number:
Name of Permit Applicant E vP 14n t-)\Dorn
_____/A/-------- T/iou,4-c BAL s
Date Signature of Permit Applicant
RISE60 Shawmut Road,Unit 2 1 Canton,MA 02021 1 339-502-6335
ENGINEERING- www.RlSEengineering.com
OWNER AUTHORIZATION FORM
I, Lc,* B •
400r1
(Owners Name)
owner of the property located at:
`FD <if/4Z Sigiir
(Property Address)
t�l rjiLC.Ncf � rte-- i ,
(Property Address)
n
,/ 76-22/41/
� 11'.1 ' - iJ1
hereby authorize /i 1 O/'+/f(/ L� 'J
(Subcontractor) y
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
ownetSignah
tule
A4u at de tor,
Date
6.2016
— Department of Industrial Accidents
n-= y���t Office of Investigations
=ABS 1 600 Washington Street
r,
`i�'�= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lemibly
Name(Business/Organization/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):
1.M I am a employer with 24 4. ❑ I am a general contractor and 1 6. ❑ New 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 8, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.:
required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.®Other Insulation
comp. insurance required.]
*My applicant that checks box al must also fill out The section below showing their workers'compensation policy information.
t 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: HDI - Gerling America Insurance Company
Policy#or Self-ins.Lic.#: EWGCR000186816 Expiration Date: 7/1/2017
Job She Address: '10 LAY e cS* . City/State/Zip: -FI O Y C n Lf l AAA O I O(o a
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert((y under the ins and penalties of perjury that the information provided �e istrue and correct.
Simmtme: Date: 11 0 /7
Phone#: 413-322-3111
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: _
Act a CERTIFICATE OF LIABILITY INSURANCE 9D5/20166M
oTY)
THIS CERTIFICATE IS ISSUED AS A MATER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL.INSURED,the policy(es)must be endorsed, If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer fights to the
certificate holder In lieu of such endoreement(s).
N PA
PRODUCER NAME T.
Mary Conroy
James J. Dowd and Sane Insurance Agency Inc. RHONE TAX
19 Bobala Road uc No,EA:413-538-7999 IA.C.Noi:'
Holyoke MA 01040 AADDORE$SRmCOnroV@dowd.COM
PROCE
CUSTOMER ID*ENERLLC-01
INSURER(S)AFFORDING COVERAGE NAIC
INSURED INsuRER A:HDI-Gerling America Insurance Comps
Energia, LLC INSURERM:Torus National Insurance Company 25996
292 Suffolk Street
Holyoke MA 01090 INSURER C:
INSURER 0
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2034052979 REVISION NUMBER:
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY
Lt�IHAVE
FFFFBEEN
O0REDUCED BY PAID CLAIMS.
ILIRTYPE OF INSURANCE AXIL SUM-
LIR POLICY NUMBER Ie9AMNYYYYI rGMIWIYYYYI UNITS
A GENERAL LIABILITY T Y EGGCR0001B6816 7/1/2016 7/1/2017 EACH OCCURRENCE $1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES(EaEUNmnmal 8100,000
CLAIMSMADE n OCCUR MED EXP(My oneperwn) E
PERSONAL.AADVINJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN%AGGREGATE LIMIT APPLIES PER' PRODUCTS•COMPOP AGG 52,000,000
7 POLICY I^ PFfT []LOC •
A AUTOMOBILE LIABILITY Y Y BAECA00018E816 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT 51.000,000
(EO apddeit(
ANY AUTO B00RY INJURY(Parpereon) S
ALL OWNED AUTOS BODILY INJURY(Per accident) S
X SCHEDULED AUTOS PROPERTY DAMAGE
X (Per N AEP10
MIRED AUTOS
X NON0WNED AUTOS
S
B X UMBRELLA LAB OCCUR Y Y 85393N150ALI 7/1/2016 7/1/2017 EACH OCCURRENCE 5L000,000
EXCESS LMB CLNMS.MADE AGGREGATE 51,000.000
_ DEDUCTIBLE $
X RETENTION 810,000 S
A WORKERS COMPENSATION Y SMICR000186915 7/1/2016 7/1/2017 X TO RV IIMITB GE0.
MO EMPLOYERS'LIABILAT
ANY PROPRIETOR/PARTNEIUEXECUTIVE E NJA E.L.EACH ACCIDENT $1,000,000
I
OFFICER/NEMER
eER EXCLUDED,
NiNEL DISEASE-EA EMPLOYEE 83.000,000
OESC0.1P110N OF OPEMTIONG below Et.DISEASE POLICY LIMIT 51,000,000
DESCRIPTION OF OPERATORS 1 LOCATIONS I VEHICLES (Atte hACORD 101,AddltIonal Remarks Schedule,If more space la requintll
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACDRD name and logo are registered marks of ACORD
C p'tommon.rv7/1/
Office'Of Consumer Affairs&Business Regula0on License or registration valid for individtd use only
ME IMPROVEMENT CONTRACTOR before the expiration date If found return to:
• Ieba0on: 165169 Type: Office of Consumer Affairs and Business Regulation •
Ezpiatlon: 1/11/2018 LW 10 Park Plaza-SuiteS170
Boston,MA 02116
ENERGIALLC --
THOMAS ROSSMASSLER •
242 SUFFOLKSTREET
HOLTOKE,MA 01040 Undersecretary Not valid without signature
Massachusetts Department of Public Safety t.
.• Board of Building Regulations and Standards
License: CS-092540
Construction Supervisor
THOMAS B ROSSMASSLER
100 MAIN STRPbT
HATFIELD MA 090
1
r-la Expiration:
Commissioner 09/02/2017
City of Northampton
' Massachusetts i 4
/ %
L
DEPARTMENT OF BUILDING INSPECTIONS
b,'.i 212 Main Street • Municipal Building ��' I
., qC
Northampton, MA 01060 .34.`
Property Address: *0 L.4KC ST.
Contractor `''// A
Name: GN U c TO,4v z / S . ss-
Address: 2-V2 SZefrei4G S?. /"
City, State: f><®L-t/O/CE MA-
Phone: S//3- i22 - 3L7/
Property Owner GG G 7� --E haat
Name: V
Address: y4K4 ST•
City, State:
p 'G 7,€6 /c6 ./4
I,-7,-in ,€ossytssl.E,c (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 /D