13-014 (3) II LAUREL LN BP-2017-0940
GIS4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 -014 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 i BP-2017-0940
Project JS-2017-001606
Est.Cost: $1000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq.ft.): 19602.00 Owner: LAMOTHE PHILIP
Zoning: Applicant: ENERGIA LLC
AT: 11 LAUREL LN
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON:2/10/2017 0:00:00
TO PERFORM THE FOLLOWING WORK ATTIC FLAT 12"CELLULOSE OPEN BLOW
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 if 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 2/10/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240.Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0940
APPLICANT/CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413)322-3111
PROPERTY LOCATION 11 LAUREL LN
MAP 13 PARCEL 014 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid °/.116
Building Permit Filled out
Fee Paid
Tvoeof Construction:_ATTIC FLAT IT'CELLULOSE OPEN BLOW
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
INF MATION 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 tel.
Ale
Signatu I uildin: 0 i 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 40k Contact Office of
Planning&Development for more information.
// Department use only
4 , City of Northampton Status of Permit:
�\ - Building Department Curb Cut/Driveway Permit
c i 212 Main Street Sewer/Septic Availability
''``�'t Room 100
\\\ / Northampton, MA 01060 WaterA^l�Ava{M66ty Two Sets of Structural Plans
\ , phone 413-587-1240 Fax 413-587-1272 PIaUSde Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
1.1 ProoeNv Address, This section to be completed by office
11 LO-O \ Lo re Map Lot Unit
C
W, .1 ^Acirort MH 01019 D Zone Overlay District
_ Elm St District Ce district
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cy ti lti9 Cfl.a-10+Yie t l t.GY_tt Y?a one MOVAV+Gm9YOl1 i 1A4i4
Name(Prim) Current mama Address: 010(00
Tls(Dac
Telephone
Signature
$.2 Authorized Anent:
Thome. 91oRs,fnn.SSMCC ;4a <cu4-f-cY St. ttoryote. MADL04o
Name(Print Current Mailing Address:
413-3aa-Sin
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(8)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection /�
6. Tota=(1 +2+3+4+5) Check Number 4' L1 7 0
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 Dented Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled ie by
Building Deputmevc
Lot Si
z
r4•'
Fran e
Setbat s Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage , %
Open Space Footage %
(1oL am miaus bldg&paved
puking)
M of Parking Spaces
Fill;
(volume&Location)
4
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 DON'T KNOW 0 YES 0
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 0
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 C> 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. WM the construction activity disturb(Gearing,grading,a cavation,or filing)over 1 acre or is it pail of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all am/Doable)
New House 0 Addition ❑ Replacement Windows Atteration(s) fl Roofing El
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs (CM Decks [I] Siding[O] Other
Brief Description of Proposed
Work: A7'77c t " tits F uI-16ouuT3r dw
Alteration of existing bedroom Yea No Adding new bedroom Yes 2 C No.c-�-
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
ga.If New house and or addition to existing housing, complete the following:
a. Use of building:One Family ... Two Family Other
b. Number of moms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?„
f, Method of heating? Fireplaces or Woodstoves Norther of each
g. Energy Conservation Compliance. Masschec k 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 Na.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS, tAA AGENT OR CONTRACTOR, APPLIES FOR BUILDING PERMIT
l(
I, VT 9 La 1 li e ,as Owner of the subject
property
hereby authorize'ThnmaS V-nsswaSS to r
to act on my behalf, in all matters relative to work authorized by this building permit application.
SF AtArt<0 2JG 1
signature of Owner /L Date !7
Thoth P)OSR rn&S. r .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.
Thorn• RossmaSSt e r
Print Name
q( �/(
ate
Signator . Owner/Agent D
SECTION 8.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:lbotnAS .7 &s rsSter 97_S90
License Number
qua rt.}ffnik: St. i011. !„11,114 nioya 9/2/ 11
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
ent,r4 iGl J(pS1(n9
com.nrNam. Registration Number
arta &UffiIrs-r +i46Vote. AAa ntt7LttJtt� tff
Address , Expire on ete
Telephone x113-70 -31 I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(80
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 R3 No ❑
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 Sectio',108.3.5.1.
D lluition of Homeowner:Person(s)who own a parcel or 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-veer 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: II LAUr° lath hlnrtYlamp1flfl. Mt9 oto co a
The debris will be transported by: fill ted toonStf
The debris will be received by: f}tll f(1 utaStC
Building permit number:
Name of Permit Applicant Olt 114 La rnOth1
Date Sig ature of Permit Applicant
City of Northampton
%c,
# Massachusetts �'
DEPARTMENT OF BUILDING INSPECTIONS 5
_ (i 212 Main Street • Municipal Building J, _ �p0�
Northampton, MA 01060 '�. Tal
Property Address: II boort! (.ant'
Contractor
Name: Thomas Rossmasre1 t
Address: 84a &uffnlY
City, State: 1-1nlynice , M- 01040
Phone: LII,S-3aa-3111
Property Owner ,
Name: a m G Ad • ■l1
Address: I ( Lai YPA lane
City, State: Noir-WhOn 0-an , MW of Oh O
I. Thomas ninssn &Ste y (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 711/17
Department of Industrial Accidents
t�= —j=Et Office of Investigations
600 Washington Street
74910= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Energia, LLC.
Address: 242 Suffolk Street
Ci /State/Zip: Holyoke, MA 01040 Phone#: 413-322-3111
Are you an employer?Check the appropriate box: Type of project(required):
IY I am a employer with 24 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.D 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
workingfor me in anycapacity. employees and have workers'
P ty r 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.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.®Other Insulation
comp.insurance required.]
*Any applicant that checks box qt 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 cheek 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.Lie.#: EWGCR000186816 Expiration Date: 7/1/2017
lob Site Address: 11 L61UYCA LQ n C City/state/Zip: NOt-k wl.fnotfvl, M'A O kpo p
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 certify under e pains and penalties of perjury that the information provided above is true and correct
Signature: Date: Z/7/17
Phone#: 413- 2-3111
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#:
ACORIJ CERTIFICATE OF LIABILITY INSURANCE „S;zoADDITYWO
16
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 poilcy(les)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 dghts to the
certificate holder In(leu of such endorsement(s).
PRODUCER NAME: Mary CORM/
James J. Dowd and Sone Insurance Agency Inc, PHONE FAX
14 Bobala Road IA�CAILLo,EFa:411-538-7444 vie,No):
Holyoke MA 01090 EADDRESejnconrov@dowd.COM
CUSTOOME
TR IDS:ENERLLC-01
INSURERISI AFFORDING COVERAGE NANCY
INSURED INSURER A:HDI-Gerling America Insurance Comps
Energia, LLC INSURER El:MEWS National Insurance Company 25496
242 Suffolk Street
Holyoke MA 01040 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:2034052479 REVISION NUMBER:
THIS IS 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 CONTRACT OR 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 HAVE SEEN REDUCED BY PAID CLAIMS.
ASK TYPE OF INSURANCE AIM WVOR POUCT NUMBER IMWOCcYEfF POLICMWOO EMX
D/TTT�'1 /1/20YYYYI LIMITS
A GENERAL LIABILITY Y V EGGCR000186816 7/3/2036 7/1/2017
_ EACH OCCURRENCE 51.000,000
IC HEN I EU
R COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) 5100,000
CLAIMS.MADE n OCCUR MED EXP(Any wepersonl $
PERSONAL ADV INJURY _ 51,000,00D
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.CDMPOP AGO $2,OD0,00D
7 POLICY
X JFfT WC
A AUTOMOBILE LIABILITY Y Y EAQCR000186816 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT
$1,000,000
IEn attldent)
ANY AUTO
BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per eccIenI) $
A SCHEDULED AUTOS PROPERTYDAMAGE
X HIRED AUTOS (Per accident) _ S
X NON.OWNED AUTOS
S x UMBRELLA LIAB OCCUR Y Y S5193N150ALI 7/1/2016 7/1/2017 EACH OCCURRENCE 51,000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE 41.000,000
_ DEDUCTIBLE ff
X RETENTION $10,090 _ E
A WORKERS COMPENSATON V GCR000186816 7/2/2016 7/1/2017 X TWC ORY
LIMIT
O1H-
EN
AP EMPLOYERS'LIABILIIPTY TIN TORY OMITS ER
ANY PROPRIETORARTNERIEXECUTIVE C NIA E.L.EACH ACCIDENT 51,000,000
OFFICER/MEMBER EXCLUDED'
(Mandatory In NH1 E.L DISEASE-EA EMPLOYEE 51.000,000
y OQ[npe Ynttr
DESCRIPTION OF OPEFATI0N60Npw EL OIGEASE POLICY LIMIT 51,000,000
DESCRIPTION OF OPERATORS/LOCATIONSI VEHICLES (Attach AGGRO 101.Addlllomditemarke Schedule.II More Span IB requInd)
CERTIFICATE HOLDER CANCELLATION30
SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIATION DATE THEREOF,NOTICE WILL BE DELIVERED
• IN ACCORDANCEWITH THE POLICY PROVISIONS.
AUTHORIZED REPRSSENTATNE
•
(
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
c—.74, fn,rr,.o../rrre+(a irtl(a,;re4rr,rfa
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
is[n0on: 165169 Type: Office of Consumer Attain and Business Regulation
Expiration: 1/11/2018 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
ENERGIA LLC
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE,MA 01040 Undersecretary Not valid without signature
1 Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: fS-092540
Construction Supervisor
THOMAS B ROSSMASM:ER
100 MAIN STREET
HATFIELD MA 61838 * =
•
N.-1--. CA—I- Expiration:
Commissioner 09/02/2017
RISE60 Shawmut Road, Unit 21 Canton, MA 02021 1339-502.6335
ENGINEERING www.RlSEengineering.com
OWNER AUTHORIZATION FORM
f L4ni oFtE
(Owners Name)
owner of the property located at:
( LrGcic /—yni_C-7
It
(Property Address) 'J�,
(Property Address)�/
hereby authorize =A Crc /:n 4 ,
(Subcontractor)
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.
wner's gnatur
/--/p- r1/41
Date
6.2016