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34-025 (7) 105 TURKEY HILL RD BP-2017-1164 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 34-025 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-2017-1164 Project# JS-2017-001965 Est.Cost:$3560.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THE ENERGY STORE 106082 Lot Size(sa. e.): 145926.00 Owner: FORTIER JOHN zoning Applicant: THE ENERGY STORE AT: 105 TURKEY HILL RD Applicant Address: Phone: Insurance: 97B E TAYLOR HILL RD WC MONTAG U EMA01351 ISSUED ON:4/20/2017 0:00:00 TO PERFORM THE FOLLOWING WORK AIR SEAL ATIIC AND BSMNT, INSTALL 4" OF BLOWN-IN CELLULOSE TO ATTIC FLOOR 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: Housed 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 4/20/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1164 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 9713 E TAYLOR HILL RD MONTAGUE PROPERTY LOCATION 105 TURKEY HILL RD MAP 34 PARCEL 025 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tv-Not-Construction: AIR SEAL ATIIC AND BSMNT, INSTALL-4"OF BLOWN-IN CELLULOSE TO ATTIC FLOOR / New Construction / Non Structto ral interior renovations (� le Addition to Existing 1� Accessory Structure Building Plans Included: Owner/Statement or License 106082 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 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 II- , i '. Delay 5 —/9— /7 Sign.• - o 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 City of Northampton Status of Permit: {1YR j 4 Building Department Curb CuUoriveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans 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 105 TOP-HE/ HILL RP Map / Lot Qo15 — Unit FLCRErdCEt js 4 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 3oF1r.1 ro:TER lot -Iv aiCEj HILL R0. Name(Print) Current Mailing Address: •1 i 3 —387 -92E 1 5F A,TpCHEO Telephone Signature 2.2 Authorized Agent: CnAtsrt?rlEC ALLF4 for 'fax K6'/ Hr LL 20. Name(Pnn' Current Mailing Address: o(P f • aih, y;S_ 2.o4 - 45-84- 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 35-42.•90 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection /234l.Y 6. Total= (1 +2+3+4+5) 3s(pO.90 Check Number 4( 5 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 'Ibis column in be filled in by Bin ding nepanment Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg_Square Footage Open Space Footage .� Lot area minis bldg&payed parking) #of Parking Spaces Fill: twWme&Localiun) A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Re istry of Deeds? NO O DONT KNOW 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 0 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 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 a IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,e ovation. or filling)over 1 acre or is it part 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ `/ Accessory Bldg. El Demolition ❑ New Signs [DI Decks [CI Siding[1:1] Other[J�J WtATrttti ZATont Brief Description of Proposed, Am Work: Ate. SFAL ATnc ? 65Nrrdt, IrtSTALL '/ of 6LOt.%A) 'IA1 n11 CELLULUS£ Yp K FLCok. Alteration of existing bedroom Yes Jr- No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X 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, JDNa FOszTI CC , as Owner of the subject property qq hereby authorize CHRWOO;) lEC /H.t-EA1 to act on my behalf, in all matters relative to work authorized by this building permit application. SEE A 1172terteP Signature of Owner Date I, 0Rt3TbyteE _ Au-ea ,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. (.HR%STbPt1et ALLE$ Print ame Si ure of 0 nor/Agent Dale SECTION S-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: t7 Not Applicable 0 Name of License Holder: CKt aropf(E{L At.tc,J 10(O0732 License Number qTe C. TA`ILoiL KILL AD. Mo4ITAGUEI /MA 0i3y i *size Addre $ Expiration Date //Iozz75" — 5"-- Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 1�839z Company Name Registration Number ENIERAV Per, LLC, y/lo/!b Address p�� Expiration Date 31 QLD R.TE- ERtraRELDk CT GGsF$]H TelephonegTelephone -5 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 r' 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 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 fur 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 focal 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: for te.w.e'l MILL Rs,. The debris will be transported by: n!0 Deaats The debris will be received by: Building permit number: Name of Permit Applicant CI-tvue�s-raPHetz A&-LFni 4110117- 614 aht Date Signature of Permit Applicant Permit Authorization 'Oe mass save Form i „ 1 it COPIMAMB Site ID: 50283734 Customer: John Fortier I, John Fortier ,owner of the property located at: (Owners Name,printed) 105 Turkey Hill Rd Florence (Property Street Address) IOW/ 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. Owner's Signature: C. e f ' , C Date: .^Jj?IV)/ I • FOR CLEAResult OFFICE USE ONLY CLEAResuit has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: - Participating Contractor Date aRo CLEAResult • 50 Washington Street,Suite 3000 a Westborough,MA 03591 . 1800480-7472 For Office Use Only Rev.102015 A cage CERTIFICATE OF LiABILITY INSURANCE o iommOn s THIS CERTIFICATE IS ISSUED AS A RATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEit11FICATE HOLDER. TH(S CERTIFICATE ODES NOT AFFIRMATIVELY OR MEGA11V2LY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I BELOW. TEM CERThFIC0.T OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN Tee ISSUING INSURER:S}, UTHOR1Lu I R-E RESENT:TINE OR PRODUCER.AND THE CERTIFICATE HOLDER I IieIPO'TA.E1.1 It ilt3 cgrtincata nater isE:,ADOITIC- RL Ii R.E: +15UD,the poiiCy{ies)mutt be endorsed. If aROGATJON.IS WANED,subject to the terms and conditions of the policy,certain policies may require En endorsement. A statement twills certificate does not confer rights to the certificate holder in lieu of suchendorsemengs), PRODUCER riWk?c'Brian Gallagher SSC L^sen-•, - enc PHONE el 2_ 93 —,-- a._ce =3----v, IOC. (- 79_9-1230 a c!")9.7-1=4 111 Sov:ces mecca Street sequiass ieeh ----ha_geacr-cola .. - t:suTetS)AFmRoe„G COVERAGE r141c3 .. _.. • :1e 3'.00:. isir 10573 p._ _cc-=_ Ins Coof5 Carolina 19959 t-. 062. WSVR_9t3 S"..2_TNet TnsPSanee Ccuaauav EN'E'RGY Put LLC IusuREnc age_ sk -acaansurce Co. 33238__ Oho E ENERGY STORE LEISURE {1 51OW 'ROUTS I 1 ntsua_R . _—. ..__ 3aCKINET.V1,0 CT 06604-1711 I INER suRY _—. _ COVERAGES CERTIFICATE NUINBER6 "+ 05*_ REVISION I IUWiS R 11I IS TO CERTIFY AT tri=FOI CIES ors SUP-i.:HCE ciarec nEs_otiei HAve 3=am Issue°TO INE INSURCO IbwN£D itaove FOR.THE POLICY oERIyn "'C. r:CM1 i 5 Ar•o:Me ':YRpQUIR P.., 1reia OR[tit-EDITION OF ANY CONTRACT OR OTHER DOCUMENT 11Th RESPECT O'^MICH THIS -ICATE .LAY Re 15506➢ OR MAY PERTAIN,IRE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN !B SUEJECT TO AU.THE TERMS. .X OL LISION5 AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. ng,SUER _....__ R- POLICY QF PMAJEYEYP-. TR • mrc orsvnnx _ing, two POLICY NUMBER Irtuworrrrv�M1wWrrvn LIMITS ,ti CCIXE'R.1TLG2*EPALtlaaitrr" EACH OCCupJ.Y.CE 1,000,'7001 _ _ sloTTEAts ronsasso _.. 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C:TfOi:i:VeiIICLe (ACA.'.J VV;naeltiorxiftxaar Eo,eGrle,rev p^xlCcnYe(3mo25nzm LsrtOuirct) Otl= O. i!xULaICE. 1i _ t RTfP(CA.TF HOLDER CAM;CE LATION SHOULD A.ry OF THE ABOVE ossson EO POLICIE5L-G F$CE'I=o BEFORE. PROOm Or _TI Su'Pl'NCE I THE EXPIRATION DATE tNE'StEOF, NOTICE WILL HE O ERE° til ACCORDANCE WITH THE POLICY PROVISIONS. I AUThOR2EEO REPF.ESNtTAZtV£ ©19RR-20'12ACOAD CORPORAT!Ori_ Anrtanssraeureon- Deg sc{ *smil Tile AGORDname Eno!O90 are registered merits of ACOED ;2R;zmenc. „iii„,,r Ly i 7,�. r ~) '_7 l/211 Joos,;`11/4✓ Of (H ✓ta'119141/6(4ef'i le Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type LLC Registration: 178392 ENERGY PRZ, LLC. Expiration: 04/09/2018 3i Old Route 7 Brookfield, CT 06804 Update Address and return card. Mark reason for change. ❑ Address ❑Renewal 0 Employment 0 Lost Card office Mat E(MPRO EME T BusinCONTRACTOR CTORegulation HOME RAPROTYPEte COttfflACTOR beeeviratto individual ouseeMy TYPE LLC before theexpirationdata. and Bu returnssto- Office o: Registration gat 10 PerOr laza-Consumer Affairs and Businasb flegulatlon 1 J6892 04/09/2018 10 Park Plaza 5170 Boston,MA 02116 ENERGY PRZ,LLC. _ 3/ BEOld T NEAute 7 t'Gs' "Z Brookfield,CT 06804 —'� - – Undersecretary 'at valid without signature Iii ri'rcrv„ Displaying t HIC registration number on all advertisements,contracts 0' your six-dig - and pei Los is required by the law. This includes but is not limited to business cards, '' I�ii ` websites,working trucks,signs and online advertising in any form. ens If you have any questions please contact the dedicated HIC line at(617)973-8788 I le:e,a*' Or visit us at Mass.Gov/Homehnprovement i t'. The Commonwealth of Massachusetts Department of Industrial Accidents • 1 Congress Street,Suite 100 Boston,MA 01114-1027 www.afass.gav/dta Workers'Compensation Insurance Affidavit guilders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Name(Buzmessiorganlaarnmavinammpan:The Energy Store Address: 31 Old Route 7airy, Brookfield State: CT zip:06804 Phone at 888-840-6641 Areyouart employer?Check the appropriate box: Type of project(required): • • • I Fly 1. l am an employer with 3 employees(full and/or part timer 1 12, New construction • 11112, I am a sok proprietor or partnership and have nu employees work;ng for me in any 8. Remodeling — capacity.[No workers'camp.insurance required.) �^I lllF---��t14. Demolition C 3. i ant a homeowner doing all work myself.[No workers'comp.insurance requiredit i�•❑p. Building addition • Ell.04. i am a homeowner and wilt be hiring contractors to conduct all work on my property. iII. Electrical repairs or additions I will ensure that all contractors either have workers'compensation insurance or are •-- sole proprietors with no employees. '.r 12. Plumbing repairs or additions • 5. I am a general contractor and I have hired the subcontractors listed on the attached En. Roof Repairs • • sheet. These sub-contractors have employees and have workers'comp.insurances [16. We are a corporation and its officers have exercised their right of exemption per MGL. •[ J14. Other c.1.52,§1(4),and we have no employees.[No workers'comp.insurance required( - n ' _.._. .. ..... 'Any apFbcartchucks that eskz box MS must also[Mout 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 submita new affidavit indicating such. ±Contractors that check this box must attach 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, tam an employer that is;mudding workers'compensation insurance far my employees. Below is the palityandjob siteinformation. Insurance Company Name: BNC insurance Agency, Inc. Policy Y or self-ins.❑r.h: BN UWC0131379 Expiration Date: 04/15/2017 Job Site Address: ibr T64+teY Q9. t.cA 'cal Mit olowZ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL.c.152,425A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as wel3 as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violater. 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 the pains and penalties of perjury that the information provided above is true and correct,and that clicking this checkbox and typing my name in the lie b ct signature. Name: Christopher Allen Date: /10114- Phone Phonea: 475-204-4585 mail chrisallen@the-energystore.com