13-101 (8) THEENER-01 GPIZ.ARRO
(M
CERTIFICATE OF LIABILITY INSURANCE 0DATE8123W/201DDfYYYY)
8
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 li
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(ies)must have ADDITIONAL INSURED provisions or be endorsed.
It 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 rights to the certificate holder in lieu of such ondorsemen0s).
PRODUCER NCAORACT
Brown&Brown of New York Inc. PHONE FAX
800 Westchester Avenue,N-311 AIAic,No,Ext):(914)337-1833 (A/C,N011(914)337-1596
'Rye Brook,NY 10573 E lk,s.certiftcates@bbinsny.com
INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A CnJM&Forster Specialty Insurance Co. 44520
IINSURED INSURER B:AN[Trust Insurance Company of Kansas,Inc. 15964
Energy PRZ LLC Oba The Energy Store INSURER c:StarNet Insurance Company 140045 _1
3 Simm;Lane Suite I CINSURERD:
Newtown,CT 06470
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 T!!?�
HIS
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 BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUI3q POLICY EFF POLICY EXP I
_LTR; TYPE OF INSURANCE POLICY NUMBER (MMICON OC _LIMITS
X CONIMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIAIS-1.1-DE OCCUR X !EPK-1219" 0312712018 0312712019 DAMAGE 10 RENTED 50,000;
S
MED EXP S 5,0001
1_EERSONAL&AD�V NJURY S 1,000,0 01—
I GEN*L AGGREGAI—E LIMIT APPLIES rr:R 'GENERAL AGGREgAjg_ S 21000100
r_1
P0,_Iz,f Loc COMPIOP A3G , 2,000,000;
OTHER._
COMStNED SINGLE Ltfilt 1,06",00 1
B ;1 AUTOMOBILE LIABILITY T
t i(Eap
X 1KPPI051229 00 0312712018BODILY IN�L;RI;Per pet�icn) S
1 03/27/2019 '
Px
("AHED I 51_14EQJLED - —___
LICs0;11_ "Jr'ls 1
BODILY INJURY(Per accidenti S
H:PED �UIT10�1 1E 'Per PROPaCE TSIPOY DAMAGE I -
(3
AUTCS ONL',.'
A UMBRELLA LIAB 3 X OCCLR 5,000,000
X EXCESS LiAB CLAIMS-VADEI IEFX.110328 j 03/271201810312712019REGAIE $
5,000,000
JAGGI
OT H
C WORKERS COMPENSATION PSEARTUTE I
AND EMPLOYERS'LIABILITY YIN BNUWCO131379 0411512018 0411512019 1,000,000
ANY PRCP9;ETCR,PAR Tr.=P.Ir Xf."'-IT11,F r_�_I El
E 5,;6; N NfAl
_X��Lu --11 .r&= -EA EMPLO�E 1,000,000
nN d
j1;a daro`rMv1V5LR)E
_L DISEASE
ff � de5Cr01U1)1er 1,000,000
it:`__ (-,R;PTzON');:0-EPATIONS beiov., I El DISEASE,POLI-Cy
A IPolution Liability j EPIK-11219" 0312712018 0312712019 lEach Condition 1,000,000
A :iErrors&Omissions
EPK-121944 j 0312712018,0312712019 Each Wrongful Act 1,
00
0,0,01
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,1Z
be attached it more space is required
)
Action Inc and National Grid USA its direct and indirect parents subsidiaries and Riates shall be named as additional insured on Commerciall General
Liability and Automobile Liability policies as required by Written contract or agreement
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BCAC,INC ACCORDANCE WITH THE POLICY PROVISIONS.
1531 East Street
Pittsfield,MA 01201
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) 1988-2015 ACORD CORPORATION, All rights reserved.
The ACORD name ana logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301 P
' Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: LLC
THE-ENERGY STORE, LLC Registration: 178392
Expiration: 04/09/2020
3 SIMM LANE STE 1C
NEWTOWN, CT 06470
Update Address and Return Card.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
178392 04/09/2020 One Ashburton Place-Suite 1301
THE-ENERGY STORE, LLC Boston, MA 02108
ROBERT NEALc�
3 SIMM LANE STE 1C
NEWTOWN, CT 06470 Undersecretary Not valid without signature
The Commonwealth of iWassachusetts
Depai-tinent of Indristi'ral Accidents
r
t, n 1 Congress Street,Srrite 100
i Boston,MA 02114-2017
www mass govldia
Workers'Compensation Insurance Affidavit:Builders!Contractors/Electricians/Plumbers.
TO BE FILED NIV7TH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibiti
Name (Business/Organization/Individual): The Energy Store,LLC
Address: 3 Simm Lane
City/State/Zip: Newtown, CT 06470 Phone#: 888-840-6641
Are you an employer?Check the appropriate box: Type of project(required):
1.0 t am a employer with 3 employees tfull andlor part-tine)." 7. ❑New construction
2.O 1 can a sole proprietor or partnership and have no employees working for me in 8. C3 Remodeling
any capacity.[No workers comp.insurance required.]
}- ❑Demolition
1[]1 am a homcouner doing all work myself.[No workers comp.insurance required.]'
10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
ro rictors with no employees.p p p 12.E]Plumbing repairs or additions
5.n t am a general contractor and 1 have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance-'- 13.❑Roof repairs
14.[20ther WeatheriZation
6.n We are a corporation and its officers have exercised their right of exemption per MGL c.
152,y 1(4),and Ave have no employees.[No workers camp.insurance required.]
'Any applicant that checks box#1 must also fill out the section hclor-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 orthe sub-contractors and state whether or not those entities have
employees. if thr sub-contractors have employees,they must provide their workers'comp.policy number.
I ain air employer that is providing workers'compensation insurance for my employees Beloit,is the policy and job site
irifor matipir.
Insurance Company Name: BNC Insurance Agency, Inti
Policy K or Self-ins.Lic.n: BNUWC0131379 Expiration Date: 4/15/2019
Job Site Address: City/State/Zip:
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,§25A is a criminal violation punishable by a fine up to$1,500x00
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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pari andpetialt' ti/perjury that tire information provided above is true and correct
Si nature: Date_
Phone#: 475-204-4585 Cell 888-840-6641 Office
Official itse 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#:
Permit Authorization
mass save Form
Site ID: 3560140 Customer: Cynthia Suopis
ogft +-�S
owner of the property located at:
(Owner's Name,printed)
120 Coles Meadow Rd Northampton, MA 01060
(Property Street Address) (C")
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: CyK&i,0,S
Date: 10/17/18
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
For Office Use Only
n.... 4 A°1M C
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Nu t!r
E C:�C)
Address Expiration ate
r
Signatu Telephone
9.Re istered Home Improvement Contractor. Not Applicable ❑
t-�-
Comoanv Name Registration Number
Address (� Q l R ( � Expiration Date
Telephone
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....... No...... ❑
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition ❑ New Signs [D] Decks [jam Siding Other
i
Brief Description of Proposed
Work: P-\ler-A' Laon�9i.S-�`i'�C�(�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No I
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housinta, complete the following:
3
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
1, f �lll.1 Q as Owner of the subject
property I
i
hereby authorizef,P.c �—
to act on my behalf,in all matters relative o ork authorized by this building permit application.
Signature of Owner Date
1, l hr i Z:. C 9_r- t 111 l� ,as Owner/Authorized
Agent hereby decAard 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.
Print Name
ig ure6f Owner/Agent 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 U-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 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW a YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 No j2r
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan
that will disturb over I acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
p _ ,~�_" - -
120 COLES MEADOW RD BP-2019-0546
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 - 101 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-2019-0546
Proiect# JS-2019-000887
Est.Cost: $2017.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THE ENERGY STORE 106082
Lot Size(sq.ft.): 71177.04 Owner: SUOPIS CYNTHIA A&SALLY BELLEROSE
Zoning: Applicant. THE ENERGY STORE
AT. 120 COLES MEADOW RD
Applicant Address: Phone: Insurance:
3 SIMM LANE WC
NEWTONCT06470 ISSUED ON:11/7/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEALING DOOR WEATHERSTRIP PIPING,
DOOR SWEEPS AND THERMAL POLY BARRIER
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: U,-il: 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 11/7/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner