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24D-010 (2) 41 &43 HAYES AVE BP-2020-0060 GIS#: COMMONWEALTH OF MASSACHUSETTS Map Block:24D-010 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2020-0060 Proiect# JS-2020-000095 Est.Cost:$600.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sg.ft.): 25831.08 Owner: PETERSON KATHERINE Zoning:URB(100)/ Applicant: ENERGIA LLC AT: 41 & 43 HAYES AVE Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:7/18/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-KNEE WALL - 2 INCH THERMAL BARRIER POLYISO 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: FeeTyue: Uatc Paid: Amount: Building 7/18/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ORA. City of Northampto Dep .,:..r�. . Building Department Vfi F. A 212 Main Street. Q E ---- Room 100 ULATION Northampton, MA 01060 JUL 2019 phone 413-587-1240 Fax 413-587-1272 ONLY APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY'dWELUN- f NLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address: This section to be completed by office Map Lot (9 0 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current M ilin A ess: L IxAk i2i\'.Xtt Torte Telephone Signature 2.2 Authorized Agent: V1111A 504 Name(Print) Current Mailing Address: y13-3ZZ_ 1\� Signa a Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building �J o� (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= 0 +2+3+4+ 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: ` Building Commissioner/Inspector of Buildings Date ✓�L� @ ,S. EMAIL ADDRESS (REQUIRED; EITHER HOMED ER OR CONTRACTOR) .► '4:. 'y ..••^^�y �". f i "'J:s:-a.rreae„«..+wr s M«� . w f..., .- ,... +►.�lIuPIFw•1b+. .K •nwq yy..” _..C ...w.•we♦.r .. Mo r ,y �Y♦q�Yew,.♦ai!•,iIY•y.ham` .w:iw.,-• �.r!IiO.-. a-'M•�'Wi _ t , 71. j JAW . .,.. .�. . ..K .._ i r � J. 3� •.��If! ..w �'a �.. `+++.� .TI � �... �v rti S •tr ��y 'p, y��� ,.,C ti.i.. -� �• �` *'s Ca (`, =):;d�!13f: •`i `:t w� t o,�.f a� ;.r t=� ?�1� i SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable plli ❑ Name of License Holder:Xbm Licenst Nu b, z 9 Address Expiratio Date S ature Telephone 8. Realstered Home Improvement Contractor: Not Applicable ❑ Company NarAe Registration Number \ Q O Address , ` 2 Expiration ate Telephone`�'� Z�,�\ SECTION 5-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...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY I, ��� J:l► 1 � �1 � 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. Tn"-\ Print Name r- �o Signatur f Owner/Agent Date I, tc) Y% ► r� , as Owner of the subject property 1/ hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature oflowner Date City of Northampton Massachusetts 'A 1' DEPARTMENT OF BUILDING INSPECTIONS �? 212 Main Street • Municipal Building yJd, cam Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work.:T_CLU\Cd \nn Est. Cost: Address of Work: Date of Permit Application: 2 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): 7 Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: (� /?--A IyQ Tom Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Rr t r City of Northampton Massachusetts G WK DEPARTMENT OF BUILDING INSPECTIONS x ~t 212 Main Street •Municipal Building Northampton, MA 01060 Debris 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. The debris from construction work being performed at: (Please print ho45b number and street name) Is to be disposed of at: R\\1 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -7 Zz-h q Signat a of Permit Applicant or Owper to If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. CERTIFICATE OF THIS CERTIFICATE IS ISSUED AS q LIABILITY I N S U RA N C E DATE(MMIDD/YYYY) MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 8/2/2018 E D Ely ICi BELOW. THIS CERTIFICATE OF INSURANCE EXTEND OR ALTER THE COVE R REPRESENTATIVE OR PRODUCER, RTHE AN DOES NOT CONSTITUTE A CONTRACT BETWEEN THE SSUINGF INSURER(S),g THE POLICIES IMPORTANT: If the certificate holderNsD n ADDITIONAL NSUREpTIFICATE ER. the terms and conditions of the olio ( ) AUTHORIZED policy certain policies may requlro an endorsement. A statement on this certificate does not confer rights P y(ies) must be endorsed. If SUBROGATION IS WAIVED certificate holder In lieu of such endorsemeain P PRODUCER , subject to The Dowd Agencies, LLC 9 to the 14 Bobala Road ncin°en C: Ma Conroy Holyoke MA 01040 PHONE J a/c—�esatl:413-538-7444 FAX E-MAIL A/C Nol: ADDRESS: PRODUCER INSURED c o ENELL Energia, LLC INSURERS AFFORDING COVERAGE 242 Suffolk Street INSURER A:Evanston Insurance Com an NAIC N Holyoke MA 01040 INSURER e:Commerce Insurance Company 35378 INSURER C:Sf.,Stone National Insurance Company 34754 -INSURER o:Guard Insurance Grou 25496 INSURER E: 8281 COVERAGES R NU R: 1131630225 INSURER F: THIS IS TO CERTIFY THAT THE POLIO ESTOFCINSURANCIBE STED BELpW HAVE BEEN ISSUED TO TH PERIOD INDICATED. NOTWITHSTANDING ANY REVISION NUMBER: TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT ILTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RED tJAMED ABOVE FOR THE POLICY TR TYPE OF INSURANCE AD DL suBR DESCRIBED HEREIN IS SUBJECT A GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICY EXP UCED BY PAID CLAIMS. X 2DB4466 MMIDD/YYYY MMIDD/YYYY COMMERCIAL GENERAL LIABILITY 7/1/2018LIMITS 7/1/2019 EACH OCCURRENCE CLAIMS-MADE a OCCUR AMA REN E S 1,000,000 PREMISES Ea occun'ence S50.000 MED EXP(Any one Person) S1.000 GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY S 1.000.000 POLICY X PRO- GENERAL AGGREGATE 52,000.000 B AUTOMOBILE LIABILITY LOC PRODUCTS- COMP/OPAGG 52.000,000 ANY AUTO BHQPBJ 7/1/2018 7/1/20195 COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea accident) S 1,000, X 000 SCHEDULED AUTOS BODILY INJURY(Per Person) S X HIRED AUTOS BODILY INJURY Per accident) S X NON-OWNEDAUTOS PROPERTY DAMAGE (Por accident) S C X UMBRELLA LIAR X S EXCESS LIAR OCCUR 7575OH180ALI CLAIMS.MADE 7/1/2018 7/1/2019 S DEDUCTIBLE EACH OCCURRENCE S1.000.000 RETENTION S AGGREGATE D WORKERS COMPENSATION S1,000.000 ANO EMPLOYERS'LIABILITY ENWC952172 S ANY PROPRIETOR/PARTNER/EXECUTIVE Y IN 7/1/2018 S OFFICER/MEMBER EXCLUDED? rlt/2019 X WC STATU- (Mandatory In NH) N/A IMl OTH- If yes,descdbo under E.L.EACH ACCIDENT DESCRIPTION OF OPERATIONS below S 1,000,000 E.L.DISEASE-EA EMPLOYEE S 1,000,000 E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach gCORD 101,Addlllonol Remarks Schodule,If more s i Paco In requlrod) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE BEFORE THE EXPIRATION DATE THEREOF, NOCANCELLED TICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIO To Whom It May Concern NS. AUTHORIZED REPRESENTATIVE A%A✓�,. . 1CORD 25(2009/09) ///©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of M Division of Professional Licensure Board of Building Regulatio Construction Suns ns and Standards CS-092540 Expires; 09/02/2()19THOMAg B ROSSMASSLR 100 MAIN STREET HATMELO MA 01038 Commissioner Lilt, _ ;�. --•-,....._....,—...�-:rte-_:•... r r i�r�rr rrr,•, r• "".• . Officc of Coo4umcr rrrr/r� /(r,,.rr/r;„/l, ' AOME I AN "s&Business Rcgulntion MPROVEMENT License or re ' registration: 165169 CONTRACTOR registration valid Expiration: Type: before the expiration date, for indtvidul use only 1/11 2098 office ofe Gnsuexpi "found return ENERGIA LLC ,d LLC 10 Parlt Plaza_mer Affairs and]Business to: Boston suite 5170 Ztegulatidn MA 02116 THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE MA 01040 Vnderseeretary Not valid tivithout si��– 1 gnature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www-mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Co ntractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Energia, LLC Address: 242 Suffolk St. City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111 Are you an employer?Check the appropriate box: 1.9/I am a employer with__1_9_ 4. [] I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8' Demolition [No workers' comp, insurance comp, insurance.# 9. ❑ Building addition 3.❑ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 1 1.❑ Plumbing repairs or additions 12.[] Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13•❑ Other comp. insurance required.] *Any applicant that checks box#1 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 slate 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: Guard Insurance Group Policy#or Self-ins.Lic.#: ENWC952172 Expiration Date: 7/01/2019 Job Site Address: City/State/Zip; M?\-O(­N l WOW 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 D _P�A for insurance coverage verification. I do hereby certify u r t e pa' s and penalties of perjury that the information provided ab a is true and correct. Si ature: Date: Phone#: 41 -322-3111 E only. Do not write in this area,to be completer/by city or town official.n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son Phone#: �4 Permit Authorization mass save Form Site ID: 3825615 Customer: BLUE RENTALS LLC I, �- ,,thq pc f<r s o n ,owner of the property located at: (Owner's Name,printed) 43 Hayes Ave 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 Signatur I ....... .... . Date: 6'f/f/0 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: Page 1 of 1 For Office Use Orly Rev.102015