17C-173 (5) 25 FAIRFIELD AVE BP-2020-0543
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 173 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-2020-0543
Project# JS-2020-000932
Est.Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq.ft.): 8015.04 Owner: SILVERMAN JOSEPH L&
Zoning: URB(100)/ Applicant. ENERGIA LLC.
AT. 25 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON.10/28/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND BASEMENT INSULATION AND AIR
SEALING THROUGHOUT
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 10/28/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
a-65 p zo Sof 3
Dep
sr- City of Northa ptonIN
, = Building Depa m�}tT 2 8
212 Main S ree{{ 219 INSULATION
0
Room 1
Northampton,
phone 413-587-1240'�a�i ?!oNs ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address This section to be completed by office
Map�(,� � Lot�7 ? Unit
25 \� �\ 1� Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
7r,`fzlLa r)
Name(Print), Current Mailing Addres
�o KAV� Telephone
Signature
2.2 Authorized Agent:
1 2 1 V OULA
Name(P t) Current Mailing Address:
LAI - .322---?N\I 1
Si ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2,060 ,OO (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Y/n
5. Fire Protection (�
6. Total = (1 + 2 + 3+4 + 5) t Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: V d6
Building Commissioner/Inspector of Buildings Date
�:k/F LCC- @
EMAIL ADDRESS (REQUIRED; EITHER HOMED R OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicabbll7e 0
Name of License Holder: l o m �j�jr� ��� 77G
License Number
M LQ2 12-!:�2 1
Addre Expiration Date
Si ature Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
Company Na he Registration Number
2147 h16 004C) \ 110IZC�
Address Expiration Date
Telephone
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 ONL Y
I, Tc)m 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.
'Tom If Rom ff c le�(
Print Nam
IdI2 311
SignatuAe o Owner/Agent Date
"1._ n as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Ckvner Date
City of Northampton
4 ..�
1 N y Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ti
;'�W, 212 Main Street •Municipal Building
7 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:
2.5 g��r
(Please print house number and street name)
Is to be disposed of at:
�11i dy�1c��te ykl��a.sof,wafre\d,M�o�\Cly
(Please print name and location of facility) -i
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
1 I /Z01G
Signat Permit Applicant or Owner Date
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.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS yt
212 Main Street • Municipal Building `�6j•.,• 0C`�
Northampton, MA 01060 SAY NOS^
Property Address: ZS �Q\�����['� Rn V\oYcy'ct .MR or'xc-ell_
Contractor THOMAS ROSSMASSLER-ENERGIA LLC
Name:
Address: 242 SUFFOLK ST
City, State: HOLYOKE, MA 01040
Phone: 413-322-3111
Property Owner
Name: JQ�DI'1 �1�\9IY`C�,n
Address:
City, State: M CA Okc)(�2
1, THOMAS ROSSMASSLER (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
�CO�mn!Mnlnwealth of Massachusettsn of Professional Licensure
Board of Building Regulations and Standards
Const") §d0ervisor
CS-092540
THOMAS B J Pires:09/02/2021
100 MAIN S Ik ET ASSLER ',
HATFIELD M4,101038
f
Commissioner
Officc of Coasumcrgffairs&Busmcss Regulation
j #IOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
)Registration: 165169 before the expiration date. If found return to:
Expiration 1/11/2018 Type'LLC Office of Consumer Affairs and Business Regulatidn ENERGIA LLC I0 Park Plaza-Suite 5170
Boston
,MA 02216
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE, MA 01040 `'�'� \:.r•>_—._
IJuderseeretary _. l
Not valid}vithOut signature
.r
AC ENERLLC-01 CHRISTINE
�-- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOILDER.1 HIS
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(ies)must have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in lieu of such endorsement s.
PRODUCER
C NTACT Christine Sullivan
Phillips Insurance Agency, Inc. PHONE
97 Center Street A1C,No,Ext:(413)594-5984
Chicopee,MA 01013 E-MAIL (A/C.No :(413)592-8499
christine phillipsinsurance.com
INSURER 5 AFFORDING COVERAGE NAIC#
INSURED INSURER A:State Automobile Mutual Ins CO
Energia LLC INSURER 13,Guard Insurance Group
242 Suffolk Street INSURER C
Holyoke,MA 01040 INSURER D
INSURER E:
COVERAGESINSURER F
' NUMBER:
NAMED A OnVEE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
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 INSR POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP
A POLICY NUMBER
X COMMERCIAL GENERAL LIABILITY LIMITS
CLAIMS-MADE X OCCUR EACH OCCURRENCE S 1,000,000
X PBP2870943 711(2019 711/2020 DAMAGE TO RENTED s 100,000
MED EXP(Any oneperson) S 5,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PERSONAL&ADV INJURY $ 1,000,000
POLICY� T 1:1 LOC GENERAL AGGREGATE 2,000,000
OTHER: PRODUCTS-COMPIOPAGG 2,000,000
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
X ANY AUTO BAP2477206 s 1'000'000
AWNED LSCHEE 7/1/2019 7/1/2020 j BODILYINJURY(Per person) S
TOS ONLY
RED TOS ONLYBRELLALIAR S
CESS LIAB PBP2870943 EACH OCCURRENCE $ 1,000,000
7/1!2019 711/2020AGGREGATE s 1,000,000
D X RETE
B WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY PER OTH-
$
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N ENWC989225
7/1/
QMaFFnICER/MC-MBER EXCLUDED? NIA 2019 7/1/2020 E.L.EACH ACCIDENT S 1,000,000
datory In NH)
'
Ifyes,descni"'0 er E.L.DISEASE-EAEMPL EMPLOYE 1,000,000
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required)
.CERTIFICATE HOLDER
-- CANCELLATION
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
ACORD 25(2016/03)
988-2015 The ACORD name and logo are registered marks ofCORD CORPORATION. All rights reserved.
ACORD
The Commonwealth of Massachusetts
kqDepartment of Industrial Accidents
Office of Investigations
jp
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2iblly
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: Type of project(required):
1.VI am a employer with_ 19__ 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have
8. F-1 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
$ 9. [:] Building addition
required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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' 13.0 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 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: Guard Insurance Group
Policy#or Self-ins. Lic. #: ENrWC989225 Expiration Date: 7/01/2020
Job Site Address: _2-IS 1� \�t \ ,� �� City/State/Zip:Y\aVe_W_f ,V\0V oc%�z
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.
Ido hereby certify u er the pains and penalties of perjury that the information provided above is true an correct.
Si ature: �d 2
Date:
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#:
i
BUILDING PERMIT AUTHORIZATION FORM
1,
O Se k S, � V mm2✓� owner of the property located at:
(Own is Name,printed)
(Property Street Address) (City/Town)
hereby authorize Thomas Rossmassler of Energia, LLC. to act on my behalf and obtain a building
permit to perform insulation/weatherization work on the above named property.
Ae"l- zZk� — - W3-543 - � // g
O er's Signature Telephone Number
lfl�/�lj`1
Date
i