12C-064 (4) 9 HAROLD ST BP-2020-0748
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-064 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-2020-0748
Proiect# JS-2020-001290
Est.Cost: $1400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq.ft.): 10672.20 Owner: BOUGHAN PATRICK
Zoning: RI(100)/URA(100)/WSP(]00)/ Applicant: ENERGIA LLC
AT: 9 HAROLD ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322-3111 WC
HOLYOKEMA01040 ISSUED ON.1212312019 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION
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 12/23/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
' Dep
OR—
r City of Northampton
Building Department �e
212 Main Street F� INSULATION
Room '1(T0. 10
Northampton, MA 0: 1?0 19
phone 413-587-1240 Fax 41-1'', 72
ONLY
�n� ^✓cp /
APPLICATION FOR INSULATION FOR A ONE OR TWO FA � tWEXLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
Map Lot Cyj 4 Unit
c\0 V�C Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 3 I
a1" ot6 �FkCCQA- E\OVI 1fU ,\`/\AOI Z.
Name(Print) Current Mailing Address:
� .\mo Telephone
Signature
2.2 Authorized Anent:
2-1—\ �U���11F, t N�IcE.MflGI
Name(Print) Current Mailing Address: IJ
Signatur T�phone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building {� 1 140 (a) Building Permit Fee
2. Electrical y, `-1 (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Q -00 Check Number 3
Ll This Section For Official Use Only
Building Permit Number: �/r '�^ �T 0 Date
Issued:
Signature: a�1Q Z)9
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder T6 m Y-p-, f ) y 02-?_'`1\J
License Number
2 M Cil 0Z 12CLI
Address Expiration Date
IS 32Z 31 k \
Signa re Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
Jn \a UL . \1�15\6q
Company,N me Registration Number
Z47 St c��►�. St-. �o`un� N�f�t Olayo oi I �nfZ070
Address 2 Expiration Da e
Telephoneu�3
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....... td' No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONL Y
nSv PA-Vkc, -�uk- N A cpcq T
I, iom 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.
1C)
Print Name
Signature er/Agent Date
as Owner of the subject
property
herebyauthorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
'&r— PC nnk-t f��t h �r r� 1Z / �W 10\
Signature of Owner Date
City of Northampton
Massachusetts
c
1 DEPARTMENT OF BUILDING INSPECTIONS �. x
M
212 Main Street •Municipal Building
„ Northampton, MA 01060 ssbh 37C�,
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:
"Ofo1 d 5 Vf'��
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Q`C a.SDr n9-FifMA01\0�-1
(Company Name and Address)
/9 rg
Sig ture of Permit Applicant or Own,9(r Da
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.
ENERLLC-01 CHRISTINE
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO/LDER01 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,theotic (o
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 rights to the certificate holder in lieu of succh a dsoment sl s)must have
ADDITIONAL INSURED provisions or be endorsed.
PRODUCER
Phillips Insurance Agency, Inc. c NTA CT Christine Sullivan
97 Center Street PHONE
Chicopee,MA 01013 A/C,No,Ext):(413)594-5984 Fa/c 84
Ne;(413)592- 99
EMAIL .Christine
phillipsinsurance.com
NSURER S AFFORDING COVERAGE
INSURED INSURER A: tate AUtom Oblle Mutual Ins CO NAIC#
Energia LLC INSURER E3:Guard Insurance Group
242 Suffolk Street INSURER C
Holyoke,MA 01040 INSURER D
INSURER E:
COVERAGESCINSURER F:
ERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE MBEOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT TH 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 BEEN REDUCED BY PAID CLAIMS.
INSR
TYPE OF INSURANCE
ADD,SUER
A POLICY NUMBER POLICY EFF POLICY EXP
X COMMERCIAL GENERAL LIABILITY LIMITS
CLAIMS-MADE �OCCUR X PBP2870943 7/112019 7/1/2020 EACH OCCURRENCE S 1,000,000
DAMAGE TO RENTED
s 100,000
MED EXP An one erson S 5,000
GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY S 1,000,000
POLICY 1XI JECT 1:1 LOC GENERAL AGGREGATE 2,000,000
OTHER: PRODUCTS-COMP/OPAGG S 2,000,000
A AUTOMOBILE LIABILITY
X ANY AUTO
COMBINED SINGLE LIMIT S
BAP2477206 1.000,000
OWNED 7/112019 7!1/2020 s
AUTOS ONLY SCHEDULED BODILY INJURY Per erson S
AUTOS
AUT03 ONLY NON'pWN D BODILV INJURY Per accident S
AUTOS Of�LY PROPERTY AMAGE
Per accident S
A X UMBRELLA LIAR X OCCUR
S
EXCESS LIAB CLAIMS-MADE PBP2870943 EACH OCCURRENCE S 1,000,000
DED X RETENTIONS 0 7/1/2019 7/1/2020 AGGREGATE S 1,000,000
B WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY S
.ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N ENWC989225 PER OTH-
QFFIIAIIIIE FR
datoCER1NY-MBE�EXCLUDED? NIA
7/1/2019 7/1/2020
It
In and E.L.EACH ACCIDENT S_ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE- A EMPLOY E 11000,000
E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may bo attached Ir more space Is required)
CERTIFICATE HOLDER
FCANCELLATION
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)
9The ACORD name and logo are registered marrksof88-2015 CORD CORPORATION. All rights reserved.
ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
4 J 600 Washington Street
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 St.
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer? Check the appropriate box:
. 1 am a general contractor and I Type of project(required):
1. 1p 1 aa employer with 1 4 ❑ g
�g
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. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ 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 10-ElElectricalrepairs or•additions
3.❑ 1 am a homeowner doing all work officers have exercised their II—E:1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §1(4), and we have no 12.❑ Roof repairs
employees. [No workers' 11❑ 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. #: ENWC989225 Expiration Date: 7/01/2020
Job Site Address:q uacoks:A Cit /State/Zi
Y P:_Y—�� Mia C){OC7Z
Attach a copy of the workers' compensation policy declaration page(showing the policy numberand expiration date).
Failure to secure coverage as requited 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 forth 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 unit the pains and penalties of perjury that the information provided above is trite and correct.
Sinature:
Date:
Phone#: 413- 22-3111
F
cial 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#:
R ISE
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Patrick Boughan
(Owner's Name)
owner of the property located at:
9 Harold Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize C w ` A
(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.
Owner's Signatur
-7—
Date
vr-E
RISE Engineering, a Division ofThielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.RISEengineering.com
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Co nstru+r04A"S609rvisor
CS-092540Expires:09/02/2021
THOMAS B ROSSML
100 MAIN STREET
HATFIELD MA,01Q3
Commissioner
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
165169 01/10/2022 1000 Washington Street -Suite 710
ENERGIA LLC Boston,MA 02118
THOMAS ROSSMASSLER �)
242 SUFFOLK STREET
HOLYOKE,MA 01040 Undersecretary Not valid without signature