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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