17A-035 (6) BP-2021-1971
244NORTH MAPLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-035-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-1971 PERMISSIONIS HEREBY GRANTED TO:
Project# insulation Contractor: License:
Est. Cost: 8000 HOME ENERGY SOLUTIONS INC 106188
Const.Class: Exp.Date: 12/28/2023
Use Group: Owner: WINSTON, MICAH A. &BHARATI E.
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant: HOME ENERGY SOLUTIONS INC
Applicant Address Phone: Insurance:
68 RUSELLVILLE RD (413)203-2454 HOWC140654
SOUTHAMPTON, MA 01073
ISSUED ON:09/30/2021
TO PERFORM THE FOLLOWING WORK:
insulation/wea th eriza tion
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.
Signature: a' rII
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
ifie
C / >, %,
� �•lA�r�, City of Nor#hamptoh '�--., �<
F
Building Department v
(��' `, ,.A ��` 212 Mairv'Stre t SEP �7INSULA lIONRoorr100 2 9
Northamptdn, M9 ` ?� ,,
phone 413-687-1240 ' & b,� ONE. Y
tanT r'rNc,,_
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMN.Y:DWELL1ttiG ONLY
SECTION 1 -SITE INFORMATION INSULATION Ply MI PERMIT
1,1 Property Address:
This section to be completed by office
244 North Maple St Map Lot Unit
Northampton, MA 01062 Zone Overlay District
__ Elm St.District CB District
^SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
2.1 Owner of Record:
Micah Winston 244 N Maple St Northampton, MA 01062
Name(Print) Current Mailing Address:
_ Telephone
1 Signature
2.2 Authorized Agent:
Shawm Mitchell
j .,___..___.__ ._. _. ._. 233 College Hwy Socithampton MA, 01073
I Name(Print) �.�-- Current Mailing Address:
//JJ
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
, completed by permit applicant
". Building 8,000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
a Construction from(6) ,
, 3. Plumbing Building Permit Fee 1�
4. Mechanical(HVAC) (/t/7 /,�
5. Fire Protection
�
'7 7/
6. Total=(1 +2+ 3+4+5) — Check Number _ / /,
This Section For Official Use Only
Building Permit Number:[bO e )"I9 l I Date
Issued'_
// _ 9
Signature: 30'COZ 1
—
Building Commissionerlinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
r
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder; Shawn Mitchell 106188
License Number
68 Russellville Rd 12/28/23
Address Expiration Date
413-203-2454
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Home Ener9Y,Solutions Inc. 193885
Company Name Registration Number
233 College Hwy Southampton MA, 01073
12 4i22
Address Expiration Date
Telephone 413-203-2454
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 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
Blown in insulation and air sealing
! Shawn Mitchell ,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.
Shawn Mitc //I/
Print Name
9/20/21
Signature,of neriAgent Date
,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 Owner Date
The Commonwealth of Massachusetts
,,,e;......,,
Department of industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.govidia
Workers'Compensation Insurance Affidavit: Btiliders/Contractors/Electricians/Plumbers
Applicant Information , Please Print Legibly
Name (Ftusincw'Organizationlindividual):Home Energy Solutions Inc
Address:233 College Hwy . .........
City/State/Zi : Southam•ton. MA 01073 Phone#: 413-203-2454
i Are you an employer? Check the appropriate box:
Type of project (required):
1 1. I am a employer with 5 4, 0 I am a general contractor and I
6, 0 New construction
employees (full and or part-time),* have hired the sub-contractors
I am a sole proprietor or partner- listed on the attached sheet, 7. 0 Remodeling
These sub-contractors have ship and have no employees 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. E]Building addition
[No workers' comp. insurance comp. insurance.:
required] 5. Ei We are a corporation and its 10.0 Electrical repairs or additiot
3,[7] 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additiol
myself. [No workers' comp. right of exemption per MGI_,
12.0 Roof repairs
insurance required.] ' c, 152, §1(4),and we have no
employees, [No workers' 13.2/Other Insulation
, comp. insurance required.]
*Any applicant that checks box F;I must also fill out the sezi ion below showing their workers'compensation policy information.
'1 iorneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
ontractors that check this box must attached an additional sheet showing the name of the sub-conrracturs and state Whether or not those entities have
employees If the sub-contractors h loyees,they must provide their workers'comp,policy number,
—-4
/um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:AmGaurd Insurance Company
Policy or Self-ins. Lie. #: HOWC251367 Expiration Date: 01/04/22
Job Site Address: 244 N Maple St City/State/Zip:Northampton, MA 0106;
Attach a copy of the workers' compensation policy declaration page(showing the polity 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
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
of up to$250.00 a day against the violator. fileadvised that a copy of this statement may be forwarded to the Office of
Invesfigations of the DIA for insurance.c.P.Vierage verification.
,,.. .
I do hereby certify an painw perjwy that the information provided above is true and correct.
„.."7
paw: 9/20/21
Phony 4: 413-203-2454 -t , _
Official use only. Do not write in this area, to he completed by city or town official.
1
1 Cif or Town: Permit/License #
..
issuing Authority(check One):
1 I alloard of Health iD Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E3Plumbing
Inspector 6.00ther
----
I Contact Person:
Permit Authorization
mass save Form
S.wwwis rtmoil erwe y er€fr erx'y
Site ID: 4275834 Customer: MICAH A WINSTON
I� Micah Winston and Bharati Winston owner of the property located at:
(Owner's Name,printed)
244 N Maple St Northampton, MA 01062
(Property Street Address) (City)
herebti,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: /VW W/ 5rON
Date: 08 / 01 / ...
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 Use Only
Document Ref:TJVGR-I29PS-86U2Z-RJXXP Page 7 of 9