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31B-031 (5)
BP-2022-0140 38 MYRTLE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-031-001 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-2022-0140 PERMISSIONIS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 2000 ENERGY PROTECTORS INC 101143 Const.Class: Exp.Date:06/16/2022 Use Group: Owner: DOBRSKA, ELIZABETH Lot Size (sq.ft.) Zoning: URC Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6S62UB0G29826021 Spencer,MA 01562 ISSUED ON:02/14/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i • • . • Fees Paid: $65.00 • 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner F: The Commonwealth of Massachusetts 2 Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Re'ised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ,1h Date Applied: 1 I i '# e; Building Official(Print Name) Signature 1' Date SECTION 1:SITE INFORMATION 1.1 Property� Address: 1.2 Assessors Map&Parcel Numbers JJ yv1/ c_. 5 l.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public 0 Private CI Municipalif yes❑ Municipal 0 On site disposal system CI SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: _ b , �Zc�hcrt`s'1 U SIA OrOhc..,vhp ► I't - G I06c3 Name(Print) City, State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other IiYSpecity: Vs Su f.N icf\ Brief Description of Proposed Work': t 1r1 i r c)r A rJ cc, vx e- i13 Scw► epZ4q e.r (k ,tp4)r— , -r• C rctc.. 5 P ck SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 1 0 U J 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ /r Suppression) Total All Fees: VJ Check No.y heck Amount: Cash Amount: 6.Total Project Cost: $ l)OD ❑Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-101143 6/16/22 Joshua Dada License Number Expiration Date Name of CSL Holder U 64 Paxton Rd List CSL Type(see below) No.and Street Type Description Spencer,MA 01562 U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 774-253-0277 jdada79@hotmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 172960 8/19/22 Energy Protectors Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 64 Paxton Rd jdada79@hotmail.com No.and Street Email address Spencer,MA 01562 774-253-0277 City/Town,State,ZIP Telephone SECTION 6: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 Issuancece of the building permit. Signed Affidavit Attached? Yes EY No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print 0\‘ner's Name(Electronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the informat on contained in this application is true and accurate to the best of my knowledge and understanding. t �'l DC-1.GiCt QiCCI2Z Printt wner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will ysi have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms __ Number of bathrooms Number of half/baths _ Type of heating system Number of decks!porches __ Type of cooling system Enclosed Open _ 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton (:," Massachusetts �w2 '<<, e * w c. DEPARTMENT OF BUILDING INSPECTIONS y t"; �1 Wf �i 212 Main Street • Municipal Building Jti cb' § _. '" Northampton, MA 01060 4s111, 3<N‘ CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: 64 PLocation of Facility: ct a ck S eery'C r', ,M A o( S 6,)-- The debris will be transported by: Name of Hauler: _Fnc,`51 pc sic-}zlS -I Jv C" Signature of Applicant: D 6 Date: ` ( `S( ly The Commonwealth of Massachusetts ,= Department of Industrial Accidents 1 Congress Street,Suite 100 �,` Boston,MA 02114-2017 d www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING At'THORITT. Applicant Information Please Print Legibly Name(Business'Organization Individual):Energy Protectors inc Address:64 Paxton Rd City/State/Zip:Spencer,MA 01562 Phone#:774-253-0277 Are you an employer?Check the appropriate boy: Type of project(required): LE)I am a employer with '1 employees(full and or part-time).* 7. El New construction I am a sole proprietor or partnership and have no employees working forme in an capacity.[No workers'comp.insurance required.) 8. y Remodeling 9. ❑Demolition :.a I am a homeowner doing all work myself.[No workers'comp.insurance required.)" 10[l Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per\IGL c. 14.©Otherinsulation 112,§l(4),and we have no employees.[No workers'comp.insurance required.] !Any applicant that checks box=I must also fill out the section below show ing their workers'compensation policy information. 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 nry employees. Below is the police and job site information. Insurance Company Name:Ace American Insurance Co Policy #or Self-ins.Lic,#:6S62UB0G29826021 Expiration Date:9101/22 Job Site Address: 3 Yil C A--‘t.... c--1' City/State/Zip:hibri-rtic„wy f (PIA- (j i% Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: `6C'�' ._ Date: '�/ / )- 2.— Phone#: e :.YS----1^0j)-7.3) 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#: '` c�,,.!rd CERTIFICATE OF LIABILITY INSURANCE DATEDAWDD/YYYY) 08/30/21 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 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. Nike csrtlflostki hoideris an ADDRICNUL INAURED,the polkcy(les)must have ADDITIONAL INSURED provisions orbs endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this oerttflcate doss not confer rights to the certificate holder In lieu of such endorsement(s). p*oaucaR 'It+1'"0' Nina Arroyo rr;+ ��,� Coonen Insurance Agency,Inc, s. , 608•g87.7122 ilA�l..Nol: 8084$7.7152 267 Main Street f+*t ; Nlnadlcoonaninsurance.00m Oxford,MA 01040 e+sularRtal APPORDINo COVERAGE NAN;r INSURER A: AIX Specialty memo INSURER tR: Safety , Energy Protectors,Inc. INSURER C: Century Surety insurance 64 Paton Road INSURER o: Spencer,MA 01562 a14uReR 4 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P&LICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR 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�BpY PAID CLAIMS.CL�p��S.� NI TYPE of INSURANCE POLICY NUNpR (RIOIdOKYYYI,flrlalDlYY]Y1 1.105TE COMMERCIAL OSNERAL UAUIUTY Minna tIRRn IQC `I 1,000,000 CLAIMs.MADE 0 OCCUR POEMS cap m6Ironou j 100,0004 MED EXP(MY 0(08.11011 $ 0,000 a — y L1N41714840.00 08/31/21 08/31/22 PERSONAL oaovINJURY $ 1,000,000 I.AGORItK1 pLIMIT S PER, GENERAL AGGREGATE ,i 2,000,000 POLICY JECT ICC PRODUCTS•COMM.AGO I 2,000,000, i OTHER AvroMOelu LIAea RTY WiER DrminaLamr $ 1,000,000 —ANY AUTO BODILY INJURY(Pre psrsorq i e � x SCT�LL&D y 8236510 12/Z)1/20 12/23/21 BODILY INJURY(P�r I,odderrl) $ AUTOSila, NON•OINNH�IR�EgD� ONLY PR TY M OE i 25, AUTOS ONLY AUTOSED �IPr I k UMSREU,A LIAR OCCUR EACH OCCURRENCE _$ 3,000,000 c EXCESS LIAO N CLASI5•MAOE y CCP100674S 08/31/21 08/31/22 AGGREGATE ,I 3,000,000 �p�pIrI E�'{ 7 ! Otl0Aim C�ATION4/ v antrum 1 (Z• , AND IMML.OYURS'IRAIN TY Y N ANY ARTNERIEXECUTIVE N El.EACH ACCIDENT $ I y�vNs EIY� ixcLUDEo? A E.L.MAW OWN ASE•EA EMPLOYJ5 I dresIbe toy DE64,RIPTION or ortrAnomo below E.L.DIS$ASE•POLCY LIM(7, I DESCRIPTION OF OPERATIONS I LOCATIONS I YaMICLta(ACORD 101,Addlbo„M Remarks Schedule.may be eteeMd M more space le,svulrb) Workers Compensation Insurance certificate to follow under seperste cover. Action Inc.and National Grid USA Its direct and Indirect parents subsidiaries and sfRllates shall be named es additional insured on Commercial General Liability and Automobile Liability policies CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Worcester Community Action , Council 484 Mein St.sta.200 AUTHORIZED REPRESENTATIVE Worcester,MA 01608 . I 1986.2015 AC D CO ON. AI rights ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AIR©® CERTIFICATE OF LIABILITY INSURANCE DATE(M4DONYYY) 08/3112021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(Ies)must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER ►IA COfITb1 ACT --_.- Nina Arroyo ------------- ----• COONAN INSURANCE AGENCY (Aic (SOS) FAx 508 987-7122 IAIC.N9l,'._...____...___.... A p ems; Nina:,,coonaninsurance.com _ a 267 MAIN ST , INeulee!il$J AFFORDING COVERAoe . _.f±Mao OXFORD MA 01540 I1euRERA; ACE AMERICAN INSURANCE CO 22687 INSURED INSURER s: ENERGY PROTECTOR INC INSURER C: . INSURER 0: . 64 PAXTON RD INSURER_ SPENCER MA 01582 Ir•tmERr; COVERAGES CERTIFICATE NUMBER: 890758 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION DP ANY CONTRACT OR 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. I`TR TYPE OF INSURANCE ylam POLICY RAISER ( 10 7rY 1 LIAM COMMERCLAL GENERAL LIABILITY EACH OCCURRENCE $ -- -107 0rYO RENTED MED Exe fenny oMprwn) { _.._.. .._.�___-.-, _ — ' PeRsoriAL s AOV INJURY CiAIMe•MADE _ ' OCCUR ME _ . N A '$ GErri AGGREGATE ppLII�MIIT..APPLIES PER •GENERAL AGGREGATE ,I POUC'e .fita i LOC pRocucrs•coMvroP ACM ....,OTTER .. _..._ ` AUTOMOBILELIABI.ITY Erbasststen11.. SINGLELIMIT $ _ ANY AUTO BODILY INJURY(Per priori) .6 ... AL`OWNED `— SCHEDULED N.A BODILY INJURY(Per accident) $ ,__AUTOS ___.. AUTOS dROPERTY DAMAGE '—�—� HIRED AUTOS ___AUTOS NON.OWNED .( EL _._. s f t UMBRELLA LIAS OCCUR EACH OCCURRENCE L — ExCEes LAB CLAIMS-MADE N'A AGGREGATE T T • WORKERS COMPENSATION X _!* AND EMPLOYERS'UABILITY g ANYPROPRIETORMARTNER ExECUTNE el.EACH ACCIDENT _ S 500,000 A concek(Mandatory In NH)IAEMSEREXCWDED7 NIA NIA 6S62UBOG2982602' 09/01/2021 09/01I2022'ea.DlsPJ1eE•EAEMPLOYE ti 500,000 ____�._•__.__,..___ _.__ If yes,deacnte visa E.L DISEASE•Pouc�Limp,s fi00,000 _DESCRIPTION oc OPERATIONS wow NIA DESCRIPTION or OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,AdaIUOMI Remark(Schedule,may bo NfasMd If mon sorts Is neutnd) Workers'Con,pensalon benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires.Of has hired those employees outside of Massachusetts. This certificate of nsurence Shows the policy In force on the date that 11is cent 9c to was Issued(unless the expiration date on the above policy precedes the issue date of this cad/fiesta of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage•Coverage Ver(fleation Search tool at woos mass.govfwd/workers-compensation)�nveslpatansl, Sole proprietor has no:elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIEB BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Eversource National Grid ClearResult ACCORDANCE WITH THE POLICY PROVISIONS. 120 Turnpike Rd Suite 200 AUTNOR12E0 REPRESENTATIVE Southborough MA 01772 Daniel M.Crowley.CPCU.Vice President—Residual Market—WCRIBMA 01955.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD .isuilwaolo woo . : .....--i-t;•0000"1„........00-40 , -mom ..---1-00 ....N. . • • ,, . . , . 4 1 i } i i P i 4 1 4 a II iii . i ll DocuSign Envelope ID:EF231 F81-8C1E-4277-8CA3-103211C58A68 RISES ENGINEERING' OWNER AUTHORIZATION FORM Elizabeth Dobrska (Owner's Name) owner of the property located at: 38 Myrtle Street (Property Address) Northampton, MA 01060 (Property Address) hereby authorize Subcontractor(to be filled in by office) 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. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. DocuSigned by. Ow c rn-16116re 12/27/2021 18:52 PM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com