25A-142 (12) BP-2022-0566
20 BATES ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25A-142-001 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-2022-0566 PERMISSIONIS HEREBY GRANTED TO:
Project# 2022 INSULATION Contractor: License:
Est. Cost: 8000 HOME ENERGY SOLUTIONS INC 106188106188
Const.Class: Exp. Date: 12/28/202312/28/2023
TERCERO-PARKER, JANIXA MASSIELL &
Use Group: Owner: JENIFER LYNN GRAY-LEWIS
Lot Size (sq.ft.)
Zoning: URB Applicant: HOME ENERGY SOLUTIONS INC
Applicant Address Phone: Insurance:
68 RUSSELLVILLE RD (413)203-2454 HOWC1361807
SOUTHAMPTON, MA 01073
ISSUED ON:05/19/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION & AIR SEALING
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney':
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: ( 2 '
t •L
1 _ iII
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
, ,),,'j 04$
- ice .; I
____ City of Northampton
'iz
Building Department
4 i 2022
» 212 Main Street INSULATION; ' '� t � Room 100
,,' ', _Northampton, MA 01060
. rNc trne........_______.
-58 -1240 Fax 41 -587-1272 01/VL 'VONMA01060
,
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION I INSULATION PERMIT
1,1 Property Address: This section to be completed by office 7 a fr--6 '(-- Map 2Sp Lot / `t' .2- Unit d I) J
Zone 01 6 Overlay District
Elm St.District CB District
r
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
J.anixaTercero-Parker ..2.9..B ._St____
Name(Print) Current Mailing Address.
_-61.7-784-0045
_._._.......Attached Telephone
Signature
2_.22 Authorized Agent:
Shawn Mitchell 33 C'ollege HWy Scuthampton_,MA, 01073
Name(Punt) Current Mailing Address
,7'Yll .6.ii— _ 413-203-2454
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
8,000 _ I
2. Electrical ;
(b)Estimates Total Cost of I
Construction from(6)
3. Plumbing Building Permit Fee _ CO
4. Mechanical(HVAC)
5. Fire Protection I
E. Total=(1 +2+ 3 +4+5) 8,000 Check Number 74/8 p
This Section For Official Use Only
Date
Building Permit Number:BP 2,022—06-C lissued:_
Signature: _ / - 5-19-?oz z
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""License Holder' Shawn Mitchell^ 106188
License Number
eUViU8Rd 12/28/23
�oomu �
^ Expiration Date
Signature Telephone
413-203-2454
| 8.Rwaisxere!Home improvement CmWucton Not Applicable O
! �
Home Energy Solutions Inc.
cwmpanvmama | �-egistration Number --' —
| |�
' 233Co/�geHvvySoutha/opmn �A O1O73 |
| _ _ _' __ -' _ _ _ ^ /�22
' 8wdmos _ ExpinsdonDute
Telephone 41.3'2U3'2454
[-
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L0. 152`§25Cp6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
| in the denial nf the issuance nf the building permit.
�
Signed Yes Q� �n O |
/
Brief Description of Proposed Work NOTE~ INSULATION ONLY
'
Blown in insulation and air sealing |
|
�
|
Shawn
A6�W hereby—declare � � info
rmation fo
regoing are
Owner/Authorized- -
de� knowledge
and belief,
Signed under the pains and penalties ofperjury,
Shawn Mitchell
' —
-----
pvmwamv --
u/9n�u�*ownc�xoem ooe ---
,
| J�niX@Te[C�FO-P@rk�[
.__ .an Owner o/the subject
property
hereby authorize Sh@VVO Mitchell -
to act on my behalf, in all matters relafive to work authorized by this building permit application,
---'
Attached 5/12/22
Signature of Owner Date
__ -_-_ -_-
City of Northampton
.7, Massachusetts s
q1/4 le-
a
'4; •
DEPARTMENT OF BUILDING INSPECTIONS
•mi
212 Main Street • Municipal Building
Northampton, MA 01060
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:
Location of Facility: Springfield, MA
The debris will be transported by:
Name of Hauler: Waste Management
Signature of Applicant: 3-Wa,c_,wt, 71/teit?i_joil Date: 5/12/22
,:e\\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
4 '"
,,Az
www.mass.gov/dia
Workers'Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (auseiessiorganizatioafindividuaii:HomeEnery Solutions Inc
Address:233 Collage Hwy
Cit, /State/Zit: Southamiton MA 01073 Phone #: 413-203-2454
,
Are you an employer? Check the appropriate box:
Type of project(required)
I,V I am a employer with 5 4. 0 1 am a general contractor and 1
6. 0 New construction
employees (full and.or part-timc".* have hired the sub-contractors
i
listed on the attached sheet. 7, 0 Remodeling 0 I am a sole proprietor or partner-ship and have no employees These sub-contractors have ' 8, 0 Demolition
'working for rne in any capacity. employees and have workers'
i 9, 0 Building addition
[No workers' comp. insurance comp. insurance.:
reauired] 5. 0 We are a corporation and its 10,0 Electrical repairs or addition
.
lE add
l am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs oraddition
i - i
myself, [No workers' comp. right of exemption per WICit
12.0 Roof repairs
insurance required,' ' c, 152, §1(4),and we have no
employees. [No workers' i 13.0 Other
comp. insurance required] 1
„ .
,4Any applicant that checks bvix tt t must also fill out the section'elow showing their workers compensation liolicy intimation.
'I iomeowners who submit this affidavit indicating they are doing all isiocii and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that chtvk this box must attached 3n additional sheet showmg.the name of the sub-contractors and stale whether or not those entities have
cmployixs. If the soh-err/rumen:sr;have etriployees,they must provide their workers'comp policy nurtiliet,
---:
/oi-n an employer that is providing workers'compensation insurance for my employees', Below IN the policy and job 'ise
information.
Insurance Company Name:AmGaurd Insurance Company
Policy#or Self-ins. tic. 0: HOWC361 807 Expiration Date: 0 1/04/2023
Job Site Address. 20 Bates St Northampton,City/State/Zip.. MA 01060
-"
Attach a copy of the workers' conipensatIoa policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MU._ c. 152 can lead to the imposition of criminal penalties of a
tine 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 II
of up to$250.00 a day .:4inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the WA for insurance coverage verification.
/do hereby certit3,an t c pains and petialtie' ; 'arty that the informafion provided above is true and correct.
&vita tore: X° Date; „5/12/22,
: 440144.-
1..'„Itc.?fle#: A1.3-2.03-2454,
IIOfficial live only. Do not write in this area, to be completed by city or town official
Permitit,kerise City or Town:
Issuing Authority(cheek,one
#
,1 I Li Board of Health 2LJ Building Department 30Cityrtown Clerk CO Electrical Inspector 5E1'lumbing
11 inspector 6.00ther
if
0 Contact li C Person: Phone#:
A _ ... .
—2.-
DocuSign Envelope ID:9EFA63D9-091C-4348-86DD-C6FF6EEE84C3
RISES
ENGINEERING"
OWNER AUTHORIZATION FORM
Janixa Tercero-parker
(Owner's Name)
owner of the property located at:
20 Bates 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.
p--^OocuSigned by:
O n i��°S°12'r�fi3re
1/15/2022 1 8:54 AM 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