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10B-102
BP-2023-0590 111 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-102-001 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-2023-0590 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 3500 ENERGIA LLC 108421 Const.Class: Exp.Date: 02/19/2025 Use Group: Owner: WEIL,JENNIFER S.&WEIL,JOSHUA J.TRUSTEES Lot Size (sq.ft.) Zoning: RR Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2022A HOLYOKE, MA 01040 ISSUED ON: 05/08/2023 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: 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 •i • ivca Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax (413)587-1272 Office of the Building Commissioner ��. (o icr73 The Commonwealth of Massachusetts ' 4, Board S ,l~OR Board of Building Regulations and Standards �Q MUNICIPALITY Massachusetts State Building Code, 780 CM o{ri.//�. USA Building Permit Application To Construct,Repair, Renovate Oi 4 6 a Rdvised Mar 2011 One-or Two-Family Dwelling "`� =%i;J n6„ NS This/_Section For Official Use Only Building ermit Number: ?# A ?. !610 D to A lied: / �t�, * 5-8-ZOZ, s �� Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 111 AUDUBON RD 1.1 a 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: Public 0 Private 0 Zone: Outside Flood Zone? Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: JENNIFER WEIL LEEDS MA 01053 Name(Print) City, State,ZIP 111 AUDUBON 413-820-0619 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other '6 Specify:INSULATION Brief Description of Proposed Work': INSULATION TO ATTIC FLOOR OPEN BLOW CELLULOSE-KNEEWALL RIGID BOARD KNEEWALL FLOOR OPEN BLOW CELLULOSE FG DAMMING-HATCH THERMAL BARRIER POLYISO SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $3500.00 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All F e s: $ Suppression) Lj Check No. 11 Check Amount: t,� Cash Amount: 6.Total Project Cost: $3500.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 108421 2/19/75 BENJAMIN BORDEN/ENERGIA LLC License Number Expiration Date Name of CSL-Holder List CSL Type(see below) 242 SUFFOLK ST HOLYOKE MA 01040 A ess n Type Description ISJ_ U Unrestricted(up to 35,000 Cu.Ft.) Signature R Restricted 1&2 Family Dwelling 413-322-3111 M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) ENFRGIA I LC 165169 HIC Company Name or HIC Registrant Name Registration Number 242 SUFFOLK ST HOI YOKF MA 01040 2/10/24 Adp�s 413-322-3111 Expiration Date Signature • 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 Issuance of the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, SEN N(P-CR uJE I I:..- , as Owner of the subject property hereby authorize ENERGIA LLC - BENJAMIN BORDEN to act on my behalf,in all matters relative to work authorized by this building permit application. tt 1 SEE PERMIT AUTHO Signature of Owner Date 1 ` SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION BENJAMIN BORDEN ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. BENJAMIN BORDEN Print N 1011/ Signature of 0 ner or Authorized Agent Da4;e4 (Signed under the pains and penalties of perjury) 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces NumbetJ 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 •oa r+n Mr�o, Massachusetts 4:�2g'N `I.{0:, DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street is Municipal Building J FCa� Northampton, MA 01060 y CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, 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: t 1 ku o 3d jZ'p . c...t-6- S The debris will be transported by: Name of Hauler: Lt SP L.t1ASr� Signature of Applicant: Date: ►6/2.3 4• 1 I •ice'✓4dv� �yi i:...y - - .. i� I { 40eit mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM Jennifer Weil owner of the property located at: (Owner's Name) 111 Audubon Rd, Leeds (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization 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. G✓� Owner's Signature 04-06-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: l '2G�74 Participating Contractor Date The Commonwealth of Massachusetts Department oflndustrialAccidents '> Office of Investigations =fit_ � Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 � d www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ENERGIA LLC Address: 242 SUFFOLK ST. City/State/Zip: HOLYOKE, MA 01040 Phone #: 413-322-3111 Are you an employer? Check the appropriate box: Business Type(required): 1.❑■ I am a employer with 16 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other Insulation *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: A.I.M. Mutual Insurance Insurer's Address: /// A Lu2)d LI t City/State/Zip: LEE fls / Policy#or Self-ins. Lic. #WMZ-800-8008072-2022A Expiration Date: 7/01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 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 form 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, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date:1/06/23 Phone#: 413-322-311 Ext 122 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1.❑Board of Health 2.1=I Building Department 30 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia Licensee Details Demographic Information Full Name: BENJAMIN BORDEN Owner Name: License Address Information City: HOLYOKE State: MA Zipcode: 01040 Country: United States License Information License No: CS-108421 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 2/23/2023 Issue Date: 4/2/2015 ExpiratIon Date: 2/19/2025 License Status: Active Today's Date: 2/23/2023 Secondary License Type: Doing Business As: ENERGIA LLC Status Chance Reason: Lions'Renewal Registration# 165169 Registrant ENERGIA LLC Name Benjamin Borden Address 242 SUFFOLK STREET City, State Zip HOLYOKE,MA 01040 Expiration Date 02/16/2024 ENERLLC-01 JOCELYN AC0R0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 7/5/2022 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 CONTACT Jocelyn M Douglas NAME: Phillips Insurance Agency, Inc. PHONE FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 Mass,jocelyn@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:A.I.M.Mutual Insurance Company Energia LLC INSURER C: 242 Suffolk Street INSURER D: Holyoke,MA 01040 INSURER E: 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 POLICY 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 BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYY) (MM/DD/YYYY) A )( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PBP2870943 7/1/2022 7/1/2023 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PR0. X LOC PRODUCTS $ 2,000,000 OTHER: E $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) X ANY AUTO BAP2477206 7/1/2022 7/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE _$ 2,000,000 EXCESS LIAB CLAIMS-MADE PBP2870943 7/1/2022 7/1/2023 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B WANDREMPLOYERS'COMPENSATION /N X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE WMZ-800-8008072-2022A 7/1/2022 7/1/2023 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Energia LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD