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41-010 (9) BP-2024-0167 50 LOUDVILLE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 41-010-001 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-2024-0167 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 900 ENERGIA LLC 108421 Const.Class: Exp.Date: 02/19/2025 Use Group: Owner: N LUEKENS JEFFREY W&DEBORAH Lot Size (sq.ft.) Zoning: RR/WP Applicant: ENERGIA LLC Applicant Address Phone: Insurance: 242 SUFFOLK ST (413)322-3111 WMZ-800-8008072-2022A HOLYOKE, MA 01040 ISSUED ON: 02/20/2024 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: I 1 "9 • • Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner (-1,--LacEn -.- Dep .iut. T o�tK -r City of Northampton ¢'� Building Department FES , � �. 212 Room Street ', . .______._ 6 2024 is/' IfsIS1.JL4 TI DN ,., `" ` . Northampton, MA 0106O '� - ..,. ._..... . phone 413-587-1240 Fax 413-587-127ii�� ,,;;�s �' ONL Y ---" :ub0 APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address 50 LOUDVILLE RD FLORENCE Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DEBORAH LEUKENS 50 LOUDVILLE RD FLORENCE Name(Print) Current Mailing Address: See Permit Autho Form 413-727-3032 Telephone Signature 2.2 Authorized Agent: Benjamin Borden / ENERGIA LLC 242 Suffolk St. Holyoke MA 01040 Name Pint) Current Mailing Address: VJ — ' 413-322-3111 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 900.00 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) # a 5. Fire Protection 6. Total = (1 +2+ 3+4+ 5) 900.00 Check Number — S3„' " /� This Section For Official Use Only Building Permit NumbEito dCf.wi g Date Issued - Signature: /G / !` 2- 16- zoZti Building Commissioner/Inspector of Buildings Date ivelice @ energiaus.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder BENJAMIN BORDEN 108421 License Number 242 Suffolk St. Holyoke, MA 01040 2/19/25 Address Expiration Date 413-322-3111 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Energia, LLC 165169 Company Name Registration Number 242 Suffolk St. Holyoke, MA 01040 2/16/26 Address Expiration Date 413-322-3111 Telephone 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 INSULATION TO RIM JOIST RIGID BOARD BENJAMIN BORDEN 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. Benjamin Borden / ENERGIA LLC Print Name 2/2/24 Signature of 0 er/Agent Date DEBORAH LEUKENS , as Owner of the subject property hereby authorize ENERGIA LLC to act on my behalf, in all matters relative to work authorized by this building permit application. See Permit Autho Form 2/12/24 Signature of Owner Date City of Northampton py y rt�•�. .�4�5`� • S� 'rI Massachusetts ��,• �.. `••�� «y sit!' DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street •Municipal Building • • Northampton, MA 01060 44 1� 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: 50 LOUDVILLE RD FLORENCE (Please print house number and street name) Is to be disposed of at: USA WASTE Boston Rd Wilbraham MA (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USA WASTE (Company Name and Address) Signature o ermit Applicant or Owner Date 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. ,� ,, City of Northampton ., r. Massachusetts s , DEPARTMENT OF BUILDING INSPECTIONS y I •Z s 212 Main Street • Municipal Building Ff� 4 r. Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address. 335 BROOKSIDE CIR NORTHAMPTON MA 01062 Contractor Energia, LLC Name: Address: 242 Suffolk St. City. State: Holyoke, MA 01040 Phone: 413-322-3111 Property Owner DEBORAH LEUKENS Name: Address: 50 LOUDVILLE RD City, State: FLORENCE MA ',Benjamin Borden / ENERGIA LLC (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date 2/12/24 The(:ommonwealth of Massachusetts . Department of Industrial Accidents __?� ►._� Office of Investigations TA' Lafayette City Center 1 2 Avenue de Lafayette,Boston,MA 02111-1750 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.El 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.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.1I Other Insulation *Any 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: Lath V I ` J oe- gt, City/State/Zip: N« h- Policy#or Self-ins. Lic. #WMZ-800-8008072-2023A Expiration Date:7/01/2024 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 216 Z Phone#: 413-322-311 Ext 122 Official use only. Do not write in this area,to be completed by city or town official. City or Town: . Permit/License# Issuing Authority(check one): 1.❑Board of Health 2.0 Building Department 3DCity/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 165169 02/16/2026 Boston,MA 02118 ENERGIA LLC BENJAMIN BORDEN 242 SUFFOLK STREET HOLYOKE,MA 01040 Undersecretary of valid without signature kV/ Commonwealth of Massachusetts t Division of Occupational Licensure • Board of Building Regulations and Standards Consi te1'On tSupervisor CS-108421 w spires: 02/19/2025 BENJAMIN El$RD ` 242 SUFFOL ST • HOLYOKE MA 01 ei4' y��lJ~Ybsl,� ooivr K� !/ * µv:�. G �2TiFl TG D/ - L /A \ - \I S s -- SA CK �...RN ENERLLC-01 ALYSSA ACORO DATE(MM/DD/YYYY) 4.,------ CERTIFICATE OF LIABILITY INSURANCE 6/20/2023 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: tf the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 Alyssa Perusse NAME; Phillips Insurance Agency,Inc. PHONE FAX 97 Center Street (A/C,No,Ext): (A/C,No): Chicopee,MA 01013 ADDRESS:ayssa@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:State Automobile Mutual Ins Co • INSURED INSURER B:A.I.M.Mutual Insurance Company 33758 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD IMM/DD/YYYY).(MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2870943 7/1/2023 7/1/2024 PREMSETOEaoNTu ante, $ 500,000 MED EXP(Anyone person) $ 5,000 PERSONAL 6 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X 120. X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: A AUTOMOBILE LIABILITY O aBINEDt)INGLE LIMIT $ 1,000,000 X ANY AUTO BAP2477206 7/1/2023 7/1/2024 BODILY INJURY(Per person) $ OWNED - SCHEDULED AUTOSRREE�� ONLY AUTOS ED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOSONLY (Pe a�identDAMAGE $ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS UAB CLAIMS-MADE PBP2870943 7/1/2023 7/1/2024 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ B AND EMPLOYERS'L IABILITYL ABILLIITY Y/N X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE WMZ-800-8008072-2023A 7/1/2023 7/1/2024 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 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 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 ACCORDANCE WITH THE POLICY PROVISIONS. 242 Suffolk St. Holyoke,MA 1040 AUTHORIZED REPRESENTATIVE i ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD