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31A-217
Property Address: rl 9 4n( o` r\ a Y l p � Name: actor 1 r f 1V M I M`e ev\r-etqf Address: v C4\f City, State: Cj MA O 3" Phone: - c 3 3 ∎- i Property Owner Name: ke 5 S l Address: Yr\ OVV Q City, State: + v O" 4((LNY\ r‘ l o ow I, i&VnJS Pi (I S (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. • ntr: ctor sign; e Y-! S Date r- f eamimo4tateatA • =7-7 - Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massac 02116 Home Improvement Con tutor Registration - =^ Regisbaiion: 146402 Type: Private Corporation Expiration: 422/2013 Trd 209431 IDEAL HOME IMPROVEMENT INC JAMES ELLIS 142 BOYLE RD GILL, MA 01354 Update Address and Marra card. Mark reason for change. f l Address fl Renewal D Employment D Lost Card PS-cm 0 500.44034- 6101216 Massachusetts - Department of Public Safet% F, Board of Building Regulations and Standards Construction Supervisor License License: CS 91207 JAMES P EWS 142 BOYLE RD ' ` f GILL. MA 01354 Expiration: 1W16/2012 <'onuni inner Tr#: 3269 ACORD* DATE (MM�HDDIYYYY) L.,...- CERTIFICATE OF LIABILITY INSURANCE 1 11/1912010 PRODUCER Phan& 413.8634313 Fax 413863.9856 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTWICATE 159 AVENUE A HOLDERR, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 391 .TER THE COVERAGE AFFORDED BY THE POUCCS BELOW. TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC 8 INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. INStNtER B: PILGRIM INS. COMPANY 142 BOYLE ROAD INSURER C TECHNOLOGY INSURANCE COMPANY GILL MA 01354 INSURER D: INSURER E COVERAGES THE POLICES 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 DESCRIED HEREIN E SUBJECT TO ALL THE TERMS, EXCLUSIONS AM) CONDITIONS OF SUCH POLICES. AGGREGATEL.MRS SHOWN MY HAVE BEI M REDUCED BY PAD CLAMS. I LIR R ADM ROUST EFFECTIVE POLICY EXPIRATION LT eLSR[ TYPE OF DANCE POLICY EMBER DATE RI LIOOn ) DATE uwvnarn umnS GENERAL UABILTIY GL 20109227 11/19/10 11119/11 EACH OCCURRENCE _ S 1,000,000 X coMMaRCIAt GENERAL tJABAITY ANINU3E TO N $ 100,000 RENTED 1 CLAMS MADE © OCCUR ME). ocP (Any One Parson) _ S 5,000 A PERSONAL & ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 ` GENT AGGREGATE UNIT APPUES PEt PROOUCTS -COMP/OP AGG s 2,000,000 7 POUcT ' J iFerPRe. flLOD $ AUTOMOBILE UABIJTY PGC10 009703302 11/17/10 1 "_ CoMeINm SINGLE LIMIT s 1,000,000 _ ANY AUTO (Ea ) – _ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Perm/son) $ B _ X HIRED AUTOS BODILY INJURY s X NON AUTOS (Per accident) ^- X MASS.P000YFORM DAMAGE � $ GARAGE UASSITY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG S EXCESS 1 UMBRELLA UA81UTY EACH OCCURRENCE S OCCUR 0 CLAMS MADE AGGREGATE _ s S _ — DEDUCTIBLE $ RETENTION $ 1 $ W A COMPENSATION WC1136680 11118/10 11118/11 X I ( (°i ' EMPLOYERS' l ABILITY YI N EL. EACH ACCIDENT S 500,000 C EXCLtIO®T 0 E.L DISEASE -EA EMPLOYEE S 500,000 IY+■ M9 Eyes. Swaths under E.L DISEAS&POUCY UAW S 500,000 SPECIAL PROVISIONS Wow OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES IEXcLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT, INC SHOULD ANY OF TIE ABOVE DESCRIBED POLICES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 142 BOYLE ROAD WRIT E N wince TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE NO OPTION OR UABRITY OF ANY BID UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATNE Attention: , � IdC GI ACORD 25 (2009101) Certificate* 23873 0 1988 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are reed makes of ACORD ' �, The Commonwealth of Massachusetts ri* Department of Industrial Accidents 5�_ k Office of Investigations ti ,v-_,- e 600 Washington Street r ° -t- Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly '1_._ Name ( Business /Organization/Individual): /,- e&l,rTt/ue / MP O Md-r Address: / L') 1 j1-e_ /e4 City /State /Zip: i i j M 4 D 13 S Phone #: J I . 3 -- Q/ 0) I Are an employer? Check e appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. i employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ❑ g myself. [No workers' comp. right of exemption per MGL 12.0 R f airs ' insurance required] t c. 152, §1(4), and we have no `._� employees. [No workers' 1 3 Otl►er ! /l bC / (.0 7)1P'(✓ comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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 my employee& Below is the policy and job site information. 1 Insurance Company Name: Led) no 19 //1x14 t' ',Ylt&_ pa,rl y Policy # or Self -ins. Lic. # 0/ a / J3 (o 6 Expiration Date: i / 1/ 8 r .D l i Job Site Address: ` l � l r \ a\r(-_ City /State /Zip: NO r r1 Attach a copy of the workers' compensation policy declaration page (showing the policy 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 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 ce under the pains and penalties of perjury that the information provided above is true and correct. Si a ature: 1 i I ? Date: I 1 \‘ ‘ Phone #: ii/ 3 .. ( 2 63 -' ,2/a 2 Official use on)7. 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 #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Suaervisor: Not Applicable ❑ Name of License Holder : q to CCJ �� ` � License Number 1 LAI 1(&)1 Address ) ) Expiration Date Sign ture Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 1 - .&L— IMP/e0' M,Uti � /r[� l '+0 Company N Registra on Number .�, le_ i 4 Q, - 3:c;-�} .\ Address ' Expiration Date 1�P S Telephone413— at)C- SECTION 10- 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 it. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 80 Sixth Edition Section 108.3.5.1. Definition of Homeowne : erson (s) who own a parcel of land on which he /she r • intends to reside, on which there is, or is intended to be, a one or amily dwelling, attached or detach ctures accessory to such use and/ or farm structures. A person who constructs m than one home in o-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Buildin: S ' ici. • a form acceptable to the Building Official, that he /she shall be responsible for all such work performed and • le : ildint permit. As acting Construction Supervisor you : esence on the J • . ite will be required from time to time, during and upon completion of the work for which t • • permit is issued. Also be advised that with ref- • ce to Chapter 152 (Workers' Compe , ion) and Chapter 153 (Liability of Employers to Employees for injuries n• esulting in Death) of the Massachusetts Genera ..ws Annotated, you may be liable for person(s) you hire to perform - •rk for you under this permit. The undersigne• omeowner" certifies and assumes responsibility for compliance • the State Building Code, City of Northampt• Ordinances, State and Local Zoning Laws and State of Massachusetts Gene Laws Annotated. Ho • eowner Signature i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [I1 Siding [D] Other [ T 1 h S . u c ��_ Brief De c ription of Pro o$ d ,, a 1 T- C t r.6 w t‘,.__ Work: t I 1 a 5 k - cf 1 lt OSC.- ■ r‘ riptiLCl c - V 1 C1 . `1t+ - V‘C@.. c t i ►Y av1 k i - l`F— r t r., O IC�" U / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? -- ------- Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Ci Ke S r , as Owner of the subject property I hereby authorize a rw S Pi l J 1 S to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner / ar V Z _� FI \ 1 s , as Owner /Authorized Agent hereby d are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u er the pains and enalties of perjury. riNt S 1 \ t C Print ame Sig ture of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW a YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW �% YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO • IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ‘t. *, i • ' Department use only --, z _ iv • • orthampton Status of Permit: . di • ; Department Curb Cut/Driveway Permit . 12 ain Street Sewer /Septic Availability JUL ' • au ' R 'Pm 100 Water/Well Availability - Nort am lion, MA 01060 Two Sets of Structural Plans r :7 240 Fax 413 587 - 1272 Plot/Site Plans _ Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Pro a Address: This section to be completed by office rl r-1 co-1-16-). (i _ - Map Lot Unit 1 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C , r C . + Z L . . V(IC (S \ O pCtli, Name (Print) Current Mailing Address: 'Y__ ,/'r - � C-e 2 .... / "? d .4__ Telephone Signature ti i _ `, ri ` 3 3 3 2.2 A th�r y ed S P i' t S V 6 04( iq. c 6 0 M oI i Name (Print) Current Mailing Address: ) ) '- (---) 5. '-1-1? , Sign t / 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 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 4 5 5. Fire Protection .1 6. Total= (1 +2 +3 +4 +5) '.-} ( — Check Number $/ /_) This Section For Official Use Only Date Budding Permit Number: sued: Signature: / Illie 7 /1 Building Commissioner /Inspector of Buildings Date 77 HARRISON AVE BP- 2012 -0046 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 217 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # B P- 2012 -0046 Project # JS- 2012- 000069 Est. Cost: $1474.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 8537.76 Owner: Kessler, Greta Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 77 HARRISON AVE Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON:7/13/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: Install insulation 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. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 7/13/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner