29-192 (3) 135 DEERFIELD DR BP-2019-1468
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaZ lock:29- 192 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 s BP-2019-1468
Project 4 JS-2019-002380
Est.cost $5000.00
Fee;$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sp. R.): 16814.16 Owner. POTAK LAUREN
zoo Applicant: IDEAL HOME IMPROVEMENT INC
AT. 135 DEERFIELD DR
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 WC
GILLMA01354 ISSUED 01:62412019 0:00:00
TOPERFORM THE FOLLOWING WORK.INSULATE OPEN ATTIC, EXTERIOR WALLS,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:
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 Occuoancv Sienature:
FeeTvpe: Date Paid: Amount:
Building 6/2420190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
/d 2- iR-i cIll d
Dep
City of Northampton
Building Department
212 Main Street
Room 100 INSULATION
(
Northampton, MA 01060
phone 413587-1240 Fax413.587-1272 ON
ED
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1-SITE INFORMATION
INSULATION PERMI Al 2 1 2019
1.1 Property Address: Th'=section to be compleup by
DEPT OF BUILDING IN ECnON9
i3`5 Map —,zf Let /,- HFMPTON.M 01060
Ov IIim1 ' If W Zone Overlay District
Elm St District CB District—
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Reco
135 betv� ,t el
(PNd) Current Mean,Addmas:1 , 3
TNephone HT1 /l
2s IS 14� if Qel, Il IVIA
ems,(PdrnD Current Maltlng Address:
Sigrletwe Telephone
SEC ON 2-EU11116TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed!by permit alticant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For OltiClal Use Only
Date
Building Permit Num Issued:
Signature:
Building Commisboner inspeclar of Beatings, Deur
ejj1S @ Ccm(ac,+-"+
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER ORNTRACT R)
SECTION{•CONSTRUCTION SERVICES
8.1 Licensed Constructloq Simbervisor: . NMApplitablble ll❑/� q/
Name of License Holder S �I(//l� - 11 ao r
Ucense Number
I() I lo- CQ10
AddressEt@kshon Gate
'�13 gln� a
` Tebphone
9. moo NO a ro eI(�m m�el� Contractor. Not Applicable�❑/��
x Ir�• IIf ILtIV\M l�i,ll� �s'(��-Tl0
Com n Nam Registration Number
Addreas Expiration Data
al l 1 ' `-" Telapnone�'IIJ
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.1bt,5 g8C(BI)
Workers Compensabon Insurance affidavit must be completed and submitted with this application.Failure to provide thk affidavit will resuk
m the denial of the issuance of the buildin Onit.
Signed Affidavit Attached Yes....... No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
loin orf cvlu c N- cI lot p-c C -ey-4f (w
wc'M , our swbol
I, C )O A"w .t f u i S 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.
�S l5
Print Nam
UI lq Il
Signature of Orem Dab
I, 1 W ye f as Owner of the subject
Provady
2he yauthoras
to on my behalf, II ma ars relative to work auttionZed by this building permit application.
����p �✓ fri�
re o Owner Auv Date
City of Northampton
Massachusetts
D ARM&Pn` OF SULDxNG xD$HSCS'LDas
212 Win St t . N iciwl null ina •�C
aoithup —, . 01060
MANDATO22RGGYF/)OR HOUSES BUILT BEFORE 1945
Property Address:
Contractor CICS �tIIS
Name: ,n_/
Address: I "H- UI\1 lP f�-Y�l
City, State:
Phone: ��•> DUB"� ' �� ��
Property Owner ✓.a r _ 1�
Name: (���,nn � •• II j,��(� \,,y
����
Address: 1. .C.�b� I,Y
City, State: ��➢r If 1A 1, k
I, dwj5 ( (5 (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 Q��Dt4A��
Date LP I (CA lr-
City of Northampton
Massachusetts
DSPM'nMSNS OF BUILDING IaaPEGT10N5
212 ly n atzeet a sunioipal Buildinq '
NozfAupton, !p 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("RIC").
M.C.L.Chapter 142A requires that the"reconshucbon,alteration,renovation,repair, modernization, conversion,
improvement,removal, demolition,or construction clan addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:!f the homeouners
halcontracted with a cor/wratian or LLC,that end&mast be rreed.
egghaere
Type of Work: k ral\. Loo Est.Cost:
Address of Work 06 NU/&� jj C\\ '
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_lob under S 1,000.00
_Owner obtaining own permit(explain).
_Building not owner-occupied
Other(specify): .
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSINUATES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
I A1011 19 1 uFoa—
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property.
Date Owner Name and Signature
City of Northampton
c
Massachusetts
zlz win 01 aiv0
sthow`u. 9uil �*
NaztM1amptan, !901060 �n�
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
N-,5 Nfxfwd t�y'-
(Please print house number and street name)
Is to be disposed of at:
(PY)! n[name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
OR
(Company Name and Address)
Q� j I [al in-
Si atum of Permit 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.
The Commonwealth ofMeissachuseets
Department of lndustrial Accidents
I Congress Street Suite 100
Boston,MA 01114-2017
www.massgoutdia
Workers'Compensation Insurance Affidavit•.Builders/ContractorstElectriclam/Plumbers.
TO BE PILED RTTH THE PERMITTING AUTHORITY.
re
,or lar n `` L�Plane Print Legibly
Name(EminesstOrgmindowbdividua0: i (3 1
Address:
cityisto zip- p13 ph.#: '�13 81D3 31 d8
AreYm alaspfgwrt Lberk We•ppavrbhbar. Type of project(required):
L�m•mpbyawilh `-}i employes lfullmNorp•ntaw).• 7. El New construction
2.01m•solepopriclmor,anmhiPmrlhnrocaplo wrAr, (tannin S. QRemodeling
mvogcfw.INo work •camp.inwvma try )
3.[]i m•homco.&a,W wwk m IE[N.wohen'comP.imwvnm rtquhrdlt 9. Demolition
0.❑1m•hmmwna and wJl be birag moaecion m cooductdl woh oo my lxopalY, t war 10❑Building addition
msve incl eucovewmneiwnlmve wodms'cmlxmaYoo iammceormwb 11.0 Electrical repairs or additions
pmpriemn wild vo mployca.
12.❑Plumbing repairs or additions
5.❑1 caaaaettzow. rmdINavah'vedlhenrbmmenan 4stu m oemrbNsbeet
Tho wbcoatrxmnhere emploYea and Wvv wmhm'camp.msunoce? 13.rr❑ra--����Ro'��ofrtPre�irs(' ,,yr. ^
6.OWe=a coryuatiov and in o6ima hive ancued thou richt ofaremptim m MGL e. 14.Lyvinm 11 I \(ADC/ �Il) I
Is;41fs1.coal we have m eoryloys.[Na waAvr'romp.ivsurmce rtquiredj
•AnY ePPaavt Wt rbeckr box al mast eW fill ata We secnoo below slwwma Wevworlmr'comPcawtion policy iofometioa
r Nommwam who submit this s6gavitivdiaavBdry m down oil work and thmhueounide coovarmn mm aubmite orwemdovit wdialiogsmh.
cap,goe, thatvbaklhiv box mustemchedmaddifioml ab¢l vhowwgthe Deme ofde mbmobecmm mdmu wheWaornotlhom mtiaa have
employs. V We vubcwmcmn Leve mPloYar,ctrl'must pmvida thcu warhen'wmp.poury ombm.
Iam an employer that isproviding workers'eampensation lnsurancefor my employees Below is thepolicy andjob site
Informadom
Insurance Company Nvmn SM
Policy B or Self-ins-14G P. 1 Expiation Data IW
Job Site Address: 1 » fau s-�•+s ' City/StaWZip: f�ytIr lJti
Attach a copy of the workens compensation Polley declaration page(showing the poll number and expire on 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 yr�a�a Ifhepalou redaenalaes ofperjury that the lnformadonprovided above L true and correct
S'¢n m . /lk- ti Dale' L.I I q I'q
Phone# Lin qlD") al �%
Official use only. Do not write in this area to be completed by city or town off slat
City or Town: PermitUceme 4
Issuing Authority(circle one):
I.Board of Health 2.Building Department A.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone p:
AC" ' CERTIFICATE OF LIABILITY INSURANCE �n11(:gi2ols N
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(5),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the poliw(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the pdicy,certain policies may require an endorsement A statement on
this certificate does not confer rights to the certRlCats hider In lieu of Such endorsemBn((S).
PRODUCER NAME: Andrea FBBIe}'
Minter A Gnnnell PHONE (413)586 IMENER; (!13)5888181
AM L E
8 NOM Hing Saect ADP ss: afeel ygweD mMplMaMl;
Posu"SIOFDrasMDwraaff Mtea
NOMampton MA 01080 INSURERA: SEIN,.lns CO Of S CamErp 19459
INSURED
INSURER B'
Ideal Home Imponnneed,III, INSURER U.
Am Laurie EN
NSVRE0.D:
142 Bwle Ford N8 MR E:
GIN MA 01354-9731 1I18YRERF:
COVERAGES CERTIFICATE NUMBER: Ere 112019 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIM
INDICATED. NOTWITHSTANDINGANY REQUIREMENT.TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BV THE Pot1CIFS DESCRIBED HEREIN IS SUS I CTTOALLTHE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SNOVM MAY HAVE SEEN REDUCED BY PAID CLAIMSeas .
LTA iYPEOFNMIMRFangsrg1Cl Mll®e Wra
NYIBCML9lIMNLLMRIry 6A9
000URfEUCE a I.M.odid
CLAMSMeDE ®OIX}IR fREMISE9 5 500.000
YEDIXP( 115`DOO
A 57291388 111172018 11/172019 PE1soNALa AIrvINLm 51,000,000
OENLAtm1�WTE WRMPtIEa FFA: GENEMLAIX#GFSE S 2.000,000
I>L'ULY ®JLCT LOL P0.0IXICT5-COIIPAPMJO S 2.000,000
O HE a
-65 ANMIMY Luesurr W.�
ANTED INGLE LIM E 1,gOg,Ogp
ANYAVIO RY(ParavA a
A OWNED scIECMED A9106/10 !!11]2018 1111]2010 RY(Pa ariEvq s
AUTW ONLY AURH
.RED MtHGNFFo MMRGE a
AIROS ONLY AIROSCaa.Y
i
VYpPW WB pxyq FIX:E E 1.009.000
A U.c me M 87281988 ttlt]2018 1111]2019 1.000.900
DED RETERinces 0ToxYIN 1EA YIA VYCMM97 01/1011019 01282020 CQOBTT $
5�'�
OIwILOtMEYeER EXLX.UCHDi 500.000
IMOMNYale X19 EL
Ylbr
p5 .5E
" - Ws
Cb
EL
DEYPoIIIOHOFOPIMROX!/IOCFnpNS IVMraL pC01O1E1.ANW W aev4 ftlWM,mqb EOYIMNnlonpq MHgYLC)
CERTIFICATE HOLDER CANCELLATION
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Evidence Of In.. ACCORDANCE WITH THE POLICY PRO DNS.
ANHO lin REPRBENFAII.
14-D
01988-2018ACORDCORPORATION. All dghtsmsemed.
ACORD 25(2016103) The ACORD name and logo are registered markt of ACORD
®. Comm o..sent,or Massaehusens
Division of Professional Licensure
Board of Building Regulations and Standards
Constru-ion Suoe,vsor
CS-091207 Expires: 1011612020
JAMES P ELLIS
142 BOYLE RD
GILLMA 01354
-- _- Commissioner CIL
.f'lv `F.v.....nnrn!/if��vw..ofm.✓/e _.
geceW IMPRvAR41r48 CONTRACTOR on
NOME IMPTYP ENPM CONTRACTOR
TYPE:r:MpgaEx
Rea'stnlratloo
14eQ2 Ex4Dz Dazlnozl
IDEAL HOME IMPROVEMENT INC.
JAMES P.ELLIS -142 BOYLE BOYLE RD U r
GILL MA 01354 Undersecretary