42-060 (4) 840 WESTHAMPTON RD-UNIT D BP-2020-0420
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-060 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2020-0420
Project# JS-2020-000713
Est.Cost: $3908.00
Fee:$65.00 PERMISSION IS HEREB Y GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sy. ft.): Owner: ZOLEDZIEWSKI EVA Z
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 840 WESTHAMPTON RD - UNIT D
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.10/312019 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND BASEMENT INSULATION AND AIR
SEALING THROUGHOUT
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 Siznatnre:
FeeType: Date Paid: Amount:
Building 10/3/2019 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
AUM
ON
- City of North mpt C E -D Dep
r s: Building Dep rtm
212 Main reeIt 1 SULATION
Room 1 0OCT - 2201%
W Northampton, A 00phone 413-587-1240 F x 4ONLY
DEPT.OF BUIL G INSP TO
NORTHAMPTON,MA 0 060
---------------
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: n ' This section to be completed by office
11.,1 Map Lot a V)Unit
Zone Overlay District
HA cjc6,L
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
zoLJZ► e-" 1sVi 94V Oj A41
Name(Print) Current Mailing
iling—
Address: _ 7�
Telephone
Signature Li
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
4 ( ,:% - 9 o9 A
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
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Feefle-
4. Mechanical (HVAC)
5. Fire Protection CA
6. Total=0 +2+3+4+5) 4!909 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: I '3- r�
Building Commissioner/Inspector of Buildings \J
^ 1 I Date� JAU \
�t v . cOVA
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not` _Applicable ❑
Name of License Holder: �A
� � , ��'l� y Q _ (__ �1. S — C:)]-,q2,R q
License Number
QN(-140g 3 ACZZ I 2-o 2-o
Address ^� Expiration Date
g
Signature Telephon
9.Registered Home Improvement Cont actor: Not Applicable ❑
lT1 _ ��- . _r o 5 - 3
CbfnpanY Na Registration Number
?�l+ o !�L .`�� . CPO 60K o4- 1 c, �2ioZo
Address Expiresate
Telephone ( 2
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.......ds� No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
"Itu to q-,f- b tow A M�C_ 0 , 4?,o fllf� VA-eke,,r DVAt,�
k,%1 16) 1 e11 ; �' D ;k�Aj
I,
�elo(r
C^C 1 as Owner/Authorized
Agent hereby declare that the statements and inf mation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
/' r
Print Name oll
Signature of Owner/Agent Date
I, V a O 1�Z► pAu f as Owner of the subject
property \ f I
hereby authorize "� ` OV-1-(2—
to act ortimy beha in a I tters el ive o work authorized by this build g per it Aplication.
Signatu of Owner Vats
The Commaolmealth of Massachit.vetts
(" Department o indiestrial Accidents
1 Congress Street,Suite 100
' Boston,.AM 02114-2017
rt'Ww anass.Aov/dia
Workers' Compensation imurance Affidavit: Buildet•s?Cutitl actors Electricians?Illutnbers.
TO BE FILED NNATH THE PERMITTING At Tl1MM.
Applicant information Please Print Legibly
N�tll�e tlituiness'i)r�arvzatioti-lnditi•itivall: y(�•�`Z'�1 t�'C;cy�� �i�-1�,-�•,1P_,r`vt�'.^)-I '"`j,r1C:.
Address:-5-K0 �'� ,r�o�C`�7,-l�cr 47 Q (s (�Z-7
City/State/Zip:T- t D!,e t_r
01 Ez(c-:"L Pllone 3-
Are you an employer?Check the appt•opriste hoc:
�� Type of protect(required):
1�I am a employer Neidt._tel employees(full and nr part-ti '
�. F1 New construction m..1 ant a sole rroprietor or partnership;and have no entplo ees carkut^ far m..in
b. Remodelinc
:trj caplci[Y,fl`ioa'nrkc�rs'cornl!.in5uran:c required.]
8.
t;un a herneowner doinnN wotic,nyc,;ff', t 9. Demol ior)
'4.J eg [flu t5•urke+:;•comp.insur;mce required.]
(—�
,..L J 1.n::a ha:n.c[,nt7 and v.•ill be Lir tg Cantractors to cea3uct all:;ori;an my 1�t'np;tt:'. I win I0 Building addition
msurc that alt contnrcturs either hate a orkrrs'a,anen;ation insurance or are>a.. t
t t l l.�Electrical repairs or additions f
rrogrielpra with no emplo)'eas. f
]?.Plumbing repairs oradditious
5.®1 am a genetll connactnr and!have hired the soh-conuar[ors listed on the attachz;t,hee+.
have empim ec,arua ha+-x„+nrr>'i,: it, iit'nrar:c� l. .❑Roofrepairs
1 1. Other t
6.[]We are a corporation ued its officers hnve excr_iscd tlrair ti�h[nf aicmp.ion per\iGl_C. ----.—.—1`l a 1031,and lire have no cinployeus.(!do workcrs'Como.iusuranre renuuotl.l ^—
`r\tt7 applic tr t that eheckc box.:l ulu.:t alao fill out Ott sCetinn bclo%V Jti,a int their o:orket,'comp;nsation pcilic� r!u:nn-at ioll
p H�nteot.rers nth: s+,then t this afiidatit utdicatinz thw are doutg al.l,n't,f,and thin hire outsi ie c.illictors must subruir a ncic o tfidat,it inchcatin”such.
3C+mtracturs that Clrtk this boat must attached as additional sheep hptitia,tet_na;ue of the sub-.oatracmors acid_tate u•hnccr ur no;arose ensurer;have
etn tnvec, 1fthe c ti thet mu-t prcmd:their t-,•4rl.ers`enmr roi;,V nun-i,fir
f u.-contrac[i�r;h_r�-employe-c.;.
I alit an eniploj>er that is proridiit•,,-;corkers`ceimpensarion insu ante fol-iitV emploi'ees. Retort'hV the police and job site
LtL10r1LLOffpT7. �
Insurance Cumpan4 Name:
Policy =or Self-ins. Lie, +: C�( eJC�0i3 Expiration Date: ' 1 1C
Job Site Address:_ _ C ii 'State;Z.ip: (7
Attach a colt} of the workers' co>npens:ation olicy declaratimi psee
(showing tete policy ruuttacr?nd capitation date).
Failure to. t:cure coverage as requn'cd under MGL c. 152. y25A is a criminal violation pimishable by s tuts up to S1,500.00
and or one-year imprisonment.as well as civil per allies in the form of a STOP WORK ORDER ani a fine Of up to S250.00 a
da} against the violator.A copy of this statement may be forwartietl to ti,c;Oi'itce(rf Investia:arms of the ULA for insurance
cut•erage verification. `
I do hc>rEht rr rlifi uLrrjer the nttiLf,s al:d iter allies f p ur Ifat the irLfof 111cLtialf pr t►riderf above is true and carred.
{ f<
Date
�2
Ufjacirfl trsc>urtlp. Do not write in this acre(,to be completed b, city of to:vlr nfficiul.
City or Town: Pert»it'1_.i
cense 4
issuing Authority (circ.lc nnc): 4
i.Board of Heaith 2,iiuildinr Department 3.Cit•yITowii Clerk 4. Flecti-ical inspector �+. Plunibin;inspector
fi. Cts tr'o.
Contact PCI-ann: Phone
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: a4v Lj" ej D
The debris will be transported by: e4xAeJ
The debris will be received by: Y
ze 0-4-Ar
Building permit number:
r
Name of Permit Applicant
Date Signature of Permit Applicant
ACORN CERTIFICATE OF LIABILITY INSURANCE DATE-(MWDDIYYW)
THIS CERTIFICATE IS ISSUED AS A MATTER OF tNFbRMATION109/2019
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 pollcy(ies)must have ADDITIONAL INSURED provisions C be endorsed.
If SUBROGATION IS WANED,subject to the terms and conditions of the poNcY,certain policies may require an endorseme t: A statement on
this cartMcate does not confer rights to the certificate holder in Neu of such endorsement(a).
PRODUCER Barbara G nld
NAA7E: � eVViCz
Webber&Grinnell PHONE
8 North King Street (413)586-0111 (413)586.6481
c No
ADDRESS: bgrynkiewlcz@webberandg6nnell.com
Northampton INSURER APPORDING COVERAGE
INSURED NARY
MA 01060 NRE
SURA: ArbeBa Protection 41360
Valley Home Improvement,Inc. INSURER 8: Arbells Indemnity 10017
Attn:Steven Silverman INSURER C:
P 0 Bax 60627�27 INSURER 0: __ ...
INSURER E:
Florence MA 01062
INSURER P
COVERAGES CERTIFICATE NUMBER: Exp,2/1/20 REVISION NUMBER:
THIS IS TO CERTIFY THATTHE 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
LTR TYPE OF INSURANCEim 101 OWDE MM
POLICY NUMBER MMIFI M11WlDD LiASiTS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE �OCCUR zTTUI&IM100,000
PR MI Es oral rr nce $
A MED EXP(Any oneperson) 5,000
8500063755 02/01/2019 02/01/2020 PERSONAL d ADV INJURY E 1,000,000
GENLAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE 2,0001000
POLICY ®JCT Q LOC
OTHER: PRODUCTS-COMP/OP AGO $ 2.000.000
$
AUTOMOBILE LIABILITY IT
E M1a1cBGNED NG UM
ANY AUTO 1
$ ,000 000
OWNED SCHEDULED BODILY INJURY(Per Pwann) $
A AUTOS ONLY AUTOS 1020Q37691 02/01!2019 02/01/2020 BODILY INJURY(Per seddent) $
HIRED NON-0WNE0
AUTOS ONLY AUTOS ONLY 0 GE t±
Peraaddenl
Uninsured motorist BI E 100,000
UNBRELLAtJA9 OCCUR
A EXCESS LIAR ECti OCGJRRENCE $ b,000,000
CLAIMS-MADE 4600068756 02/01/2019 02/01/2020 AGGREGATE g 510001000
DED RETENTIONS 10,000
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY YIN STATl1T R
B ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? FN7 NIA 4220651237 02/01/2019 02/01/2020 E.L.EACH ACCIDENT g 1,000,000
(MMdatary in _
B yes,describe under EJ_.DISEASE-EA EMPLOYEE $ 1,000,000
DESCRIPTION OF OPERATIONS below 1,000,000
E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addltlomrl Remarks Schedule,may be attached H maro
apses is(equired)
CERTIFICATE HOLDER CANCELLATI N
SHOULD ANY OF THE ABOVE DE&CRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE Tl1EIWOF,NOTICE WILL BE DELIVERED IN
Town o1 Greenfeld ACCORDANCE WrrH THE POLICY PROVISIONS.
14 Court Square
AUTHORHED REPRBSENTATIVE
Greenfield MA 01301 �/J +/� 4
A
®1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered maria of ACORD
r' Commonwealth of Massachusetts
Division of Professtonal Licensure
Board of Building Regulations and 5landartjg
ConstrM&,-tjAn'tt j�rvispr
CS-077279
pires: 0612112020
STEVEN A SILVERMAN'-=' I' C
268!COMER ftpD
SOUTHAMPTON�JUTA 01'073,; O.
Commissioner CIL A'I
or
wv
Office of Consumer Affairs and Business Regulation
One Ashburton Place Suite 1301
Boston, Massachusetts 02108
Nome Improvement Contractor Registration,
-- - Type: Corporation
VALLEY HOME IMPROVEMENT INC - - _ Registration: 105543
P.O.BOX 60627 Expiration: 07/16/2020
FLORENCE,MA 01062 - -
Update Address and Return Card.
s/r`,�. f1?1 y,t:y.;.. .1fiti� ... j l.r dL%:!/•//1''!d
Office of Consumer Affairs&Business Regulation
HOME IMPROVEME[T CONTRACTOR Registration valid for individual use only
TYPE:Corooratlon before the expiration date. It found return to:
Rgjoraation 90 on Office of Consumer Affairs and-Business Regulation
1QS643 _=';r; 07iib/2020 One Ashburton Place-Suite 130.1
VALLEY HOME-044 'k?4AAEN INC Boston,MA 021013
Tr•
arEVEN A.SlLV4 r-1MAN.
340 RiVEfi51DFDr1:.
NORTHAMPTON,MA 01062 Undersecretary Not valid Mtilout signature