35-142 (4) BP-2021-2107
35 WESTWOOD TERR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-142-001 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-2021-2107 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 3500 IDEAL HOME IMPROVEMENT INC 91207
Const.Class: Exp.Date: 10/16/2022
Use Group: Owner: LORENCO, TERESA M. & PETER A.
Lot Size (sq.ft.)
Zoning: WSP Applicant: IDEAL HOME IMPROVEMENT INC
Applicant Address Phone: Insurance:
142 BOYLE RD (413)863-2128 WC9057697
GILL,MA 01354
ISSUED ON:10/28/2021
TO PERFORM THE FOLLOWING WORK:
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.
Signature:
i • r . y2 . Ti
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
L Add V V
-- Dep
, =r f City of Northampton -- V�
/ ''' �, Building Department
' 212 Roomin Ot0 et OCT 2. 7 2027lf1SULA TI ON
• , .` Northampton, MA 01060
`'.r.. phone 413-587-1240: Fax 413-.
'rH4htnn ,n"INSPEC inn. Oil!..
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILYDWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: Th'.i:section to be completed by office
i 35 \M-V —rk f Y• Map Lot Unit
Ro(&+ta.-- ( "k Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
. dteo-I1 `NA\\S 35 u.)-tS\-Lvood. 1. ie. V &re.nc-t.
Name(Print) Current Mailing Address:
` U13. 331-91�39
ow Telephone
Signature VVV
2.2 Authorized Agent: ``
0 s�\1_ G�k.s \y h ey,A4u ad, ei,, tyu
Name rint) .. Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3 5-bO (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 1*()
5.Fire Protection .
6. Total=(1 +2+3+4+5) 35O0.O0 Check Number L/f bt../
This Section For Official Use Only
.� ^� Date
Building Permit Number: ) `O /0 !-7 Issued:
Signature: / Id. Z8`ZOZ)
Building Commissioner/Inspector of Buildings Date
-e1k‘ jP @ Com-cc(,s-v-.ad-
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicableic 0
/
Name of License Holder: vW{•er 1S CAtl S t l d 6l
License Number
\9?‘ v lei). 61 ( as(
Expiration Date
ql. . O` 3-0)Idsb
Signs re Telephone
9.Registered Home Im rovement Contractor: Not Applicable 0
`cam l rtcme,4 ►u ugoa-
Company Name A ,�/� Q Registration Number
1
3
ddress -1 Expiration Date
Telephone 11)1D3 al
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 buildin permit.
Signed Affidavit Attached Yes No 0
Brief Description of Proposed Work NOTE:O TE: INSULATION ONLY
10 ,9S-f-- d,;crlse,(JcUX- ev\-erk ov vim,( [S
I, joawe v"t,l 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 enalties of perjury.
Jam- - �;kks
PriNe......‘
_ l alga J a i
Signature of Owner gent Date
I, ()Owl \ kA (/t`\ , as Owner of the subject
property dalYUL
hereby authorize a S
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
z„�-=,.� City of Northampton
.# ¢ • �, mac;Sty sue. s(Q;
Massachusetts
: `� ,..
N:
" r1 DEPARTMENT OF BUILDING INSPECTIONS �'
212 Main Street • Municipal Building rp 1S
Northampton, MA now Inii-i
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 35 uD Off. ..,) r.
Contractor Jara-tc Name: EkAS
Address: \kik "" Le a
City, State: all' 1 1 ` l
Phone: 43 ' Q5 ' c)k A
Property Owner `k ��
Name:
Address: 2J5 Z-�oo c I "e.({i'
City, State: Ffor en U'- mi
,.
I, ja,okt S IJ 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.
Contractor signature L.L\.' /--
Date 1o1ac)-\ak
City of Northampton
Massachusetts fr > f
{ G 4 8/ DEPARTMENT OF BUILDING INSPECTIONS fts
212 Main Street • Municipal Building ilb„ :a
OC.
Northampton, MA 01060 'r'i;Q-15ki
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("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement,removal, demolition, or construction of an 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: inSuj cko(1 Est. Cost: 3s-tu' 00
Address of Work: 3b WtSk' 30O Gt. -QX(.
Date of Permit Application: \0\da.\d
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$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 RESPONSIBILITES 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:
o)a a ]a t )ooes & k s l auo Nkx►kt 1 a, , - ) u i-oa--
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 Na ignature
•
City of Northampton
Y Hr 1�
�`'//��'`'. °%• Sys {'.. rc
Massachusetts k•
•` DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Munici al Buildingyam`'
,wws Northampton, MA 01060 cs�n_- ��a'
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:
95 -WOO d
U�re 1:6r•
(Please print house number and street name)
Is to be disposed of at:
ew , fit► , low 1—} fl .►r
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signa ur 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 of Massachusetts
Department of Industrial Accidents
{ � Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Ideal Home Improvement, INC
Address:142 Boyle Road
City/State/Zip:Gill MA 01354 Phone #:4138632128
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 10 4. ❑ I am a general contractor and i
employees (full and/or part-time).*
have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. 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
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.® Other insulation
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also till 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.
tCont-actors 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 employees. Below is the policy and job site
information.
Insurance Company Name: Selective Insurance Co
Policy#or Self-ins. Lic. #:WC9057697 Expiration Date:1/26/2022
Job Site Address: 35 -01) 0k T- .1'r . City/State/Zip:ff 0(e...n CC) Q
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 here certi der the p . nd penalties of perjury that the information, provided above is true and correct.
Signature: Date: 10 I as la
Phone#: -11 - 1SUt3- a O4
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):
10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5.1alumbing
Inspector 6.0Other
Contact Person: Phone#:
ACO ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
`.,./- 01/29/2021
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(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 Patrick Gooden
NAME:
Webber&Grinnell PHONE (413)586-0111 I F'°X (413)586.6481
IAICANo.Exth LAlC,No):
8 North King Street MISS, pgooden ebberand rinnell.com
ADDRESS: � g
INSURER(S)AFFORDING COVERAGE NAIC N
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259
INSURED INSURER B: Selective Ins Co of Southeast 39926
Ideal Home Improvement,Inc. INSURER C:
Attn:Laurie Ellis INSURER D:
142 Boyle Road INSURER E:
Gill MA 01354-9731 INSURER F:
COVERAGES CERTIFICATE NUMBER: Exp 11/21 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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER (MMIDDIYYYY) (MM/DO/YYYY) LIMITS
1�COMMERCIALGENERALLIABN_IY EACH OCCURRENCE $ "1000000
DAMAGE I 0 RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 500,000
MED EXP(Any one person) $ 15,000
A S2291368 11/17/2020 11/17/2021 PERSONAL 8.ADV INJURY $ 1,000,000
GEN'L AGGREGATE UMIr APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY 1 ] 2,0
JECT LOC
00,000
PRODUCTS-COMP/OP AGO $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
A OWNED AUTOS ONLY AUTOS--x SCHEDULED A9105410 11/17/2020 11/17/2021 BODILY INJURY(Per accident) $
X
HIRED v NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY I% AUTOS ONLY (Per acddent)
Uninsured motorist Ell $ 100,000
UMBRELLA LIAB ^ OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y i N STATUTE _ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC9057697 01IZ6/2021 01/26/2022 E'L.EACHACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? ` '
(Mandatory In NH) 1,000,000
If yes,describe under E.L.DISEASE-EA EMPLOYEE $
DESCRIPTION OF OPERATIONS be E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION 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
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATNE
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
•
•
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constru..ti 55i%i rrisor
CS-091207 spires:10/18/2022
JAMES P ELUS - •
142 BOYLE RR x
GILL MA 01 +
Commissioner �� !� ndi.&.
•
v.n wsrvndc ✓ .......__..•• _. ......••
. rr./,WWf/WZ hi eV/44tAge,44r/.4 -.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR •
• TYPE:Corporation
• Registration Expiration •
• 146402 04/21/2023
IDEAL HOME IMPROVEMENT INC.
JAMES P.ELLIS
142 BOYLE RD • $G. R`4( "
(SILL,MA 01354 Undersecretary