Loading...
35-222 (14) BP-2021-2251 38 LADYSLIPPER LANE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-222-001 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-2021-2251 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 4000 IDEAL HOME IMPROVEMENT INC 91207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: SCHMALE JEFFREY & CARRIE CARLEVARO Lot Size (sq.ft.) Zoning: WSP Applicant: Applicant Address Phone: Insurance: ISSUED ON:12/01/2021 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: 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 i • f� ''1 • Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner f o a City of Northampton E, " '..4 •--11A Af,r.-tee i Building Departl> ent t d ; # 212 Main Room ot0 Street I DEC -- 1 c� INSULA TION try.,1r . - „ Northampton, MA/010(10 I '06.4- phone 413-587-1240 Fait 413~5$ i JL Y `"'�-.. ..==-` ! - � ^1''r7TF�aAt1t ,1r,1N3Pt-`CT10tV5 APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: Th'r section to be completed by office • ?�c[ l ckysl 1 efte ( Map Lot Unit ,/� y Zone Overlay District r Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: eff utitc, Name(Print) Current Mailing Address: `i t"1 J _Q . Oa 7?�.4.02,1„,ce.AA4...,I _ Telephone Signature 2.2 Authorized Anent; skive.S _ik I(.s I LP l� - I r 10 e(Prin � 01 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 tiO00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee b_t 4. Mechanical HVAC "� 5. Fire Protection 6. Total=(1 +2+3+4+5) 4000 Check Number qiqd This Section For Official Use Only Building Permit Number: b v' a/ — 5 Date Issued Signature: /Z- /-ZOzi Building Commissioner/inspector at Buittfin % Date ve Ct -e1C1 @ m CctSt• a - EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction upervisor: Not Applicable 0 Name of license Holder: `� &((S 01 (a1 0, License Number Gi. < n\o. I o.( �-a- Addre�s Expiration Date �113.9)) • d l a-$ Signature Telephone 9.Registered Home lnarovement Contractor: Not Applicable 0 1tl.� I--\-cx . (rn PM/CMet + N j L(o)- Companv Name Registration Number \\ xj (La . 61(k MA U a► a3 Expiration Date 7/1AA1\-- Telephonev` 3"71P-5.a c)-9 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 buildi g permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: I NSULA 7 ION ONLY 11"I0 S4 \Vrl CI luk0 Ten cAittiC, CA AV (SeGUilin I, ki(onfS 2,t 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. caMt5 ats P• Signature f Owner/Agent Date I, V�CSI a\ l(,iv, ,as Owner of the subject property hereby authorize to act on mybehalf,in all�tive to work authorized bythis buildingpermit application. Pp 11'(1a` 1 Signature of Owner Date City of Northampton Massachusetts �; cam, . 4*2,1514f4DEPARTMENT OF BUILDING INSPECTIONS 7+ ' ti 212 Main Street • Municipal Building dp 'CD Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: J(e3 lafkisitec-ex Contractor 1 Name: JCk.C&Q Sll S Address: \'-{) rb uq L Icy City, State: 01( n(V4 Phone: 13 _i 3• a )•<1 Property Owner 1 Name: II ,ATT,Y 'e-AA Address: (5p�J4 l blu�tt x ` City, State: \ 1�1Y��(Y�li(�(\ �?1'r (U1 I, d0.XIM S l 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 Date N\\W -1 City of Northampton Massachusetts Att * N. y °r DEPARTMENT OF BUILDING INSPECTIONS % , �• "` . 212 Main Street • Municipal Building fed Northampton, MA 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("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: incAli C,1 1(.\ Est.Cost: L1 0 0 0 Address of Work: -31 l.,lJ -t1 WV, . Date of Permit Application: 1\ 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: 1 ,I(Vl i,r►rr�.,r n�f' Date Contractor Name I 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 FSH n1A� s�� Massachusetts 41/ DEPARTMENT OF BUILDING INSPECTIONS 4 212 Main Street •Municipal Building •;•C Northampton, MA 01060 r - ‘ 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: A LIB SI �,,�.M l �' , (Please print house numberand street name) Is to be disposed of at \ i2 \- M& p. va ►(�.��, l� (kUt (Please print nameand location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signatur 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 t Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 wfvw.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. 0 T am a general contractor and T employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ 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 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.® Otherinsutatlon employees. [No workers' 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. 1Contractors 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. Lie. #I:WC9057697 Expiration Date:1/26/2022 Job Site Address: .� ,... (l l.(Sk I ffer \AA& City/State/Zip:0 06irtql1OrA I Y 1i 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 sly un the pai enalties of perjuty that the information provided above is true and correct. Signature: Date: l 1 la 3 le)- Phone#: "h3 DL " a l X 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 21:1Building Department 31:City/Town Clerk 4.0Electrical Inspector 5EIPlumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts r` Division of Professional Licensure Board of Building Regulations�up and Standards Cons i ii%ii(r viSOr CS-091207 r rijpires:10/16/2022 JAMES P ELir7S � f 142 BOYLE , GILL MA 0136 +'. • Commissioner pia<a. Ii. t7 ia. vvnuti�aaivN4tt v 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 • GILL,MA 01354 Undersecretary AcoREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYVY) 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(ies)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 FAX IAI a,Ext): (413)586-0111 (A/C,No): (413)586-6481 8 North King Street E-MAILgooden webberand rinnell.com ADDRESS: ® g INSURER(S)AFFORDING COVERAGE NAIC# 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 AUULbUBH POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN SO WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 5D0,000 MED EXP(Any ono person) $ 15,000 A S2291368 11/17/2020 11/17/2021 PERSONAL aADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- PRODUCTS-COMP/OP AGG $ 2, JEGT Loc 0 ,00000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED v SCHEDULED A9105410 11/17/2020 11/17/2021 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y IN N B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1.000,000 OFFICER/MEMBER EXCLUDED, Y N/A WC9057697 01/26/2021 01/26/2022 (Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 if yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS/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 REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD