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29-143 (8) BP-2023-0159 263 RYAN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-143-001 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-2023-0159 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: GOLD STAR INSULATION & Est.Cost: 4300 CONSTRUCTION LLC 065992 Const.Class: Exp.Date: 03/16/2023 Use Group: Owner: CHAM ANDERSON DONALD E &C 'OL Lot Size (sq.ft.) Zoning: WSP Applicant: GOLD STAR INSULATION &CONS 'UCTION LLC Applicant Address Phone: Insurance: 1 CONGER RD (774)329-4664 65620B5N23815620 WORCESTER, MA 01602 ISSUED ON: 02/09/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 4 • .>9 ) Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner g-f 7 n a I to kit eia‘eit/ F I-1___E: : . "- 19100 The Commonwealth of Massachu efts I Board of Building Regulations and S .. ,ds F c u - - 2023 I OR Massachusetts State Building Code, 7 0 C i 1' MUNICIPALITY USE Building Permit Application To Construct,Repair, noSate'(4f f flt lirEcriiised Mar$011 One-or Two-Family Dwellin' This Section For Official Use Only Building Permit Number: 2( - a-•�J -.) -. Date Applied: 4755 /11 2-9'ZOZ3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION .1 P o�rty Add a 1.2 Assessors Map&Parcel Numbers titian 1W Ioftnu)ThPolob`L 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R ord: 0On 1-ndexs0n -?-1Or \c.e) (ni4 0106Z Name(Print) nn City,State,ZIP 263 A cvi I 0 0! kl 5c'22&o Cc4oio62 a gma;l-cc i No. and Str el Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 1A�ddition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other la Specify: 1n,SAAJC dJGT ON Brief Description of Proposed Work2: Pi-L6i Ioom op i Rio,,) Ce.lL.L,dose SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ (3. 1 I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ frt" 0 Standard City/Town Application Fee 0 Total Project Cost' (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ ) Su pression Total All Feeshs 6 �^ p Check No.60 4 Check Amouh .At: ' Cash Amount: 'r 6.Total Project Cost: $ `�.) 30o, Jo 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) OC S/Ci �J License Number Exp ation ate Name of CSL Holder Keuivl 1 C Le4 List CSL Type(see below) L( No.and Street Type Description l 01 mo‘m U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry . 110313 m H O)s O-c RC Roofing Covering WS Window and Siding mo/ Qp q q SF Solid Fuel Burning Appliances I 1!7--Jc, 3 t.e h PiO�°�C4 j C 11 I Insulation Telephone Email address D Demolition 5.2,_Rpega tered Home Improvement Contractor,,Q (HIC) V o2 t2' 03-WO' ( ��t 1A - � tJ'v �l'�"1 LL C HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name pp l do ,cam, Not andCanSew' ��� b (14 329)-K - Email address City/Town,State,ZIP Telephone SECTION 6: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 No .l7 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Lb 14 r t1Sv,l0. C r� to act on my behalt in all matters relative to work authorized by this building permit application. Don CV,ziersaq Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. SE)(el3 34:1/44" gi0,1Au i nt- - 2�23 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton Cf '`! Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building y. '",- 4. Northampton, MA 01060 rs 3-��'` CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 1'13 06 e,r 54 0Or -C-e.0 P11' 0( &024 The debris will be transported by: Name of Hauler: 0az n'144 McA/C4 Signature of Applicant: _CD. Pe/WaL Date: Ol- 2 -Z.023 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =., ,r—� 1 Congress Street, Suite 100 " = Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individuai);C�7 � A ' ' Address: r7n P 1- City/State/Zip: W() (C2 S4E c O Phone #: ) )(J Are you an employer? Check the appropriate box: Type of project (required): 4. am a generalcontractor andI 1. am a employer with 1❑ 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 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. employees and have workers' q. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.C lam 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 Roo epairs insurance required.]'' c. 152. §1(4), and we have no f �J /19 employees. [No workers' 13. ther ,7T,31 S(� �, f comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 employees. Below is the policy and job site information. Insurance Company Name: 1/'� Policy #or Self-ins. Lic.#: to .0 a / S Expiration Date: Job Site Address: 3 R t�C n R U 11Or't°.(Ice.� ! O/0(2L City/State/Zip: '•0 ar-Cf'1 C (no O/ 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 hereby certi ' er the pal and penalties of perjury that the in formation provided above is true and correct. Si nature: Date D 1 " IQ - ZAY2- Phone #: 7y 3 )-vnn' • to Official use only. 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#: ACORO® DATE(MWDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/15/2022 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), AUTHORIZE( REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the polloy()es) 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 of this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Chris Fournier HO Berlin Insurance Group (A/C.No.Est): (508)_459-1226 FAX Nol; 618 MILTON ST ADDRESS: serviceteam©berlininsurancegroup.com INSURER(S)AFFORDING COVERAGE NAIC I WORCESTER MA 01606-2819 INSURER A: UNION MUTUAL FIRE INSURANCE SD. 25860 INSURED INSURER B: SAFETY INSURANCE COMPANY 39454 Goldstar Insulation&Construction LLC INSURER C: STATE POOL-WORKER'S COMPENSATION 1 Conger Rd INSURER D: XS BROKERS INSURER E: Worcester MA 01602 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO1 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI: CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERME EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP I LTR I INSR wvn POLICY NUMBER IMMIDD/YYYY1 (MM/DD(YYYY) LIMITS X'COMMERCIAL GENERAL LIABILITY j EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE L I OCCUR PREMISES(EaENTED ocaurencel $ MED EXP(My one person) $ 5,000 A X BOP0187043 11/11/2021 11/11/2023 I PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i i GENERAL AGGREGATE $ 2,000,000 POLICY �E� i LOC (PRODUCTS-COMP/OP AGG I$ 2,000,000 ' OTHER: i $ COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILELlABILITY i(Ea a dent) 1 ANY AUTO BODILY INJURY(Per person) '$ OWNED SCHEDULED X 5916246 02/24/2022 02/24/2023 BODILY INJURY(Per accident) $ B ' AUTOS ONLY X AUTOS PROPERTY DAMAGE XHIRED NON SWNED $ AUTOS ONLY X AUTOS ONLY (Per accident) I , $ X UMBRELLA UAB OCCUR ' EACH OCCURRENCE `$ 1,000,000 A EXCESS UAB CLAIMS-MADE X CUP0187067 11/11/2021 11/11/2023 AGGREGATE $ DEC (X j RETENTION$ 10000 E $ WORKERS COMPENSATION I STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER!EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBEREXCLUDED? N N/A 6R327873 08/31/2022 08/31/2023 1.(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 H yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Pollution Liability Aggregate 500,000 D X CPLMOL110273 03/04/2022 03/04/2023 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Thielsch Engineering CERTIFICATE HOLDER CANCELLATION Thielsch Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 195 Francis St. ACCORDANCE WITH THE POLICY PROVISIONS. Cranston,RI 02910 AUTHORIZED REPRESENTATIVE ©1888-2016 ACORD CORPOATION. All rights reserve ACORD 26(2018/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ALA Type: LLC GOLD STAR INSULATION&CONSTRUCTION LLCM`,. Registration. 200228 1 CONGER ROAD ` Expiration: 12/03/2024 WORCESTER, MA 01602 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 200228 12/03/2024 Boston,MA 02118 GOLD STAR INSULATION&CONSTRUCTION LLC GLEN S. POWELL 1 CONGER ROAD ,a'GL.( WORCESTER,MA 01602 Undersecretary Not valid without signature - - ---- ' - Commonwealth mMassachusetts Division or Professional Liceoaue Board mammmg Regulations and Standards ' °"'"".^w+t="/Superv'on, CS085992 ^`^ ~"707 MAIN STREET Commi"loner *�� � -