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11A-004 .. BP-2011-0498 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0498 Project # JS- 2011- 000812 Est. Cost: $4812.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 22041.36 Owner: HOBBS DAVID B & LYNN SCHUMANN Zoning: URA(100)/ Applicant. IDEAL HOME IMPROVEMENT INC AT: 17 EVERGREEN RD Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON :121112010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTICXALL & BASEMENT 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. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 12/1/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0498 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 17 EVERGREEN RD MAP 11A PARCEL 004 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid l Typeof Construction: INSTALL ATTIC.WALL & BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 091207 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay it 3 l6 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. Department use only City of Northampton Status of Permit: - Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability, r ^. • ; J Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 4 1.1 Property Address This section to be completed by office Map Lot Unit VQYr� I'"elri �"CcA- Zone Overlay District i Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record V 1 v(_ 16 hS Sa Q S t '2OZ11..1t r Name (Print) , Current Mailing Address: C Telephone / - ��� _ O'N3 Signature i./ tp 2.2 Authorized Agent: Name Print) Current Mailing Address: 413 - & Sign ure Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant 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) I q C 71 9 — Check Number f This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: Oh D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all awlicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [[:I] Decks [cJ Siding [0 Other Work: escript JGf�i'7(l/�(�L)s + 6ASe )e r! f 1 +73� ! d� fYl._ .If Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housina, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property hereby authorize ow to act on my behalf, in all matters relative 7orkauthorized by this budding permit a plicati n. Signature of Owner Date c 7belief. J6 rw S r � ' as Owner /A uthorized declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge Signed under the pains and penalties of perjury. me Prin T '__ I LA / p //c) Signal6re of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder 'JL.( ryV S F/ S 9i l rl 14�� &,k i?,l 6,11 tV4- assy License Number Address I i I Expiration Date Sigrir ture Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address t Expiration Date I Telephone 7 0 4 SECTION 10- 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....... 2r' No...... ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detache s accessory to such use and/ or farm structures. A person who constructs more than one home in o-year period shall not be considered a homeowner Such "homeowner" shall submit to the 13auilging Offici,al a form acceptable to the Building Official that he /she shall be responsible for all such work perfor med un buildine permit. As acting Construction Supervisor your presence on ob site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers Co ensation) and Chapter 153 (Liability of Employers to Employees for injuries resulting in Death) of the Massachusetts eral Laws Annotated, you may be liable for person(s) you hire to perform wor'k for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature C-1 Property Address. Contractor Name: 16 1IL 4dW lt-0 7VcNeil i Address: / 4 City, State. �"' M 4 c � Phone: Property Owner c V Name: d 7 ` ✓) Address: City, State: �'� S �- 0 S I, f6t twS (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. Contracto nature Date -� � BOaTC� Q ll ��r' g t� r . One Ashburto Jj &- e Room 1301 Boston. Massrchasetts- 02108 Home Improvemed. €'° ReWs"fim 146402' _ - - Type .. Private Corporation IDEAL HOME IMPROVEMENT 4IttE: Expiration: 4/22/2011 Tr# 281399 JAMES ELLIS 142 BOYLE RD - GILL, MA 01354 Update Addiress and return card. Mark reason for cha:r2 Add� F-I Renewal El Employment (i . Laic G' _DPS -CA s+ 4ou-v' 0&D35LIFOF%4CA10921200R Massachusetts - Del)nrtment of Pulrlic Saf'en 80:trd (if 8uildi.. a Rc�ulations and Standards License: CS 912177 }P- S OX JAMES P ELLS : 142 BOYLE RD } GILL, MA 01354 Expiration: 10/16M12 [ , nrnressirmrr Tr--: 3269 ,aco oR CERTIFICATE OF LIABILITY INSURANCE D fns 010 NYYY PRODUCER Phone: 413-063 - 4373 Fa)c 413 863 - 96% THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 159 AVENUE A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 391 ALTER C RAGE AFFORDED BY THE POLICIES W. TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. INSURER B: PILGRIM INS. COMPANY 142 BOYLE ROAD INSURER C: TECHNOLOGY INSURANCE COMPANY GILL MA 01354 INSURER D: INSURER E: COVER 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMS. N� INSR TYPE OF INSURANCE POLICY NUMBER POLICY POLICY EXPIRATION GENERAL LIABILITY GL 20109227 11119/10 11/19/11 EAC OCCURRENCE _ $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PREMISES WA ocetaenoe CLAIMS MADEMX OCCUR MED. EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 PRO - POLICY M W M LOC $ AUTOMOBILE LIABILITY PGC10009703302 11/17110 11/17/11 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per Perms) s B X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per ) MASS. POLICY FORM PROPERTY DAMAGE X E (Per accident) $ *GE LIABILITY AUTO ONLY - EA ACCIDENT $ AU OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR M CLAIMS MADE AGGREGATE S S DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND WC1136M 11/18/10 11/18111 X uMrrs °TM°I EMPLOYERS! LIABILITY YIN `+ ANY PROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT S 500,000 OFFICERNEMBER EXCLUDED? EL DISEASE -EA EMPLOYEE $ 500,000 (Mandatory in NH) If yes, describe under E.L DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLESJEXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 142 BOYLE ROAD EXPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: 1 �- aCtZ.l kl wICZ ACORD 25 (2009101) Certificate # 23873 ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations -' 600 Washington Street x Boston, MA 02111 } www.mass gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business/Organizatior dindividual): Address: / �'ok J y� e_ e4 City /State /Zip: �� M,}- Phone #: � �,�--` � -- �/ c Are an employer? Check the appropriate box: Type of project (required): 1. I am a employer with _ 4. E] I am a general contractor and I 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 g, ❑Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions re 3. ❑ I qu a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ R f repairs ' insurance required.] t c. 152, §1(4), and we have no f �� employees. [No workers' 13. Other / n comp. insurance required.] *Any applicant that checks box #I 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. #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: J�� h no ld M tA / lZ flee — Oa- i'1 Policy # or Self -ins. Lic. #: f/v C / 1(0 L Expiration Date: Job Site Address: / F � (-- �� r� e h k cJ City /State/Zip: {fi t' 41 l� F 0 / C) 3 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 under the pains and penalties of perjury that the information provided a ove is true and correct }' Date: ) � � (� Si ature: �,/ Phone # 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 #: