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16B-066 BP- 2011 -0629 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 -0629 Project # JS- 2011- 001014 Est. Cost: $795.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 11412.72 Owner: WOLFGRAM CAROL Zoning. URB(100) Applicant. IDEAL HOME IMPROVEMENT INC AT. 262 NORTH MAIN ST A_ pplicant Address: Phone: Insurance: 142 BOYLE RD (413 ) 863 -2128 GILLMA01354 ISSUED ON :1/13/2011 0.00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION - ATTIC AIRSEALING BEFORE SLOW 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 1/13/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0629 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 262 NORTH MAIN ST MAP 16B PARCEL 066 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction:_ INSTALL ATTIC INSULATION New Construction A vt .5 co, 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 R 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 V Dela Signature of Building O facial 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 Nampton, 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 1.1 Property Address This section to be completed by office / U it Map Lot Unit Zone Overlay District 1 r I re- Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner f Record: Name (Print) Current Mailing Address: &j Telephone Signature 2.2 Auth or'zed Anent: Name (Print) Current Mailing Address: 01 3,5 Sign a Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit 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) r ] c l !5 Check Number ' 410 j ff This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building CommissionerlInspector of Buildings Date r' 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 © 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 O 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 O NO Q) IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 1711 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [O] her [ Brief De cn tionfrroposed n j 1 Work: 0 6 /�'X !�L � L � A4 3 IF 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 housing, complete the followina: 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. I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR ,J �APPLIES FOR BUILDING PERMIT I, r- t " ) 0 rn as Owner of the subject property J hereby authorize to act o my behalf, in al m rs rel tive to work authorized by this building permit application. It � x i -- -1 Signature of Owner V I Date 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 he pains and pen ties of perjury. n(k MIS �� I t S Print Name SignaKire of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: Not A � Name of License Holder F'! / / r } l j � f License Number /0)lh )"'71 Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name i ��,( Registration Number J� Address Expiration Date �c2 Telephone 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....... 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 engag individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780 Sixth Edi; Section 108.3.5.1. Definition of Homeowner- person (s) who o a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one o family dwells attached or detached structures accessory to such use and/ or farm structures. A person who construe re than one ome in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the BuillmnsQfficia l, n a form acceptable to the Building Official that he /she shall be responsible for all such work performed under t 1 ermit. As acting Construction Supervisor your presence on the jo ' 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' Com nsation d Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts G eral Laws �the u may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for com ncBuilding Code, Cit y of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations x 600 Washington Street _ Boston, MA 02111 www. mass gov/tha Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Lezibly Name ( Business /Organization/Individual): f9 1 Address: �'� �/ yJ �_ K QA City /State /Zip: l� , I M q D l 3 Phone #: Are an employer? Check Ike appropriate box: Type of project (required): 1. I am a employer with 4. Q I am a general contractor and 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 g_ E] 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 1011 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 R repairs ' insurance required.] t c. 152, §1(4), and we have no / , j r)u employees. [No workers' l3. Other / n S �( l�l I/ comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. I 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: kec Policy # or Self -ins. Lic. #: f/l C I t �o L� Expiration Date: Job Site Address: �/►�� . `>� City /State /Zip: 6( t1CC �� 6 ) 1 Q G a-- 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 andpenalties ofperjury that the information provided ove true and correct Signature: Date: 0l 1 Phone #: Official use only. Do not write in this area, to be completed by city or town gfj`wW 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 M Property Address: 0, NS L Contractor L_ �1 / MPkov��a Name: I Address: City, State: Phone: Property Owner Name: ((•�� U Address: �= a rY • �� 1'r City, State: :: M o i(tnc P �'4 oi o & a I, j arws J l is (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. Contract si nature ' Date AcoRCT DATE (NNiWD1YYY`� CERTIFICATE OF LIABILITY INSURANCE 111IW2010 PRODUCER Phow 4134634313 Fac 413483 - OM THIS CERTFICATE 15 ISSUED AS A MATTER OF INFORMATION A.H. RIST INSURANCE AGENCY, INC. OWY AND CONFEM NO RWH73 UPON THE CERTWICATE 159 AVENUE A HOLDER. TMS CERTNMATE DOES NOT AMEND, EXTEND OR P.O. BOX 391 BY THE POLICIES BELOW, TJJRNERS PALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. 94SURER g: PILGRIM INS. COMPANY 142 BOYLE ROAD GILL. MA 01354 INSURER C. TECHNOLOGY INSURANCE COMPANY INSURER D. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE ISSUED TO INSURED .NAMED ABOVE FOR THE POLICY PERIOD INDICATM iNOTWITHSTANDiNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH" THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRMED MMIN M SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAM ADM LTR 94M TYPEOFINSUIRAHM POLICY NUMBER POlJGY041ZI E POLICYEXMATI014 LIMITS GENERALLIABAJTY GL 20109227 1i119110 11/19/11 EACH OCCURRENCE 1,000,000 X CeARCUIL GENERAL LIABILITY S 100,000 CLAgN3 MADE nX OCCUR MED. EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEW AGGREGATE LMT APPLIES PER: PRODUCTS - COMPIOP AM S 2,000,000 POLICY PRO LOC S AUTOMOBILE! LIABILITY PGC10009703302 11117110 11117/11 ConAGINED SINGLE LSRT ANYAUTO (Ea ) $ 1,000,000 ALL OWNED AUTOS BODLL.Y INJURY X SCHEDULED Auros (per Person) S B X HIREDAUTOS BODILY INJURY $ X NON4WNED AUTOS (Per acickINA) X MASS Pot"FORM a t PROPERTY DAMAGE s GARAGELMBILITY AUTO ONLY - EAACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS I UMBRELLA LIAWTY EACH OCCURRENCE $ OCCUR n CLAIMS MADE AGGREGATE $ S DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND WC1136680 11/18/10 11M8i1i X ANY PROPIUETOMPARTMEMUMMCUTNE EMPLOYERS' LIABILITY YIN EL EACH ACCIDENT S 500,000 C I OFFI EXCLUDED? • - EL DISEASE -FA EMPLOYEE S 500,000 U yes, Aesaft miser I SMUL PaovlSIONS' a EL OISFASE-P(XJCY LIMIT S 500,000 OTHER DESCRIPTION 0 IPTION OF OPERATIONSILOCATNSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL.. PROVISIONS Classification: insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT, INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE � 2 $oY R 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 SMALL IMPOSE NO OBLIGATION OR LV31LITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE �f Attention: �rac iRt1 Icz ACORD 25 (2009101) Certificate # 23873 ®1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and kW are registered marks of ACORD Board o ur mg of _: i s an tan ar s One Ashburton:Fla =;e , Room 1301 Boston. Masse c;haset s. 02108 Home Impro vemeAf Re0istratim 146402 • Type: Private Corporation Expiration: 4/22/2011 Tr# 28999: IDEAL HOME IMPROVEMENT I#\IC. JAMES ELLIS 142 BOYLE RD _ -� - - -" - _. GILL, MA 01354 - - - - -- -- - Update Ad4ress and return card. Mark reason for chant Addy _ L j Renewal [j Employment { Ast G DPS -C? -3 .;^ 1,_0,'08- DBSLIFORNICAt08212008 - - - �laaachu.ctts - Department of Public Sat . Ctt 4 Br►ard uf' Buiklin;� .r Rc�trlatirrrt+ .rnd `tMI( lards License: CS 91207 JAMES P ELLIS 142130YLE RD GILL, MA 01354 Expiration: 10/16/2012 ' ( nuni..i ncr 3 Try: 269 r