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38A-006 DATE (MMIDD/YYYY) ' . CERTIFICATE OF LIABILITY INSURANCE 11119r2010 PRODUCER Phone: 4138634373 Fax 413.063S85e THIS (ERTWICATE 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 AtMs THE COVERA(,'E AFFORD BY THE POLICES BELOW. , TURNERS FALLS MA 01378 INSURERS AFFORDING COVERAGE NAIC 8 INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. INSURER It PILGRIM INS. COMPANY 142 BOYLE ROAD INSURER C: TECHNOLOGY INSURANCE COMPANY GILL MA 01354 INSURER D INSURER E COVERAGES + THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAND 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 POLICES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. INSR ADM. POLICY EFFECTIVE POLICY EXPIATION LTR INSRC TYPE OF INSURANCE POLICY RIMER POLICY (IM IXOril DATE DOODO/YYl LAWS GENERAL LIABILITY GL 20109227 11119/10 11119111 EACH OCCURRENCE _s 1,000,000 X commaRmAL oENERAL LIABIJTY WAGE TO RENTED $ 100,000 CLAWS MADE © OCCUR MED. EXP (Wry one Person) $ 5,000 A PERSONAL SADV INJURY $ 1,000,000 GENERAL AGGREGATE s 2,000,000 GEM. AGGREGATE UMIT APPLES PER PRODUCTS - COUP/OP AGG $ 2,000,000 — 1 1 I jf :T ELOC $ AUTOMOBILE UABBJrY PGC10009703302 11117110 11/17/11 COMBINED SEIGLE LANT ANY AUTO (Ea accident) $ 1,000,000 ALL OWIE3) AUTOS BOOLY INJURY ( Per Person) s X SCHEDULED arms _ B X HIRED AUTOS BODILY INJURY s X NON-OWED AUTOS (Per ) — X MASS. POLICY FORM (Per DAMAGE $ GARAGE UABIJTY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN FA ACC $ , AUTO ONLY: AGG S EXCESS/ UMBRELLA UABIITY EACH OCCURRENCE S OCCUR D CLAMS /AWE MS AGG REGATE s S _ — DEDUCIBLE $ -- RETENTION $ $ WORKERS COMPENSATION AND WC1135680 11/18/10 11 /18 /11 X Js I F IRER EMPLOYE S' LIABILITY YIN EL EACH ACCIDENT $ 500,000 C OFFICER,! REXW re? © EL DISEASE -EA EMPLOYEE S 500,000 IYSraslovy In NE) EYes. desa nseder EL DISEASE UNIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSILOCAT IONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT. INC. EXPIRATION ANY OF THE MINE DESCRIBED POLICES BE CANCELLED BEFORE THE DATE THEREOF, THE ISSUING INSURER WEL ENDEAVOR TO MAIL 10 DAYS 142 BOYLE ROAD WRITTEN NOTICE TO TIE CERTIFICATE HOLDER NAMED TO TIE LEFT, BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE NO OBLIGATION OR UABLI1Y OF ANY KBE) UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHOR TTATIVE � Attention: �� i tCZ ~ ACORD 25 (2009101) Certific # 23873 ®1988 - 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD gi‘e eoin,mcvneweetai ytA644,6acateen A rt F---=.5:Att. z Office of Consumer Affairs and usiness Regulation (llgi 10 Park Plaza - Suite 5170 Boston, MassacIntetts 02116 Home Improvement Ciintravtor Registration Registration: 146402 Type: Private Corporation Expiration: 4122/2013 Tr* 209431 :- :::17.___ ‘,1... i ti • IDEAL HOME IMPROVEMENT INC -- _ - _• 7-----, '__:_-4--<-: : -. - J,__ - _::_ - _ -- , -- _, 1,.,_, JAMES ELLIS • , ---- 77-, - -=, !::, 142 BOYLE RD - • -------------:,--- -=-, ;-,-;:, GILL, MA 01354 , : ,, -_-,-__.• ,.... - _., - - -- . - ---.:-_ - „---.1 - -__- - -1 , -- - -,, , ,,--_,:z _ - ..'- . .: - _• , -,:f . -- - --7 -- -.=.:*-_--> 'Update Address and return card. Mark reason for change. ---- ---j EI Address El Renewal El Employment El Lost Card DPS-CAI 0 50■4•04/04-G101216 * Massachuktts - Department of Public Safet:1 Board of Building Regulations and Standards Construction Supervisor License License: CS 91207 JAMES P ELLIS 142 BOYLE RD GILL MA 01354 Expiration: 1W1e/2012 ( ninn 6sioner I'm: 3269 ■., / ' * • ' The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations .. ti 600 Washington Street 4, 7 Boston, MA 02111 ,,,,,... ' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): / 6ectc.. / 14-0 A.te / 1P/? °vex�> Address: /401 & yJe_ e'.. City /State /Zip: ( I l M 4" D 13 Phone #: 4 41,3— gi, 3 - Q/02 I Are an employer? Checke appropriate box: Type of project ( required): 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. 0 New construction 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' $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10. ❑ 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 12.0 Roof repairs ' insurance required.] t c. 152, §1(4), and we have no 13. J _ Pt) � employees. [No workers' � er I n S 4( (�(I7 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. :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 employee& Below is the policy and job site information. _...- Insurance Company Name: Lec lino / / /IV/1. Y7,Zl'? t pa-i'1y Policy # or Self -ins. Lic. #: t t r C /I 3 (p (r> U Expiration Date: 1/ 1 / I j i i J Job Site Address: City /State /Zip: 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 c • under the pains and penalties of perjury that the information provided above is true and correct. Signature: p n S Date: Phone #: °7-1 , 2 ' 3 ,N2 1a 7 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 #: - T / a ° tip 4 sss r `� c, , Massachusetts A. ' ' - ` � * c t !er, , . I ‘ t , ` DEPARTMENT OF BUILDING INSPECTIONS . , - ■ y � t. 212 Main street • Municipal Building J ,f- , `1`` b Northampton, MA 01060 I P TO Property Address: 6 k7 /(ILL/J-- f ,,,.-j. Contractor Name: I ,(_._ 40NC_ , Ni e ieD4em,e _ Address: ‘ y';), ✓- \J . K_K City, State: t t \ m r- Phone: 4 _ g(v al A Property Owner 1 (� Name: 0 1 QC (.-) h -(k O . Address: 1 " . 0 • ( Q( . )-_ City, State: 0 {Cv C P te - CI, vc„ I , 3k,vvv) 5 El ' ' 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. Contract signat re <- P 1 ro- Date f 01 1l, ! • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supe isor: Not A ❑ Name of License Holder : a-/ l [e (r / I , S i s 1 License Nu ber 14;.), 1 eliC_ � J �'r l l MA--. a) 3 /r� fo)c), Address / Expiration Date CC-i- (-113- -r). -1 ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ / kka�. /hi M_ 1 MPr orrePic � J / * A Company Name Registra ion Number i� ykk 12,1 G 1 I i N74. O) 3 S-.\/ q 01,4 1 3 Address - Expiration Date C ---'e ,( 1 ��5 Telephone "H ) - ,-'a le.--- SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I 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 buiIddin ermit. Signed Affidavit Attached Yes XJ No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellines 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: Pe . n (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 :1 ily dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs mo an one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building . 1 cial, on a form acce'table to the Building Official, that he /she shall be responsible for all such work performed under the . ildi i • : mit. As acting Construction Supervisor your presence • • e j • • site will be required from time to time, during and upon completion of the work for which this pe • • issued. Also be advised that with reference : apter 152 (Workers' Com. - nsation) and Chapter 153 (Liability of Employers to Employees for injuries not re . mg in Death) of the Massachusetts G- -ral Laws Annotated, you may be liable for person(s) you hire to perform wor. "or you under this permit. The undersigned " : eowner" certifies and assumes responsibility for coin. 'mice with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massach . tts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El Or Doors 0 Accessory Bldg. El Demolition ❑ New Signs [p] Decks ED Siding [D] Other [ / r') S 4.l? &tZ (IL-, Brief ate �} Desch tion f Props d Wort: �,a ( s pf cellud0 ({n i ptit W iC -- "'al 3 16,, - ce /laid t2I rc A alt: - Kt w . i s4 ce I /tab//tab.( , s I a - / lltloye - to krza✓ w�. rr 8 l - A im, --- Qo s c rz�u�l5pr<cZ Cc I /, '` Alteration of existing bedroom Yes No A ding new bedroom Yes No f. fk Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, 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 . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT T OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, (i`� I ,.1 U as Owner of the subject property hereby authorize jj LYYW S Elit to act on my behalf, in all matters relative to work authorized by this building permit application. - 1 1 Signs of er Date , I C. J I/lei E / (, 5 , 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 and r the pains an (ties of perjury. e-S e / S Print Name r1 l l Sig ature of Owner /Agent / 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a S ial Permit /Variance /Finding ever been issued for /on the site? NO *�4 DON'T KNOW !!j YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO C.' DON'T KNOW o YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO (fdi 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 t! IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • a m • w Department use only � • y of Northampton Status of Permit: $ � �O\� Bu • ing Department Curb Cut/Driveway Permit Main Street Sewer /Septic Availability �� � � Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of St uctural Plans :i, . ' te e 413 -587 -1240 Fax 413 -587 -1272 Plot/Site Plans �'� Other Specify A AP' ' , TION 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 SO (,,,, , LJ , �' St Map Lot Unit �{, Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owne of Record: c ..l1 n PO.6 c.-1,. (�o3RA VOre nce x`1 Name (Print) / Current Mailing Address: j ©) 0 (' 2, I Telephone 5 .-i Signature 1 3 ° & ` J ,-/t,,,, 2.2 Auth • rized Agent: James elks 14--, i . 6,11 NO- QI3 Na (Print) Etk Current Mailing Addrs: Lfl - � ' (0 3-02/o2 I S ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit 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) Check Number Art? 9 _ _57S This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date AIL . .. File # BP- 2012 -0374 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 56 LAUREL ST MAP 38A PARCEL 006 001 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 `J Typeof Construction: INSTALL 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 INF9RMATION 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 / 16 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. . .. 56 LAUREL ST BP- 2012 -0374 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A - 006 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0374 Project # JS- 2012- 000597 Est. Cost: $2207.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 6882.48 Owner: DUDA JACQUELYN Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 56 LAUREL ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GI LLMA01354 ISSUED ON:1 0/1 7/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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 10/17/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner