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23A-174 (3) Property Address: v (0 1 V k \D. C on t r actor ame / 6 4 6 I M e e OV e N e A t I / / V C Address: /7-.) &yJC ea. City, State: ( I l J � NIA-- Phone: L k 3 2'63-- 2i a Property Owner yi , Name: A-1 a#12 Gj ealbytil Address: \3( Pl City, State: 10 ✓-nee N (D/ 0(0‘; c I J C�� S FIL rt9S . (contractor) attest and affirm that the building I intend to insulate does not have any o pen 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. C•ctor signatkrfe Date J " ' + f • ACORD* DATE (MMIOD/YYYY) ille „i CERTIFICATE OF LIABILITY INSURANCE 11/1912010 PRODUCER Phone: 4138634373 Fax 4138E3 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 AVER T+iE COVERAGE mrsooteo BY THE POuclES BELOW. TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER k NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. INSURERS: 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 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. tNSR ADM POLICY EFFECTIVE POLICYEXPRATION LTR ttNSRC TYPE IISURA4ICE POLICY NUMBER POLICY AWAIDOITY1 DATE MAMMY) LIMITS GENERAL LIABILITY GL 20109227 11/19110 11119/11 EACH OCCURRENCE $ 1 X COMMERCIAL. GENERAL LIABILITY DAMAGE TO RENTED ) s 100,000 CLAIMS MADE © OCCUR NBD. EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEPL AGGREGATE LIMIT APPLIES PElt PRODUCTS - COMP/OP AGG $ 2,000,000 1 — 1 POLICY 1 ! .;F[:: 1 ( ! LOC — $ AUTOMOBILE LJABIJTY PGC10009703302 11/17/10 1 11 1 7/ 1 1 �.� COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY RY _ INJU X SCHEDULED AUTOS (Per ) s B X HIRED AUTOS — BODILY INJURY $ X NON-OWNED AUTOS (Per ate) _ X MASS_ POLICY FORM PROPERTY s A GARAGE LIAB TTY I AUTO ONLY- EA ACCIDENT s — ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LosturY EACH OCCURRENCE $ OCCUR a CLAIMS MADE AGGREGATE ^ $ $ — — DEDUCTIBLE $ R RETENTION $ -- s — - WORKERS COMPENSATION AND VVC1136680 11/18/10 11/18111 , X !WC oRY ST a I I °THE EMPLOYERS LIABILITY YI EL EACH ACCIDENT s 500,000 C ANY PROPRIE ORATAR RNE Mandatory EL DISEASE -EA EMPLOYEE S 500,000 Ems. describe under EL DISEASE -POLICY LIMIT $ 500,000 SPECIAL PROVISIONS edow OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES /EXCLUSIONS 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 EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 142 BOYLE ROAD WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE NO OBLIGATION OR UABLITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE g c Attention: - �`� rae. �nn ACORD 25 (2009/01) Certificate # 23873 ®1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ , 1 # 'If 4 I Board o lw • mg - ns an. tans ari s One Ashburton 1' Room 1301 • Boston. Massichasetts 02108 _ Home Improvement Registration 146402 Type: Private Corpiration • Expiration: 4/22/2011 Tr# 281991 „ . • IDEAL HOME IMPROVEMENT INC. - JAMES ELLIS 142 BOYLE RD GILL MA 01354 _ • Update Ad4ress and return card. Mark reason for eltanL [ Add. Renewal fl Employment [ DPS-C- •-cw- . - • - • . _ , / Nlatssachtisetts - Department of Public •'satet‘ N. Board of ButItlin2 Regulation and 'standards License: CS 91207 JAMES P ELLIS •,;.t .• 142 BOYLE RD GILL MA 01354 Expiration: 10/16/2012 Tr 3269 • • N. The Commonwealth of Massachusetts Department of Industrial Accidents 1Of , � _= , Office of Investigations 600 Washington Street x! Boston, MA 02111 A www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information / �� Please Print Leeib1v Name ( Business /Organization/Individual): / -f t'L,/ �� () / ) A- i-entr Address: P--'k 1 jle_ /e4 City /State /Zip: (, Li 0 4" D1 .3 S Phone #: (-PO- 863 Q/ i A employer? Check the appropriate box: Type of project (required): 1. I am a employer with I') 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6 . ❑ New construction 2. ❑ 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. 0 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 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.❑ R f repairs insurance required.] t c. 152, § 1(4), and we have no / 13. I Other / r employees. [No workers' S 4( Lt_ • ,� �J 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 employees. Below is the policy and job site information. _.. Insurance Company Name: l —eC" 1 f'1L) 4 /r) atii,„._ay,par Policy # or Self -ins. Lic. #: IN C, 1) 3 (p (e O Expiration Date: 111151 a% / i Job Site Address: \56 ii C ity /State /Zip: ID rerl e t' iNj 1 0 to 6 a J 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 above is true and correct. Signature: - -- 1 j p r Date: Phone #: 6 / 3 `', 263 /a 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Jot me s �! _ Name of License Holder : C // 5 Jot q i c) o r7 License Number / j k 1 C /li X14 oi3 Jo- /. Id, ' •s ) Expiration Date (11-1...A.-- 4 4/3 Z3-- { /: 2 Si. ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ /beat 1 ,. i rNP,C nt o ✓e -i•-te/J t qv A Com an Name Registration Number JL vie PA. 6,11 r-.4 oil/ - a 1 1 A..ress /� ) / Expiration Date 4 p re s Telephone tlig '23 '�1 g 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 buildin Emit. 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 homeown to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, 'xth 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 detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two- • • . • io i shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, o.. • acceptable to the Building Official, that he /she shall be responsible for all such work performed unde , I uilding permit. As acting Construction Supervisor you : -sence on the job site will be required from time to time, during and upon completion of the work for which • permit is issued. Also be advised that with r- ence to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuri-: of resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perf• work for you under this permit. The undersi . ed "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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n Or Doors U Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [q Siding [0] Other [ j nSu.. a..1 n&- Brief Description of o 0 Work: s "U c f, o o d / ' .6 ` , dendr (w LI/s ; I A r i M rb i V j ; 0 [ a c5 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 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _ I_ /the 1-e- ( aiA A , as Owner of the subject property hereby authorize Jam, S ( 1 / 1 5 to act on my b - . _ , i t : ma' er., relative to work a orized by this building permit application. ti 45 I'( ` . Signature of c er Date I, h'1 Ty)/ 5 I I / 5 , as Owner/Azed t hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u der the pains and penalties of perjury. nines mes c s Print ame i �I: 1/ Sign ure 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 Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 1 .1`, YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 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 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O ,Date Issued: C. Do any signs exist on the property? YES ® NO a 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 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 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 1.1 Property Address: This section to be completed by office Map Lot Unit nZ o re ice Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: l � a1/ie“.) 40;6 an v.S 17? us pap/ r- /r 7 Name (Print) y ) Current Mailing Address: • Telephone � 4. Signature � r 7 2.2 Authorized Agent: jame Ellis JL y k'J 6,11 M4 i .3b/ Name Print) Current Mailing Address: Si n ure 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) tO Check Number /3 7P -- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP -2011 -0677 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 36 PINE ST MAP 23A PARCEL 174 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONINd3 FORM FILLED OUT Fee Paid Building Permit Filled out ��� � rj Fee Paid Typeof Construction: INSTALL ATTIC & WALL INSULATION New Construction Non Structural interior renovations Addition to Existing :cc ssory Structure Buildin Plans Included: ncr/ Statement or License 091207 _ sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF CATION PRESENTED: A' n : ed Additional permits required (see below) NNING BOARD PERMIT REQUIRED UNDER:§ n nediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ": NG BOARD PERMIT REQUIRED UNDER: § 1 ,i d ng Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed r 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 Signal i Building Official Date Note: 1 'ice of a Zoning permit does not relieve a applicant's burden to comply with all zoning require _ its and obtain all required permits from Board of Health, Conservation Commission, Department of pub' ,, 'narks and other applicable permit granting authorities. * Vario are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Plannil Development for more information. 36 PINE ST BP- 2011 -0677 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 174 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- 2011 -0677 Project # JS- 2011- 001105 Est. Cost: $1260.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 5183.64 Owner: RATTIGAN MATTHEW Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 36 PINE ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON :2/11/2011 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL ATTIC & WALL 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 2/11/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner