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23C-076 (2)
• Property Address: -; , i I GlQ i Contractor Name: r1. itC 1-ji iik I M f QVC (vie hi 7_ Address: l 't � y L ( ' - i__._ City, State: C'' I I1, - Phone: 41 57' l Property Owner {� Name: I ''l C Address: 0 5 k), , l (ReU City, State: rStir 41 O'CC y1 C c 4 I, Javyye 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. Coyrtgacto gne$urG, Date d / y) 2.9ite 0, /t.„weididacitemee2pa Office of Consumer Affairs and : usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement diirdiacor Registration Registration: 146402 TYDe: Pdvate Corporation ;______!,,.., Expiration: 4122/2013 Tr* 209431 IDEAL HOME IMPROVEMENT INC :: '' JAMES ELLIS 142 BOYLE RD GILL MA 01354 .. A. : ;, , ,-------_,-,,---__-„,---:,;- Update Address and return card. Mark reason for change. ---i 0 Address 0 Renewal El Employment []Lost Card DPS-CA1 0 50M-0404-G101216 - - —_---__—_ — - ----_—__„-------- --- -- - -- -- - ---- --,...— - ------ - _ Massachusetts - Department of Public Safety tandards Construction Supervisor License ..., License: CS 91207 -- -; - JAMES P ELUS •:'-a• . - • 142 BOYLE RD GILL. MA 01354 ..cr2:4" e•-- .-----...--.-.3..• Expiration: 10116/2012 C'ommissioner Tr#: 3269 \ / ACORIY DATE (PAM OD/YYYY) I,,,,,,- CERTIFICATE OF LIABILITY INSURANCE ' 11/1912010 PRODUCER MUNK 413. 8634373 Fax 413.863.5658 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 THE COVERAGE AFFORDED BY JHE POUCIEp BELOW, TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER k NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. NSuaBo 8 PILGRIM MS. 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 ROICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDEON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TIE INSURANCE AFFORDED BY TIE POLICES DESCRIBED HEREIN IS SUBJECT TO AU. TIE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MI ADD1 POUCYEFFECTIIE POUCYEXPMATION LTR I1SRC TYPE INSURANCE POLICY N1 DATE 0OSI001YR DATE NMSOD11M /IB'I'S GENERAL UABLJTY GL 20109227 11119/10 11/19111 EACH OCCURRENCE S 1,000,000 X tit GENERAL LIABILITY DAMN:PET° RENTED Oa s 100,000 enemas I CLAIMS MADE © OCCUR NED. EXP (Any ane person) S 5,000 A PERSONAL & ADV INJURY S 1,000,000 GENERAL AGGREGATE a 2,000,000 GEM. AGGREGATE LMTAPPLES PRODUCTS - COMP/OP AGG $ 2,000,000 —1 POUCY n. Floc s AUTOMOBILE LIABMJTY PGC10009703302 11117/10 11/17/11 CONSI,ED SINGLE Lear ANY AUTO (Ea accident) s 1,000,000 -- AU. OWNED AUTOS BODILY INJURY _ X SCHEDULED AUTOS (Par m san) _ S B X HIRED AUTOS BODILY INJURY S X NON-OWNED AUTOS (Per ) _ X MASS. POLICY FORM (Per $ GARAGE LIABILITY AUTO ONLY - EA ACCDHNT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO S EXCESS Ii UABIJTY EACH OCCURRENCE S OCCUR El CLAWS MADE AGGREGATE _ $ S DEDUCTIBLE S RETENTION S ! S WORKERS COMPENSATION AND WC1136680 11116110 11/18111 X Bi alys 1 I °a ' EMPLOYERS' LIABILITY YIN EL EACH ACCIDENT S 500,000 C © EL DISEASE -FA EMPLOYEE $ 500,000 M Yes. °eta iei°er EL DISEASE-POLICY LUIT S 500,000 SPECIAL PROVISIONS infer OTHER DESCRIPTION OF OPERATIONS !LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE HEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 142 BOYLE ROAD WRITTEN NOTICE TO TIE CERTIFICATE HOLDER NAKED TO THE LEFT. BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE NO OBUGATION OR UABIU Y OF ANY KID UPON THE INSURER, ITS AGENTS OR REPRESBITATIVE& AUTHORRED REPRESBNTATNE Attention: . g icl ACORD 25 (2009!01) Certificate * 23873 01988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered narks of ACORD 4 _ .. The Commonwealth of Massachusetts Department of Industrial Accidents 'u Office of Investigations . - , ;� 600 Washington Street y Boston, MA 02111 V ' m , ', ` www mass gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information ( Please Print Legibly Name ( Business /Organization/Individual): l '� , /4-6 Ni l ' ') to R ave.( ! / -- _ Address: / ( 64) \J-C_ ieei City /State /Zip: C, i 1 M4 O 13 Phone #: (-/" /-- 3 -- 2l 0) I Are an employer? Check appropriate box: Type of project (required): 1. I am a employer with 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. 0 New construction 2.0 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. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 employees. [No workers' 13. Other / /1S -(./GC 7 / 1 !1 �'l 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: 1,e�' h n L) lea / I t 1'af' ty__ puny ��/ v Policy # or Self -ins. Lic. #: PVC l 13 (o /01;0 Expiration Date: i i 1/ 8 / ,% i i Job Site Address: An L " i ) 14 ■ ∎ fi City /State/Zip r ) O r (? W'1 C e V i1 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 ce under the pains and penalties of perjury that the information provided above J ve is true and correct. Signature: V_E J p r-e S Date: ( / 0 l i t 2 Phone #: f ,� °; d '3 /a 2 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 #: • FACTION 8 - CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : rY S E 6 ( q ( / License Number o tic tea-ok Address J Expiration Date X1 3- a-I Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 1 i t. (b Ii r14- o■3`‘`t y ��-1- , o‘3 Address Expirati n Date Telephone 413 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 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 ho 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 fami elling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than ome in a two- ear l eriod shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, o • rm acceptable to the Buildin, • : I, that he /she shall be res . onsible for all such work i erformed under the buildin . • e 't. As acting Construction Supervisor your presence on the job site wi equired 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 (W • -rs' Compensation) . 'd Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of assachusetts General Laws notated, you may be liable for person(s) you hire to perform work for you under this : -rmit. The undersigned "homeowner" certifi- :. nd assumes responsibility for compliance wit he State Building Code, City of Northampton Ordinances, State . . • Local Zoning Laws and State of Massachusetts Gene .1 Laws Annotated. Homeowner Signature 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition p Replacement Windows Alteration(s) ❑ Roofing n Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [0] Other [/ Brief De cri.tion f Propqse• Work: - s C// 0 : in e, ..:/L , ' - 3 Fs - Q II LM. 11 -I . i K-" % I b'4 4=4 - - N.. Me ack cent dx -1 wai . , 1.4 g C IRtq co k 4 - rt rn kv,z }- 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 stones? 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, � 0 � 7 C_k Cruw \/ , as Owner of the subject property hereby auth ize c-,. kkP45 F) I I i X — Hi`u -- t M PPd ire -1 e'r /7 to act on myeh If, in all attess relativ to work autho ed by this building permit applicati . / - Y—S9 i nature of Owner 'Date I, IA, i -S ` f ' I S , as Owner /Authorized Ageapereby declare that the statements and information on the foregoing application are true and accurate, to the best of my know e -arid belief. Sig ed under the pains and penalties of perjury. rime -) C itt S P ame Signature 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 ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 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 ® , Date Issued: C. Do any signs exist on the property? YES ® NO irk IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 4;) 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 r IF YES, then a Northampton Storm Water Management Permit from the DPW is required. I e e 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 .. .7. • D APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE ( 1243 ` . ►1 • ' 0 MILY DWELLING SECTION 1 - SITE INFORMATION n 2 W 1 1.1 Property Address: This secti •. r • • • • mpl ted by office nM�aror o°O 3 W I I t Map Unit Zone Overlay District 0 renCe MA-' Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Pa- id r Crew re t SA- aS ,bra Name (Print) Current Mailing Address: l ' Telephone 51 s ,Signatur .. 2.2 Authorized Agent: ICC s TI1 ► l s J4 &ii j i t \ 1 1 A of Name (Print) � Current Mailing Address: / 4I �-- V 6- alp S re 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) (57)q -- Check Number Ifoc This Section For Official Use Only Date Building Permit Number: Issued: Signature: �y�— 6/3/t f Building Commissioner /Inspector of Buildings Date • 25 WILLOW ST BP-2011-1115 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C - 076 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 -1115 Project # JS- 2011- 001794 Est. Cost: $2509.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 9801.00 Owner: CROWLEY PATRICIA Zoning: URA(100) //WSP Applicant: IDEAL HOME IMPROVEMENT INC AT: 25 WILLOW ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON:6/30/2011 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 6/30/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner