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24C-067 (2) Property Address: J i\47.9 c ,/7 So T r Contractor Name: J OS t t j u ( Z Lq (i4 L Ho M /A,reok- Mq NT Address: I 't a U`1 L L f. 6 City, State: 10- L m. A C) 13 4 4 Phone: `1-' r _ 71.,r3-- ., ► a Fs Property Owner �! Name: U__ (- re) S Address: 9 ci- Nis; 4 So 11 City, State: N O (Z- I H iq M PT& Pj (l I, JOS / IJ 4 L I U SL y (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and toe) wiring in the spaces to be insulated and that I have provided the pro • erty ner with - copy of this affidavit. Contractor signature k U Date S - - lr - 11 ACME" DATE (MMDDIYYYY) ‘.....-- CERTIFICATE OF LIABILITY INSURANCE I iiH912010 PRODUCER Maroc 413-883-4373 Fmc 4136638658 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 ALWR THE COVERAGE AFFORDED BY THE POLICES BELOW. TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. B: PILGRIM INS. COMPANY 142 BOYLE ROAD INSURER C: TECHNOLOGY INSURANCE COMPANY GILL MA 01354 INSURER 0: 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES. AGGREGATE UNITS SHOWN MAY HAVE BEEN RED BY PAD CLANS. '' LTR NSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE PraXTooVMTION USES DATE YYSIDUITO DATE BMIDDIYYI GENERAL tAB6.ITY GL 20109227 11119/10 11119//1 EACH OCCURRENCE _ S 1,000,000 X comeaciAL Gramm LNABatTY DAMAGE T° RBRM) s 100,000 PREMISES (Es soaee„ee) I CLAMS MADE © OCCUR MED. EXP (My ore person) _ $ 5,000 A PERSONAL a aw PU Y _ S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LAW APPLIESPEt PRODUCTS - COMPAQ .Go S 2,000,000 —, POLICY n nLOC AUTOMOBILE UAeanY PGC10009703302 11/17/10 11117111 COINED SINN Lena ANY AUTO (Es occident) $ 1,000,000 __ ALL OWED AUTOS BODILY INJURY X SCHEDULED AUTOS ('er person) S B — — X mammas BODILY INJURY X NON -OWNED AUTOS (Per s ) 3 X MASS POLICY FORM PROPERTY DAIAAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG S EXCESS I UMBR9.LA LIANJTY EACH OCCURRENCE S OCCUR a CLAIMS MADE AGGREGATE S S DEDUCTNLE S RETENTION S $ WORKERS COMPENSATION AND WC1136680 11118110 11/18111 X ug: I OMER EMPLOYERS' LMDIUTY YIN EL EACH ACCDENr $ 500,000 C ANY PROPRIETORMARTNERADIECUTIVE OFFICER/MEMBER OWNED? © . EL DISEASE -EA EMPLOYEE $ 500,000 Byes moo* ELL OISEASEPOLICY S 500,000 SPECIAL PROVISIONS Wow OTHER DESCRIPTION OF OPERATIONSILOCA CLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICAM HOLDER CANCELLATION , IDEAL HOME IMPROVEMENT, INC. SHOULD ANY OF TIE 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 NAKED TO THE LEFT, BUT FAILURE TO GILL MA 01354 DO SO SHALL IMPOSE ND OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. %AIJTHORIZED REPRESENTATIVE Attention: - ��� ' ACORD 25 (2009111) Certificate NI 23873 ft 1988-2009 ACORD CORPORATION. AI rights reserved. The ACORD Mare and logo are registered marks of ACORD /a,e,,4.4..4 RI - Office of Consumer Affairs and : usiness Regulation IIPI 10 Park Plaza - Suite 5170 Boston, Massacetts 02116 Home Improvement tiiialf:Cactor Registration Registration: 146402 Type: Private Corporation Expiration: 4/2212013 Tr* 209431 IDEAL HOME IMPROVEMENT INC., JAMES ELLIS 142 BOYLE RD GILL MA 01354 Update Address and return card. Mark reason for change. Address Renewal El Employment 1:3 Lost Card PS-CA1 0 5044.0004-G101218 — — — . Massachusetts - Department of Public Safer 4, Board of Building Regulations and Standards Construction Supervisor License License: CS 91207 JAMES P ELLIS 142 BOYLE RD GILL MA 01354 Expiration: 10/16/2012 (DinrnI%%u,uer Trt 3269 ,\ The Commonwealth ofMassachusetts Department of Industrial Accidents ,,;,; , 4, g; ~ Office of Investigations ji , 600 Washington Street Boston, MA 02111 ' A { ' >; www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information '1 Please Print Legibly Name ( Business /Organization/Individual): / 6€61.1___ , tw / Mel O VP 11b'ntr" Address: ,q0 & li-e_ i' 4 Cit /State /Zip: ei, r I J 1 Mpg" 01,3 Phone #: 4-{ 4-- t� 3 -- ,2/ 0) i Are an employer? Check the 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. ❑ New construction 2. [DI 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' [No workers' comp. insurance comp. insurance.t 9. ❑Building addition required] 5. ❑ 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 12.0 R f repairs ' insurance required.] t c. 152, §1(4), and we have no / C(.3 �,L employees. [No workers' 13. Other / fl S G(. ! 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. _ _. - L Insurance Company Name: Le( 11110 4 / r , rezn 6e effhpany Policy # or Self -ins. Lic. #: Pia 113 (0 to 1. f Expiration Date: i i b 8 / I J j ( Job Site Address: 1 L f -.S SCS 0 , +S City /State /Zip:► V )Q dkti l (7111 L4 1 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 pa and penalties of perjury that the information provided above is true and correct Signature: C - I p r S Date: C siq / 1 Phone #: ` F13"° b 3 4 '3 , 2/a 3 , 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 Su • .: • . Not Applicable ❑ Name of License Holder : W S F/ii 9 / s0 7 awid\ / LON er_t. , Address / Expire ' Date - /- 1 0 - = -al e nature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ Registr Number � ' t J&j . l� i I I ' 4 01 5 � 3 Ad ess ) ( Expirati Date f✓ f . S i Telephone 41/2 3 °104 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) 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-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job 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' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [D Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors Accessory Bldg. 0 Demolition ❑ New Signs [p] Decks [q Siding [CI] Other [ I r) ,I a?2 AY L.. Work f �p �:( .IISC i n 04121 6-4 �2D a 30? - 'Leiter war -- c e-C.k_ Alteration of existing bedroom Yes .r° No Adding new bedroom Yes F'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 CONTRA TOR APPLIES FOR BUILDING PERMIT I a' , as Owner of the subject property hereby authorize f /)S " ' /1 / 1 5 to act on my behalf, in All matters relative to work authorized by this building permit application. Signature of Owner Date I, ti C yy s r I (I 5 , as Owner /Authorized A ent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno`Tw edge and be ief_ Signed tinder the pains and Anattigs of perjury. a.mes lI \ Print Name Signature of • Agent Date ` ' f 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 S YES 0 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 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 'is) IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, cavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. C r -10 RECEIVED Department use only • City of Northampton Status of Permit: 3uilding Department Curb Cut/Driveway Permit MAY 1 201 I 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability DEPT. OF BUILDING IN;SPtGTiONS Northampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON, Milo (i„ O 4 13 587 -1240 Fax 413 -587 -1272 Plot/Site Plans F�� �� Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION L 1.1 Property Address: This section to be completed by office /; Map Lot Unit t` ` � C SSAC ©l '� Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 OMme of Record: - C r ( ry s s a WV CLS pro , Name (Print) ke.C.-C Current Mailing Address: Signature 43 us SS Telephone " Tl .3 "' cx J� 590 6 2.2 Autlyirlzed Agent: , arni Pills /4I-a & J 6/11 6 ff 0i- yi (Print) Current Mailing Address_ I - 3 - ,3 0 2 10 gnature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (L(., 7 - (a) Building Permit Fee 2. Electrical 1 (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) c '4 J - Check Number /135 /1(,-t5 - This Section For Official Use Only Date Building Permit Number Issued: Signature: �. ✓ Ildi - 2-7 // // Building Commissioner/Inspector of Buildings Date 74 MASSASOIT ST BP- 2011 -0926 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 067 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 -0926 Project# JS- 2011 - 001511 Est. Cost: $2418.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 13068.00 Owner: CROSS JANE R & PAUL SPECTOR Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 74 MASSASOIT ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON :5/11/2011 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 5/11/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner