25C-208 (8) .
.,\ , ..„
_*___..___ f. Y✓e Y (1 r l' -1-1, li u
_ii rg Office of Consumer Affairs and : usiness Regulation
- - - - - 1 - :m e 10 Park Plaza - Suite 5170
` Boston, Massaci etts 02116
Home Improvement Contractor Registration
Registration: 146402
_ Type: Private Corporation
- Expiration: 4!22/2013 Tr# 209431
IDEAL HOME IMPROVEMENT INC - �
JAMES ELLIS "" = _ -
142 BOYLE RD
GILL, MA 01354 -
-_-_; - ` -- Update Address and return card. Mark reason for change.
-- - ❑ Address 0 Renewal 0 Employment 0 Lost Card
, s-cm €, 5044-04lO4- G1O12e6
•••••• ll.tssachusetts - Department of Public Safer=
- 0 Board of Building Regulations and Standards
9
Construction Supervisor License
License: CS 91207
.t
JAMES P • Fit 1S - , !,,, - -
142 BOYLE RD - A
GILL MA 01354 it
�, -- ---- Expiration: 1W16/2012
(•ummi.a.m Tr#: 3269
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
j Office of bzvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): l i) L_ ; V (� ( / I "1 to / 0 vif At r
Address: / v)]- _ (IA
City /State /Zip: (_<*; 1 J 0, 9 '0 i CI-/ _ Phone #: / 1, -- 6 6 11 r
Are you an employer? Check a appropriate box: Type of project (required):
1. ❑ I am a employer with r7 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. El 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. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work officers have exercised their < 1 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] ' c. 152, §1(4), and we have no l
13.0 / k. 6(
employees. [No workers' / _5 i
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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 .(C i 1L1 /1.76i3 / l l i S- ( � C i C � . i { C L C i'T ^ ) )1438.1 ^t y
Policy # or Self -ins. Lic. #: ' : C J / & C j '4 ?- f t Expiration Date: 1/ /1 S
Job Site Address: 15 knolen City /State /Zip: 1 r `
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: - (l Date: / 6/1 1 —
Phone #: /) 1 3 b? 6 - , Q/6?
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 #:
SCAM City of Northampton
Massachusetts „„ — ,-,,
y DEPARTMENT OF BUILDING INSPECTIONS y
'' '” � 212 Main Street • Municipal Building ,ss NA"
Northampton, MA 01060 Y A
Property Address: /5 Lin der) Lt
Contractor
Name: / oa_ MM,r? /MI°tOV LC vi
Address: 04.k doll___ 'd-
City, State: 6) 0 , 6 1
Phone: 4'13 - 3' , ' 1 a 8
Property Owner I. % Q �
Name: ��1 co C
Address: /5 of n CI-41 \SJ
City, State: /V() r !"Y► yj , N4-
I, Ja,mes ?ill 5 (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.
Contractor si a e
1 t ore s
Date
4'/(011
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / � 1 Not Applicable 0
Name of License Holder : '.1u � S ` I t l /.1 v 7
License Number
/ Lhk v3 i -4 C1 )1 / 'ph (/i
Address Expiration Date
s ._ - / � 3 Of
e Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registr tion Number
6 4) m - di 1-1- a l 4 r 3
Address ' 1 Expiration Date
Telephone `/ � 5
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 ermit.
Signed Affidavit Attached Yes 2 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 ily dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs mi e than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Buil ,' • : Official, on a form acceptab uilding Official, that he /she shall be
responsible for all such work performed unde e building s erarri .
As acting Construction Supervisor your presence on - • : . site will be required from time to time, during and upon
completion of the work for which this permit is issu - • .
Also be advised that with reference to Chapter (Workers' Com • ; • sation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in D= ) of the Massachusetts Gene : Laws Annotated, you may be liable for person(s)
you hire to perform work for you u -r this permit.
The undersigned "homeowner" - -rtifies and assumes responsibility for compliance ith the State Building Code, City of
Northampton Ordinances, : ate and Local Zoning Laws and State of Massachusetts Ge -ral Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [
/ nSac. 1 1:tyL .
Brief Descriptiorygf Pr rased ( //
Work: X��o LYQ/IS Oat �i t�� /!S a a
Alteration of existing bedroom - Yes No Adding new bedroom Yes -No
Attached Narrative Renovating unfinished basement Yes 7 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, t 1 601‹:„._ , as Owner of the subject
property .
hereby authorize c` ,l r S S
to act on my behalf, in all matters relative to work - ■ • rized by this building permit application.
Y- It/ -"/ I 2 --
Signature of Own: , Date
I, c -iiine S F I. � , as Owner /Authri
Ageltbereby declare that the sta and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed der the pains and enalties of perjury.
. Jc mi.s Ili s
Print Name
12 re .
S re 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 ® DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0
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 ® NO .J
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 0 NO IS
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
RECEIVEE.1 City of Northampton Status of Permit
• Building Department Curb Cut/Driveway Permit
PR 212 Main Street Sewer /Septic Availability
� " ` f Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
DEPT NOR7 0ORFT HAU BULOMG rON, INSPMA 010ECnO60 N ,hor e 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
ndP Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
I. I. 6o I ► .5'ix-rr>e
Name (' •nt) Current Mailing Address: /.
Telephone
Signature
�
2.2 Aut >• ized A • ent: •
fifyy_S I 60, ecl. 6111 M4 i
Name (Print) Current Mailing Addr
3- W6.3-o21a
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 �j
4. Mechanical (HVAC)
5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) ��f-�, 00 Check Number / 70f
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
15 LINDEN ST BP- 2012 -0895
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 208 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 -0895
Project # JS- 2012- 001579
Est. Cost: $1428.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 4399.56 Owner: IPPOLITO MELISSA ANN & RONI GOLD
Zoning: URC(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 15 LINDEN ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863 -2128
GILLMA01354 ISSUED ON:4/23/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: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 4/23/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner