31A-163 (4) ,,..
,._,„.., .9 --e0,,,.......za ....,/,.....4,,,,,oet&
` t Office of Consumer Affairs and usiness Regulation
_ _ ` � f =. 10 Park Plaza - Suite 5170
^ `` =`o' Boston, Massac »setts 02116
Home Improvement hilt for Registration
Registration: 146402
�-- Type: Private Corporation
—`° 1 v Expiration: 412212013 Tdi 209431
IDEAL HOME IMPROVEMENT ING.= _ ;_ ,.y - �
JAMES ELLIS
142 BOYLE RD - = f= -
GILL, MA 01354
; f ' Update Address and return card. Mark reason for change.
Q Address 0 Renewal [J Employment [3 Lost Card
DPS-CAI 0 5OM.04/04- G1O1216
0 Massachusetts - Department of Public Safet;.
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 91207 - , - .
JAMES P ELLIS
142 BOYLE RD
GILL, MA 01354 M
- --- .. Expiration: 10/16/2012
('ommissiuner Tr#: 3269
',, The Commonwealth of Massachusetts
Department of Industrial Accidents
, - �_ ,,,,*!.. ` Office of Investigations
1,� 3- ,,,,, 600 Washington Street
,' - .- Boston, MA 02111
''.i.; - , ' www.massgov /din
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): /6e4t'L ,14-ON l Mel (r} ltQ,./Ve fr _
Address: /-e_ e4
City /State /Zip: (2 r i . i 0 4 - 013c4 L- 11,..4-- Phone #: 3 -- Q/021
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 g, ❑ 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
employees. [No workers' Mo 13 r ,,/ th / n �/ ,_ _ > GCS rAi
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 contrac tors 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: /-QC /1 nO / h 44 ranee— pally
Policy # or Self -ins. Lic. #: Vie 11,3 (p 10 Expiration Date: 11 /1 8 / O I 1
Job Site Address// S Mal n 4 - City/State/ZipMdr t'1'+ 0 A`
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 rani under the pains and penalties of perjury that the information provided above is true and correct.
Signature: V--e-i )
P o S Date: i aq i I t
Phone #: iii 3-, 263 ' /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 #:
Property Address: `d k ma e.r.t, ea. Nor-1 ii 4'T
Contractor
Name: VA IL-40W— (M1
Address: F el &y k,
City, State: a (�
Phone: N 3 %Co 011 1c6
Property Owner f
Name: t CMIC� k4Z--
Address: 162 I "l O r\ kr e
City, State: N6-1. tV +0) ti
S ( 1 S contractor attest and affirm that the building ) 9 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.
Contr = ctor s gnature
Ores.
Date I't
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su isor: Not Applicable ❑
Name of License Holder : JV V nt.S Pa S li
/ AO O 7
License umbef
/L'A e- ��
&y . 61 1 MA 0/3 ,53- /v /i(0 )A
Tess /
Expiration Date
412 -- b3- / a2
nature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
/ 1' C W 1 ._/Mi O If e NI &) r / N c i ( 4 - 6 U,A
Comnanv Narne Regis Number
y . 6,ri iM 0i'3 / ►1
ress / Expiration Date
&,�,_ (� L." f7 0 s . Telephone '/L 4S D(c
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 lr 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 10835.1.
Definition of Homeowne • 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 • two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A • rson who constru 1 I ire 1 I an one home in a two- ear 1 riod shall not be considered a homeowner.
Such "homeowner" shall submit to the : 1 • ' g Official, on a form acceptable to the Building Official, that he/she shall be
tensible for all such work , rformed un . le buildin . i rmit.
As acting Construction Supervisor your presence on • - 'ob site will •.- - • wed 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 • ' - ' • • • - nation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) o : •. . s usetts t ..• end Laws Annotated, you may be liable for person(s)
you hire to perform work for you under • • - rmit.
The undersigned "homeowner" ; - and assumes responsibility for comp • ce with the State Building Code, City of
Northampton Ordinances�t� d Local Zoning Laws and State of Massachuse a.. General Laws Annotated.
Homeowner Signature
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) D Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks IC] Siding [D] Other [X
inSui ,r
Brief ' i; hk e /close . pkteritrAaJkS 4 calla. ` ( o) 07)/a – tr
bare/112j .
Ceihriti 49
Alteration of existing bedroom Yes ,-- No Adding new bedroom Y -"'No 132,0
Attached Narrative Renovating unfinished basement Yes No t%0a.-
Plans Attached Roll - Sheet 711: 1A4
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 FOR BUILDING PERMIT
1, & l ta) I tZ_ , as Owner of the subject
ro
P PertY /
hereby authorize k1 iYS (/ 1 5
to act on my behalf, in all matters relativ- to work authorized by this building perm' application.
\
A. AAA A. 1 " .. �11■ A 11
Signature of '' • r Date
I, J r II! Pi I , as Owner /Attu
A wi hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Jil rnes (il - S
Print Name CAL gjOi I
nature of Owner /Agent ' Date
Section 4. ZONING Alt 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 DON'T KNOW i� 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 Doctxnent #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW (?; YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO
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. WiII 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 0,
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
� '''..``��' y ' ,
.r ?„ /
! .�
� Department use only
4 ,,,,,(_, s' # , ',ity of Northampton status of Permit
, wilding Department Curb Cut/Driveway Permit
t /' 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 DWEWNG
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
jD g �G� yn a r-c, /C1–.
Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 0.1. of Record:
i I cht k_ Iu i) fZ o &i a prDperly
Name (Print) Current Mailing Address:
JL 4 �:� Telephone II 3 -- 2c, - i
Signature
2.2 A zed Aaent:
(Lne.S c � ' i l , s I + eo ed. Cr I / , N,¢- t 3 Su
9 rint) Current Mailing Address:
. --- -.--C ( 4. 1 A LH 3- -s43 -- 1 a9
S' ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS f
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 ,t _
6. Total = (1 + 2 + 3 + 4 + 5) 6 ✓ 3. -) - Check Number Ori,,
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP -2011 -0876
APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS /PHONE 142 BOYLE RD GILL (413) 863 -2128
PROPERTY LOCATION 108 MAYNARD RD
MAP 31A PARCEL 163 001 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 �� 7
Fee Paid
Tvpeof Construction: INSTALL WALL & BASEMENT 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
INFOMATION 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
s/Z 1 r
Sig ature of Build' g Official Date I
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.
•
108 MAYNARD RD BP- 2011 -0876
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 163 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 -0876
Project # JS- 2011- 001434
Est. Cost: $6330.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 10497.96 Owner: KUNITZ MICHELE
Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 108 MAYNARD RD
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863 -2128
GILLMA01354 ISSUED ON:5/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL & BASEMENT 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 5/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner