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32C-301 • Aco D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/21/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER . CONTACT Tra Ruklewicz A.H. Rist Insurance Agency, Inc. PHONE o ), (413) 863 -4373 I ( . N (413)863 -9658 159 Avenue A E-MAIL ADDRESS: P.O. Box 391 INSURERS) AFFORDING COVERAGE NAIC S Turners Falls MA 01376 INSURER A Nautilus Insurance Company INSURED INSURER B :Pilgrim Insurance Company Ideal Home Improvement, Inc. INSURERC:Tec1lmloloQy Insurance Company 142 Boyle Road INSURER D INSURER E : Gill MA 01354 INSURER F : COVERAGES CERTIFICATE NUMBER:2011 -2012 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR T YPE OF INSURANCE ADDL SUBR POUCY EFF POUCY EXP LIMITS - LTR INSR YWD POUCY NUMBER (MM/DDIYYYY) (MM/DDIYYYY) GENERAL UABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 10 0 000 PREMISES (Ea occurrence) _ A CLAIMS -MADE I x I OCCUR NN083776 11/19/2011 11/19/2012 MED EXP (Any one person) S 5,000 PERSONAL & ADV INJURY 5 1,000,000 GENERAL AGGREGATE S 2,000,000 GENT. AGGREGATE LIMIT APPUES PER PRODUCTS - COMP/OP AGG 5 2,000,000 — 1 POLICY n P Q ri LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1Eaaccident) 5 1,000,000 B ANY AUTO BODILY INJURY (Per person) S ALL OVVNED X SCHEDULED PGC10009703302 11/17/201111/17 /2012 BODILY INJURY (Per accident) S AUTOS AUTOS Y' HIRED AUTOS X PROPERTY DAMAGE NON IMED (Per accident) pLITOS S r UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS -MADE AGGREGATE S DED I RETENTIONS t S C WORKERS COMPENSATION x IT RYTIMiT51 I� R AND EMPLOYERS' UABIUTY YI N ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? I Y) NIA (Mandatory in NH) 3Ti1C3294412 11/18/2011 11/18/2012 EL DISEASE - EA EMPLOYEE 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT 5 500,000 DESCRIPTION OF OPERATIONS! LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Classification: Insulation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ideal Home Improvement, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 142 Boyle Road Gill, NIA 01354 AUTHORIZED REPRESENTATIVE Tracey Kuklewicz/TJK ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025,,(lane) n1 The Arnim nom end Ivan era ranictared merke of Annar) ✓le e'ammonwea /l1 o /L •;ae Jell Office of Consumer Affairs & Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to Registration: 146402 Type: Office of Consumer Affairs and Business Regulation Expiration: 4/22J2013 Private Corporatio i 10 Park Plaza - Suite 5170 Boston. MA 02116 IDEAL HOME IMPROVEMENT INC. —� JAMES ELLIS �– 142 BOYLE RD , GILL, MA 01354 Un dersecreta ry N� No alid without signature - Dci;artnient nf• Public 3 ftiar;i of Ruilditi,“ Re *2uiati n. anti 1/4,1,111(1,1-,;. � CQ_ns iuction Su ue !r s Licerse License: CS 91207 t'' M JAMES P ELLIS e V. a 142 BOYLE RD GILL, MA 01354 c ': Expirstron 10116[2012 “ nnn Nsiomo1 -- 1= . 3265 The Commonwealth of Massachusetts Department of Industrial Accidents ` Office of Investigations 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): /! j-CG% ? Ut`2t i I`j; �) /( 1 Address: / o City /State /Zip: � l I 1 " 1 ' ' �'� I 5 LI Phone #: '-- 6 1l Are you an employer? Check e appropriate box: Type of project (required): 1. Q I am a employer with "7 4. n I am a general contractor and I have hired the sub - contractors 6. ❑ New construction h ay employees (full and /or part time).' ' 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• ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. CI 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.❑ Roof repairs insurance required.]' c. 152, § 1(4), and we have no E r employees. [No workers' 13. r Other i t'� ; ;.- / t(J] 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. // r Insurance Company Name: / ..CC r : + r} L� 1 Q� Li //1St i 1 t (r i C.t -- � "l \ , Policy # or Self -ins. Lic. #: v ��- � ' L j i i {' 3,2 `C--r; ;, Expiration Date: 1 / / S / Job Site Address: l / /Calf mil// City /State /Zip:60 r (1/4 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. fir Date: v GI Signature: t� ► Phone #: 13 , b 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 #: I City of Northampton d -0 o 2 `'�S s sic Massachusetts �� ,,_ ff r % 14 i , i ` t t :, DEPARTMENT OF BUILDING INSPECTIONS y , 1 v �- 212 Main Street • Municipal Building As h � O a \ r Northampton, MA 01060 ; )v 30� Property Address: I Vc_'1k.1 D- Contractor / Name: Jaf,es elf, 5 Address: Pi i30 �� eL, City, State: (;► i i Phone: X13 - / 3- -.11 A Property Owner ,_ - '/ C me: rS Address: Q t va L .s4- ar�� City, State: y r 4 0 1t . I, Vl'le S C- 111 (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 s' • na e * re Date 6/42)(0/1 J SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ s F Il . } ` Name of License Holder : q 1 t7t/ 7 License Nu ber 1 4Z7 v o ier.1 . Cal/ -44— 0/ /0 6Ji Address / ) Expiration Date 413 go 3 - t.li a-C Si net re Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ j & 'NI p°/ aver pti / % 40 k Company Name Registration Number 0 4,A +may k i&'. 6 1 Imo- o) 64:;\/) .4- / j 13 Address ) I , L Expiration Date .. c = = . (0 re S , Telephone q/.3 P ?-.2. / SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit mu t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied D . • lines of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not posses . icense, provided that the owner acts as supervisor. CMR 780, Sixt Edition Section 108.3.5.1. Definition of Homeowner: Pers, (s) who own a parcel of land on which ,. she resides or intends to reside, on which there is, or is intended to be, a one or two amily dwelling, attached or detach=. structures accessory to such use and/ or farm structures. A person who constructs • re than one home in a tw • ear period shall not be considered a homeowner. Such "homeowner" shall submit to the Bui .' • . Official, on a fo • acceptable to the Building Official, that he /she shall be responsible for all such work performed under " • build' • • permit. As acting Construction Supervisor your presence on th :. site will be required from time to time, during and upon completion of the work for which this permit is issue. Also be advised that with reference to Chapter 15 orkers' Compen . 'on) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) . 'the Massachusetts General • s Annotated, you may be liable for person(s) you hire to perform work for you under this . ermit. The undersigned "homeowner" certifies ., d assumes responsibility for compliance wi • the State Building Code, City of Northampton Ordinances, State and • al Zoning Laws and State of Massachusetts Gene : Laws Annotated. Homeowner Signature / t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n / Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [ I rISLO AA dYL._, C o , 0 00f � opo e�i_ Work: pad mod. / I Work: : ,R -A00 — d.em Q7 5 ( o) "R► � , Alteration of existing bedroom Yes No Adding new bedroom Yes U --•'* ----- 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, er chat ro Ilk , as Owner of the subject property / I hereby authorize ��-1 .S F I / S to act on my behalf, in all ma ers relative to work authorized by this building permit application. ?/�.c C� /, / if,,( c /v 7 5 7 a /..,,, Si na ture of Owner Date / / I, 3 ) ij l S , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed nder the pains and penalties of perjury. Signed ? I l l S Print Name 4A ,O. (0/(21-rob A— .= of Owner/Adent 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 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 Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 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 Q 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 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 CO 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 JUL I U 212 Main Street Sewer /Septic Availability L - -_ _ Room 100 Water/Well Availability DEFT. BUIL TON , MA Northampton, NORR THAMPTON Northam ton, MA 01060 Two Sets of Structural Plans p one 13- 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 tical-eY Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 pevner of Record: 2 r t d QA C k 4 k_ u..s ( .Dca Name (Print) / � Current Mailing Address: X /7 C K L p 7 / / ` .- C `Q 0� I / /� 7 1;EI ur pLlS�ne Signature 2.2 Authorized Agent: A C (• S 1`f-a. 6 � Gi I) M - al .1 Name (Print) Current Mailing A dress: J Q.QA 4-13- 3- at Signa 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) ' i 5b. O 0 Check Number This Section For Official Use Only Building Permit Number: Date d: Signature:��/� Building Commissioner /Inspector of Buildings Date F 21 VALLEY ST BP- 2013 -0030 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 301 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- 2013 -0030 Project # JS- 2013- 000045 Est. Cost: $4950.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 6708.24 Owner: CRONKITE HERSCHELL A Zoning: URC(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 21 VALLEY ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 G I LLMA01354 ISSUED ON: 7/10/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATE EXT WALLS 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 7/10/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner