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31A-194 7,,,p City of Northampton r �o r o4. +x'15 c._ ,Slc". Massachusetts o ( 4 ,* w \ .. r '„ DEPARTMENT OF BUILDING INSPECTIONS y; 212 Main Street • Municipal Building 'Ps: ,1,�Q� '` Northampton, MA 01060 hW ' Property Address: Z5 vv C h l rt)W a .(.__ Contractor Name:ame: airn/ S C1 L y3 ) 1-L 1 S Address: / L+ ' tecL City, State: 6 i 1I WI J l Phone: 41 - (a �-I Property Owner , Name: G..Y1yl- - l U rrvLitr1 Address: ?6 k)k-.5h' n9 a v City, State: 1\10 0'f. 't'llail e --i U) M4 • I, --6(JV1'V % ' I \ r 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. Contractor sign e C Y� Date ,oKji3 massacnusetts vvorKers• Compensation Insurance Plan BerkIeiAcadia Insurance Company NCCI Carrier Code 33391 J Administered by Berkley Assigned Risk Services ASSIGNED RISK SERVICES P.O.Box 1100,Minneapolis,Minnesota 55440-1100 Phone(605)945-2144 Fax(866)215-8118 Toll Free(800)634-4589 www.berkleyassignedrisk.com CERTIFICATE OF INSURANCE 1.The Insured: WCIP Policy Number:WC-20-20-004440-00 Ideal Home Improvement Inc Tax ID#: F 20-5754084 142 Boyle Road Gill,MA 01354 Policy Period: From: 11/18/2012 To: 11/18/2013 Date of Mailing:12/5/2012 The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the Policy listed below. This is to certify that the Policy of Insurance described herein has 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 Policy described herein is subject to all the terms, exclusions and conditions of such Policy. TYPE OF INSURANCE: LIMITS£1F MOM/' ' Coverage Part One States) Workers'Compensation Statutory MA Part Two Bodily Injury by Accident $500,000 each accident. Employers'Liability Bodily Injury by Disease $500,000 policy limit. Bodily Injury by Disease $500,000 each employee. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. All Entities/Insureds: Certificate Holder's Name and Address: Ideal Home Improvement Inc Election Election Category Status Name Ideal Home Improvement, Inc, Officer Exclude James P Ellis 142 Boyle Rd. Gill, MA 01354 Date Issued: 12/5/2012 Rist A H Insurance PO Box 391 Turners Falls, MA 01376 Signature_ ,/17.11:,:'/-,-/-.._ The Commonwealth of Massachusetts ... Department of Industrial Accidents ;till=:--•l . MN1 _ Office of Investigations e. =IOt ° 600 Washington Street • Boston,MA 02111 � • ww».mass.govtdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): /6 49 a c._ /t iPaOV f( /V 1 /N C . l Address: l40 60 y e_ i c- City/State/Zip: 111 14 T 0 l 3 Phone.#: 4f r- '(e 3- l 4i Are u 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 ❑New construction listed on the attached sheet 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' g Y P tY t 9. []Building addition [No workers' comp.insurance comp.insurance. required] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.n I am a homeowner doing all work officers have gercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL l2.0 of repairs insurance required.]t c. 152,§1(4),and we have no L employees.[No workers' 13. Other t h GC.�6t t 1 d - 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. Ville subcontractors 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. f Insur ance Company Name: ((6Ldi& !it 1 v iC (l f n px rt (( Policy or Self-ins.Lie.#: IA) C " U 0 =6a 4-49-0'06 Expiration Date: I I J 1 I E L?i 3 Y P tf- Job Site Address: 0 %) l t,a.0-11Y21 I t./t let City/State/Zip: Ak 1 1/41-- ot1Yr Ti°>t i1 4 Attach a copy of the workers'cornpensatidt policy declaration page(showing the policy number and expirdtion 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 coverge verification. I do he ..0 ify under the'pains�and penalties of perjury that the information provided above is true and correct. Signature: ��.---inl� 3 Dates fo b'i 2 _ Phone 4: iili ' -' V(e'3 -` '''gut I 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 rvisor: Not Applicable'1❑ Name of License Holder: \.L 'Y)e S 8 I I, S q 1 -) License Number )L;. 6-0* )d ) ( H11 -- 0 ) ) 0/ 1C0 l ►* dress Expiration Date ' nature Telephone 9.Realstered Home Imorovement Contractor: Not Applicable ❑ / ._.. > /N1P 08(eNe'1; 1 `"/to Li 0. Company Name Registration Number t �, oe I �l + Liid.a-1 Is ess Expira ion Date —,_ 2,--0 C r. S . Telephone`t%- 3 l -/ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit m 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 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:Per (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 mo • an one home in a two- l—not be considered a homeowner. Such"homeowner"shall submit to the Building ■ a cial,o - -. acceptable to the Building Official,that he/she shall be responsible for all such work performed under t. . I i• ling permit. As acting Construction Supervisor your pr ce on the jo s • will be required from time to time,during and upon completion of the work for which thi rmit is issued. Also be advised that with refer a to Chapter 152(Workers'Compensa :, and Chapter 153(Liability of Employers to Employees for injuries no esulting in Death)of the Massachusetts General L. Annotated,you may be liable for person(s) you hire to perform for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance wit e 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 ❑ Addition ❑ Replacement Windows Alteration(s) [] Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[0] Other[ 310 b q-S lO-rsi S / �-G � _ IZ i j - k-w c<.(I to flu - pa vow - a s-t - Ri Brief Descri tion o Proposed ' v�- to ca Work:$bOv-' cier-e Haack-emu-0 va eJGh/dails lb carkaty f o - RA) K-focal Poor Alteration of existing bedroom Yes . No Adding new bedroom / Yes No Attached Narrative Renovating unfinished basement Yes -- No Plans Attached Roll -Sheet sa.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 ( 1 A A_ ,as Owner of the subject property /,7 �� hereby authorize 'JOV`►Y lA S 1) / S to act on my behalf, ir<all matters relative to work authorized by this building permit application. o4 -3°.I 3 Signature of Owner Date ,as Owner/I uthorized,J ereby 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. yyi s E 'i, S Print Name Lt fa Signature of Owner/Agent Date Section 4. ZONING AR 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 '.''? YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 Q DON'T 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 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 O NO cj 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 Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. y ,, Department use only City of Northampton Status of Permit - -'"�✓ Building Department Curb Cut1Dnveway Permit V\3 212 Main Street Sevier/Septic A laid P� ' Room 100 Water/Weil Availability M G`NSp o° ,orthampton, MA 01060 Twa Sim of Str al Plans oe. oN • •ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans o�Noc Other p fy 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 li ,aS k t rc_ I,,.' Map Lot Unit �V alt Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephgo�n13-- - I Signature 2.2 Authorized Anent: la ,meS E I i ��5 i t4,9\ eo yh 1 lI �i�- �, 3 �' (Print) Current Mailing Address. _.. 41 3 g 6 3 Sigeature 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) 60S Check Number 021257 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-1052 APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863-2128 PROPERTY LOCATION 85 WASHINGTON AVE MAP 31A PARCEL 194 001 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 al® 0 453" Fee Paid Typeof Construction: INSULATE 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F ATION 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 Al i ;7 I;( Signature of Building •fficial Date 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. 85 WASHINGTON AVE BP-2013-1052 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31A- 194 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-2013-1052 Project# JS-2013-001737 Est. Cost: $3608.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq.ft.): 9191.16 Owner: FORMAN SUZANNE Zoning:URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 85 WASHINGTON AVE Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 Liability GILLMA01354 ISSUED ON:5/6/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE 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 5/6/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner