22B-112 (3) 53 MEADOW ST BP-2018-1397
GIS#: COMMONWEALTH OF MASSACHUSETTS
MamBlock:22B- 112 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-2018-1397
Proiect 4 JS-2018-002485
Est Cost $1700.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. R.): 12806.64 Owner. BUNK BRIAN D&LAURA P SIZER
Zonine URB(74)/URA(26)/WP(23)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT. 53 MEADOW ST
ApplicantAddress: Phone: Insurance:
142 BOYLE RD (413) 863-2128
GILLMA01354 ISSUED ON:7/3/2018 0.00:00
TO PERFORM THE FOLLOWING WORK769 SQ FT 9" CELLULOSE OPEN ATTIC, WHOLE
HOUSE AIR SEALING
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 7/3/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Ins a'1-
File d BP-2018-1397
APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413)863-2128
PROPERTY LOCATION 53 MEADOW ST
MAP 22B PARCEL 112 001 ZONE URB(74)/URA(26VWP(23)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OIY'P��
Fee Paid ( -00
Building Permit Filled ou
Fee Paid
Typeof Construction- 769 SO FT 9"CELLULOSE OPEN ATTIC.WHOLE HOUSE AIR SEALING
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
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Sperial 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
Ml �
Signa of Build1bg0 tial 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.
Department use only,
-y I of Northampton Steals of Permit::
HEC,EIVED e1; ingDepartmenI Curb Cut/Driveway Permlt
2 2 Main Street SeweDSeptie Avatlabft
JUN 2 g 2018 Room 100 Water/Well Availability
orth mpton, MA 01060 TWO Sets of Structural Plain
phone 41 -58 -1240 Fax 413-587-1272 PkWSitePlana
DEPT.OF 6UILDmDINSPECt[DW Other Specify .
TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i -SITE INFORMATION
1.1 Property Address: �o�,,, �In�I� 1 \ 11 ''�� ^^��Th,(iiss�section to be completed by office
mZlnLil�o SI Map 01A u Lot 1 ri. Unit
1.
Iormu, OV Zone Overlay District
l Elm St.Damic CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
rora r, c �
Name(Print) Cument Mailing Addre s
1-113 724 G�1°I
Telephone
Sig pre
2.2 Authorlzed A
me(Pnot ) �Cyyu��ment Mailing Acidness:
Signet Telephone
E ION 3-E TI TED CONSTRUCTION T
Item Estimated Cost(Dollars)to be Official Use Only
completed by pennit applicant
1. Building ryl (a)Building Permit Fee
2. Electrical W (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) Check Number
This Section For ORiclal Use Only
Date
Building Permit Number: Issued'
Signature:
Budding Commissionedinspector of Buildings 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 fined in by
Building Department
Lot Size
Frontage
Setbacks Front
Side U R: U R:
Rear
Building Height
Bldg.Square Footage on
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
FFill:
volume&Lacatiou
A. Has a Special Permit/Variance/Finding giler been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Regi of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document k
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , 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 O NO V
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,ex ation,or filling)over 1 arse or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Altenation(s) Q Roofing El
Or Doone ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[[-I] Other[
won��TATI l�\��G�Q (Ol(�( A1C ��J 1bIR Vl(AIS�O i✓ LL\�u �1
Alteration of existing bedroom_Yes -/No Adding new bedroom Yes _>LNo
Attached Narrative Renovating unfinished basement Yes 0
Plans Attached Roll -Sheet
Se. If New house and or addition to existina housing, complete the following:
a. Use of building. One Family Two Family Other
It. 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 weflands?_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 COMPLETEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, C)l i(1 n � r1� as Owner of the subject
property
hereby authorize
to act op in behalf, i I matters relative to work authorized by this building permit application.
Sign u.of Owner Date
I '- X11 k S i lS ,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 un r the pains and enalties of perjury.
I S
Pnm N e
Sgneture of O+merl ent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable ❑
Name of License Holden Ss 6C, 1I✓���
License Number
Addre Expiration Date
J w�
Sig .tuns Telephone
9.Regillitrig FLOM IM al CqP r. Not Applicable ❑
�cuu�4 rnycm� rif 14Ku od-
Companv Name Registration Number
1q u 3l Mddress �r a Fxpiration Date
QNB^ Telephone 1`�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(S))
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 buildi permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was amended to include Owner-occupied Dwellings ofone(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 W be,a one or two family dwelling,attached or detached structures accessory m 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 98 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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: Fky(t" u --
The debris will be transported by:
The debris will be received by: i 111
Building permit number: 11
Name of Permit Applicant c� XYZ S l t S
V 61—t
Date Signature of Permit Applicant
City of Northampton
55 Sic
•y Massachusetts
➢
'f. S
ARIS�BT OF BU=MG I PEO 1=6 26
212 Min Street a Mnicipal B ilding
9 0C
NoitTam�ptyonn, NA 01060
Property Address: ��J Mud Jt Q,Y)u
Contractor
Name: c '@.4 Y1R S L l lS1
Address:
City, State:
Phone:
Property Owner ��(i �•.xA�
Name: ,�
Address: r)?p
City,C b v u Statee:� �'�G'/Pri�l
I, S v�y tS (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 signature ^
Date \A�D���
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Ogee of Investigations
600 Washington Street
Boston,Mass. 02111
w inEmass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Plea
se Print Legibly
Name(Busines/Org"iaNld ' X 11 `) `p IsoIroVtoYfT
Address: A.,
City/State/Zip: nk] I M[X O Phorl ( dI d Q
Are y u an employer?Check he appropriate box: Type ofconstruction
1. am an employer with 4. i I am a general contractor and I Please Check One
employees(full and/or part time).• have hired the subcontractors o 6.New construction
2. I am a sole proprietor or partner listed on the attached sheet. o 7. Remodeling
ship and have no employees These subcontractors have o S.Demolition
working for me in any capacity. employees and have workers' o 9.Building addition
[No workers'comp.insurance comp.insurance.$ o 10.Electrical repairs or
required]. 5. :1 We are a corporation and its additions
3. ❑ I am a homeowner doing all work officers have exercised their o 11.plumbing repairs or
myself[No workers'comp. right of exemption per M.G.L. additions
insurance required]r c. 152, §1(4),and we have no O V.Roof repairs
employees. [No workers' MA3.Other
wrap.insurance required.]
'Any applicant Nat checks boa#1 must also fm out the section below showing their worker'eompensation policy information.
£nmmeowmen who submit this affidavit itis is nfiog they arc dome all work and then hire outside contractors most submit a new affidavit
hidicafimgawk.
.Comators that check Mie ber must watch an additional sheet showing the name of the s sob mcnesetor and state whether or not those
entities have employer.If the subcontractors have employer,May must provide their worken'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and
job site
ceComp ny (�t(tc Uc (n5�/x✓1�� CO .
Insurance Company Name: J (�fy.,-f p
Policy 4 or Self-ins.Lic.#:y�vW,^,,^—q06 I(0gJ ___Expir\atiion Date:_��,,�Ql_1n-1
Job Site Address: l5� 1' �CbtK W sSit , City/State/Zip: r —[Vc 'lu— III x-rA
AtLych 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 152 can lead to the imposition of criminal penalties of a fine up
to$1,500.00 and/or one yew imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of
$250.00 a day against violator.Be advised thin a copy of this statement maybe forwarded to the Olfcc of Investigations of the
DIA for coverage verification.
I do herby��gf+r+a,-. er thelain an penalties ofpe7ury thin the inform tionprovided above afro andconech
signature.' l _ Da[e:_
Print Name: f lwnly% Skl(S Phone#:q�>' 0�2J'ov11
OJ ehil use only Do am write in this area to be completed by city or town ofJleinf
City or Town: Permitflicense#:
Issuing Authority(circle one):
Lannert oftli ath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: PM1one#:
A��® CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,EXTEND ORALTER THE COVERAGEAFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sb AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT: H Me ceNDcate Nobler is an ADDITIONAL INSURED,the policy(las)must have ADDITIONAL INSURED pmisiolm or beendomd.
If SUBROGATION IS WANED,subject M Me Damm and conditions of the policy,carlaln policies may mints an endowment A ata0ament on
this ceNMcsts does not confer rights to Me certifloats holder In INu of such eodomemnt(a).
PRODUCER DOIJUNCT XAME, Ar10rea Feeley
W,Ubers Grinnell (413)58&0111 ce. (413)583-cae1
S No"King Street nooriEss: aleleygymmbemmonnel min
Iveins Ci)OSCi IXGCOVFAAGE NICE
NMnemplOn M1N 01080 nJMIgER A: 5¢letlill lOS CD dS Ge101ine
INAUNERJ INSURER a:
low)Home ImIaOVement.Inc. INSURER c:
Ann. aWie ENiD INSURFA D:
142 Boyle Road IXsuRRR E,
Gill MA 01334&731 INSURER F:
COVERAGES CERTIFICATE NUMBER Ekp1112018 REVISION NUMBER:
THIS IS TO CERTFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD
INDICATED. NOTMR ANDIWMIYREDUIREMEMTERMORCONDITIONOFANTCONTRACTOROTHERWCWEMWRHRESPECTTOWHICHTHIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCEAFFO RDED BY THE POLICIES DESCRIBED HEREIN IS SLBJECTTOALLTE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY MID CLAIMS.
IATA TPE DF INSURRNCE POLICY NUMBER U.REIRISK YEFF MY UYnS
X COMMERCMLOENERAL WBNTY FACHOCCURRENCE S 1"Coo
CIAIM"ADE ®OCCUR RENISES EarcnlnYlre 5 500,000
MEDEXP!AMXM — 515'000
A SM13W 11/17/2017 11/17/2018 PERSONALAADVINJURY 5 1'000'000
GEN'LAGGRECTE UMITAPPUES PER: GENERALAGGRE.0 54'000'000
X POLICY �J—EGT ❑LDD PRODUCTS-DGAP TE 5 2,000,000
OTHER:
OBILEWOUIY COM&NED SINGI£UNIT 51.DDD,DDO
YAUTO AUDI LYIMIURY IPm Pvewl 5
A ONNEO SCREDRAD A9105410 11/17X2017 11/172018 RORLY INJURY'.a� 5
AUTOS ONLY ALTOS
HIREDON-0WNEO PAOPS T DAMAGE 5
AUT030NLY AUTOSONUY
UnimUred molmet BI s 1oo,00D
UMBRELLA LJAS 00GJR EACXIX-CURRENCE 4 1'WU'000
A EXCES6 AS CUIra51MDE 52291368 11/172017 111172018 AGGREGATE E 1W0,000
DED I I NE ENNGN s 5
WORImCOMPENSAROW
ANDEMROYERS-UNNUTY H STRUIE ER
A OFFICERMEMBER F%CL�1 ]SUN ❑ XIA Nt:9057897 01262(110 01X2102019 EL EACHACCIES 500,000
IMeMMory in XH1 E DISEASE-EARNAEMMYE£ 5 500'000
DEAERJ IGNOFOFERATIONAC DIGEASE-IX%ICYLINIT E 500'000
CRIFTION OFCPEMTON9/LOCAMIX9/VEHMLEE 1PCWW Iw,P61MwY R�nuq RMCule.mry e.YUY,w'a menpenurqul.e1
CERTIFICATE HOLDER CANCELLATION
SHOILDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E MINGDON MTE THEREOF,NOTICE WILL BE OEWEREOIN
Evidence of Inwmnce ACCORMNCE WITR THE Pol1CY RIpASI0N3.
AOTIpiMH1 REPRE9EXTATVE
®1966-2015 ACORD CORPORATION. AN rights nwrvad.
ACORD 26(2016103) no ACORD nam and logo are mtstered mike of ACORD
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
cense CS MI207
JAMES P ELLIS
142 BOYLE RD
GILL MA 01861
i. iratiore
-- - — -- ---- Commissioner 1
0f762018
INH (`i Ras auNflegul
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HOME IMPROVEMENT CONTRACTOR
G - TYPE:C.Morvion
•�`� OJ/2F. giraDnn
019
IDEAL HOME IMPROVEMENT INC.
JAMES ECUS
142 Boyle Rd L
Gill,MA 07354
Undersecretary