24D-126 (5) 247 STATE ST BP-2019-0117
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D- 126 CITY OF NORTHAMPTON
Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2019-0117
Project# JS-2019-000194
Est Cost, S7000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sa. ft.): 4094.64 Owner: SELLERS JOAN R&MARK
Zoning:URC(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT. 247 STATE ST
ApplicantAddress: Phone: Insurance:
142 BOYLE RD (413) 863-2128 WC
GILLMA01354 ISSUED ON:7/31/2018 0.00:00
TO PERFORM THE FOLLOWING WORK 550 SF R30 CELLULOSE OPEN ATTIC, 560 SF
PERIMETER FOAMBOARD, 110SF DP 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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 7/31/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Conunissioner
Department use only"
City of Northampton Saba;Of Pa"it
Building Depart
m o C r r I Permit
212 Main Stre R G V C A '
Room 100 We
te A lability
Northampton, MA 0 060 'III Plena _
phone 413587-1240 Fax 35 7-7271 30
PMUSile erg
Others
APPLICATION TO CONSTRUCT,ALTER,RE IRXq""e T r+A 94E OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION B�- 7
1.1 Properly Address: This section to be completed by office
Map �J-q 0 Lot //lo Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
l Aql Lqa:y ti *r1A10M
Name(Pnn Current Mailing Address:
t-113-1¢58. 53qq
Telephone
Signature
2.2 Au
thorized Agent:
CAIIS 14a lr �Za1 �'�III YYll1
N Curren)Mating Address:
C�.w� �II3-gra- a(a�
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed brmitapplicant
1. Building —f COD (a)Building Permit Fee
2. Electrical l Vv�J (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit I"
4. Mechanical(HVAC) I�lf
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Lisa Only
ate
Building Permit Number. Issued:
Signal e:
Building C missionedlnspector of Buildings Date
Section 4. ZONING Alt Information Aunt Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
this column to be filed in by
Buildingnepsnmcnt
Lot Size
Frontage
Setbacks Front
Side U R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
perkinso
#of Puking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ver been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Regis of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page.. and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT 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 (D-
IF
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex tion,or filling)over 1 acre 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 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks (p Siding IDI Other
Brief De�sy npt n f Pro osed
Work;WWX &30 e'onaL9.4-Q?MCkll j:4 6`4 E QflgnWVfaf L%ar -; 110 S>f dQ t.Aa1lS
Alteration of existing bedroom_Yes Z No Adding new bedroom Yes --N,01�No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing. complete the following:
a. Use of building:One Fani 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 fl.of wetlands?_Yes No. Is construction within 100 yr. fioodplain_Yes___.No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. SephcTank CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, l kn �Q1164, _ ,as Owner of the subject
property
hereby cn I,S
to ac[ n my alf, inallThatters a live to work authorize y this building per application.
OT r t/
Signature if gr,,r Date
I, � IQTA f( MS , 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 de the pains and penalties of perjury.
Fri ame I � �,,
Il
Sgnature of rlAgent Da e
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construc0on Supervisor:
Not Applicable ❑
Name of License Holder: 01I
QIA6 I
License Number
1 a�U �11 �YIP�. Ul39f lo-l(0- 8
s Expiration Date
I3" I
Si azure Telephone
9.Rer is aretl Hm Cn tor: Not Applicable 11I 14U Uo01--
Campanv Name r Registration Number
Addre/3.�5.�r Expiration Date
Telephone�"�p
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
Workers Compensation Insurance affidavit ust he completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin permit.
Signed Affidavit Attached Yes....... N...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 family dwelling,attached or detached structures accessary to such use and/or fans
structures.A imirson whoconstructs more than one home in a two- d 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 all such work performed under the buildine 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,1 as defined by MGL c 111, S 150A.
Address of the work: A41 9
The debris will be transported by: 1'fA
The debris will be received by: NA7
Building permit number: 11
Name of Permit Applicant V0(YIQS �IIIS
14Ulig
Date Signature of Permit Applicant
city of Northampton
Massachusetts Av y <$
L
DSFARTfII'NT OF BUILDING INSPECTIONS
212 [Lin SC t • Municipal Building
�I LN,otNamptan, MA 01060 Shr YJ�
Property Address: all I
Mor
Name: jwQS
Name: � t /�/�-�1
Address: 1/l- � !(.F;C
City, State: 11(71 l l
Phone: Li I's
Property Owner (�
Name: X1 .1 fYS
Address: 1G��'1C�%fe- E7 ' Iry
City, State: /
_ 1 or I,1.1 mptm
(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 signatur�
Date -16,011
R
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` -- Please Print Legibly
Name
(Busucs/ Orrg izy)io v , at 1-bmf Lmpro nk
Address
City/State/Zip: ('XII AMLL hone#: •g aldQ
Are y u an employer?Check he appropriate box: Type ofconstruction
I. ' am an employer with 4. ❑ I am a general contractor and I please Check One
employees(full and/or part time).• have hired the sub-contractors o 6.New construction
2. L I am a sole proprietor or partner listed on the attached sheet. a 7.Remodeling
ship and have no employees These subcontractors have o 8.Demolition
working for me in any capacity. employees and have workers' o 9.Building addition
[No workers'comp.insurance comp.insurance.t u 10.Electrical repairs or
required]. 5. We are a corporation and its additions
3. f I an 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 requvedl t c. 152, § 1(4),and we have no o 'y.Roof repal�W.LlJt17_I
employees.[No workers' SA3.Other
comp.insurance required.]
*Any applicaat that checks box al must also ml out the sce,ioo below showing their workers'eompermation policy information.
tHomeownen,who mlimit this affidavit indicating they ere doing all work and then hire cubicle contractors most submit a new affidavit
indicating such.
$Comacmra that check this one must much an additboal sheet showing the name of the sub-contractors and state whether or not Mose
estldca have employees.If the sob-eoneractan have employees,they..at provide their workers'com,policy number.
I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and
lob site Informations. (�p1t��Ut 1 nC VXD n CL Co .
Insurance Company Name: J fury..-7 (� __
Policy#or Self-ins.Lie.4:ryW� L Q 6 (0 qj Expiration Date:_�I�,e`..u�n
Job Site Address:—0 1 JZIA.I< J't" City/State/Zip:1 IV1 lr]✓ 11 UA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(date).
Failure to sectio,coverage as required under Section 25a of MCL 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
$250.00 a day against violator.Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations ofthe
DIA for coverage verification.
I do herby ° er the pai an penohles of penury thdthe information provided and coma
Signature.' l ,Q�1�1 Date: 11111r��Gp1, 1 (a
Print Name:e:�('nQ.� �31]S Phone#:�r'' pU- o1I �S7a
Of aid use only Do not write in this area to be complacently city or Iowa ofprial
City or Town: P srmitnicensel:
Issuing Authority(circle one):
I.Board of Haath 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
AC RO® CERTIFICATE OF LIABILITY INSURANCE D"EIMYI
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THIS CERTIFICATE IS ISSUED AS A MUTTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATP/ELYAMEND,EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONBTTTIRE A CONTRACT BETWEEN THE ISSUING INSURERIS),AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER
IMPORTANT: It Me oerSTcate holder is an ADDITIONAL INSURED,Me polkY(Ies)meet have ADDITIONAL INSURED provisions or be endomed.
If SUBROGATION IS WAIVED,subject to Mebane and conditions of the polity,certain Policies may reguim an andomement Astetament on
this certificate does not confer rights to the certificates holder in lieu of such ondomenlentls).
PRODUCER uNXMEmuJ And 9 Feeley
Webber B Grinnell Pxoxx B (413)535-0111 (413)5065481
8 North King Street AppR�s_ afealey�webberarMgrinrlell can
INWRERDNATNRgXGCOVEJIAGE NAIOF
Northampton MA 01000 NSURER<. Select'.1.Co a S Cardiae
INSII0.ED INSURER B:
Ideal Home Improvement.Int, INSURER C'
AMUs.9 Elll6 INSUREri O'
142 BOfb Road INSURERS
Gill MA 01364-9731 INKNER F_
COVERAGES CERTIFICATE NUMBER FxP 1112018 REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POUCHES OF INSURANCE LISTED BELOW HAVE RISEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTNATHSTANDINGANYREDUIREMEW..TERMORCONDRIONOFANYMO CTOROTHERDDCUMENTw1T WR ECTTOWHICKTIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSUIUNLEAFFORDED BY THE PIXIDIES DESCRIBED HEREIN IS SUBJECT TOALLTHE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHDWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE INW W D PD.HUMBER mm.l MX YEV UNITS
COMNERCNLGEXERALUABILJTY Ega10LCURRENCE $ 1.000'BSIO
CIAIMSMAOE Ix CDA PREMISES Es � $ 500,809
MEDEXPlAnvmeV e^^ 4 15,000
A 52291358 1111712017 111172010 PERSONALIAWINJURY S 1000.D00
GEN'LAGGREWTEUMRAPPUEAMR; GENERALAGGREGATE 5 2,000,000
X PoLILV ❑JELUT LCC RRODUCTS-LpAPgPAGG 5 2,000000
OTHER; 6
AUTO.0.".W&UIY ��MNEOSINGIE LIMB s 1.000.000
ANY AUTO aOP'LYIWURV IPvpvaml S
A e°ums GNLv sHEEDUUE0 A9105410 1111712017 W1712018 BODRYINJURYEPI im10 S
X HIRED Na10L1NED PROPEATYDMIPGE 5
AUTOBCNLY AUTOSONLY Par NWu
Unin3anl ngtaibl Bl 6 too.o00
X UMBRELLA LIAR OLLUR E&bRURRENCE S 1000'"
A FX ... CUIMSMADE S4281353 11117IM17 1111712018 AGGREGATE S 1.000,000
DED I I REIiXhON$ 5
.En COMPENSarm PE}UTE X EOR
AND EEMPLOYMW LN DUL
ROPRIETORRMRTNERIE%ECUTIVE .P .CCYJENT F 500.000
A aFHDERmFMeERExcwo3oe NIA '.09057897 012&2018 0112W2019,a..."In HN) DISEASE-FAEMPLOVEE $ 500'000
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OFSCRIPPON 01OF OPERATgXS Mbx EL DISEASE.PoUCY UNIT 5 500,GpJ
C.P..OF OPERAncx6l LCCwiwe l.1.IAC.1w,Ammo.+Runty ealneuN,.1 Oa tll+=I.0 X men 11-nyul.sQ
CERTIFICATE HOLDER CANCELLATION
SHO -DANYOF TIEASONE DESCRIBED POLICIES BE CANCELLED BEFORE
TIE EXPIRATION DATE THEREOF.NOTICE YRLLBE DEJUW REO IN
Emdenue of Ineasno, ACCORDANCE WITH IME POLJDY PROAMONS.
AUnN0.0.dRE5eliAT1VE
0 JNB.2015 ACORD CORPORATION. All rights reserved.
ACOR026I2018103) The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
-" Board of Building Regulations and Standards
cense: CS-MI207
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JAMES P ELLIS
142 BOYLE RD
GILLMA 01364 //��
(—JZn c'A-- E:piray.n:
- -- - ---- --_-..Commissioner_. 10116)2016
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HOME IMPROVEMENT CONTRACTOR
TYPE:Cwp�
_..:Rware0on Ezolre0on
11O 0912112019
IDEAL HOME IMPROVEMENT INC.
JAMES ELLIS
142 Boyle Rd Gr---�-J
Gill,MA 01364
Undersecretary