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17D-015 (4) 11 VERONA ST BP-2019-0514 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-015 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-2019-0514 Proiect# JS-2019-000836 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sg.ft.): 12588.84 Owner: THOMAS CAIJLIN&DANIEL GOMEZ GONZALEZ Zoning:URB{1001 Applicant: IDEAL HOME IMPROVEMENT INC AT. 11 VERONA ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED ON.1013012018 0:00:00 TO PERFORM THE FOLLOWING WORK.592SF R30 CELLULOSE OPEN ATTIC, 259SF R10 SLOPES, 512SF PERIMETER FOAMBOARD 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 10/30/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner nt 00arty " City of NorthamptonP+ Building Department Curb CutiDrivvljr iPermit 212 Main Street S `moo-WAbi Room 100 WaYeill ' ' . Y Northampton, MA 01060 TiiuoSOW of,Struid it101at , phone 413-587-1240 Fax 413-587-1972 F—RECEN - EN APPLICATION TO CONSTRUCT,ALTER, EPA&, RENOVATE OR DEMOLISH J ONE OR TWO FAMILY DWELLING OCT 2 6 P019 ff�� SECTION 1 -SITE INFORMATION 18 p—f q—b_I V 1.1 Property Address: 's s ion to be completed by office DEPT OF GUILDING INSPECTION NORTHAM�ION.MA 0106 Lot 6n/ � Urtlt �iMll�f'�'�' Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: N ��(,P22riinQnt��) � Current Mailing Address: "`*' O- , �/i '�'r'�� J J��'�t f Telephone Signature 2.2 Authorized Agent: S PAN Is Na a(Print) Current Mailing Address: Signature Telephone SECTI N 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit a2plicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) V 5. Fire Protection 6. Total=(1 +2+3+4+5) (� Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: !o L 2 i ll B Building Commissioner/Inspector 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 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 Q DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Gr YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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 a 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 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 [O] Decks [M Siding[o] 'n he Brief De cnptipn f Proposed , ,,�, /1� ` Work:��5{ RAIWDl e_ Q ,i'1 GSL '. Aq 10 r)t)Slcapes;51'A4 i trlavv +6- {�C>,.maw d Alteration of existing bedroom Yes �No Adding new bedroom Yes \/No Attached Narrative Renovating unfinished basement Yes \./No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing,complete the fdllowina: 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 ' l +ln 1YV[Gr as Owner of the subject property hereby authorize �� /�� IS to act on my behalf, in all matters relative to work authorized by this building permit application. l 0aJYi'�"� V V-D »k') l I Signature of Owner Date I C, Jana � ZT/I 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 under the ppins a�ndp�enalti s of perjury. uap/�p- S Print Name ry,. (: of a� Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructigo Supervisor: Not Applicale ❑ Name of License Holder U,C`�S �6 S �! 1A 0 CILicense Number 2 u -(c,J of rrq, 1'0-1u-,• )-o Addres Expiration Date 1?p SignAture Telephone 9.Re0stered Home I r ve r: Not Applicable ❑ �— CompanY Name Registration Number Nu L LINs u.'14. /� Addres t Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit Inust be 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....... 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: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 accessory to 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 all 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: I I Venna- &�4 The debris will be transported by: ueG The debris will be received by: IA' Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton sus ::..sic .> Massachusetts . N q DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: �- Contractor JOX4-S ,�t(5Name: Address: q-x �A- y u City, State: t r/u, Phone: l <Z�� c� Property Owner C '(-4 �n I S G rqm Name: , / I � f � e+p Address: 1 V u(`�� C%,�Com" City, State: doyeA 1Z , " I, ( TU9(-(,5 (contractor) attest and affirm that the building I intend to insu ate 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 olas�I� The Commonwealth of Massachusetts Department of Industrial Accidents 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(Business/Organion/Individ ) r Address: City/State/Zip: 3 Phone#• l� Are y u an employer?Check he appropriate box: Type of construction 1. Vam an employer with 4. C I am a general contractor and I Please Check One employees(full and/or part time).* have hired the sub-contractors ❑ 6.New construction 2. C 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.$ ❑ 10.Electrical repairs or required]. 5. C We are a corporation and its additions 3. !11 am a homeowner doing all work officers have exercised their ❑ 11. Plumbing repairs or myself[No workers'comp. right of exemption per M.G.L. additions insurance required]t c. 152, § 1(4),and we have no ❑ V.Roof repairs employees. [No workers' mA 3.Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach 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: S6tubUC, l Y cz U-Vx .n Ct CU Policy#or Self-ins.Lic.#: W C qo519qi Expiration Date: Job Site Addressj) 1 ' )^&,Sf City/State/Zip j j 0),W C t i 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 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 of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herbyer the pai a penalties of perjury that the information provided ove i t�ue and correct Signature: Date: )(� �f Print Name: Ij( (�,Q,S �� S Phone 04y>y'Ag •o� �•� 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): I.Board of Heath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: DATE(MMIDDIYYYY) ACORL7® CERTIFICATE OF LIABILITY INSURANCE 01122/2018 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 H the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 Andrea Feeley NAME: Webber 8 Grinnell HONo . (413)586-0111 FAXJAICNo: (413)586-6481 8 North King Street E AIL afeeley@webberandgrinneil.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC A Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina INSURED INSURER B; Ideal Home Improvement,Inc. INSURER C: Attn:Laurie Ellis INSURER D: 142 Boyle Road INSURER E: Gill MA 01354-9731 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 11/2018 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. INSLTR ALWL bUtIll POLICY EFF TYPE OF INSURANCE )NSD WVD POLICY NUMBER MMIDD MMIDD LICYEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 DAMAGETORE CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 15,000 A S2291368 11/17/2017 11/17/2018 1,000,000 PERSONAL BADVINJURY $ GEN'LAGGREGATE LIMITAPPLIESPER: GENERALAGGREGATE $ 2'000'000 X JEa LOC PRODUCTS $ 2'000'000 POLICY ❑ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea atddent ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105410 11117/2017 11/17/2018 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED 1 NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident Uninsured motorist BI $ 100,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE E 1'000,000 A EXCESSLIA6 HCLAIMS-MADE S2291368 11/17/2017 11/17/2018 AGGREGATE $ 1'000,000 DED I I RETENTION$ 1 1 F $ WORKERS COMPENSATION PERv OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I,'%I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500'D0� A OFFICER/MEMBEREXCLUDED7 NIA WC9057697 01/26/2018 01/26/2019 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT $ ::1 - E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additicnal Remarks Schedule,may be attaohod if mora space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. AU rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construesion Supervisor CS-091207 Expires: 10/16/2020 JAMES P ELLIS 142 BOYLE RD GILL MA 01354 ... - -. .- -- Commissioner ;':��a wr.rru,ro.rttrrn�/,i c�3l�rr::;ar,rtr,er�: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR r` TYPE:Corporation ' Registration Exoirat on -�'r :746402 04/21/2019 IDEAL HOME IMPROVEMENT INC. JAMES EWS 142 Boyle Rd Gill,MA 01354 Undersecretary