35-026 (6) 1054 RYAN RD BP-2019-1408
GIS a: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:35-026 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeorv: INSULATION BUILDING PERMIT
Permit s BP-2019-1408
Project p JS-2019-002271
Est.Cost:$5758.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class Contractor. License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Siu(sp.ft.): 17554.68 Owner: SIEGEL FREDERIC&JENNIFER
zoning: Applicant. VALLEY HOME IMPROVEMENT INC
AT: 1054 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:611&2019 0:00:00
TO PERFORM THE FOLLOWING WORK.•ATICINSULATION, BASEMENT PERIMETER
INSULATION AND MUDSILL
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:
Fee'1'vpe: Date Paid: Amount:
Building 6118/20190:00:00 $65.00
212 Main Street. Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I
gP--l9-�yob
City of NorthamptFn
INSPEGTION
3
Dep
Building Dep rimt RECEIVED
. z1 e
oRoom o 2.1 U
-58
LA TI
ON
Northampton, N 0
-587-1240 Fax 4phone 413ONLY
DF�T 07
NORTHAMPIO
MAmcup
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I -SITE INFORMATION INSULATION PERMIT
/
1.1 Property Address: This section to be completed by office
!"'ol
(/_A./,n Map � Lot CIA& Unit
/Q� r' w� Zone Oreday DistrictI Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGEM
2.1 Owner of Record: 1
Am &AA A V_ocl-.ansl<; to 5y �H I2d Mote rP .
Name(Print) Current Mailing Addre
3 Telephone 4 I� 60o(; ov26
Signemre
2.2 Authorized Anent:
�- C �' oni,l �� YC�MSIn.anw) Fav } ftn�2
Name(Print) Cummt Meiling Address: + 1p. `p ,, ,,�N ,
• 41?, �i�12 NRGog0 T1
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b 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) IDCheck Number �•
This Section For Official Use Only
Date
Building Permit Num Issued:
Signature: G' 7-&17
Building Commissioner/Inspector of Buildings Date
ekA.- @ valwv,,v ''vv prig,) eAA.Q_ k . ux,
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION!-CONSTRUCTION SERVICES
8.1 Licensed Construction P Supervise : Not Applicable ❑ �1 O
Name of License Holder: � 1"" I?P . Ti t U M :4- T P h-1 _QsVt. 0 2-
License
License Number
�� oar 1Cc� ,ouKnaAlnhcrA {Enln4 � 21 �' o
Address Expirati�nExpireticn 0��
L4 11S,
Signature TelePho s
9._Rsaistered Home Improvement Contractor. Not Applicable ❑
Uel( 1n 55141
Cempanv Na Registration Number
31t vexra ria 41I 1 I ?so
Address Expiration Date
Telephone 41-6 -5 9 4-152 2
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.155,§25C(8))
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 building permit.
Signed Affidavit Attached Yes....... u4A No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY i +
I, 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 pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
1, ,as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
If
{ SECTION S-DESCRIPTION OF PROPOSED WORK(shack all aabflcabk)
New House ❑ Addition ❑ Replacement Windom Alteration(s) ❑ Roofing ❑
Or Doors
Accessary Bldg. ❑ Demolition ❑ New Signs 10] Decks [0 Siding" Otharl=o
Brief Description of Proposed
Work:
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yea No
Plans Attached Roll -Sheet
bh%IttNew house i3dd or,addition to;eXistiNa IIOUainfi:cwntlleta the=►olltivJinii:
a. Use of building:One Family Twa Famlly Other
b. Number of roans In each family unit: Number of Bathrooms
c. Is them a garage attached?
d. Proposed Square footage of new cohatrudlun. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstovea Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is contraction 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
It. WIII building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer_ Pilvatewall Cltywater Supply_
SECTION 7e'-OWNER AUTHORIZATION-WISEZOMPE.ETM5WHEN
OWNEFLWAGEN'FOR'coNFFCA0:T0R p,tE// IEs.EOR,Bui6DINGPIRm
1 YC n �I.tn� ��tn F',1. aP15z Ll as Owner of the subject
property 1 I &1A
I e—
V
here uihorize V cs1 L/✓� §-t n `ri el
to on my behalf,ilf, e o work au horized by this building par It application.
pf.Rwger Pete
I, Vv^-aAck--.I- VC. O l.v. 3 D 4�1.[-t as Owner/Authorized
Agent hereby declare that the statements end Information on a foregoing application are two and accurate,to the beat of my knowledge
and belief.
S dd under the pains and qepalfies,of perjury.
_dn NamP t e
slgbaaaaaf Oamartn¢ea gam 51-,m hcl
City of Northampton
cF Massachusetts rrG
rP
OBFMO' W OF BUILDING INSFFOf IWVS
loin S[root 8N iclpal eulld ng
eor=trn, lu 01060
h SJR,,
Debris 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.
The debris from construction work being performed at:
(o s 4 R Via„` RZ I �lAr t' C e " R ® 10 G -2-
(Please print hous umber and street name)
Is to be disposed of at:
VaIIe'-A 0, 4 -ea � � Ibk �d
(Please p ntname of facility) N O �
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
Massachusetts
;" ill` DNPANTNENT OF BUILDING INSFECTIONa
212 Main arrear • Municipal Building
NorWa Wn, Mx 01060 rrjr,-y��a
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair,modernization, conversion,
improvement, removal,demolition, or construction of an addition to any pre-exisdag owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: W (',A,&1-1 Est.Cost: +
Address of Work: �O
Date of Permit Application: C J,� f 2c Ll
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter I42A.SUCH OWNERS ALSO ASSUME THE RESPONSUJILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
C /3 �2011 . coleve ��v�vwavl lD 5 :54 ,3
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
ip[
DXPARTNBNT OF BUILDING INSPSCTZONS �� m
212 Main strut • Nuniclpal Building9 p, P
Northaupton, M 010060 1 n
A
Properly Address: IA cS�} u a tn. I'Cd r6r'PL H cB 0 1 0'2
Contractor
Name: 14�Pu
//'�� mai UEr 11��v.
Address: Pa y,.o r Q
City, State:
Phone: L�13 c5 S 1F i; 2-2,
Property Owner
Name: A%"A� j O,LI aDGk1
Address: I O S4 K u au
City, State: LnreAiVe PA OIOG,7
I, c, -kw P. (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 p
Date C /--/
0
The Coluutonxealth ofmassachusetts
Department o/fndalwlal Accidents
I Congress Street,Suite 100
Boston,MA 02114-1017
xmx:nrass.gor/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetrlti"n 'Plumbers.
TO BE FILED WITH TILE PEIMMING AUTHORITY.
Applicant Information I Please Print Lealhly
Name 12minavOrganimnon'ludix•idwit: QQI`t'N WCC C �m rilTJ�1PsMYn'I
Address: .s}i0F:tvt✓SjAe. �.—I.re l� �. exec (-0(02-1
City/State/Zip: 1 kb!fni-C kA 01001- Phone* 413 Sea4--f�aa�
Are you nn employer".Check We oppropdstt box:
'p Type ofproJect(required):
L®1 nm a emPioyer xiW�emplayees fNll mW w pmiimel' 7. ❑New construction
I sm a sole pmprieturor pvsmcxaip anJ bav<nx empla.'ecs ned:in_ (w m:in
ur'cspec.n.lxuxorl:na"comp.in:wancc rcyuircJ.l 8. Remodeling
I.Olanahemcvwmrr J•wng till xah myxclr l�'v x'vken'wmp.inwnnacmquimr.l! 9. ❑Demolition
-.❑lam alsmmnnvc aodxill be bi:mg conuwmrsw maG:a ail wodmmy pWaty. will 10❑BUildmg addition
ensure that:Al rope-mors ddet barx aon;cs'rnwpmauim vasma:xe yr ora sole 11.1—]Electrical repairs or additions
proprimws xiW no m+pley'res.
12❑Plumbusg repairs or additions
e.❑1 mn a aeneml epnaacmr anJ I bare hired the wb-mnoarm+x lisad m Jm aeucM1.J sMa. 13. Rf re irs
T�e.ewb.ew+aarmn M1x•e my+lmee.an;l luv wxken'c••u+p luaus.;+� ❑ au �
6.�Ne nn a carpvmroo ped its omaera have exer:isaJ di u.nght 1.1 []Other_
ly].ebsrssJ wa bout no anployees.INo xm'keri mmP.inwraae rcgwcd.l _III
Aoy appliomnlmt cheeks box rl mxn alx+flit call,action below shvxing their xmkne comp:waion policy iwemwuop.
Hmncovmmsuiw mbmltthisaltdacil iodiwnntW:y are dvinl ail xvrk and shrn hie uaunc crosmaws mwtwu ,,pax pal bnicrosbcmh:p wch.
:Omvacmr.that chak This box musr.Jmched ao:eWilivnol ehses sboxing We naw ur We wRxmaawn adJ arum whoihbc w nq Wnse moots have
<mplmrs. If Ih:sohsonmxwrs M1nc anplmcn.Thr+m .�moulds Ibeir umrkerv'comp.Npey nvmM.
f am an employer Marls prerriding nmrkers'i ompen.aorion insamuce for mp employees Below is the policy and job site
information. p
Insurance Company Nope: ttr�'aCl R SP1SVrQYI(� �"7rV. +o .__ __
Policy or Self-ins. Lia+:_ 065 O a3 O 2 \s __ Expiration Daw: 2[1 C,)r
Job Site Address: C'ity,State'Zep:_,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and espiraHen date).
Failure to woos coverage as regnb'ed under MO L r. 152. $25A is a criminal violation punishable by a fine up to S 1-500.00
and'or one-year imprisonment.as well as civil pe Itic,in Ibc form of a STOP WORK ORDER and i fine of up to S250,OU a
day ag min the violator.A ropv of this stateuwro ay be forwarded to the Office of btceslig:uions of the DIA for insurance
coverage voitetailon.
1 du hereby ccrclfy umjrr[be sd color mpe ullfer fp nr tem the info»rn/ion tnnrlded oboes is rate a»d rorrert.
i�roanve: � � ' /fn Darr.
Phone a
Offu tai eine only. Dip not o•rhe ba this area,to bc cnmpfeted br ciq or Imrn nffrri ii. --
City a)-Town: PermhUcense S__
Issuing Authority(circle one):
I.Board of Health I.Building Department 3.City/Towns Clerk A.Etectdcal Inspector 5, Plumbing Inspectm'
nta
C — —
Contact ct Person: Phone if:
AC RO IIF CERTIFICATE OF LIABILITY INSURANCE ° T "M°°"Y"'
01NBI20%
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY MEMO,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. N Me ceOIITaM holder Is an AODMONAL INSURED,t1m pollcy(les)must have ADDITIONAL INSURED provisions or M endorsed.
N SUBROGATION IS WAIVED,subject to the terms and condNlons d Ile pcllcy,Certain policies m y Require an andoreemad. A statement on
this certllicate does not confer Hghfc W Me certificate holder In Wu of such andonee nerd e.
ACOYCG NAME. Badprs GIyBMHNQ
We00er&Linnet PHLYN (413)5860111 (419)564481
N
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AGOREae: blpynkiawlu®vNeOhaeMgdnmAcem
INHIRER AFFOROPIOCWERAR YMCA
Noml BYeon MA 01080 M91RE1 A: Arbate P"rod" 41360
WNIREU -Neu.B. Artnto Indemnity 10017
Valley Hama MNmvam r*.trc HSUREN c
Aen:Steven Senurran NaDREAo
P 0 Bm 06627 INSURER E:
Florey MA 0102 Imump:
COVERAGES CERTIFICATE NUMBER: EAP WiM REVISION NUMBER:
THIS ISTD CERNFYTHATME POLICIES OFINSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTNRHSTMDWGANYREQUIREMENT,TERMORCONDITIONO MYCO MACTlMOMERDOCUMENTWTHRESPECTMWHICHTMS
CERTIFICATE MAY BE ISSUED OR MAYPERTAhl,ME INSURANCE AFFOROEO BY THE POLICIES OESCRISEO HEREIN IS SUBJECT TO ALL ME TERMS,
"MUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY MO CLAMS.
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A 8600063755 0211IID1a ➢211!1@8 r£RewALA Anv iNnm s 1,00uD5
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AumYwYAUAeaRr ! 1,000,000
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A mRfN DIA MBOMAGE 480006675 02 inwo 02110020 IDNEEMTE S.O110D00
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B ANVPROPRlIORRN1HERhXEwT6E YO NIA 4220061297 Invori Dle OL0wmo El.---p AIHrt I
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ME E% TION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Torn of GReHm id ACCORDANCE WITH ME POKY PROWSIONS.
14 Court So.
AUfNOIm®IOMeeEYTAl1VE
Gre.0.1d MA WWI
019116201SACORO CORPORATION. All rigida reserved.
ACORD 25(2016103) The ACORD name antl Iegs en RegMtHed merle of ACORD
Comrnonwe a lth of Massachusef is
Division al Prof'svanal Licensure
Board 61 Building Regulations and Standards
COOShyyYlSp�SlSpgrVI50r
f
CS-077279 4 E3pires06!2112020
�'
STEVEN ASILaIERMAM'='
263 FOMER R"D
SOUTHAMPTON)OA 01073
1.00S 136to
Commissioner
✓/GB ,JL%Y1172Ca2CC`G�ICCL>/! �,'��CC�i-�(!C/IU�G��f-.3'
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
_ =-- Type: Corporation
VALLEY HOME IMPROVEMENT INC _ Registration: 105543
P.O.BOX 60627 _- - - _= Expiration: 07/16/2020
FLORENCE,MA 01062 =-
_ Update Address and Return Card.
Office of Conevern,Move a Bushels Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:C"co shoo before the expiration date. R found return to:
Realatudo0 Etmillill Office of Comumer Affairs and Business Regulation
tO6ag3-:=e,. 07/162020 One Ashburton Piece•Suite 1301
VALLEY HOME IMPROVF9ElgT INC Boston,MA 021N
$40 RIV A.SILVERLMN
NORH,UrIPON,IA 01 C_)
NORTHAMPTON,MA 01062 Undersecretary Not valid without si8nffiure