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23D-004 (12) 15 NONOTUCK ST BP-2020-0775 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-004 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-2020-0775 Project# JS-2020-001342 Est. Cost: $3000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 5270.76 Owner: SCHATZ KELLY Zoning: URB000)/ Applicant: IDEAL HOME IMPROVEMENT INC AT. 15 NONOTUCK ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED 01016/2020 0:00:00 TO PERFORM THE FOLLOWING WORKATTIC INSULATION AIR SEALING THROUGHOUT 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: i Building 1/6/2020 0:00:00 $65.00 i 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner City Of'North mpt Building Depart nt / e • 2:12 Maiq St Room on t Northampt , MA 01 phone 413-587-1240 Fax 413-58 ocri Y NL 5 °`% Z o r r n, � :fit tssq„ «y M. APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELL G ONLY SECTION 1 -_SI NFORMATION • INSULA'T1 X 111 -PERM/T 1.1 Property Address: Tri'->section to be'completed bypffice 1 Mal) Lot Unit one Overlay Distra 2ct . :Elm St'D�stnct -- -GB,Distnct ` SECTION -PROPERTY OWNERSHIP/AUTHORIZED AGENT_ 2.1 Owner of Record: 1 fforcnu— Name(Print) Curient Madmg.Aditress: 1111 lot Signature Telephone 2.2 Authorized Agent: Name(P' _ Current Mailing Address: Signature Telephone SECTION-3-ES- IMATED CONST.RUCTION'COSTS_'- Item Estimated Cost(Dollars)'fo-be Official-Use Ohl completed b ermit a 1'icant 1. Building (ap Bmlding Permit Fee 2. Electrical mg (b)'Estlrnated Total Cost of•- - Construcfion from 6 : 3. Plumbing BuildPermit Fee: � 4. Mechanical(HVAC) I 5.Fire Protection ._ ; 6. Total= 1 +2+3+4+5 ��0 Check Number. : .. T#t Section for=Official'Use,Ont ;: Z :. Building Permlt Number Date Issued: signature;:. <a.. .,. . ZOZQ � � Builtling Cammissionedinspector of Eui(dings Oate. EMAIL ADDRESS (REQUIRED, EITHER HOMEOWNER OR CONTRACTOR) SECTION 4 CONSTRUCTIONSERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 i Name of License Holder: License Number Number OAA _ 1' 4� 1LJGL ,l �-�/l Adrife Expiration.Date X13 S�e3 alb Signatu a Telephone .9.Reosteredlome�imorovement`Contractor y Not Applicable 0 1CA�0.l A� 1 YYl cD((51 t;{UL o)-- Company Name Registration Number �resG `� /' Expiration:-Date A AA2�/V Telephone"1I Q _J l SECTION 5WORKERS',COMPENSATION INSURANCE AFFIDAVIT(M:G L di__ Workers Compensation Insurance affidavit st 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.....- Brief Description of Proposed Worki NSULA TION ONLY! V � A C-�(��,��2 -� C• c�� 2e,�S.2. Gv�� S-e:et�Q,ci I, JOAM ,as Owner/Authorized Agent-hereby.declare.that-the.statements and info►mation on the foregoing application:are true and accurate,to the best of my knowledge and belief. Signed underthe pains and penalties of perjury.. Print Name Signature of OwnerlAg t Date as Owner of the subject property hereby authorize C' � J to act on my behalf,in all matters relative to wd*authatized bythis building perm_it application - Signatur of Own Date, ,_ I City of Northampton Massachusetts : DEPARM=T OF BUILDING INSPECTIONS y� i 212 Main Street • Municipal Building JbaaCa Northampton, MA 01060 I Property Address: Contractor Name: SllS Address: i City, State: _Gm MA- Phone: gig->-SU'3- DI �6 Property Owner Name: UVT L Address: 15 �C�S10 LJ1 s City, State: I, �) S `IS (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 Ou1N�-- Date City . of Northampton Massachusetts .`a DEPARTMNT OF BUILDING.INSPECTIONS 212-Main Street .0 Muaiaipal Suilding �J a Northampton, M& 01060: AFFIDAVIT Home Improvement Contractor Law Supplement to Permit:Applicanon The Office of Consumer Affairs and Business Regulation("OCABW')regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four familyhomes.Prior:to: performing work on such homes,a contractor must 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-existing 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:Ifthe honseowner,has contracted with a corporation or LLC,`that entity ml ist he registered. nn Type of Work:_ Est.Cost: Address of Work: �5 nQoo hd.CX_ S+. Date of Permit Application:_ l a I{q 1 �� I hereby certify that: Registration is not requiredforthe following reason(s): Work excluded by law(explain,): _Job.under$1,000.00 _Owmer obtaining own.permit:(explain): Building not owner-occupied Other(specify): ' OWNERS OBTAINING THEIR OWN PERMIT-OR-ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR,APPLICABLE HOME EVIPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBrrRATIUN PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OVMRS ALSO;ASSUME'THE RESPONSISII.ITES FOR ALL WORK PERFORMED UNDER THEBUILDING FE RiVHT:SE NEXT PAGE FOR MORE INFORiVTATION. Signed under the penalties of perjury: I hereby apply for a building permit as t]16 g t of th C owner. lotS 1A0 Date Contractor Name HIC Registration.No. OR: Notwithsfandingthe above notice,I hereby apply for a building permit as the owner;sof the above property Date Owner.Nazne actcl igiinture I - of ,Northampton. Mssachusetts DEPARTMENT OF gUIZDING INSPECTMUS 212 Main Street •Municipal Sunda ng y � Northampton, MA 03.660- Debris. psa Affi,,davit In accordance of the provisions.of MGL c 40,:S541 I acknowledge that as•aa condition of the building permit all debris resultingfrom the construction activity governed b 't his Building"Permit shall be disposed of in..a properly licensed solid waste disposal facility; a$defned;by MGL c 11 �,S 150A. The.debris from construction work being performed at: S�- (Please print house-number and street name) Is to be disposed of at: (Please print and Location of facility) Or will be disposed:of in a dumpster ons ite:rented or leased from: (Company Name and.Address) . l r1 . Signatu 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'ta the locatio. 11-ithere he debris will be disposed. r J The Commonwealth ofMassachusetts Department of Industrial Accidents I Congress Street,Suite 100. Boston,MA 02114-2017 wlvw.massgol►/dia Workers'Compensation Insurance Affidavit:Builders!Contractors/ElectrichmiPlumbers. TO BE FILED WITH THE PERMUTING_'AUTHORITY. A tic tInf on Please Print bl Name(Business OnMizatioMndividuual): Do r Address: eiry/State/zip:reW W)' a Phone#: Areyou on employer?Cheektheappropriate[w:: Type of project(required): t. I am a employer with '-b employees(fulland/or part-time).• 7. ❑New construction 2.[]I am a sole proprietor or partnership and have no employees wonting for me is 8. Remodeling any capacity.1N0 workers'camp.insurance requited] 3.[J[am a homeownerdoing aft wodc myself o workers 9. ❑Demolition lAl 'comp.iasutnnce requited.)t 4.rlI am a homeowner and wM be biting contractors to coWwAan wotk as toy property. I wilt 10(]Building addition sme eothat allcamactms eitherhavewodmW commmmdon fimmaee or are sots 11.0 Electrical repairs or additions proprietors with no employees 12.0 Plumbing repairs or additions S.Q I am a genas!contractorand I havehimd the sufrcom actors fisted an the agaehed sheet. Itese subcontractors have employees and have workers'comp.insutmce3 , 13.Q Roof repairs - 6Q We am a corporadon and its otiBcers haver exucLwd theirright of exemption per MGL c. 14• then 1 1 t��lUl 1 r I(� 152,¢1(4),and we have no employees,[No wodmw comp.insuance mquhed,) "Any applicant that cbechboa#1 must afro fill out the section below showing their wort a compensation policy information. t Homeowners who submit this affibvit indicating they are doles all wakand then him outside coot mctoa must,sufnnit a new a0idavit indicating such. tContractors that cheek this box must attached an additional sheet showing the name of the subcanhnetors and state whether or not those eatities have employees. If the sub•cantmctots have employees,they must provide their workers'comp.policy number. Jr am an employer that is providing workers'compensation insurance for my employees Belowjis the policy and fob site information. t Insurance Company Name: g� k).,11�T�� 1 n(S �f�,i�lA C, Co r Policy#or Self-ins.Uc.#:,,!�C Expiration Date: 1 o a D Job Site Address: .Yl()YlpbAC,r--�� City/State/zip:are-nu. Iry� Attach a copy of the workers'compensation policy declaration past:(showing the policy number and expiration date). Failure to secure coverage as required underMGL c.152,§25A is a criminal violationpunishable by a fine up to$1,500.00 and/or onayear imptisotunent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against this violator.'A copy of this statement may be forwarded to the Office bf Investigations of the DIA for insurance coverage verification. I do hereby IUn r the pales naddes of perjury that the Information provided_above is true and correct S• s Glow` Date: �L511°1 Phone#: - 1 a•S� Official use only. Do not write In this area,to be completed by clay or town offielaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector .Other Contact Person: Phone#: i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Stper visor CS-091207 Expires: 10/16/2020 JAMES P ELLIS - � 142 BOYLE RD: GILL MA 01354. Commissioner .%�� irr�:�r�<icii-�lf��:,%Lai-i¢rl«elJ: •• _.Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE::Corporation Registr41dn Exairation :1:46462_ = 04/21/2021 IDEAL HOME illlli?(20UF:NIENT;INC. JAMES P•ELLIS`'•,M1` -;;l �2 C 142 BOYLE RD - GILL,MA 01354 --- Undersecretary I - AC R" CERTIFICATE OF LIABILITY INSURANCE DATE�ae�01`9 THIS CERTIFICATE IS ISSUED ASA 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 If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 Webber&Grinnell PHONEEtI: (413)586-0111 A 413 586.6481 8 North King Streetft-MAIL - Lo afeele ebberand rinnell.com Arc,No): ( ) ADDRESS y 9 INSURERS)AFFORDING COVERAGE NAIC 9 Northampton MA 01060 INSURERA: Selective Ins Co of S Carolina 19259 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 1/2020 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. INSR AUDL 5U1JK POLICY EFF PO CYEXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDNYYY' LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREMISES occurrence $ 500,000 MED EXP(Any one person) $ 15,000 A 52291368 11/17/2019 11/17/2020' PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,000 POLICY izo F-1 LOC2,000,000 PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 JE,,, ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105410 11/17/2019 11/17/2020 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident s X UMBRELLA LIAB 1 X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR CLAIMS-MADE 82291368 11/17/2019 11/17/20201 AGGREGATE $ 2,000,000 DED I X1 RETENTION S 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LYIN IABILITY STATUTE ER A oFFICERJMEMB ANY PROPRIRIPARTNER/EXECUTIVE EL EACH ACCIDENT S 500,000 MBER EXCLUDED? � NIA WC9057697 01/26/2019 01126/2020, 500,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE S It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers Compensation Excludes Coverage for James Ellis. 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. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD