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30B-072 142 RIVERSIDE DR BP-2020-0831 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30B-072 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-2020-0831 Project# JS-2020-001433 Est.Cost: $4500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sg. ft.): 11107.80 Owner: DOLLARD ANNE E Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT. 142 RIVERSIDE DR Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED ON.1/23/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring U.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final• Final: Final: Rough Frame: Gas: Fire Dwartment 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 1/23/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner lid^ `':�. DeP " off '' City of Northampton Jq ,`, ', 41 Building Department' act > I - 212 Main Street \ q�� Q� Room 100 rtigVi n�^ , ULATION Northampton, MA 01060 ^~ phone 413-587-1240 Fax 413-587-12 �qoF o ONLY Tio NS APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address: Th'tr section to be completed by office 1"14 ,Q 1�JC6zA d Q �Map _ Lot / Jnit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lovv,Z)01[atil 14A Na (Pi t)-- � Current Mailing Address: ,-b& — Telephone Signature 2.2 Authorized A ent: S DA t t s 14a Lswu N7% Current Malting Address: gu3 �1 Signature Telephone SECTIO 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by 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) Check Number 9 This Section For Official Use Only �.. '/i Building Permit Number: �W —� � i Date � Issued: Signature: I Building Commissioner/Inspector at 2,uikiings Date EMAIL ADDRESS (REQUIRED EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: A 1 1 I oO 'LAI�k I r � License Number ca--w U- I()I I(J- ELt\,\ Lt A dress Expiration Date Signat,ri Telephone 9.Registered Home Im r v ent Con Not Applicable ❑ )14WoCY Company Name n d'� Registration ' Number A ress �� \ � ^�( Expiration Date Telephone"' LIJrC�'1 SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) 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 ermit Signed Affidavit Attached Yes....... No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY ulva >+ MIS 4 1 &Wed- cruu*cu, 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 underthe pains and alties of perjury. Pri ame , �- _ _ ►la� � aa Signature of 7 Agent _ Date I, (An(w—bo t lard, as Owner of the subject property hereby authorize to act on Xmbehalf,i all matters relative to work authorized by this building permit application. Signature of Owner Date -- � City of Northampton Massachusetts A— ' L..'jc..` DEPARTHENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building `fry J - Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: Contractor Name: �a-I�II� 0,t'I S Address: u W- City, State: v 11 I ffla Phone: Property Owner ",, Name: 1�Y 1t'L�. bU��Gt Address: 'vl a. ��,�(,( 1E41CU N . City, State: _�oy-cn d0J'" ;EZ1, S ( 5 (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 GIJL IIt Date 11x`1 )b y City of Northampton .. Massachusetts •,"i m _ DEPARTMENT OF StT LDING INSPECTIONS f ` , 212 Main Street • Municipal Building y0, 3� .,�,,, 6.•;. ••,\``- Northampton, HA 01060 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 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:If the homeowner+h^a(s�contracted with a corporation or LLC,that entity Waist be registered. Type of Work: 1� ' "'"`�1.� Est. Cost: Address of Work-- Date ork Date of Permit Application: b 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 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERIMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a bui t as the agent of the owner: 1 L-+Uq0 Date Contractor;Fame HIC Registration No. OR: Notwithstanding the above notice, I hereby apple a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton 0 r, Massachusetts M DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 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: (Please print house number and street n me) Is to be disposed of at: \O (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ) " , t w � Db Signature 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Buffders/Contractors/Electriclans/Piumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, ApiplIcallt uNrutation Please Print LcL4bly Name(BusiNWOrgani7itinn/individual): I� Address: City/State/Zip: -)� Phone#: Are you an employer?Check the appropriate box: Type of project(required): I. l am a employerwith Lb employees(full and/or part-time).* 7. ❑New construction 2.[_]I am a sole proprietor or partnership and have no employees working for me in 8. (�Remodeling any capacity.(No workers'comp.insurance required.] 3.[]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 ❑Demolition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or aro sole I IQ Electrical repairs or additions proprietors with no employees. 12,E]Plumbing repairs or additions 5.E]1 tum a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? 14.[ Roof repairs,/�, t /`t. 6.❑We are a corporation and its officers have exercised thew right of exemption per MOL c. 14.�thCC t I i��/�D Lt '1(!� 152,¢1(4),and we have no employees.[No workers'comp.insurance rcquired.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeownets who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those catities have employe". 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: Policy#or Self-ins.Lie.#: L. j� Expiration Date- lQ ��nn Job Site Address: �V�X�I ''Jt City/State/Zip: 6 ore n_ �OAA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyun r the pains naldes of perjury that the information provided above Is true and correct Si a ( Date: t Phone#: L B - �?U 2)- ;7:4 1 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: CORD® DATE(MMIODIYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/08/2019 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. 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 NAME: Webber&Grinnell PHONE (413) A1C No Ext: (413)586 0111 AIC No: (413)586 6481 DRess: afeeley�webberandgrinnell.com 8 North King Street AD INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: Ideal Home Improvement,Inc. INSURER C: Attn:Laurie Ellis INSURER 0: 142 Boyle Road INSURER E: Gill MA 01354-9731 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp l/2020 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMDD/YYYY MM DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE500,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 15,000 A S2291368 11/17/2019 11/17/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRT D LOC PRODUCTS $ 2,000,000 POLICY © OTHER: $ AUTONOBILELYIB7LITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105410 11/17/2019 11/17/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE S2291368 11/17/2019 11/17/2020 AGGREGATE $ 2,000,000 DED X RETENTION $ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ A OFFICERIMEMBER EXCLUDED? N f A WC9057697 01126/2019 01/26/2020 —- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ M n +Q� V DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation Excludes Coverage for James Ellis. F 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 26(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts 9: Division of Professional Licensure 3oard of Building Regulations and Standards "ollstr0c'ion Supervisor CS-091207 Expires: 10/16/2020 JAMES P EL1dS ' 142 BOYLE RD BILL MA 01364' bt Commissioner CL Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 146402 -> 04/21/2021 IDEAL HOME IMPROVEMEW INC. JAMES P.ELLIS -- 142 BOYLE RD GILL,MA 01354 Undersecretary