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24A-201 (2) 48 MURPHY TER BP-2020-0939 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A-201 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-2020-0939 Project# JS-2020-001595 Est.Cost: $2500.00 . Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sa.ft.): 11412.72 Owner: LOPEZ EMILY Zoning: URB(100)/ Applicant. IDEAL HOME IMPROVEMENT INC AT. 48 MURPHY TER Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED ON:2/20/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE OPEN ATTIC, AIR SEALING 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 2/20/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dep alf -`'- City of Northam�tonF� Building depa anent B 19 212 Mpin T 1?01?0 11kSULARoorTION ii�QO!,�F°T et�i�,�,� Northampton MA phone 413-587-1240 Fax 413-5 TSN/n 2c r�o�, - ONLY APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INS ULA TI QN PERMIT 1.1 Property Address: Th'"section to be completed by office uq minx fhb Map -� Lot dy 1 Unit nof-'t y` ,,, _„� tone Overlay District 1 ' I Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner-of Record: 1 0K 'ky Mlel,('MQ —r6(• , r )1'10 _ Name(Prin Current Mailing Address: '�I 3- 4U4q 7S(4 _ Telephone Signature 2.2 Authorized AaenlL Na (Print) Current Mailing Address: g i-�)- 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 ti 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) bZ b cc T Check Number �jThis Section For Official Use Only Building Permit Number: V ��"/ / Date Issued. Signature: AN _ _._ Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED, EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supe 0 . Not Applicable ❑ Name of License Holder: �� ,lX n � ^( I License Number (lJ�i` 1 ►'Y 0 i 10- r U1140 Ad ess Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 142 u • D- 1- a'( Address Expiration Date Telephon�le'3� �I�� SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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 buildi permit Signed Affidavit Attached Yes....... No...... ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY 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 nderthe pains a nalties of perjury. S tS Print Signature of 07,6r/Agent Date I. &�- 1, _. as Owner of the subject property C hereby authorize to act on my beh If,in all matters relative to work authorized by this building permit application. i 1 ac,) I�o Signature of er U U Date -� City of Northampton Massachusetts �. r < " DEPARTMENT OF BUILDING INSPECTIONS s: 212 Main Street • Municipal Building Jdr S^ Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: Contractor Name: z� l(� Address: 1 k•U� City, State: Phone: + Property Owner Name: Address: UN f 1 1 uj,Qv)u r-VT {/ City, State: ( C.JI'`)1Vv. ) QbI , I, duy—'�' ao > (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 Date City of Northampton A tt Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Hain Street * Municipal Building Northampton, NA 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 pro-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 has contracted with a corporation or LLC,that entity must be registered. — rv-) CO Type of Work: ,�Est. Cost: 1�s 00 Address of Work Date of Permit Application.- 'A MAD 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 PER'MI'T.SEE NEXT PACE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Ar Nat Date Contractor Nalile HIC Registration No. OR: Notwithstanding the above notice, I hertb-, impil, iOr a building permit as the owner of the above property: Date Owner Name xno.S;:.gnature City of Northampton t i Massachusetts r DEPARTMENT OF BUILDZNG INSPECTIONS 212 Main 8traat •Municipal Building cb 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: u2 ff) -Tcla . (Please print house n tubera d street name) Is to be disposed of at: �l (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: n1pF (Company Name and Address) Sig ture 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 " q www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): y► 1 ►1(1 I M az)utm cn- _ Address: ) C)Nv_ City/State/Zip: �11 dv jk70- Phone #: H �5 U3' o) Aru an employer?Check the appropriate box: Type of project(required): 1. I am a employer with D4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ T am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ oof repairs insurance required.] t c. 152, §](4),and we have no employees. [No workers' 13. Other �1�5�-Q.�Ct/l comp. insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number, 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Stvzc�oc i nsuL� c9- Policy#or Self-ins. Lic.#: Expiration Date: oZ Job Site Address: �g m lel Yl l i,( 1 ''�C-CSP City/State/Zip: 0 0�+I lrl10 !'). alct 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 c. 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido here �ceplW�foyun •the pains nalties of perjury that the information provided above is true and correct. J Signature: �ti� Date: Phone ik 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 5.Plumbing Inspector 6. ether Contact Person: Phone#: AC"R ® CERTIFICATE OF LIABILITY INSURANCE DATE /14/2020 ) ovla/zozo 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). CO, CT PRODUCER NAME: Patrick Gooden Webber&Grinnell PHONE (413)586-0111 A D Na: (413)586-6481 IC ANo Ext): 8 North King Street ADDRESS: Pgooden@webberandgrinnell.corn INSURERS AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Select ve Ins Co of S Carolina 19259 iNSURer n 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 11/20 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 CONTRACTOR 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, OXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAin CLAIMS INSR AU UL UR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIOD/YYYY MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1'000'000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any oneperson) $ 15,000 A I S2291368 11/17/2019 11/17/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Fx_�PEoT F-1 LOC PRODUCTS-COMP/OPAGG Is 2,000,000 OTHEP. COI $ AUTOMOBILE LIABILITY Ea acccident INED SINGLE LIMIT Is 1,000,000 ANY AUTO BODILY INJURY(Per person) I $ A OWNED SCHEDULED A9105410 11/17/2019 11/17/2020 BOO LY INJURY(Per accident)'I S' AUTOS ONLY X AUTOS PROPERTY DAMAGE AUTOS ONLY HIRED X AUTOS ONLY Per accident $ X $ X UMBRELLALIAS X OCCUR EACH OCCURRENCE 1 $ 2,000,000 A X EXCESSLIIAB CLAIMS-MADE S2291368 11/17/2019 11/17/2020 AGGREGATE $ 21000'000 r1Fr1 RFTFNTION S 0 $ WORKERS COMPENSATION PER U AND EMPLOYERS'LIABILITY STATUTE ER _ Y/N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ A OFFICER/MEMBER EXCLUDED? NIA WC9057697 01/26!2020 01/26/2021 tMandatory m NH) E.L.DISEASE-EA EMPLOYEE' g 500,000 IT yes,descnbe under 5001000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be 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 i Commonwealth of Massachusetts ` �' Division of Professional Licensure Board of Building Regulations and Standards . I i CS-091207 Expires. 10/1612020 JAMES P ELCIS 142 BOYLE RD GILL MA 01364 ' Commissioner .Tr �ivri�rww iii/lfr �j�.,��lxd JcrC/iw�l,/J ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation RS9isbration Unlration 146402. 04/2112029 IDEAL HOME IMOROVEME' INC. JAMES P.ELLISCCPx - 142 BOYLE RD GILL,,AAA 01354 Undersecretary