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17A-034 (2) 250 NORTH MAPLE ST BP-2021-0092 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-034 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-2021-0092 Proiect# JS-2021-000143 Est.Cost:$3647.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: NEW ENGLAND INSULATION - DENNIS CHICOINE 023411 Lot Size(sa.ft.): 14766.84 Owner: YOUNG CHRISTINE E Zoning_RI(I00)/URA(100)/WSP(100)/ Applicant: NEW ENGLAND INSULATION - DENNIS CHICOINE AT. 250 NORTH MAPLE ST Applicant Address: Phone: Insurance: 129 LYMAN (800)488-5407 WC WOONSOCKETRIO2865 ISSUED ON.7/24/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE WALLS 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 7/24/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner I.- The Commonwealtlt r efts Board of Building Re FOR , i MUNICIPALITY Massachusetts State Building C C_, USE Building Permit Application To Construct,Repair,Renovate Ot 1)6molish a Revised Mar 2011 One-or Two-Famih"Dwelling This Section For Official Use Only Building Permit Number: Date Applied: LV i�J 55 �]-Zy-ZOZ� Building Official(PrintNamc) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors?4ap&Parcel Numbers �i ly_IIA N/>L4-2 63`f 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public© Private Q Zone: — Outside Flood Zone? Check if yesQ Municipal© On site disposal system ❑ SECTION 2: PROPERTY OWNERSBIV 2.1 Owner'of Record: Name(Print) City,State,ZIP No.and Street Telephone Email Addr6ss SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply) New Construction Existing Building EF Owner-Occupied ❑ 'Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition Q Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Workl: L V� SECTION 4:ESTPHATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1.Building $ 3 1. Building Permit Fee:S Indicate how fee is determined: Z.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)z multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire S Suppression) Total All Fees: Q Check No r heck Amount l.� y Cash Amount: 6.Total Project Cost: S Loi OU 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r�Af License Number ExpD Name of CSL Holder List CSL Type(see below) No.and Sum' Type Description _ U Unrestricted(Buildings u to 35,000 cu.ft.) �/Y�U �` /� 2�� — R Restricted 182 Family Dwelling Cityrrown,State,ZIP I M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel-Burning Appliances Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /3 7-�7 C, /`C o/ IYf- HIC Rcgistmdon HTC—GmpartyName or-MC Registrant ame Number Expiration Date No.and Street �f \.��G'��•`/SCS C ��/,��G.�CN�/'2y��(��-�L L'-7 Email address City/Town,State,ZIP c Telephone SECTION 6:WORICRS' 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 permit. Signed Affidavit Attached?' Yes......... 12 No..........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED 14IMN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorizeVZ. /Y to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name nicSSipatare) 7 r7 Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Daze NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Proeram can be found at www.mass-aov/oca Information on the Construction Supervisor License can be found at ti,.ww.rnass.9-ov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.fr.) (including garage,finished basement/attics,decks or porch) Gross liN�ng area(sq.1) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. 'Total Project Square Footage"maybe substituted for"Total Project Cost" I i The City of Northampton Building Department 212 Main Street Northampton,Massachusetts 01060 Phone(413) 529-1402 Fax (413) 529-1433 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance with the provisions of MGL c40, s54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of f=acility_�S Ctj&,*LJ Z5IAA11--� The debris will be transported by: Name of Hauler_ ! Z �, � C_-f--1-7f V/� --G _ _ _ _ _ _ _ _ _ Signature of Applicant: ___ ___ _Date:__ __ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE FERNUTI'1NG AUTHORITY. Applicant Information Please Print Legibly. Name(Business!Organization/Individua):��5 C.0e-�,,40)Y Address: CTi► jy City/State/ZiplX/ 2 G Phone#:1—goc,—(n k--6-K& 7 Are you an employer?Check the approp ate boa Type, of project(required), 1.El I am a employer with employees(full and/or part-time)-* • 7. ❑New on 2.❑I am a sole proprietor or partnership and have no employees working forme in $. D Rmitodeung any capacity.[No workers'comp.insurance required] 3.❑I am a homeowner doing all work myself[No worker'comp.fi surawx requircd.l t 9. Demolifim 4.❑I am a homeowner and will be hiring contractors to conduct an work on my property. I will 10 O Building addition ensure that all contractors either bavc workers'compensation insurance or are sole 11.0 I1=1riteal repairs or additions proprietors with no employees. 12-[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed an the attached sheet 13aROOf ICpalIS These sub-contractors have employees and have workers'comp.insurance.: . r 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14' thr 'S C f 0/-- 152,§1(4),and we have no employees.[No workers'comp_insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy irff conation, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an ensployer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name- i Gl AAG4 Policy#or Self-ins.Lic.#:_ �y Expiration Date: Job Site Address: 5 U It/.IYI}} Citylstate/Zip•AW7I A) tp)oAlM c<n Attach a copy of the workers'compensation policy declaration pave(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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pave and penalties of perjury that the information provided above is true and correct Signature; A Date• Phone#: l�C�G �{((��y0"7• Official use only. Do not write in this area,to be completed by city or town officiaL 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 6.Other Contact Person: Phone lk CLEAResult CONTRACT CLEAResult 50 Washington street. 111 Westborough.MA.01581 Customs Manes:Christine Young Email:;.young!443 jtomcagt.net Phone:413.563-4644 Premise Address:250 N Maple St.Normampton.MA oIo62 Mailing Address:250 N Mage St.Northampton,MA 0!062 Project ID:3991-,24 Date:-eB.26.202o Job Description 4 Contractor will perform or cause to be performed the following work on these'Premises'in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the'Work')which are incorporated herein by reference. Measure Description Location Quar ty Lk* TOW COst Customer Cost Walls- Wood Shingle- 3' Dense Pack Cellulcse 1632 SF $3.574.08 S893.52 Blower Door Test 1 each $72."5 $18.1 C. Total: $3.645.83 Program Incentive: -$2.735.12 Customer Total: $911.71 Payment Customer agrees to pay Contractor for the Work.the Customer Share of the Contract Price as follows:Payment tt1:$0.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1,3 of the total retail costs).Mail check&contract to CLEAResult.So Washington Street. .Westborough, MA,01581. Final Payment:$911.71 as the final payment for the Work shall be payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work Customer understands that he she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$2.735.12. Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Dispute Resolution The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute conceming this Contract.the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer s"I be required to submit to such arbitration as provided in M G.L c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seder,provided you notify the seller in writing by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Page t of 4 -747 " a r• ', G�Z� �4Z0 W �1''� wit r Customer Signature D e indicate your selected IIC here,if applicable Initial here if you want the Program to assign a Participating Contractor 2/26/2020 Noam Perlmutter CLEAResult Signature Date Name of CLEAResult Representative i kti 1y 4 Page 2 of 4 ,Srs.: Y Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstruiAPSIb'pervisor CS-023411 Eacpires:02/24/2022 r DENNIS E CHICOINE 129 LYMAN ST WOONSOCKET RI 02895 <" ��IS'ti•i:10�' Commissioner 1 ORIC80ConslnnarAffairs&Business Regulation MOPE IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 137271 � 10/23/2020 KDENNIS E C�ICOINE t DENNIS E.CHICOINE 129 LYMAN ST. WOONSOCKET,RI 02895 Undersecretary DATE(MWDDIYYYY) ACOR�� CERTIFICATE OF LIABILITY INSURANCE 07/20/2020 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 Joan Brannan NAME: Esten&Richard Agency,Inc PHONE (401)766-4200 FAX (401)762-4210 AIC ..Ext): AIC,No 342 Park Ave E-MAIL ADDRESS: P.O.BOX 639 INSURER(S)AFFORDING COVERAGE NAIC# Woonsocket RI 02895 INSURERA: Motorist Insurance 13331 INSURED INSURER B: Beacon Mutual Ins- New England Insulation Inc CNA Surety INSURERC: 129 Lyman St INSURER D: INSURER E: Woonsocket RI 02895-1939 INSURER F COVERAGES CERTIFICATE NUMBER: CL2052906745 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 AUUL bULSK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDIYYYY MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE FXI OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one penton) $ 5,000 A 5000055684 06/21/2020 06/21/2021 PERSONAL&ADV INJURY $ 1,000,000 MGEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER Property damage-Single $ AUTOMOBILE LIABILITY OOMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED 5000055684 06/21/2020 06/21/2021 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAR i X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR i LI CLAIMS-MADE 5000056214 06/21/2020 06/21/2021 AGGREGATE $ 2,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION XSPERTATUTE EORH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDED? NIA 3599 04/29/2020 04/29/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Dishonesty Bond C 62288667 02/04/2020 02/04/2021 50,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more 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 North Hampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street AUTHORIZED REPRESENTATIVE North Hampton MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Table 1 Personal Protective Equipment Levels and Appropriate Physical Distancing Recommended PPE Level 1 Level 2 Level 3 Long Pants X X X Close toed shoes X X X Cloth Mask or Dust Mask X X Tight-fitting Gloves X X X Utility Gloves over tight-Fitting Gloves X X Tyvek@ or other Coveralls X X N95 Mask or Equivalent or Greater Protection X Face Shield or Safety Glasses X Minimum Physical Distance between workers if 6 feet 4 feet 2 feet wearing similar PPE.Worker wearing lowest level PPE determines minimum physical distance, (NOTE: These are estimated distances based on protection provided by PPE. Workers should try to maintain 6-foot physical distance if possible.) Table 2 Personal Protective Equipment Level Recommended According to Task Task Level Level Level Technical pre-screening(single worker performing a X walkaround, not entering building) Technical pre-screening(single worker performing a X walkaround and/or entering unconditioned, unoccupied areas in a building) Performing measure upgrades(or combustion safety testing X of a heating system) In-process inspection(PPE compliance monitoring-inspector X onsite concurrent with WX workers,outside only) t