36-061 (4) 1041 BURTS PIT RD BP-2022-0044
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-061 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-2022-0044
Project# JS-2022-000071
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.): 13198.68 Owner: JIMENEZ REYNALDO&MILDRED
Zoning: Applicant: IDEAL HOME IMPROVEMENT INC
AT: 1041 BURTS PIT RD
Applicant Address: _ Phone: Insurance:
142 BOYLE RD (413) 863-2128 WC
GILLMA01354 ISSUED ON:7/13/2021 0:00:00 --
TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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. I ' /
Certificate of Occupancy Signature: ' • , i
J
FeeType: Date Paid: Amount:
Building - 7/13/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
. . .
. . ,
• -.> .--
_ .
. .
.
c-i'
.,,
- • ._ City of No a rpton CS 1, .........„, ..,,... ..r,,,,. ..,:zLLA 0R,
,-.f.Lvs...._„..,,,,„:„,„,„ „,,,,,,,: „L:.;..7, ..t ,,,.... :,,L,„::,,-„it- ,...i:....„.„...i„tt.L„t.,,,,,,..,..,„
,.. ...,,.,,„..,,..:„. 2,,,L......,,,,.?„:„,:„: ,..,L,: „,.....,.:...,,,.
Building •epa m* v - '-' ::••L'-4";-- .i.-i, . .,?•.'Vtfti..i,,,t;, ,,. ...;`:-':::,..N',,:::-.:,:-.--'':2;'-t'''''- ',n•-;
+. 212 . ain -treet 4 i °I' , ,.. S
I'- ,,.c..7 .11-',:,„tr.A.,+. •- Pf.if-W,,:.,;, .-,N:..::: ,. _...., _, .,..!...„ ,r ,:,,.., :,,,..d ,.„ ,,,„ ...,..;:,:,,,:,
::,1;i .-.,i,t,,..:;,z':=Ag4::;*?-fg,IT$,,P..?.
Northam* 5 , 1. ''I , , ,„. .. ...,,re ,,.Y4.,r4-',.,"„ .-ri,-(:,t,-,'P-',,---i:,.. '''''..-Y ,',',.Y.w,,,,-;.:-..,-... ..•,-.,•„•-1:-.....i,
, ..0i-'liit,j..',, -.- .,,,,,,'•
phone 413-587-1240 .. 4(41,1'-;, - 72
71)44;Nsp ..-..r...,;,1„, --„wy,::.•,-„,,i.,-, ,,-,,--;‘,..t:tr„,, ,,:.--. ...;,,, 5r -- If-.i.--! ,,,,,-;: .-., •*-2,-,1-.7,-;-;t-t,,..t.c
, .
'414 &-c7Yo 'I,'-'-; ':1:•--';',', -7,:`,`.-.--'••: :- :°14-.1-:;.+....,..;i,:•.•:, -. ..-2.-,;,/,,,, ,.:.:-.:•-,-,.,;.--. :N:r:.......-.:,.. ..,,,,,
APPLICATION FOR INSULATION FOR A ONE OR TWO 6 7 LUNG ONLY !I
,,.._.SECTION 1 -SITE INSULATION PERMIT:
INFORMATION- ' ,
be ,by office
.nrs section tocompletedofC,..., :.: .-..;:.,.;.•.: .-.,,...,
1.1 Property Address: .
. . _
I oLit bu,iis 'N. fick• ap Lot Unit
noyeru, f(Y)k Zone • ': - Overlay District, ...,...: -: • _,,_1.,,,., .,
- ,• Elm St.District -- , - CB District
. .. ,.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: '
..---
cnItottd. 3ti(lthczd ta-u Ewr-K 0+ €6 , k-A oft(Ick,
Name(Print) Current Mailing Address:Lit 3 ,-,.6-1391-ll4C114
/Pa.14.ttiC, Qiiiiiinir Telephone I
Signature
2.2 Authorized Anent:
0 .
\kkilkeN cAtts tua- 64u 4,1 ,a 1( (fru
Current Mailing Address:
Na,' ' '• .. ki\... ,t...A., .
LA i 5. 61,2 . aveg
Signature Telephone -
. . .
SECT,• 3-ESTIMATED CONSTRUCTION COSTS •. ,
Item Estimated Cost(Dollars)to be ,' •: Official-Use Only
completed by permit applicant .. - - _ 2 .,
1. Building (a)Budding Permit Fee ;' - -
2. Electrical (b)Estimated Total cost of '
Cnnstruction.from(6)
- .
3. Plumbing . ,
- • -Building.Permit Fee- I. -
,
.-
. 4. Mechanical(HVAC) ,
. ,5.Fire Protection - . ,
41°r3
B. Total=(1 +2+3+4+5) , ,Check Number '
Ifite‘Srifotfort.For'Official Use Only
,iii ' : --: :-..,A.,,,.':,: 'Date
Building Permit Number: .._ ,L_Sde --4_"____ ,.:- ., Issued
. .
1 8 il
Signature: Ai -1 1 ; . . .
-- -- ..,,.',-,,-,;,,,-.,,,,,,‘ , . ,
Building commissiooerrinSperiornf Buildrpgs!,:: , : - Date
ckimcccs-t-, lle,i-
+--:, -
. ..: ._,
EMAIL ADDRESS(REM, ,IRED'; p:ITHER HOMEOWNER OR CONTRACTOR)
.•::, • I
.,.
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ' Not Applicablep 0
Name of License Holder:J 5 li
%.t S -1 t aoi
License Number
14)1 16(Al ke (ZIA , Gm 1 "ma to•tco• aa•
Lik-/C.‘ ' Expiration Date
1►3- . at in
Signs e Telephone
9..Registered-:Home Improvement Contractor '_
• _.._Z7,, ; Not Applicable O
Company Name i Registration Number
- 61CI Gtt maku•ai• a.3
dress
1QA.,./.‘.,... . _ — Expiration Date
Telephone` .Z1-4 -ai
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 build' g permit 1
Signed Affidavit Attached Yes No 0 INSULATION
Brief Description of Proposed Work NOTE: ONLY
t pLioS-I• lit° ail U,tcr . oii1 c; q{5W 'Fb,1 &tilswasecuu(1
I, JoavveN a(l5 1 ,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.
JO.Altec &.iZs
Print N " ` I
Signature of Own r/Agent -- Date
I, Mt < Qd_ CI rnerigt ,as Owner of the subject
property '
hereby authorizeJTiiV\.Q S C�l.l,l.S _ ,, .
to act on my behalf,in all matters relative to work-tautrror ized by this building permit application:
41441(444. Vl laN f a-(
Signature of Owner wr Date
I
1
I
•TH: City of Northampton
Massachusetts 'w {
tom° x
s
r
: 7 DEPARTMENT OF WILDING INSPECTIONS t ;,
iI +
`M 212 Main Street • Municipal Building
Northampton, MA 01060 3rJ1.
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 1041. &AS ei-
Contractor J .S 0(IS
Name
•
Address: ` -te &A(L Q ( -
City, State: el l t
Phone: LW> - 3 -
•
• Nroperty Owner
Name: `' JuiA
fiLe
Address: tO4( evt- 114
City, State: WI/A_ I' \c
cJ ,,1ik-S Olt S (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 /'I1 m
a '
City of Northampton
Y�yN,M
t, ' Massachusetts f'fS "'sf^1;
cs3 .,vtR iy.
# r i
$ Q i:d DEPARTMENT OF BUILDING INSPECTIONS 1 ` ' C�° m—
�;a 212 Main Street • Municipal Building %1'Ti 1 .,,.05:
r Northampton, 01060 �sk;Y ���,
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:1.f the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work tY cki—t Y\ Est.Cost: ' 3000
Address of Work IoLkl 8 we ` i- (24 ,
Date of Permit Application: 1 I53I),i
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 PERMIT.SEE;NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the anent Of the owner:
1 Al 1 . 1 4 ; t 4(4,L0-)-
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 Naroe arrd"Sicnature
City of Northampton
O
ix
77,
Massachusetts ' ;
Ott
Y, DEPARTMENT OF BUILDING INSPECTIONS ?n i t
1 ; 212 Main Street •Municipal Building
Northampton, M& 01060 • ;t4C�
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 resultingfrom 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:
1bL1 tiViS Pi.F Cd .
(Please print house number and street name)
Is to be disposed of at:
Ids alkottl �o� t}- . G) k eNA
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signatur 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.
• :A. I IIe e,ommonwealf of Massacfutseus
..- Department o fdrudustrialAccidents
•,- Office of Investigations
. , j Lafayette City Center
s'_;' 2Avenue tie Lafayette, Boston,MA 02111-1750
re , www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/tndividual):'Ideal Home Improvement, INC
Address:142 Boyle Road
! CitylState/Zip:Gill MA 01354 Phone#:4138632128
Are you an employer? Check the appropriate box: ;Type of project(required):
1.0 I;iam a employer with 10 4. ❑ Tam a general contractor and T 6. ❑New construction
employees (full and/or part-time).` have hired the sub-contractors
.❑ Fain 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'
comp.insurance. 9. 0 Building addition
[No workers' comp.insurance p
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
13.❑ T:am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself, [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no insulation
employees. [No workers' 13. Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
141 Homeowners 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 entities have
ymployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an�etnployer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
insurance Company Name:Selective insurance Co
policy#or Self-ins.Lie.#:WC9057697 , Expiration Date:1/26/2022
Job Site Address: i CH I Y+ �,k City/State/Zip:h OY•J (L met
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
`ailure 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 fme
afup to$250.00 a day against the violator.- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do her ' under tl ' s and penalties of perjury that the information provided above is true and correct.
1
Signature: Date: 1 LC1I XI
Phone:# LW) ' liA' at a4
Official use only. Do not write in this area,to be completed by city or town official.
City.or Town: Permit/License#
Issuing Authority(check one):
1DBoard of Health 20 Building Department 3.0City/Town Clerk 4.0Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#:
e
i BELOW THIS CERI1MCAt b Oh INSURANCE DOES N111 CONS IT1 U 1E A CON TRACT BETWEEN 1 HE ISSUING INSURER(S),AUTHORIZED
EREPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is en ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
i If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
! this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
RODUCERtv
CO TACT Patrick Gooden
ebber$Grinnell PHONEFax
(413)586-0111 (413)586-6481
(g/G No,Est): (A(C,Nob:
la North King Street E.MAI pgooden webberand rinnell.com
ADDRESS: ® g
INSURERS)AFFORDING COVERAGE NAIL I
Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259
INSURED INSURER B: Selective Ins Co of Southeast 39926
Ideal Home Improvement,Inc. INSURER c
Attn:Laurie Ellis "``INSURER D:
I 142 Boyle Road INSURER E:
Gill MA 01354-9731 INSURER F
OVERAGES CERTIFICATE'NUMBER: Exp 11/21 REVISION NUMBER:
I THIS IS TO CERTIFY THAT THE POLICIES OP 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
i 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. '
soft
TYPE OF INSURANCE IN Sp yIsvD POLICY NUMBER POLICYVY POLICY EXP
(MMIDDlYYYY) (MMIDDANYY) LIMITS
X COMMERCIAL GENERAL LIABILITY 1,000,000
EACH OCCURRENCE $
DAMAGE TO RENTED •CLAIMS-MADE OCCUR i PREMISES(Ea occurrence) $ 500'D00
MED EXP(Any one person) $ 15,000
I,A S2291388 11/17/2020 11/17/2021 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATELIMITAPPLIES PER: GENERAL AGGREGATE $ 2.000,000
POLICY❑1,21ei El Lac PRODUCTS-COMPIOPAGG g 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED A9105410 11117/2020 11/17/2021 a DOILY INJURY(Per accident) $
AUTOS ONLY X AUTOS
�vr (TIRED v NON-OWNED PROPERTY DAMAGE $
0-'4AUTOS ONLY AUTOS ONLY (Per accident)
Uninsured motorist BI $ 100,000
UMBRELLA LIAB r"H '
OCCUR EACH OCCURRENCE $
—
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION$ _ $
WORKERS COMPENSATION PER
U7E ERH-
AND EMPLOYERS'LIABILITY
B ANY PROPRIETOR/PARTNER/EXECUTIVE Yri NIA WC9057697 01/26/2021 01/26/2022 E•L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? l ) 1,OD0,000
(Mandatory In NH) E,L.DISEASE-EA EMPLOYEE $
If yes,;describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT $
i
'ESCRIPTIDN OF OPERATIONS l LOCATIONS)VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
I i
CERTIFICATE HOLDER CANCELLATION
f
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOREED REPRESENTATIVE nn
1
i)1988-2D15 ACORD CORPORATION. All rights reserved.
I►CORD25(2018103) The ACORD name and logo are registered marks of ACORD
t
�: i
1
Commonwealth of Massachusetts `ry.
II) Division of Professional Licsnsure
Board of Building Regulations and Standards
Cons ***A Ti li prvisor
s dpq s .
CS-091207 ye 4 -03plres 1 Oil 612022
.
JI4MES P ELiES
142 BOYLE R b ^'.rr A - N .n
GILL MA 01364 64 yet'
a *'
Commissioner of,• BlEriae
•E3l+P�+M5r1t,aM:�sr+..•ra.. ,.........;........+w........w..a..... .. _
Ofpceoti+onsumerAffetre&BusinessR=.: talon
HOME IMPROvEllllENT CO •R
TYlE Corporal.81003199
'4 C s 04�21/2921
IDEAL HOME IMP:'� +.ati� ,4 ,.
• rss `
JAMES P.E
142 BOYLE ,. •
>`
HILL, r1304 Uncle) -. Amy
......� ��...._._ _ - -. .w.----- -
I i '
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
Registration: 146402
IDEAL HOME IMPROVEMENT INC. Expiration: 04/21/2023
142 BOYLE RD
GILL,MA 01354
Update Address and Return Card.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
146402 04/21/2023 1000 Washington Street -Suite 710
IDEAL HOME IMPROVEMENT INC. Boston,MA 02118
JAMES P.ELLIS 1'
142 BOYLE RD 4(4.1
1 4.
GILL,MA 01354 t valid without signature
Undersecretary