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B P-2021-2191 24 INDIAN HILL COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-536-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2191 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: ' License: Est. Cost: 3000 IDEAL HOME IMPROVEMENT INC 91207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: PRITCHARD DAVID W Lot Size (sq.ft.) Zoning: WSP Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL, MA 01354 ISSUED ON:11/17/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI ON 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. Signature: ^ ii Fees Paid: $65.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner 4 Dep in:410 : .•Ti1 :.i;"4, ,,. City of Northampton NOV 1 S ,02, "- Building DepartMent ,,- a ti 212 Main Street , SULA TION ,. f Room 10 nPPT.OF '. .e . �UILDIN,1 `'. . ` Northampton, MA opTHA pop T h �.PECTIONS .,;/. phone 413-587-1240 Fax 413-587-1272 o,oc,° ONLY APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: TW r section to be completed by office ALI I1101\04 1i111 Map ,t 9 Lot 3C/ 3 Unit noy�C�MCA W` Zone Overlay District 1 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: wko., Q Liqmeo-&uName(Print) Current Mailing Address:• Telephone Signature 2.2 A thorized Aqe • , S ts - lua 6KIU 2e4 0111 11114 ame(Print) 2,(.... .../ .,. Current Mailing Address: Ut3 .1U3. alb` Signature Telephone SECTI N 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building "3 V()Cl (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee ill 4- 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) 3000 Check Number .1/ V GO/ Section For Official Use Only Building Permit Number: c7�/" a!-f / — Date Issued: Signature: __1171Z )/- &-Z(J Z.1 Building Commissioner/Inspector of Buildings r ./� e Date tt1 S @ C t ccs 1 ' f t P EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction S e►rviso►r: Not Applicable 0 Name of License Holder: C `is . i.&S quo] ber 19 k (� I w` , N t 1 License Nut to res Qk,..A., Expiration Date 41 3. $l43 • al 4n Signatur Telephone 9.Registered H me Improvement Contractor: Not Applicable 0 \WU I mP 1 N( uo)- Company Nam Registration Number U • &it f Li- aI.33 dress Expiration Date QA.;\....„ Telephone4(2)A6 • Min SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build! permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: INSULATION ONLY °Ileo S+ l'q o Ctl tu,lo t t() cut c I Ng I-C St 1 t S; aW Rai I, t1JAM S , as Owner/Authorized Agent hereb 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 enalties of perjury. Print Bartle C D ` It I I Signature of Owner/A nt Date I. NMI MI t OL `91(1iMLY d ,as Owner of the subject property G ,n� hereby authorize 'lul,t f . v y.( to act on my behalf,in a atters relative to workauthor zed by this building permit application. ,Da ' - it I a-( )_-, Signature of Owner Date City of Northampton s/: �,f,,- s.., Si;;" Massachusetts A_ l ' '� DEPARTMENT OF BUILDING INSPECTIONS �- 1. ? 212 Main Street • Municipal Building ' J^ .4' Northampton, MA 01060 r/'W~'iO� MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: ALj I, O t O_ n , Ita Contractor Name:ame: cJ(LOUS Ru. S Address: 'o, """'4 U a V l City, State: << I, tu Phone: 9 i,3' 9 - ell e a Property Owner -6 0601/4._ „p(` ard Name: Address: 1 o l 3XXiSl&L i�'• City, State: iyuact u) out I. ciQS �\ (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 signature2 ...,?. ,,,. Date 1 1)gI?'l • • City of Northampton Massachusetts .kts r c• DEPARTMENT OF BIIILDING INSPECTIONS ; 212 Main Street • Municipal Building '. ra Northampton, MA 01060 of�i `�O 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 has contracted with a corporation or LLC,that entity must be registered. Type of Work: I 1 `SW.Cthc 11 Est.Cost: 3 0 0 d Address of Work: '4 Ind d tan r\ i Date of Permit Application: 11 '41a1 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 agent of the owner: 111 W 34 I ata.J1-60q,1111 r (-11 y-o 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 Name and Siiature • City of Northampton •08. . ro Massachusetts . "c'{ 4'1 * DEPARTMENT OF BUILDING INSPECTIONS �• , 212 Main Street •Municipal Building _rw>+ 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: ak-i hat t an ��11 (Please print house number and street name) Is to be disposed of at: a.Q11.Q \ (Please print name a d location of facility) Or will be disposed of in a dumpster onsite rented or leased from: \q 60.4u itex( i at ((Company Name and Address) Signa ur 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 . ' Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Ideal Home Improvement, INC _ Address:142 Boyle Road City/State/Zip:Gill MA 01354 Phone #:4138632128 Are you an employer? Check the appropriate box: Type of project(required): 1.© I am a employer with 10 4. ❑ T am a general contractor and employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑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 10.0 Electrical repairs or additions 3.❑ I 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. 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. 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:Selective Insurance Co Policy#or Self-ins. Lie.#:WC9057697 Expiration Date:1/26/2022 Job Site Address: j�`1 \ LiikiA �,I I City/State/Zip:fi'o(ulcA (' "sl. 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. I do here certi tder the p rs d penalties of perjury that the information provided abovecorrect. is true and \\1\.)-( Signature: Date: I t Phone#: q i J` ` at ?r<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 (check one): 10Board of Health 20Building Department 30City/Town Clerk 4.0 Electrical Inspector 50P1umbing Inspector 6.0Other Contact Person: Phone#: Aco ®n CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) `•-----' 01/28/2021 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 pollcy(iea)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 Patrick Gooden NAWebber&Grinnell PHONED Eztl. (413)586-0111 FAX No): (413)586-6481 8 North King Street � d�ADDRESS: pg g ooden ebberand rinnell.com INSURER(S)AFFORDING COVERAGE NAIC# 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: 142 Boyle Road INSURER E: Gill MA 01354-9731 INSURER F COVERAGES CERTIFICATE NUMBER: EXP 11/21 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'SUlYK POLICYM/DD EFF) (MM�/YY ) LIMITS LTR TYPE OF INSURANCE NM UDI WVD POLICY NUMBER (MO YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR DAMAGEIO RENTED 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2291368 11/17/2020 11/17/2021 PERSONAL SADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JECT ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED AUTOS ONLY x AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE [� NIA WC9057697 01/26/2021 01/2612022 E,L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ` I (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i • Commonwealth of Massachusetts �t J� Division of Professional Licensure Board of Building Regulations and Standards Constru bd%iSPprviso r CS-091207 OMIres 10/16/2022 JAMES P ELU8 Vi 142 BOYLE RR GILL MA 01354 z v .1 Commissioner 'dail • •y..~•• v,iifiliio.R.srivei Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR • TYPE:Corporation Registration Expiration 146402 04/21/2023 IDEAL HOME IMPROVEMENT INC. JAMES P.ELLIS 142 BOYLE RD '4•j . • GILL MA 01354 Undersecretary