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15B-040 (2) BP-2022-0202 212 CHESTERFIELD RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-040-001 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-2022-0202 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est.Cost: 4000 JAMES ELLIS 91207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: ROZENFELD LAURIE S Lot Size (sq.ft.) Zoning: RR/URA Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL, MA 01354 ISSUED ON:03/02/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/W EATERI 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ( i . r II Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1-11C7",- . Der R ;a7>k`'1,; City of Northampton q'q / i � _- Building Department R �` -� `, 212 Main Street ., � ' 0�2 • ..'� { Room 100 -----, INSULATION „_ -' Northampton, MA 01060'1+4n-3(A�sPEct--N • """ ` phone 413-587-1240 Fax 413-587-�27 OIlL. APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: Th'.,section to be completed by office L4 k p,n /A 4flQ.fJ Map Lot Unit MAZone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Recor : l autit, oz-In�f,�d q tlr✓W Imo. Nam (Print) Current Mailing Y�-Address U13-ua-6 .3a13 Telephone Sig a re 2.2 Authorized Agentr� __LA. S be,lt S t kid eau u az1 , 611 orq r .me'rint) \ Current Mailing Address: • 11.l.?.--A. .A_A7\ k-41 - 3. .a.(4-(2) Signature Telephone SEC ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i1 1 00 0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 40 \ 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3 +4+5) 4000 Check Number 1,1)61(1 .. te This Section For Official Use Only Building Permit Number: 3 Y,- a' -�M Iss •- Issued:I Signature: n---- 3-/'262Z Building Commissioner/Inspector of Buildings Date -e11 i fl @ CGrnc t . r' -€-+ EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) i SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Constructio /�Sup�e�rvi�sor: Not Applicable 0 Name of License Holder: \ CUV�S �jt(( S q I a O l q i �.l� ,�.-a l Gz(I (AA LicenserrN V��umbe/Ir^^ ' 'lY' l.T Address Expiration Date Sign ure Telephone 9.Registered Home Im r vement Contractor: Not Applicable 0 kXLM Q u I r tiffit(>r�lP I L-Kif c 4- Company Na e Registration Number qd (.264 . Gtt YV U1- a.'S 2 1 Expiration Date Telephoneq 1 T 01(d 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 buildi permit. Signed Affidavit Attached Yes No ❑ Brief Description of Proposed Work NOTE: INSULATION ONLY 1 LN -f tOOtA 'fcx ( tauffw Cra.cJ(&pcu,t_; q-S c GI" C r LA I cs e.. 0161-eI 1 ai tl c; Ot,t v S-e ck l t r -i) I, dvu _S aS ,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. Print al al lea Signature of Owner gent Date I, Lakiv vZ OZ,l `')' t ck. ,as Owner of the subject property hereby authorize S l tS _ to act n my behalf, in a afters relative to worts a_.tnor::e :<;;v:his building permit application. _.______.._____ &117 l az Sign u of Owner Date ; . City of Northampton '___ 19r.N......s! Massachusetts _ '`- „k ,47,,w) DEPARTMENT OF BUILDING INSPECTIONS Ii z '' 212 Main Street • Municipal Building v',• `D Northampton, MA 01060 tslya. %t�� MANDATORY° FOR HOUSES 1BUILT BEFORE 1945 Property Address: 9 51�•�,p�rd`S ''�U ..cu (:_QJk Contractor Name: �t5 a V ,/ ad Address: 1'01 6UA LI City, State: Gik OVIA Phone: \-41 ' a ' D.1 a'y Property Owner Name: Y l-t. 6oz.tafuut Address: -1 S N H0<<G1iO 1 City, State: \, S nka I, 1S &Lk 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 C, , Date al c)I 01 ' I • City of Northampton Massachusetts *II `• s : DEPARTMENT OF BOILDING INSPECTIONS \` 212 Nain Street • Municipal Building Northampton, MA 01060 riy ..•, ,1J 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: A01/4, Est. Cost: it 000 Address of Work: "L auipvvyas \ U(C4X) l CJh Date of Permit Application: p�,t at I a o• 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 1'Hir 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: • Date Contractor Na e HIC Registration No. OR: Notwithstanding the above notice, I hereby apni for a building permit as the owner of the above property: Date Owner Name and Si:mature • City of Northampton �5 s Massachusetts �;t7- c� * s l =�� 4 ins s. j DEPARTMENT OF BUILDING INSPECTIONS �': 212 Main Street •Municipal Building ' Northampton, MA 01060 sry•.-. `�� 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: `- S In X6 S * COAk (Please print ouse number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: � Q \- � m . 196 U 511 (Company Name and Address) Signat e 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. , :,..4\ The Commonwe lth of Massachusetts Department of ndustrial Accidents ` � Office of nvestigations zi ,j Lafayett City Center f 2 Avenue de Lafayett , Boston,MA 02111-1750 :^%: 5% ww».maIss.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 #:413-863-2128 Are you an employer? Check the appropriate box: Type of project(required): 1.. I am a employer with 10 4. ❑ I am a ge eral contractor and I employees (full and/or part-time).* have hire the sub-contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on he attached sheet. 7. ❑ Remodeling ship and have no employees These su -contractors have 8. ❑ Demolition working for me in any capacity. employe . and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers h ve exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of a emption per MGL 12 0 Roof repairs insurance required.]ui . c. 152, § (4), and we have no q ] 13.0 Other Insulation employees. [No workers' comp. in ance required.] *Any applicant that checks box#1 must also fill out the section below showi g their workers'compensation policy information. 1.Homeowners who submit this affidavit indicating they are doing all work a d then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing th name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their orkers'comp.policy number. I am an employer that is providing workers'compensation i surance for my employees. Below is the policy and job site information. Insurance Company Name:Selective Insurance Co. Policy#or Self-ins. Lic. #:WC9057697 Expiration Date:1/26/2023 Job Site Address:Lk Ske,cptwed% \\tA1io a.s.A City/State/Zip. g_fLd.S Mat Attach a copy of the workers' compensation policy declar.tion page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of GL 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 a• 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 certify ider the arts c d penalties of perjury at the information provided above is true and correct. Signature: 0 V\.._ N'---___ Date: C)' a( I a Phone#: 413-:.3-2128 Official use only. Do not write in this area, to be complet d by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 20 Building Department 3DCit /Town Clerk 4.0 Electrical Inspector 5E:Plumbing Inspector 6.0Other Contact Person: y Phone#: 1 Commonwealth of Mass usetts letDivision of Prof ssional Licensure Board of Building Re ulatons and Standards Cori.strttj;41( prior CS-091209 rapires:10/16/2022 JAMES P ELUS ‘t1 7 142 BOYLE 19 1 GILL MA 0136j V - • jr • Commissioner diet .. lorrittt istanknintes • 772,/ify/. Office of Consum r Affairs&Business Regulation HOME IM PR VEM ENT CONTRACTOR • T PE:Corporation Expiration 14 02 04/21/2023 IDEAL HOME IMPR EMENT INC. JAMES P.ELLIS 142 BOYLE RD /214•4" GILL,MA 01354 Undersecretary • ACO® CER • TIFICATE OF LI•BILITY INSURANCE DATE(MM/DDIYYYY) `----- 01/20/2022 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 ACONTRACT 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 st(ch endorsement(s). PRODUCER CONTACT Brandon Andrade NAME: Webber&Grinnell PHONE Wit): (413)586-0111 FAX No): (413)586-6481 8 North King Street ADDRESS:; bandrade©webberandgrinnelt.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 11/2022 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 HE 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S 500,000 MED EXP(Any one person) S 15,000 A S2291368 1h/17/2021 11/17/2022 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE S 2'000'000 POLICY JECT LOC j I 2,000,000 { PRODUCTS S OTHER: I - ) S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO ( BODILY INJURY(Per person) S A — OWNED X AUTOS A9105410 11/17/2021i 11/17/2022 BODILY INJURY(Per accident) S AUTOS ONLY _ XHIRED "s/ NON-OWNED i PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY 1 (Per accident) k j Uninsured motorist BI s 100,000 UMBRELLA LIAB _ OCCUR pi EACH OCCURRENCE S EXCESS LIAB t AGGREGATE S CLAIMS-MADE I){ DEO RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORJPARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1'000'000 B OFFICER/MEMBER EXCLUDED? Y N/A WC9057697 01/26/2022 01/26/2023 (Mandatory in NH) ' E.L.DISEASE-EA EMPLOYEE S 1'000,000 It yes,describe under DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT S 1'000,000 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. 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD