10B-107 (2) BP-2022-0201
24 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
10B-107-001 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-2022-0201 PERMISSIONIS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 4000 JAMES ELLIS 91207
Const.Class: Exp.Date: 10/16/2022
Use Group: Owner: MCCOY, CLARA A
Lot Size (sq.ft.)
Zoning: URB/WP 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/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:
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
• )9 1 •
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
t,.-,,,,,, °TOR
City of Northampton / \,
- ..- Building Department illq ` '
- 212 Main Street ,,f_ 9 - 7 su
LATION
r k < - Room 100 r
' 7-7 d, �
Northampton, MA 01080N, 4,e) /phone 413-587-1240 Fax 413-5874'• a•>�� o
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APPLICATION FOR INSULATION FOR A ONE OR TWO AMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS LI .VA TION PERMIT
1.1 Property Address: Th',. section to be completed by office
?4 Ak4AAbon fi.d Map Lot Unit
ld1/4, ' 0 /t Zone Overlay District
V--� Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owne of Record:
0Sa MC Coy ' aq u. t2e( t U.12fIR
Name(Print) Current Mailing Addressl 1'T`.J Al -)aoi co
(J _ ('CG'tkJ/ Telephone
Signature
2.2 A thorized Ascent: /'
S . 1 k-W. ez� lQ eel t �t i (no
N e(Print) Current Mailing Address:
Signature Telephone
SECTI 3-EST MAT C S UC ION COSTS 1
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ", [000 (a)Building Permit Fee
2. Electrical i (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee 44. Mechanical(HVAC) iib
5.Fire Protection
6. Total=(1 +2+3+4+5) 14000 ~. Check Number 'oZ 0 ,
This Seotton For Official Use Only
619-al.- AO I Date
Building Permit Number. .. . . • .- Issued:
Signature: _ 3 - 1- ZOZ Z.
Building Commissionerllnspector of Bdlldrnga Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction
Supervisor:
� Not Appllicable 0
Name of License Holder:V aA`�/- p
S L/�,�(� 1/ao j
61(
License Number
\yk , lQ , 1r'1.M IO/(9',101-
.� Expiration Date
/VVL- 1J o.1 C} D
Sign re Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
\c3-W rrtp voucxrurti- ►LI(L4o)-
Com an Name Registration Number
\`-. u� � , (I ( Imo. �' ac- a3
Address U Expiration Date
(�Telephone wr) Iu
�u
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 buildingpermit
Signed Affidavit Attached Yes G d No 0 p A i A�
Brief Description of Proposed Work NOTE: INSULATION ONLY
I N 5 ckt ne Fu.(,ic 'vua li bco•( Sf -6.rn b0Wak St opes • !O-
SUS CAA( S k
s ���� , 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 unde the pains and penalties of perjury.
Print Nam J
Signature of Owner/ ent Date
`A ` ' CON ,as Owner of the subject
property do
,AK authorize \JwA -S
to act on my behalf,in all matters relative to work authorized by this building permit application.
t V ( '9.Signature of Owner Date
City of Northampton
Massachusetts * `c
DEPARTMENT OF BUILDING INSPECTIONS �*
212 Main Street • Municipal Building ,4p1•,
Northampton, MA 01060 A� "
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 1 A �� lick. Us/is
Contractor �S ����S
Name: U
Address: 1 y cl 6).01 a+L—retil
City, State: &) t (Y ,ot'
Phone: -i\3' t2)) • o/
Property Owner U�Q /�
Name: �/� f r 1{.��l(
r7
Address: d►� U.U,U ooC 6 a ,- S'
City, State: Utcis O
I, V cki 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 AM
Date 1 a a.
City of Northampton
or jM M�
Massachusetts
{ ' DEPARTMENT OF BUILDING INSPECTIONS
�:.et�f 212 Main Street • Municipal Building '� s, CS' 171 .
r Northampton, MA 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 I42A 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: t n9lA.VCl. Est.Cost: LibbD
Address of Work: 4)14vd1,I,ban CAI ► �X- S
Date of Permit Application: a\),a,1 d.�•
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:
1 hereby apply for a building permit as the agent of the owner:
da.6/.0 S &Isk\ HOWL \ ono. l Li e of o?--
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby anpN f)r a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts 'co
.4r �.
X i DEPARTMENT OF BUILDING INSPECTIONS
;fie �7 212 Main Street "Municipal Building v` �a
Northampton, MA 01060 'Ik
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:
)tq AutauVw 6d
(Please print house 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:
kLULDS r"-VAV t-u 6.4 Lia 31 (
(Company Name and Address)
- )'a
Signat a 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
tr. Office of Investigations
Lafayette City Center
i{ 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 #: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 general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ID 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'
[No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' right of exemption per MGL
ycomp. 12.❑ Roof repairs
insurance required.] c. 152, §:(4),and we have no
employees. [No workers' 13.0 Other Insulation
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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. Lic. #:WC9057697 Expiration Date:1/26/2023
Job Site Address: A"1 Audubon Gt • City/State/Zip:\JaLc m t-
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 cern der the pa sand penalties of perjury that the information provided above is true and correct.
Signature: ( J Date: o� C).l�
g '
Phone#: 413- 3-2128
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):
I❑Board of Health 20 Building Department 3tCity/Town Clerk 4.0 Electrical Inspector 5E1Plumbing
Inspector 6.0Other
Contact Person: Phone#:
ACORD CERTIFICATE OF LI A BILITY INSURANCE DATE(MM/DD/YYYY)
`.. 01/20/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A D CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EX END OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ' CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDMONAL INSURED,the p licy(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 s ch endorsement(s).
PRODUCER CONTACT Brandon Andrade
Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481
8 North KingStreet (Ng,No.Ext): (A/C,No):
ADDRESS: bandrade@webberandgrinnellcom
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 11/20' REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE B=EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF A Y 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 B:EN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE ADUL SUBR POLICY EFF POLICY EXP
INSD WVD POLICY NUMBE-. (MM/DD/YYYY) (MM/DDIYYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000
PREMISES(Ea occurrence) S
MED EXP(Any one person) S 15,000
A S2291368 11/17/2021 11/17/2022 PERSONAL BADVINJURY S 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY n E a n LOC PRODUCTS-COMP/OPAGG S 2,000,000
OTHER: S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
A — OWNED X SCHEDULED A9105410 11/17/2021 11/17/2022 BODILY INJURY(Per accident) $
_ AUTOS ONLY !� AUTOS
XHIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY X AUTOS ONLY (Per accident) S
Uninsured motorist BI S 100,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED RETENTION S S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N1,000,000
B OFFICER/MEMBER EXCLUDED? n N/A WC9057697 01/26/2022 01/26/2023 E.L.EACH ACCIDENT S
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Sc ••Is,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
OD 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and log. are registered marks of ACORD
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Commonweal, of Massachusetts
te$ Division of Pr.6 tonal Licensure
Board of Building R_';ulatlons and Standards
6 n-U.
Constr.sNisbiOryisor
ca4)91207
JAMES P Et-gE
142 BOYLE ilk
.•
GILL MA oiw ,,,• : e;
Ctl•
Commissioner atnaLit.., •
.••• .••••••••••10..
wornIsisttlienitilin uor
• -44/1i
Office of Consu r Affairs&Business Regulation
HOME BARR?VEMENT CONTRACTOR
• r PE Corporation• ; rApiration
141,0'2 04/21/2023
IDEAL HOME IMP 5 EMENT INC.
JAMES P.ELLIS - /2 •
142 BOYLE RD a44,.04.
•
GILL,MA 01354 Undersecretary
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