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24D-019 (3)
BP-2022-0825 4 LAWN AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-019-001 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-2022-0825 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 15000 JAMES ELLIS 91207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: ELIEZER HUTTON, Lot Size (sq.ft.) ELIEZER HUTTON,IDEAL HOME IMPROVEMENT Zoning: URB Applicant: INC Applicant Address Phone: Insurance: 4-6 LAWN AV APT 2R NORTHAMPTON, MA 01060 142 BOYLE RD (413)863-2128 WC9057697 GILL, MA 01354 ISSUED ON:07/13/2022 TO PERFORM THE FOLLO WING WORK: INSULATION 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: 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 • j i . CRIT Fees Paid: $105.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner G-7 f :: City of Northampton V - PFOR %F• d._J .» ti Building Department �N. J(/j /' ,'- 212 Main Street / 111//LATION Northampton, MA 01060`\oc r"0/1), phone 413-587-1240 Fax 413-587-12 NAM''' ` '"Js /ONL Y __. _..__ .. ry tApECrJOn OT�G Jg APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY , SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Ad1dress:(� Th'' section to be completed by office L1_4 I o • Map 0/q() Lot D le q Unit •/� �( " M� Zone Overlay District 1� 1 wc 11 , Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:1 t v c n \- l L ei1 N "�tV1 a�0 6� //_c 6 rictfy, -col, E X CakeLt Name(Print) CurrentMailing Address IA „ TpRho1- Suu - 4 L US ele Signature 2.2 uthorized Agent: �11dQJLc is ►4a 3 Le 6, CH( rn.� ame(P t) pt...,\;\7\ Current Mailing Address: Sign re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building '� OW (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee „ [U'16 4. Mechanical (HVAC) '►{m' 5. Fire Protection 6. Total= (1 +2+3+4+ 5) t5,000 Check Number 43 i S Q This Section For Official Use Only Building Permit Number: 8r" --p(h ..1a; Iss Issued: I Signature: , 1 I/ 3/,41 Building Commissioner/Inspector of Buildings Date -Q4�k © Cmcc . -h— EMAIL ADDRESS (REOUIREr. EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:nv � Not Applicable ❑ Name of License Holder: ',) O-c S FADS q I ,N O1 License Number ‘-1 a fiDlN (2VA• (ji Pt 1 b•1 U 2� ss Expiration Date -113•g\S"). alag Si ature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ \cLtc .`mp rovrAT 1 ( 4 U )- Company Name Registration Number ILka eptiea . Addr s I ,,� Expiration Date `Telephone '� u¢(Y") 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 building permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: I SULA / iOlY ONLY \5\o u-c 15 f ckL L. ' lq uu S+ Gl.nviocu,_--evA-vto- uaki ts; t Logo24 I. • IVY, t Y\ C r v' a1 kk , 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 Na Signature Owner/Agent Date I. v�k 11. k-ktN 1 ,as Owner of the subject property hereby authorize cj(A/14Af S j1 I ( S to act on my behalf, in all matters relative to',very; :u:r.crized by this building permit application.eth laa- Signature of O� Date City of Northampton f.,,, : , Stis L..si9,% ,{{ v. Massachusetts ' DEPARTMENT OF BUILDING INSPECTIONS s.; 212 Main Street • Municipal Building J.-,y:. I Northampton, MA 01060 s -11 1n5 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: Li" U L-CUAD(\ Ave- Contractor Name: j(kif v ..Q S 5.ck S Address: k4 11 City, State: l (.A Phone: 4 v) p p•3 at a-0 Property Owner _ Name: D 11'01 hlkk (-C11 '-- vii-c i) Address: a 140 Q-ed.S I5iiI,dg e • City, State: CVNA G1, I 'y Pr I, C 1C,UO/V 13 `W; (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 &:. ...;l1,--N Date i 1 i - • City of Northampton oatN�M- • Massachusetts i � ;h p iz r ,l DEPARTMENT OF BUILDING INSPECTIONS 7•. �' ► 212 Main Street • Municipal Building Jb, tt37 �• +. Northampton, MA 01060 DsN 450 r`� 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: f1SU 1 O&,TIOn Est. Cost: 15,000 Address of Work: "I' 1p Lew)n Alt . Date of Permit Application: 1 j71)a. 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: 7171.)NX [(I NA o k4CiAkte i t 0)-- Date Contractor Name HIC Registration No. OR: dOLAKO \ls glao� Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton '" Massachusetts Y' • • y - i- .ft DEPARTMENT OF BUILDING INSPECTIONS _ 212 Main Street •Municipal Building ,, �„ Northampton, MA 01060 iS .4 1?:11,` 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: y-4vf.. (Please print house number and street name) Is to be disposed of at: IGUN) -tee_ Ime , ILf? x�. (U0iI Please print name an location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 1I1Ia ) Sig ature 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 c �.sOffice of Investigations ./ Lafayette City Center , / 2 Avenue de Lafayette, Boston, MA 02111-1750 t' . 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): 1.0 I am a employer with 10 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling shipand 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.+ 9. 0 Building addition required.] 5. 0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no Insulation employees. [No workers' 13.0 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. 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 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: -I-l 7 Lin Au-c- City/State/Zip:I 'U U J , 1 MA A 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her certify nder t • and penalties of perjury that the information provided above is true and correct. Signatur . -, Date: 1 171a Phone#: 413 63-2128 Official se only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1 EJBoard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5EPlumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts DiAtision of Prof ssional Licensure Ar) - Board of Building Re ulations and Standards Constrit;ftit Abrvisor CS-091207 5txp1res:10/16/2022 JAMES P ELLIS 142 BOYLE% GILL MA 0134, Commissioner datiG 141.11111118DOM1W$ . . .K1/...//l/r^// //77.7/147,ie7r/ct6A,././i Office of Consurn Affairs&Business Regulation HOME IM PR 4I%/BRENT CONTRACTOR • PE:Corporation Expiration • 146,02 04/21/2023 IDEAL HOME IMPROVEMENT INC • JAMES P.ELLIS 142 BOYLE RD . ' .14,761(4.72114m4' GILL MA 01354 UnderBOOn9tarV A YYY) /DD/Y 2022 CERTIFICATE OF LIABILITY INSURANCE D1 DATE(MMMM/DD!Y 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 Brandon Andrade NAME: Webber&Grinnell PHONE (413)586-0111 FAX No: (413)586-6481 INC,No,Est): ( ) 8 North King Street ADORLsS: bandrade@webberandgrinnell.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 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. NSR SUER POLICY POLICY NUMBER (MM/DD/YEFF POLICY EXP M/ TYPE OF INSURANCE INSD LTR INSD WVD YYY) (MDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 �/ DAMAGE TO REN I H..) 500,000 CLAIMS-MADE X OCCUR 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 PRO PRODUCTS-COMP/OP AGG S 2,000,000 JECT LOC OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S A OWNED X SCHEDULED A9105410 11/17/2021 11/17/2022 BODILY INJURY(Per accident) S AUTOS ONLY _ AUTOS X HIRED X NON-OWNED ONLY PROPERTY DAMAGE S AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE S _ — EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S $ WORKERS COMPENSATION PER OTH- STATUTE ER AND EMPLOYERS'LIABILITY YIN 1000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S , B OFFICER/MEMBER EXCLUDED? Y N/A WC9057697 01/26/2022 01/26/2023 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS!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 1/1 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD