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22D-079
BP-2022-1100 24 CROSS ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 22D-079-001 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-2022-1100 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 2000 JAMES ELLIS 91207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: RENKOWIC JOSEPH 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:09/08/2022 TO PERFORM THE FOLLO WING 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: 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: el • it 5.9 - ly(J Fees Paid: $65.00 • 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner . FiE----•-5t.-ii...-, - 780,ki- /900 Dep <:Y>-T14 o. City of Northamptorf -'--,�!-_r ! FO R Building Departmer?It SEp it 212 Main Street , 2 70.2 . ' ,; Room 100 n�,r SULATION '` Northampton, MA.Q1Of0rFU2o»,/Gi .,.r, - phone 413-587-1240 Fax 413- '7r,M'''d roNS ONL Y 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 014 Cos Map ec� 0 Lot O�q Unit i ____ Zone Overlay District not.tna Ma Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow er of Record: Fortou, �( h �L a CrOSS �� Name(Print) � ) ]' Current Mailing Ad�i�e .l O -q i ^� Sign tub re � � Telephone �`--�t VG 2.2 Authorized Agent: s bkts _ Ida, u Ed 6 i 1 t/Yut ame(Print Current Mailing Ad ress: Ul;- 73U3' .1.4 Signatur Telephone SEC ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant _ 1. Building 0()° (a) Building Permit Fee 2. Electrical V (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Feer--444.* 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) a.(X)Q___ ___` _ Check Number nn nn `1 This Section For Official Use Only Building Permit Number:Y�'_ OU "• // ✓ Date I Issued: //. . 1 Signature: �' 7`Z�ZZ Building Commissioner/Inspector of Buildings Date - l\ Q @ CCXYLC.a --f .►'"1 EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable e 0 Name of License Holder: j a S �t`. _II a 01 License Number ,CIA 01/4 l nta IaIU. a.)-N Addres Expiration Date Signs re Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 CU (k ci -VA/RiL oleyoixNat- it.icel-toa_ ompany Name Registration Number �j Addres Expiration Date \, Telephone')())' &fr •CM S CTION 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 ffidavit will result in the denial of the issuance of the build' permit. Signed Affidavit Attached Yes No ❑ /�+ /� Brief Description of Proposed Work NOTE: INSULA I-g- IO ONLY 14N2s� ,10o\( acuid S A.0 u s, 379 S-f. cioi SI(IS Cu 1/ S e(if 1 I. va'1 v `_ S t I 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. 1I1, r S nttS — — 4#040 Signal re of 4wnerlAgent Date I, V 05-L VI r IX I ( \ X 3C� , as Owner of the subject property jj hereby authorize c, JO ► %.L FA`(_s to act on my behalf, in all �matters relative to work authorized by this building per it application. O ewil r Date J Signature of IIPP"F .. City of Northampton ,; Massachusetts DEPARTMENT OF BUILDING INSPECTIONS i'• � ,.) 'cavam.F 212 Main Street • Municipal Building Sf 1 Northampton, MA 01060 bjy � MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: d C( >S A- l 1-1 O1''e(1c,2_. Contractor da.)(kt5 Name: Address: tLi K ki U. at City, State: Gtt( ryu, Phone: vl« ' DUB 5 - 31 A Property Owner d . Name: OS-e,Pl'1 qkntov,,kc_. Address: a L Qrç SS C 1 ' City, State: k1ciQncL I,jeA.N2 S Olt( c (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. C----,„ Contractor signature (_..A.:,\.,.\ Date \2') 0 IA)N Ippir" • MAC City of Northampton �oaT Pra Massachusetts ;tis .c, ;� 11 DEPARTMENT OF BUILDING INSPECTIONS 7`•. 212 Main Street • Municipal Building yJ j 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 CHIC"). 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:lithe homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Y 1,SU jS1f.ems Est.Cost: a o00 Address of Work: a`"[ QS' a • Date of Permit Application: St 930i a,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 UNREGISTE D CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE N T ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY F ND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WO K 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: CLUlk I.--ionNk,I rn pak,tinerrt 1-40 Date Contractor Name HIC Registration N . gi o OR: 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 .- :_ DEPARTMENT OF BUILDING INSPECTIONS 1s •;1r 212 Main Street •Municipal Building Northampton, MA 01060 •, 2,C.. 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: at 0(0�S (Please print house number and street name) Is to be disposed of at: 6S-0,9 ( a�-6((Please print n(114•JakiAlk me end location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Si 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 Commdnwealth of Massachusetts /J)J�/. Department of Industrial Accidents V „ 'l �, Office of Investigations . \ Lafayette City Center ,� / 2 Avenue de Lafayette, Boston, MA 02111-1750 �:�..trse 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. ❑ I aria a general contractor and I 6. New construct on employees (full and/or part-time).* have hired the sub-contractors 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. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance cottp. insurance.: 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 y 12.0 Roof repairs insurance required.] t c. 1152, §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. Lic. #:WC9057697 ! Expiration Date:1/26/2023 Job Site Address: am Cstrn SA City/State/Zip: p Y-eackPia/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and exp ration date). Failure to secure coverage as required under Section 251 of MGL c. 152 can lead to the imposition of criminal enalties 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 O ER 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 O fice of Investigations of the DIA for insurance coverage verification. I do h eby certify u er the paiT andjpenalties of perjwy that the information provided 1?)(5 bove is true and correct. Signature: i Date: b i a)— Phone#: 413-8 -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): 1❑Board of Health 20 Building Department 3 '❑City/Town Clerk 4.0 Electrical Inspector 5E iumbing Inspector 6.0Other Contact Person: Phone#: 1 I Commonwealth of Massachusetts Division of Pro sionaai Licensure Board of Building R ulations and Standards ConsirrtiL" �li�.r '?li'Jisor w. } CS-091207 61pires:10/16/2022 JAMES P ELk7S 142 BOYLE 4 GILL MA 011 • .110IS'i:IL+ Commissioner dad Santa. • e..W.WM//:1!!// t //J(I-il?Y:cf.: A r• Office of Consul Affairs&Business Regulation HOME IMPR VEMENT CONTRACTOR • T PE:Corooration s..<i •t gxpiration • 146,02 04/21/2023 IDEAL HOME IMPROVEMENT INC. JAMES P.ELUS 142 BOYLE RD #+(4•(1 . GILL,MA 01354 • Undersecretary I ' DD/Y PIFFRE® DATE(MM/DDfrYYY) CERTIFICATE OF' LIABILITY INSURANCE o1MM/ 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),AUTH IZED 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 conditionslof 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 (413)586-6481 (A/C,No,Extl: (A/C,No 8 North King Street EMAIL bandrade@webberandgrinnell.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S Northampton MA 01080 INSURERA: 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 CONTRACTOR 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 TERM 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 WVD POLICY NUMBER (M /YYYY) (MM/DD/YYYY) UMMIDD X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE S DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S 15,000 A S2291368 i 11/17/2021 11/17/2022 PERSONAL&ADVINJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY PRO- I 2,000,000 JECT LOC I PRODUCTS-COMP/OP AGG S OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED A9105410 ' 11/17/2021 11/17/2022 BODILYINJURY(Peraccident) S AUTOS ONLY X AUTOS X AUTOS HIRED ONLY X AUTOS NON-OWNED ONLY PROPERTY DAMAGE (Per accident) S - _ Uninsured motorist BI S 100,000 UMBRELLA LIAB — OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y r N 1,000,000 B ANY FFCERMEMB R/PARTNEREXECUTIVE Y N/A WC9057697 1 01/26/2022 01/26/2023 E.L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? 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 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 j I I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD