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24A-098 (2) BP-2022-1210 15 DICKINSON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-098-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1210 PERMISSION IS HEREBY GRANTE) TO: Project# INSULATION Contractor: License: Est.Cost: 11000 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2022 Use Group: Owner: ADB-2 PROPERTIES LLC Lot Size (sq.ft.) Zoning: URA Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL,MA 01354 ISSUED ON:09/26/2022 TO PERFORM THE FOLLOWING WORK: INSULATI ON/WEATHERIZATI 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: 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ITYINP k A- >2 - °I e Fees Paid: $71.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner .., SS feu r• 1917 anti'lam City of Northampton \/r/ .7:4 i " oR Building Departments � , 212 Main Street 2 1 / INSULATION i Room 1�0_ (/Q2 / 4, Northampton,MA' phone 413-587-1240 Faz41�� F _..„.... Qf4L �Ntiaspoc_, ` o,,i APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: Th's section to be completed by office Map / Lot C`6 t v� Unit 16 J)I ckvs St Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 46 r A rlro pc ril &,k. Q Ail (fover c . Flo eenG.c- Na a(Print) Current Mailing r ss. Telephone Signature l 2.2 AJCLr4Cj rized Agent: CO ' , ly-j- ✓5-oyk.e_ e1.- , g1i1 M4:1 oI30v Name(Print) Current Mailing Address: 1 xn� 41 13 n 3- )f Signat re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ii 00 v (a)Building Permit Fee J _ 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) Li)/� 5.Fire Protection ` 6. Total=(1 +2+3+4+ 5) /l) D0 0 Check Number 1/7 a.‘4-- This Section For Official Use Only Building Permit Number: 6a_d'`�^ij-iO Date Issued: Signature: / 9• ZG-ZOZ Z Building Commissioner/Inspector of Buildings Date a EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Su /eervisor: Not Applicable 0 Name of License Holder: I (v•f(S cPt w '" / S ` Ige License Number I dress l Expiration Date 4-kg- 6 . 3_ al Si nature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Imo_ i4ONte i M Pr2oVe ru N T t 4 6 ‘4-0 �--- Company Name Registration Number Address j Expiration Date Telephone�,3''�-a) 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 ` TE: INSULATIONONL 7 ad40 a-- J &-t p Lci sp-• e (tric�i''II(k5DJts • /00 r g '` cknSt I liC(l Gu-��0 S( - c Plea r; 3 f— ( o - ✓L y �i I - ) �s4 I SO - qo I -'- -.g ba j f1 - e d-. as Owner/ thorized ent b reby declare that the statements and information on the foregoing application are true and accurate,to the best f my know edge and belief. Signed under the pains and penalties of perjury. Print Name q/ j Sign ure of Owner/Agent Date Abe - a grope r4 1 ( ,as Owner of the subject property hereby authorize an')is e'1 to act on my be alf)in all afters relative to work a,;irorized by this building permit application. Signature of 0 er Date - of Northampton City Nort ampto tz,4_YT-. :,p Massachusetts �cv�' '" A:. h ' 2:34 _;` ('e DEPARTMENT OF BUILDING INSPECTIONS y,J6 Y 212 Main Street • Municipal Building ,�:T ",1ys .:�° "° Northampton, MA 01060 'V '�+7.' MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: /5 U/Gkan S(Iv__.JJ Contractor 14 c(I) Name:ame: �! ,�" Address: ('f.L. ' 7%/ &-- City, State: C y ( I tv6--- 01 3S 1 Phone: y 13_ n 3- XI $ Property Owner rt ,,//�� per i�I/ Name: 46IS-1 1'►'d pe `/. 1 J 0— Address: 1 t (210 vera SA-- City, State: 410 re f C-t, ' 4— ] c I. jkale-S elf `} (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. Contrac - lCgrtue , ( Date Q f)0 City of Northampton Massachusetts qt+' 14 ' r1 F 0•4 DEPARTMENT OF BUILDING INSPECTIONS 7'• j `x "'+c"-:+"'v'' 212 Main Street • Munici al Buildin �J" at P 9 :...-,y.Yc' 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 contrac rs 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("HI "). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair,modernization, conver on, improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building co taining at least one but not more than four dwelling units....or to structures which are adjacent to such residence or buil ing"be done by registered contractors. Note:If the homeowner has contracted- d L with a corporation or LLC,that entity must be registered. Type of Work: /nS(4 a,A ux Est.Cost: `�, o av Address of Work: 15 Ot e yt Date of Permit Application: QI)O 1.1)0 yL 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 I T ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY F 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: TbOIXA)— l --ifOMI fyPdo✓e_r1c / qv- I-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 Signature • City P of Northampton _ zz Massachusetts ,.: . 4" :.JIIP/4i --ems DEPARTMENT OF BUILDING INSPECTIONS � _ 212 Main Street *Municipal Building ^" Northampton, MA 01060 �'°1 :i:-j1 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: /5 AC-kin Silk_ (Please print house number and street name) Is to be disposed of at: i, (Please print name and ocation of facility) Or will be disposed of in a dumpster/ onsite rented or leased from: (Company Name and Addres ) 9/24).0 1--1 Signet 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. The Commonwealth of Massachusetts ___. Department of Industrial Accidents i +ti Office of Investigations Lafayette City Center ``� 2 Avenue de Lafayette, Boston, MA 02111-1750 r 1 fyH �� i \_ r_ wwx.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 #:41 128 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.❑ 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 workingfor me in anycapacity. employees and have workers' p tY 9. 0 Building additi n [No workers' comp. insurance comp. insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repai s or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repai s or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] I. c. 152, §1(4),and we have no Insulation employees. [No workers' 13.❑ Other comp. insurance required.] *My 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. j _ Policy#or Self-ins. Lic. #:WC9057697 Expiration Date:I/26/2023 Job Site Address: /6 d)l C.L11 St'ri- Jr City/State/Zip:/ V ar 4e O1 D40 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 hereby certify u der the pains and penalties of perjury that the information provided above is true and correct. Signature: CA."-- Date: qkc)114 1— t Phone#: 413-863-2128 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): l DBoard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: • 1 I ACc RO CERTIFICATE OF LIABILITY INSURANCE DATE(rdM/DD/YYYY) klaw...../ 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 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 8 Grinnell PHONE (413)586-0111 FAX (413)586-6481 A/C,No.Eat): (A/C,No): 8 North King Street E-MAIL bandrade@webberandgrinnell.com ADDRESS: 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. INSR EXP LTR TYPE OF INSURANCE INSD SUBR POLICY NUMBER (MMIDD/YCY YYY) (MM/DDFF Y/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGED CLAIMS-MADE X OCCUR PREMISESO(EaEoccNTErence) 1$ 500,000 MED EXP(Any one person) 'S 15,000 A S2291368 11/17/2021 11/17/2022 PERSONAL&ADV INJURY i S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000 PRO- 2,D00,000 POLICY JECT LOC 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 X SCHEDULED A9105410 11/17/2021 11/17/2022 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S X AUTOS ONLY X AUTOS ONLY (Per accident) Uninsured motorist BI S 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE S DED _RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN 1 B ANY PROPRIETOR/PARTNER/EXECUTIVE Y N I A WC9057697 01/26/2022 01/26/2023 •E.L.EACH ACCIDENT S , , OFFICER/MEMBEREXCLUDED? 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Piol ssional Licensure Board of Building Re ulations and Standards Congrwl.114 Itl%1IPpr,riSOr CS-091207 6tpires:10/16/2022 JAMES P ELPS 142 BOYLE tip GILL MA 0136A ,44 , Commissioner dati: ...•••••••••...•• Wt./1M Mate1W1110 . . . . . .,Y.WV11/47/11/hc>7...///m.744.9r/ilsitonfi Office of Consum r Affairs&Business Regulation HOME IMPR OVEMENT CONTRACTOR • • PE:Corporation 4. :1 •I gxpiratlon 146402 04/21/2023 IDEAL HOME IMPROVEMENT INC, JAMES P.ELLIS -- 142 BOYLE RD • /;.aeoio4' GILL,MA 01354 Undersecretary .• . •ow •••• 411••• • •