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36-199 (15) BP-2022-1666 348 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-199-001 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-2022-1666 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2022 Contractor: License: Est. Cost: 1500 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2024 Use Group: Owner: PINKHAM SANDRA Lot Size (sq.ft.) Zoning: WP/WSP Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL, MA 01354 ISSUED ON: 12/29/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/W EATH ERI 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: 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 ,� ' )Q * Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • DePFO40,LT !gel --`',, City of Northampton 3 - h Building Department a' C t. 28 i 212 Main Street �Qj2 , 1NSULA TION i ,i._74-: pc Room 100 h '` Northampton, MA 01060�'/�`.r`� • �`�107- OI"IL, Y . ,,�77 phone 413-587-1240 Fax 413-587-1'272 APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: �p �.•,, Th`s section to be completed by office '- W�-C 1l 1L ` R4• Map Lot Unit �j or€CI- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow r of Record: cQn IcJ\um 3 t -ti n , Nam Print) Current Mailing Addres Telephone Signature 2.2 Author-zed A ent: ��!! t,11lS - ILf A 13NU ,31I( i'V i Na e(Print) Current Mailing Address: rt_AA/...\ 14C2) ' SP).0)la-</ Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed/le by permit applicant te 1. Building t� (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee L-i4ifi 4. Mechanical(HVAC) 5. Fire Protection 6. Total= (1 +2+3 +4+5) `U L" f00 Check Number ii:L02 � This Section For Official Use Only } Building Permit Number Vfr"-- "-/ii1�� I Date sued: //2 Signature: IZ- 2.9- 2(}ZZ Building Commissioners/Inspector of Buildings Date U, I 1 p @ Coeaci2 +,(lc+. EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicablea ❑ Name of License Holder: `\fakkOSC.- 16 ` l a 0 l 1 License Number U_ )04 aii ilui to.,,,Q,1 Address Expiration Date Ut9). S\j9)) . ata,i Signal e Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ cILLuJ V-U - \qc0\ft rt 114(4940D'- Com an Name Registration Number N c l.Q 01 YY`�l U• a t•a ddress Expiration Date ...e... A.r.\(?-4 Telephone tag) o1a u SECTI N 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 ry No ❑ Brief Description of Proposed Work NOTE INSULATION ONL Y aas-E (AI I CS o h,c-) 11 t S4 d ens ectc- e -I-ex to{ ()owl ; air Seu.1 I. d ..] Cl l tS , 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. Jurr.e-S ak lS Print Nam )../vv\_ . Signature of 0 er/Agent Date I. CS (C&., et(N eOm , as Owner of the subject property hereby authorize cj/C&�'Q) _v` t l to ton my behai , " all matters relative to work aut„r:cnzed by this buildi ang permit application. (Sf ) a a / a-ygnature of Owner Date Tr, City of Northampton �<L. %, S15 ,.S/C_ Massachusetts '- f��, y �` DEPARTMENT OF BUILDING INSPECTIONS a ' yl .` 5. 212 Main Street • Municipal Building Jff Northampton, MA 01060 ryes MANDATORY'FOR HOUSES BUILT BEFOR - 1945 Property Address: 3-4% r Wehe Stn Cct . Contractor Name: a S \AtS V V. Address: NA "vy Le (2A City, State: 6* Phone: 141)) ' L05,c(a-2 Property Owner �,^ '/ ���� \ Name: � Ww �� Address: ?i-1' t .h arry±n 64. City, State: t1,O € riVP' 1, dostAos eI<< 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. j I Contractor signature P(....A1/4:/\..." ?jvv. __ Date 01 ()I aCr • City of Northampton +ram. Massachusetts DEPARTMENT OF BUILDING INSPECTIONS �• ��212 Main Street •Municipal Building Northampton, MA 01060 _• :)`��' 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: • (Please print house number a d 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: `d IF+dro�e .e1-1-- 4A O L I I (Company Name and dress) Sig ture 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 'a 1 i'' Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 4 ;_4Y 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.El I am a employer with 10 4. 0 I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. 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 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. $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 1 Job Site Address: - 4(1) ) c tl'lp 14' 1 °d • City/State/Zip:'1,O( a._ 11 J21 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 he by certify un er the pal penalties of perjury that the information provided above is true and correct. Signature: Date: to (5I A-ar- 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): l DBoard of Health 20 Building Department 3.DCity/Town Clerk 4.0 Electrical inspector 5Elumbing Inspector 6.0Other i Contact Person: Phone#: j i AC ® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 01/20/2022 �r 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). j PRODUCER CONTACT Brandon Andrade NAME: Webber&Grinnell PHONE (413)586-0111 LtNo): (413)586-6481 (A/c,No,Ect): 8 North King Street E-MAIL bandrade@webberandgrinnelicom ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC d 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 ADDL SUER POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD_WVD POLICY NUMBER (MM!DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) $ 15,000 A S2291368 11/17/2021 11/17/2022 PERSONALBAovwJURY $ 1,000,000 GENII_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GENII_ — POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT S OTHER: _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED v SCHEDULED A9105410 11/17/2021 11/17/2022 BODILY INJURY(Per accident) S AUTOS ONLY /� AUTOS XHIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accident) Uninsured motorist BI S 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y I N 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA WC9057697 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 $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ ' DESCRIPTION OF OPERATIONS I 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD