17C-048 (5) BP-2023-0158
80 FOX FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-048-001 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-2023-0158 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 5700 CONSTRUCTION LLC 065992
Const.Class: Exp.Date: 03/16/2023
Use Group: Owner: PARIS,MIRIAM S. &WARNER, JOH A
Lot Size (sq.ft.)
Zoning: URA Applicant: GOLD STAR INSULATION &CONS 'UCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 02/09/2023
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:
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 VI LATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: it91,4
T14
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
llff r P of the Rnilrlina f nmmiccinner
�ili L,L3 iv A---t- Pt/ _
gz, The Commonwealth of Massachusetts
wBoard of Building Regulations and StandarFE B - 9
2023 4,..s Kith
Board of Building Regulations and Stand4rds iliumFOR
Massachusetts State Building Code, /80 CMRIw rultrmr,,INSPECT oN5 CIPALITY
w1RTNAMr,T(1N,MA 01O-) USE
Building Permit Application To Construct,Repair,Renovate Or Denitilish-a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nurnber:QP )-3-- /5 9 Date Applied:
4,u1r-J �-5} / Z-9-zo23
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.�� Addr : S 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes i Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: n.
Name(Print) / City,State,ZIP
,/6--1711
No.and Street Telephone Email ddress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ I Othercify: .yl &/tdcip
Brief Description of Proposed Work': f.. j G Q�-en e l l_<1✓ i 0 c ,.
Li 60 GI 5 , �.G4GC Lam. .C at-G A (G —r C e—//U /0 JP✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1 0 6 1. Building Permit Fee: S Indicate how fee is determined:
2.Electrical $ ( - 0 Standard City/Town Application Fee
0 Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees _
Check No.1 )Li Check Amount: L%, Cash Amount:
6. Total Project Cost: $ / t 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) G c ! /2 /�
Uin 0 J/e4 1 License Number Expi 'on D e
N of SL o der
1 G -1 �� , S L List CSL Type(see below) {�
No.and Street T Type Description
0 ' C U Unrestricted(Buildings up to 35,000 Cu.ft.)
✓ Q 1�� R Restricted 1&2 Family Dwelling
City/Tovnt State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
S1 Ark-GG y( 5l� G r_/(kce/ i Solid Fuel Burning Appliances
I Insulation
Telep o e mail address '-,)1,--1 D Demolition
5.2 Registered I ome Improvement Contractor(HIC) a oo a p� ' a/3 fay
d/ ,9---p7 /1 S C��G'`1`rG� HIC Registration QNumber Expiration Date
HIC pany Name or HIC a ant Name /
,U,'� i, 9744/ C. /CJjCci ,
No.and Street Email ess
City/Town,State,ZIP lielephone
SECTION 6: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 113 -- No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 5O/d S /
to act on mybehalf;in all matters relative to work authorized bythis buildingpermit application.
PP
1
kg I n ak rn eG,c, , .1 ,, a3
Print Owner's Name(Electronsgnature) ate
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
5 0 (d s'-vew- - --r,S,J19-/- cr-) a/ ,79
Print Owfier's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fluid under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
GLias € r@ �d cud , c',_
City of Northampton
'Or Massachusetts
t
041
. DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 rsww 0
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: S' d' V errC� m er/ca
3
The debris will be transported by: U`S H" `�
Name of Hauler: (V 1--L -A,; �i '
Signature of Applicant: 5t4't (O¼-CL( Date:
ACORD CERTIFICATE OF LIABILITY INSURANCE °ATEIWAIDDIMY)
-- 11/15/2022
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 polloy(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 art endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(sJ. g4
PRODUCER CONTACT NAME: Chris FournierO Berlin Insurance Group lac Ne,Extl, (508)459-1226 FAX
Noll
61 B MILTON ST E-MAIL serViceteam berlininsuran rou corn
ADDRESS: C� Ceg p.
INSURER(S)AFFORDING COVERAGE NAIC S
WORCESTER MA 01606-2819 INSURER A: UNION MUTUAL FIRE INSURANCE CO. 25860
INSURED INSURER B: SAFETY INSURANCE COMPANY , 39454
Goldstar Insulation&Construction LLC INSURER C: STATE POOL-WORKER'S COMPENSATION
1 Conger Rd INSURER 0: XS BROKERS
INSURER E:
Worcester MA 01602 INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
ILTR TYPE OF INSURANCE iusn DDL SMD, POLICY NUJCBER M/DD/YYYY) lMMFF MIDD(YYYY) UMITS
X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $
MED EXP(My one person) $ 5,000
A X BOP0187043 11/11/2021 11/11/2023 i PERSONAL&ADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: 1 GENERAL AGGREGATE $ 2,000,000
POLICY PRO-
JECT LOC PRODUCTS-COMP/OP AGGI $ 2,000,000
i
OTHER; E COMBINED SINGLE LIMrr
AUTOMOBILE UABIUTY (Ea accident) = 1,000,000
ANY AUTO BODILY INJURY(Per person) $
B OWNED AUTOS ONLY X S ACHOEDULED X 5916248 02/24/2022 02/24/2023 BODILY INJURY(Per accident) $
UTS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
S
X UMBRELLA LAB OCCUR j EACH OCCURRENCE $ 1,000,000
A EXCESSLLIAB ! CLAIMS-MADE X 4 CUP0187067 11/11/2021 11/11/2023 AGGREGATE $
DEO X I RETENTION$ 10000 $
WORKERS COMPENSATION 1 PEER 1OTH-
AND EMPLOYERS'LIABILITY S ATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N Si,EACH ACCIDENT i 500,000
C OFFICER/MEMBER EXCLUDED? ' N 1 N/A 6R327873 08/31/2022 08/31/2023
(Mandatory In NHI EL DISEASE-EA EMPLOYEE $ 500,000
It yes describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
Pollution Liability Aggregate 500,000
D X CPLMOL110273 03/04/2022 03/04/2023
I
DESCRIPTION OF OPERATIONS 1 LOCATIONS(VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Thielsch Engineering
CERTIFICATE HOLDER CANCELLATION
Thielsch Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
195 Francis St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Cranston,RI 02910
AUTHORIZED REPRESENTATIVE
01988-2016 ACORD CORPORATION. All rights reserved.
LCORD 25 120161021 Tha Amnon mania one;Inn^are rantclereii►..ftrt..#f ar_non
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
s1 vi i t tea.
r y a
;r9 rM ' Type: LLC
GOLD STAR INSULATION&CONSTRUCTION LLC Registration: 200228
Expiration: 12/03/2024
1 CONGER ROAD
WORCESTER, MA 01602
M —..k, -f F H q-
_" Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:LLC Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
200228 12/03/2024 Boston,MA 02118
GOLD STAR INSULATION&CONSTRUCTION LLC
GLEN S. POWELL
1 CONGER ROAD 9YCL.//
WORCESTER,MA 01602
Undersecretary Not valid without signature
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Co nstruCtionStiptirvisor
CS-065992 Expires;03116/2023
KEVIN R ALLEN
707 MAIN STREET .
BOYLSTON MA 01505
k(JA,A:1-0,
3410
Commissioner alpitia
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