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23D-148 (6) BP-2023-0212 I l l HINCKLEY ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23D-148-001 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-2023-0212 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: GOLD STAR INSULATION & Est. Cost: 3500 CONSTRUCTION LLC 065992 Const.Class: Exp.Date: 03/16/2023 Use Group: Owner: ALISE WILL, Lot Size (sq.ft.) Zoning: URB Applicant: GOLD STAR INSULATION & CONSTRUCTION LLC Applicant Address Phone: Insurance: 1 CONGER RD (774)329-4664 65620B5N23815620 WORCESTER, MA 01602 ISSUED ON: 02/22/2023 TO PERFORM THE FOLLOWING WORK: ATTIC 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 599F Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 4ir 17)7/0 ( i .-i--,---_____ i r_i&-? -(Nz--..--i-r-_ . / , ---___z_z..„:„..,.. : „ _. .,, (v�/ � /13 - i `�`�The CommonwMassacuseFE W Board of Building Regulations an S 20 FOR Massachusetts State Building Cods_780�� //MUNICIPALITY ' krH 4/D�n.,G rn1 p j USE Building Permit Application To Construct,Repair,Renovate Or l h`tr do Reused Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Pennit Number: 6 0-a 3— 21 3.- Date Applied: ,!�„,� 71CoS3 ,ii - 2 2Z 2023 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 IP`r y clres: ��I 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes TV no 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 0 Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 (ti ger'of Recce(IA F&rice Name(Print) City,State,ZIP till I-tAln cY!ey 15:ie.e4- 818 aa9 g 8Z lttli ""7 6 VAre -m10 No.and Street Telephone Email Address 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 Additiot 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 1316ecify: nScAC ,1 Brief Description of Proposed Work': Ft- T I 6,e f e/\ ! J -i,..i (elk, (D SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ '5 Q^c 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ � 0 Standard City/Town Application Fee Cl Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ 6 Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3 2�'d 0 0 Paid in Full 0 Outstan ' g Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Nitc)- siL -fArt, Ex irate n ate Name of CSL er 61 hil List CSL Type(see below) U No.and Street Type Description ,i q^ 1 _ U Unrestricted(Buildings up to 35,000 cu.ft.) `^' ` V R Restricted 1&2 Family Dwelling_ City/ n,Sta ,ZIP M Masonry RC Roofing Covering WS Window and Siding 11�� SF Solid Fuel Burning Appliances G fi I Insulation Telephone it address r re,yiaddress r re,yin D Demolition 5.2 RegisteredH me provement Contra for(HIC) eV �- n ' U CA+ 1� Registrationumber Ex iraatt n to HIC Company me or HI egistrant Nip e 1 c� $ 34,4lel (o + 4 1C/a -cam No.iftej _ p ,l i „ /� digzsa, Email address City/Town,(•St�atee,,ZIP Y r "1/r Teleph �� 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 Q-"" No ..0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 6)61d 5cx ± L1 C to act on my behalf,in all matters relative to work authorized by this building permit application. 4 AiSe- LA a () Print Owner's Name(Electronic Signature) at 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 thjs plica'on is true and accurate to the best of my knowledge and understanding. s)..3 ooLi iie/ Print ner's or Authorized Agent's Name(Electronic Signature) Die 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 fund 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" City of Northampton '^ r"` Massachusetts �� DEPARTI�NT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vi,\', � - Northampton, MA 01060 sb,y xD`\J 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: �bif- d 1 3 Location of Facility: 7 The debris will be transported by: Name of Hauler: U '1/51-Q--- --/WV1P---iry..jae-4/4--- Signature of Applicant: Date: 9 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 -te_ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name: (old 54ar- sulit,>~,on Cove,5hrw4-° 1 L Z- (Business/Organi7ation/Individltal): Address: ( 1) City/State/Zip: 61144 dl -Phone 1. [Jyt{m a employer with & 4.❑I am a general contractor and I 6. ❑New Construction employees(full and/or part-time).* have hired the sub-contractors listed7. [I]Remodeling on the attached sheet.These sub- 2. -1 I am a sole proprietor or contractors have employees and 8. ❑Demolition partnership and have no employees have workers'comp.insurance. 9 El Building addition working for me in any capacity. [No workers'comp.insurance 5.❑We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their right of 11.❑Plumbing Repairs exemption per MGL c.152, §1(4), 3.II I am a homeowner doing all work and we have no employees. [No 12.❑Roof Repairs Myself, [No workers'comp. insurance workers'comp. insurance required.] 13. the: 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 Ina eom 1 1 ► Name: Policy#or Self-ins.Lie.#: ) Expiration Date: 6,2i ,aeSa3 Job Site Address: II ,rn C City/State/Zip: '>clof;-e-rlIZ r 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 under the pains and penaltPs of perjury that the information provided above is true and correct. Sienature: giArL' Date: D/ i ido33 Phone#: 11ti 391 ie OFFICIAL USE ONLY. DO NOT WRITE IN THIS AREA, TO BE COMPLETED BY CITY OR TOWN OFFICIAL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: A�D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYV) 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 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 NAME: Chris Fournier Berlin Insurance Group tAIC.No.EMI: (508)459-1226 FAX Berlin Nol: 61 B MILTON ST AIL ADDRESS: serviceteamIberlininsurance9roup.com INSURER(S)AFFORDING COVERAGE 1 NAIC# 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 D: XS BROKERS INSURER E: Worcester MA 01602 INSURER F: I 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. INSR ADDLISUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I INED iwvn POLICY NUMBER (MMlDDlYYYYI IMM/DDlYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY II EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A X BOP0187043 11/11/2021 11/11/2023 i PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: i {GENERAL AGGREGATE $ 2,000,000 PRO- POLICY JECT LOC I PRODUCTS-COMP/OP AGt f$ 2,000,000 OTHER: o $ AUTOMOBILE UABILITY Ea aceidentSINGLE LIMIT ' $ 1,000,000 I ANY AUTO BODILY INJURY(Per person) I$ OWNED V SCHEDULED X 5916246 i 02/24/2022 02/24/2023 BODILY INJURY(Per accident)1 $ B AUTOS ONLY V AUTOS PROPERTY DAMAGE d' HIRED X AUTOS ONLNON-OWNEDY $ AUTOS ONLY (Per accident) I $ i X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 A , EXCESS LIAB CLAIMS-MADE X CUP0187067 11/11/2021 11/11/2023 AGGREGATE $ I DED j X I RETENTION$ 10000 $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? N N/A 6R327873 08/31/2022 08/31/2023 E.L.DISEASE-EA EMPLOYEE $ SOO,000 (Mandatory in NH) If 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 1 DESCRIPTION OF OPERATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 195 Francis St. ACCORDANCE WITH THE POLICY PROVISIONS. Cranston, RI 02910 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConatrtittiOrtStifierVisor CS-065992 gvire3:03116/2023 KEVIN R ALLEN ot = —.- 707 MAIN STREET ' BOYLSTON MA 01506: " 4 Commissioner • • • • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration 'rz i .,.. .. .�. . ' ,._. ,'� Type: LLC GOLD STAR INSULATION & CONSTRUCTION LLC Regip220228 1 CONGER ROAD 12/03/2024 -- 00'M.,. " r Expi ration:ration: WORCESTER, MA 01602 W .. 4* MOO IN 110.1.01•PR 1 Ai ,� 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 op� GLEN S. POWELL = 1 CONGER ROAD ,t, , ,,. ,4„,,4„,,a i WORCESTER,MA 01602 ,, ..% Undersecretary Not valid without signature