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41-057 (9) BP-2023-0477 29 RIDGE VIEW RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 41-057-001 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-2023-0477 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 2000 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2024 Use Group: Owner: MEGHAN� ABRAHAM, KEITH& Lot Size (sq.ft.) Zoning: RR Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL,MA 01354 ISSUED ON: 04/19/2023 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I ; a :f) Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner IJ�Ii!-T ZOiL, ib Dep R :aT_ " City of Northampton qo .� �` Building Departm nt 9 % , pp t, 212 Main Stree�Rro� � 2 INSULATION L r Room 100 `?r��, � � �� - Northampton, MA 0106fi''4'ro ,^,^ phone 413-587-1240 Fax 413-58 .27 ONLY 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 MI 'fit k -V(tu.) CA- Map Lot Unit 0(ef\CA. MA Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:han Rbru.hcun &l eticiViteko CO . RLYefIce. Nam- Pri Current Mailing!Address. A �t�- pia- 53y�A._.J k J Telephone ignature Ill 2.2 Aut orized Agent: 01"2SaI11S t4o, 153,4u 1 , ea Gil MP Name(Print) Current Mailing Address: Signature -elephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building a 00O (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+ 5) c OOO Check Number This Section For Official Use Only; 3 A1) , I-77 ` Date 1 Building Permit Number: I Issued: Signature: _ /q 20?3 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicablea 0 Name of License Holder: e_� S eiu - 1 id107 at License Number (bN , gym► - 1O. 1 (.p.a Address J. Expiration Date kJ' I)' Z�� . alai Sig at e Telephone 9.Re istered Home Im rovement Contractor: Not Applicable 0 I m0yo\iti 1 gull-4 Company Namt 61 I mil-- Registration Number Address Expiration Date TelephonV(3-103'0)I4 SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit m st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: INSULATION ONLY oP I, J w S Ds , 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. .._ ` ' -__ P.414411.Mr ' -'\ iii1), Id3 Signature of Ow,•r/Agent Date I, M.Q1Van ht rowan ,as Owner of the subject property ( �(� n S `, C hereby authorize �JwIV�C U`UJ to act o behalf in all matters rel ve to wore ,is building permit application. u( (I 1a3 Signature of 0 e Date r, City of Northampton f»� Massachusetts c t . _ L , 4DEPARTMENT OF BUILDING INSPECTIONS t1 -.4� 212 Main Street • Municipal Building ` '-: ;� � Northampton, MA 01060 '"fV �'D\ MANDATORY OR HOUSES BUILT BEFORE 1945 (/1Property Address: . v1, D Ric(. / FTà €ncL Contractor d C�fikeS "Name: 11 �, Address: `"1) 6Aiv Q(�/y� City, State: 3hL[ 11 t A Phone: 41 .S.g . a.t 0 Propertyame: Owner VI ^n R i,V.� Name: ' � �1,� I l/� Address: a . AL04.\ tlk) c4 City, State: tO( C— V,t4' I.c,a .c, E;('IS (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. Contractor signatu D Mr\ Date t..A) 13\a3 City of Northampton e 1tt^M-P O' ... \5 ri Massachusetts • `tit.? E r« , DEPARTMENT OF BUILDING INSPECTIONS �; ;a 307 212 Main Street • Municipal Building 1., a� Northampton, MA 01060 rrN \:' 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("HIC"). 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:If the homeowner has contracted_{ with a corporation or LLC,that entity must be registered. Type of Work: 1 U `C-\lCn Est.Cost: a 000 .00 Address of Work: Act (cky..„ V v,) 1I art 1 1 t Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job under S 1,000.00 Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOIR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: qk\ a s iSo�— Date Contractor`._, :, 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 of Northampton Massachusetts `.' r A,11% r , r4 Ty* DEPARTMENT OF BUILDING INSPECTIONS ' {� � 212 Main Street •Municipal Building t' , Northampton, MA 01060 ssyn-51'�`� 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: 6c .et,0 a (Please printkiouse number and 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: W..(-aQ \+,fm...C. (C mpany Name and Ad re �: _/•\ LEIc3(a3 i 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 Commonwealth of Massachusetts Department of Industrial Accidents :`~—' Office of Investigations t Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 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.❑■ I am a employer with 10 4. ❑ 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. ❑ Demolition working for me in any capacity. employees and have workers' 9. ID Building addition [No workers' comp. insurance comp. insurance.' required.] 5. ❑ 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.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.Q Other insulation employees. [No workers' 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 Policy#or Self-ins. Lic. #:WC9057697 Expiration Date:1/26/2024 Job Site Address: d i 1 17 City/State/Zip: 11 or-en cc, m 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 here certify under a pains n p allie s ofperjury that the information provided� above is true and correct I /Signature: ,�� v^�, Date: Lit L 31)3 Phone#: 413863 28 Official use nly. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): I❑Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 51:'lumbing Inspector 6.0Other Contact Person: Phone#: • THE COMMONWEALTH OF MASSACHUSETTS • Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 146402 04/21/2025 IDEAL HOME IMPROVEMENT INC. JAMES P.ELLIS 142 BOYLE RD n'4.j'e, • • GILL,MA 01354 Undersecretary Commonwealth of Massachusetts • Division of Occupational Licensure Board of Building Regulations and Standards Cartsii; + W ,visor CS-091207 Iires: 10/16/2024 JAMES P EL 142 BOYLE . GILL MA 01#4 .r• 13 Commissioner cru c, /. ` iEen --- -.�..�..m a dam... �.. _ t._._.�. . ..K* _...,...�_,<�� _• �:��, • AC Ro D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `,,.- 01/25/2023 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: Alera Group,Inc. PHO No,Extl: FAX (413)586-0111 F No): (413)586-6481 LA/Webber&Grinnell Division ADDRESS: bandrade@webberandgrinnell.com 8 North King Street 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: Evanston Insurance Company Attn:Laurie Ellis INSURER D: _ 142 Boyle Road INSURER E: Gill MA 01354-9731 INSURER F: COVERAGES CERTIFICATE NUMBER: EXP 11/2023 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 AODL-SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY $ 1,000,000 EACH OCCURRENCE CLAIMS-MADE X OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) S MED EXP(Any one person) $ 15,000 A S2291368 11/17/2022 11/17/2023 PERSONAL&ADvwduRv S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY PRO 2000,000 JECT LOC PRODUCTS-COMP/OP AGG S , OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED A9105410 11/17/2022 11/17/2023 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X H Nee NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 4,000,000 A EXCESS LIAB CLAIMS-MADE S2291368 11/17/2022 11/17/2023 AGGREGATE $ 4,000,000 DED X RETENTION $ 0 S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 B OFFICER/MEMBER EXCLUDED? Y N/A WC9057697 01/26/2023 01/26/2024 1000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ , If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Pollution Liability Per Occurrence 2,000,000 C TBD 01/25/2023' 01/25/2024 Aggregate 2,000,000 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