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25A-089 (4) BP-2024-0068 50 COOLIDGE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-089-001 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-2024-0068 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est.Cost: 3000 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2024 Use Group: Owner: LEINHART MARK&CAROL CARSON-LEINHART Lot Size(sq.ft.) Zoning: URB Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL,MA 01354 ISSUED ON: 01/24/2024 TO PERFORM THE FOLLOWING WORK: INS ULATION/W EATEHRIZATION 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: firx .>2 . c ' Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 2� DepFO -'" ��J City of Northamp � � Building Departmehf �.Ln % 212 Main Street \°�-'% �'? /� SULATION - Room 100 �00 �:fa, Northampton, MA 01060\,)%0 �'" _. phone 413-587-1240 Fax 413-587-1' 7�'s ,i' l ONLY r 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 50 Coolla -, kx. Map Lot Unit flo r_-II F' I tX l MP' Zone u J2.e, Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow er of Record: I ,-ttfhccV+- 50 CO1 Id -, IA o Name(Print Current Mailing Address ider-mot, Telephone Signature 2.2 A thorized Agent: s 14a sec, C3l fl'a ame(Print) .Th _ Current Mailing Address: 41,3 :RP)) • 3 in Signatu Telephone SE TION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 300 0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee �I 4. Mechanical (HVAC) u 5. Fire Protection p �/ 6. Total=(1 +2+ 3+4+5) 3 0O0 Check Number 4;J This Section For Official Use Only Building Permit Number: OO- oN'U 1 Date Issued:_ Signature: /AZ __—_ / - 23- ZDZL Building Commissioner/Inspector of Buildings Date tl 3 p @ Can.cCcs-F. VLQ 4 - EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I Not Appllliicaablle 0 Name of License Holder: ��\ a it S "! fa 07 License Number ,(61 eg , 311 1(1i _i i 0-i L9,0)t( Address ' Expiration Date ,.i I rN 14 I . `1V�». a l(/-U Signa Ore Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 L l I,rnp O0�4 ILf WO Company me Registration Number iU CI ) (4.,-( 025 Address 2 Expiration Date Telephoned') 'a ix CTION 5-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152,§ 25C(6)) Workers Compensation Insurance affidavit m t 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 ONLY Brief Description of Proposed Work NOTE: INSULATION ONL I 50/5 s-F 619 6 tOustm.errh Ce4 I(tiqj . s-F ce,ensei i3cuagic. CepI 1 t I. da,puS -- 1 I S , 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. Sign d under the pains and penalties of perjury. a s ( tS not Name ., Illpidt-1 Signature of Own /Agent Date I, COLVO t LeAn V , as Owner of the subject property �`� (/� (� hereby authorize c-^�`-► ' `-� f (_ i S to act y behalf, in all matters relative to wo; c.. . .r::ed by this buildin permit application. 2561-ena,a7-- 9 Si nature of Own Date HAM City of Northampton Massachusetts • y` *aia, DEPARTMENT OF BUILDING INSPECTIONS 2 I 212 Main Street • Municipal Building Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 50 Ol I d • Contractor _ is s Name: �J Address: '9-k U,0y `J City, State: I l t 1`,�r Phone: 413 - a_0) ' 0,2in Property Owner Name: LeA n YICU ' Address: COOI acle City, State: (--wuktyvtun f 1 tfc I, V)( Q'.c (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 signat Date I �� aL City of Northampton ' Massachusetts • * • DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 I''O-j• . ‘�, 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: VSu l CA- L \ Est. Cost: 000 Address of Work: 50 Cool 1( c - uc Date of Permit Application: l 10 I aLF 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 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 FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply uilding permit as the agent of the owner: 1\tolay- , 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 of Northampton ' Massachusetts �jj DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building %tU\:� 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: 50Cooi `, � ' . (Please print house tuber 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: e_ai 1.----Tx\ L\rnfOrDVet"Nerf exvtc a 50 WO (Company Name a d Address) t I I Oa Sign ture of Permit Applicant or Owner Dare 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 tip, Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 S vi 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): 1.0 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 listed on the attached sheet. 7. ❑ Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ T 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 insulation employees. [No workers' l3.® 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: 1/26/2024 Job Site Address: 0 C0 0� (d qL IitfC.- City/State/Zip: {)ortrianitottnm fT 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 ' under th • nd penalties of perjury that the information provided above is true and correct. Signature: `/-\ Date: l /10 I°� I Phone#: 4 8632128 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❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.❑Other Contact Person: Phone#: AR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 11/07/2023 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. PHONE EXt). (413)586-0111 FAX Ne) (413)586-6481 (A/C,Webber&Grinnell Division E-MAIL bandrade@webberandgrinnell.com ADDRESS: 8 North King Street INSURER(S)AFFORDING COVERAGE NAIL# 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/XS Brokers Attn:Laurie Ellis INSURER D: 142 Boyle Road INSURER E: Gill MA 01354-9731 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 11/2024 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. INP TR TYPE OF INSURANCE INSO wvD POLICY NUMBER (MM/R DD YY EYYY) (MM/DD/Y POLICY YYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2291368 11/17/2023 11/17/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 RO- POLICY JE LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED AUTOS ONLY X SCHEDULED A9105410 11/17/2023 11/17/2024 BODILY INJURY(Per accident) $ AUTOS X HUTOSIRED ONLY X AU X NOTOS N-OWNEONLD PROPERTY DAMAGE (Per accidentl $ AY Uninsured motorist BI $ 100,000 UMBRELLA LIAB EACH OCCURRENCE 4,000,000 X X OCCUR EACH $ A EXCESS LIAB CLAIMS-MADE S2291368 11/17/2023 11/17/2024 AGGREGATE $ 4,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN , , B ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA WC9057697 01/26/2023 01/26/2024 E.L.EACH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Per Occurrence 2,000,000 Pollution Liability C CPLMOL115005 01/25/2023 01/25/2024 Aggregate 2,000,000 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 l ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 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 .7 142 BOYLE RD .t: //04' GILL,MA 01354 Undersecretary • 0 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re juiations and Standards v;' b CS-091207 res: 10/16/2024 • JAMS P ELts ._ _ 142 BOYLE 00 GILL MA 013 4 k t Commissioner clad g. i ncia. : ... _ r..._._......,..,., ...m.e.� ., __ e a • 1 F