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24D-218 (5) BP-2024-0168 13 PERKINS AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-218-001 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-2024-0168 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 600 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2024 Use Group: Owner: JOANNE,TRUSTEE CAMPBELL Lot Size (sq.ft.) Zoning: URC Applicant: IDEAL HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 142 BOYLE RD (413)863-2128 WC9057697 GILL,MA 01354 ISSUED ON: 02/16/2024 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 c 1 ♦ Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner • 7-1 .... f, tht- 1q 2-7 t._ - Depp rRoomCity of Northampton Building Department F F B 1 6 -�2� 212 Main Street I ; 100 INSULATION ,,.. �� t car�.u�i i ,*, .� Northampton, MA�0105N�n� +a w"— phone 413-587-1240 Fax`4f3 587-1272 QfJI.., Y 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 `3 P-Wir1s I JVl- Map Lot Unit 1l c c\r -r p� yyV3 Zone Overlay District ' Il ! u,�111 r �f Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1r nOwwner�off Record: W� N _ ( __-- 13 LOA14rlS Hue. nUrt'iaNton 11r1 4 Name(Print) Current Mailing Address (� jc wi'-.',_ c-e�-�,'„rol-'-2�� Telephone -1 A J sto � a7T Signature 2.2 Authorized Agent: .' t3us I4 ? ACAIcZ (LQ( i al( Ina e(Print) J . Current Mailing Address: 41?,•ELA • ,lab Signatur Telephone SE ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building l I „00 • 00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee d4 ti4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+5) U--00 •00 Check Number 4836 This Section For Official Use Only Building Permit Number:h,74 '"//1 { Date I Issued: i Signature: 72 11. ZOZ9 Building Commissioner/Inspector of Buildings Date - 1 l i Sg c Cum cad-. ae--4— EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR) 1 SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �j� Not Applicable ❑ Ma Name of License Holder: �� u S O S Cl`li"'O 7 License Number tea (jck l.:e. (1 . Gu MA o I35H- ►o' Ica.atl J Expiration Date Sign re Telephone 9. Registered Home I provement Contractor: Not Applicable ❑ ducu i wyrovenufr - Company Name Registration Number �,P,( , But Yv`k U-a("cotJ Address .� Expiration Date TelephonM ' "pr IA SE TION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NO `E. INSULATIONONLY etc,Q-c- Ir1 F6 e) ICYIdekoa u (S142-Q._, f j 1 f' iq tq IT 6 S I l (S I. Aktvat Vct 1 r 1 S a<<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. Signed under the pains and penalties of perjury. dins airs to a l la(f Signatur f Owner/Agent Date I, docur\ra, (?Ltyi pb vl l , as Owner of the subject property /� � hereby authorize dCt-��► n\S .._w to act on my behalf, in all matters relative to wcF-: :zed by this building permit application. Signature of Owner Date City of Northampton Massachusetts At;:. g 1V + y: 4 �� DEPARTMENT OF BUILDING INSPECTIONS . 212 Main Street • Municipal Building ". Northampton, MA 01060 h 3t?�� MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: l 3 P 4ic(t'1S .• Contractor Name: V ia.m S a't Address: NA 6".1Lk ` City, State: c13i i 0 J. Phone: 14j'• 3 o; f 4 Property Owner Name: 0C Qp D€.l1 Address: 19) P-eA k nSAtic City, State: nomo ,CY1(l m'tt I, \bu ko (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 signature\\ Date a k Ia4 City of Northampton opyr+^MPr�., s✓ a Massachusetts t; .A,... •C-424,1,�`•_ DEPARTMENT OF BUILDING INSPECTIONS tot r :� 212 Main Street • Municipal Building •S' . fib' Northampton, MA 01060 rs 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: I v LA Q t.n Est.Cost: (-/-O°.00 Address of Work: 112, \L4c 1 €. Date of Permit Application: aN1aLf 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 ENTERLNG 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 for a building permit as the agent of the owner: a1(210►-F cJ CV s Ill 1 1kat HOIfte i m • IYcptia.)-- Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby appix: for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton '4,. • Massachusetts �Sw ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building• s c� Northampton, MA 01060 1s4n {t` 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: 13 13Av-r.S hue• (Please print house 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: iCLICU 1i00Q metioV�x -#- , y Le ( (fit I " (Company Name and Atldress) I 9 \ N Sign re 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. ,.%a The Commonwealth of Massachusetts Department of Industrial Accidents 1` , 1 Office of Investigations `s i' Lafayette City Center �.. � 2 Avenue de Lafayette, Boston,MA 02111-1750 e, -. 3.Y=Y 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 employees (full and/or part-time).* have hired the sub-contractors 6. 0 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. El 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.❑ 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.© 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 Company Policy#or Self-ins. Lic. #:WC9057697 Expiration Date: 1/26/2025 Job Site Address: I J P X1_lri.S 1' 1 t/(.• City/State/Zip:n ortti lmp t 1 aci 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 y certify u 'er th ' s and penalties of perjury that the information provided above is true and correct Signature. - di Date: c2 I q 1,2)V Phone#: 3-863-2128 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): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: Aco Lf CERTIFICATE OF LIABILITY INSURANCE DATE(MWODIYYYY) 4baimer.'.' 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(les)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 (413)586-0111 FAX (413)586-6481 (A/C�L.Ext): (A/C,No): Webber&Grinnell Division AAADMMDRESS: bandrade®webberand9 rinneli.com 8 North King Street INSURER(S)AFFORDING COVERAGE NAIC 0 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. INSRR TYPE OF INSURANCE ADDL SUBIwv0 POLICY NUMBER''. M/DOPOUcY EFF POLICY EXP LIMITS INSIL WVO (MMIDO/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 REN D CLAIMS-MADE XI OCCUR PREMISES Ea occurrence) $ 500,000 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 $ 2,000,000 PRO- 2,000,000 POLICY ACT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A9105410 11/17/2023 11/17/2024 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS HIRED X NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY ^ AUTOS ONLY (Per accident) Uninsured motorist BI $ 100,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAR CLAIMS-MADE S2291368 11/17/2023 11/17/2024 AGGREGATE $ 4,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WC9057697 01126/2024 01/26/2025 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In 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 $ Per Occurrence 2,000,000 Pollution Liability C CPLMOL115005 01/25/2024 01/25/2025 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 ©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 142 BOYLE RD,MA O 354 '�"..?",,?; 4•4,0fC Undersecretary J of, Comrnom teatth of Massachusetts • Division of Occupational Licensure Board of Building YR,�,Regulations and Standards Co£&$'tco a�t4 c.. kfiaar CS-091207 z' • lures 10/10/2024 JAMES P ELz 142 BOYLE L GILL MA 01344 $. x Commissioner Clra °. Yfcn __. �...-..�,........ _ ! ..__. ...a... .