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17A-218 (8) BP-2024-0436 160 NORTH MAPLE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17A-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-2024-0436 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 800 JAMES ELLIS 091207 Const.Class: Exp.Date: 10/16/2024 Use Group: Owner: L GERSTEIN RICHARD 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: 04/16/2024 TO PERFORM THE FOLLOWING WORK: INSULATION!WEATH ERI ZATI ON 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: ,""*. ,4. o..,4 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner .1 q Q.i ''<.Q. �,s DepO _R N•Ae r City of NOr ham tOn '. : .. ,, Building ( eparrier�P/� ' .,s 212 Main Stfeet 2 2�r Room S ee•op1 24 NS ULA T/ON . - itt- i « . Northampton, MATtio,:'poi • ..�=' phone 413-587-1240 Fax 4 -•�N� c --`„i /^ ONL. 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 !I no no Or rnal nW S+ . Map Lot Unit �X 1 Or d n, r yrn`C Zone Overlay District vC� I 1 l Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: RI Un a kk. 6e/6i-to-) l uo n O,0Y1 Map , l--[(X P,c'1 c-2._ Name(Print) Current Mailing A dr ss SCe � 3 37-� o Telephone Signature 2.2 •uthorized Agent: Il,IA,l c 311 ' 14. 6,4V ( C(f ( Name(Print) Current Mailing Address: e ' of 12) -E9 3 .a a S Signature Telephone SE ION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 5w (a) Building Permit Fee 2. Electrical b (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee IV4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+ 5) '00 Check Number "{ U 71 This Section For Official Use Only Building Permit Number: 4/AA 1-//~ -I/%e --4- Date Issued: Signature:6/,..4 ...-h Wcx.0(/')--J -CAL i C ' -1L-c'd 4(I(,I Z1/4-( -1;r1 Building Commissioner/Inspector of Buildings Date • 4/1 11CJ P @ Cc m.ccLS+ (l2f EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder c)0.rA¢S la<iS (1 is o 7 License Number 19)1 Oa k- ICLO 6111 (YU 1 o 1 u,'a N dress Expiration Date -'U . q 17, .193 .r)IM Signature Telephone 9.;Re isHome Improvement Contractor: Not Applicable 0 liAL \ rvlPYoArtl en4" 114(i I-I od- Company Name Registration Number . e y gl_, 611 ( YV u-a1 %lc ddress Expiration Date l ) I SECTION 5-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 builds permit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: INSULATION ONLY a s-F -I" Catl uto -Cfeil 6-ty. S I, Ck3Jlt t?i1(c ,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. V -QS G(IS Print N Signature of Owner/Age Date I. 6tunctpd . 6viciu-n ,as Owner of the subject property hereby authorize tI C__ to act on my behalf,in all afters relative to work authorized by this building permit application. -see _ . Signature of Owner Date City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ••� •..Y 212 Main Street • Municipal Building l�;, =S _ .._ Northampton, MA 01060 � MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: I APO noon IY t map\k„ S} Contractor 1 C --�\` Name: v �� Address: 1q) (6„ti .Q City, State: Cn Phone: `l 1 • lam- ' o)i a b Property Owner R n ���> t1�- VP�C Name: ,fin S�tn Address: 1U-0 C\OI l ( lccPt,e, t ' City, State: kOI€ 1C. 01 I, (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 VL Date ( C(la` ' * City of Northampton 5 S + Massachusetts .6% 1 " • r DEPARTMENT OF BUILDING INSPECTIONS �'. •" 212 Main Street • Municipal Building Northampton, Ma 01060 s�f-.li0(�,C 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: , A Est. Cost: qOO Address of Work: ) f,Q(tfl plk, a • Date of Permit Application: (" lq I auf- 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 a owner: t_kVq lak4- c Iry S It-to21-1-0 a- Date Contractor Na e HIC Registration No. OR: Notwithstanding the above notice, I hereby apple for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton s A� Massachusetts • �- s • DEPARTMENT OF BUILDING INSPECTIONS a. r }r, aa 212 Main street •Municipal Building Northampton, MA 01060 .rsy�. ��'A`-` 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: )l90 wen (Please print house nurrtber 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: \a-i" Ham I r vo�'� )tu t�la- $ t ( (Company Name an Address) 2)--C. C/V/N LI ig Sign, ure 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. mass save Savings through energy efTiciencY PERMIT AUTHORIZATION FORM I, Richard Gerstein owner of the property located at: (Owner's Name) 160 North Maple Street Florence (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. This form is only valid with a signed contract. The permit will be secured by the subcontractor, at no additional cost. Richard ae ieirr Owner's Signature 04-01-2024 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: ;Okra kfro ( ( ppo r F Participating Contractor Date Document Ref:JTLGP-JCTOP-RHVFC-OY9QF Page 1 of 1 • E,r.�,,�x �,'�r.x .. ;K„dr. .%`-�t.7,, �� � row ��.. >1'�� „,'" ; 7-`"�" y,, �� , ,S,S � ,r�' �"�c", '�?"v,.•rs�"S�`�`r , ,, �• �� x> ,....' .,-�` �f:� '' x '"t4� '�C`'4-�- c�.°,.,c"�. , �*Y s..�..v .s s r >. �'f "�`.i x � x{,w,� �� 9 ! ... , v :vr r_.,..«+„-:.:nw++• -.mu._-n.....»rs.,,....-.....n.e.v..r. 4 A R 4 Signature certificate } Y ?',r Reference numb,: JTLGP-JCTOP-RHVFC-OY9QF ; , ;:' a� , Signer Timestamp Signature - h Cole Payne Yf?_' Email:cpayne@riseengineering.com Cole �}/�/ten ; ' y p Sent: 01 Apr 2024 18:53:42 UTC / jr Signed. 01 Apr 2024 18:53:42 UTC 4 r" , IP address:174.242.145.40 ; A �, ; r' Richard Gerstein ,�9.. Email:drrickg@gmail.com f j Sent: 01 Apr 2024 18:53:42 UTC D/�r��y�( ��?+,�IIl Viewed: 01 Apr 2024 20:50:05 UTC f�(,e j(/[ I r 4 Signed: 01 Apr 2024 21:32:13 UTC '„ Recipient Verification: s. (et, p IP address:73.159.46.43 a iEmail verified 01 Apr 2024 20:50:05 UTC Location:Florence,United States f d r ' ,r,,. 01 Apr 2024 21:32:13 UTC to A - _ { , ;F 1Page 1 of 1 h t ,F A ' ti;1/4".',":„.., [ . [' Woo ? . 4 1. ,,,,, 1 S, ,.-;>,-; p3.::,[ Signed with PandaDoc PandaDoc is a document workflow and certified eSignature �, r.•:,►_ ` I,_; >::;. solution trusted b 50,000+companies worldwide. 1 !o— =.,....;',, [ , 1 ,, .. b: am �, .,p,,, ti" .�'ry - `�• s ., . , 1r;t ' %',,'4.: f} t ?% , yux r ,,, is K'.Y„'•y, s• '� x '"„,....' s, Y. C`i,,, J+°7, x..,,r s1"# ,rCw' fi "tx,ram , "i *t..-e. ,, x.s r , > . e .✓ �"+. r-C r k=..,; X`<�. �L ,," C l', ='' x .�.1�us.�aaF,^_i&°�;Hai.� ,` ,�d,`sa�a�x,.�+� in`ird`,�".,�':�s-k�.`...r, s".��ad,n•; r..�2� :a���<,:��+',.sv�'ew x.�3..��Mr�» �9 w�e'�..' .a`ems. �,::5,`�� .>`�.K7�',�` "d:Fa��sia�,'t.�`��.: .ri''? ...3��� a,'.��3',aa" ' ';• The Commonwealth of Massachusetts Department of Industrial Accidents 'i ,: Office of Investigations . r. 1= Lafayette City Center -tc:5 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): 1.0 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. 0 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. 0 Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions m self, [No workers' comp. right of exemption per MGL YP 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.© Other Insulation 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. 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 Company Policy#or Self-ins. Lic. #:WC9057697 Expiration Date: 1/26/2025 Job Site Address: 1 Q,O V\O 4 '► \ f 1 04'JL . 9—' City/State/Zip: 11 Ul(eji Ct 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 her y certify under a pains nd pei alties of perjury that the information provided above is true and correct. Signature: G -- Date: 9 1 Gl I d tT Phone#: 413-86 128 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): 10Board of Health 20 Building Department 313City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: ' ® DATE(MM/DDM'YY) A�o CERTIFICATE OF LIABILITY INSURANCE 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 pollcy(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 (413)586-0111 FAX No): (413)586-6481 (A/C.No,Est):EMAI Webber&Grinnell Division Lss: 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/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. INSRY ExP TYPE OF INSURANCE Mgp WVD POLICY NUMBER (BR MMIIDDDYNYTY) (F MM/DD//YYY ) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X1 OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S2291368 11/17/2023 11/17/2024 PERSONAL&ADvINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE 0 LOC PRODUCTS-COMP/OP AGG $ 2.000,000 '—" I OTHER: $ AUTOMOBILE LIABILITY CO eB1INEDct)SINGLE LIMIT $ 1,000,000 (EANY AUTO BODILY INJURY(Per person) $ A OWNED ONLY AU X SCHEDULED A9105410 11/17/2023 11/17/2024 BODILY INJURY(Per accident) $ A PROPERTY DAMAGE HIRED �/ NON-OWNED (Per accident) $ X AUTOS ONLY x AUTOS ONLY Uninsured motorist BI $ 100,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4.000,000 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 1000000 ANY PROPRIETOR/PARTNER/EXECUTIVE J NIA WC9057697 01126/2024 01/26/2025 E.L.EACH ACCIDENT $ , , B OFFICER/MEMBER EXCLUDED? j 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMB $ 1,000,000 DESCRIPTION OF OPERATIONS below Per Occurrence 2,000,000 Pollution Liability C CPLMOL115005 01/25/2024 01/25/2025 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE l ©19864015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF IlflASSACHUSETTS Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR • TYPE:Corporation Registration Expiration 146402 04/21/2025 IDEAL HOME IMPROVEMENT INC. JAMES P.ELUS 142 BOYLE RD GILL,MA 01354 Undersecretary Commonwealth of Massachusetts • Division of Occupational Licensure Board of Building Regulations and Standards CS-091207 . _ rres: 10116/2024 JAMES P EL 142 BOYLE GILL MA 013t Commissioner &8Qc tJfl�9l��C.