17D-017 " t J BP- 2011 -0199
GIs #: COMMONWEALTH OF MASSACHUSETTS
`' slk�lT'17 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0199
Project # JS -2011- 000348
Est. Cost: $3452.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES
Zoning: URB(100)// /WP Applicant: IDEAL HOME IMPROVEMENT INC
AT. 125 STRAW AVE
Applicant Address: Phone: Insurance:
142 BOYLE RD (413, ) 863 -2128
GILLMA01354 ISSUED ON. 101412010 0.00:00
TO PERFORM THE FOLLOWING WORK .- INSTALL ATTIC & EXT WALL 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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si
FeeType: Date Paid: Amount:
Building 10/4/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0199%
hALG
APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESSIPHONE 142 BOYLE RD GILL (413) 863 -2128 N �)
PROPERTY LOCATION 125 STRAW AVE ( %E Art �0�
MAP 17D PARCEL 017 001 ZONE URB000) //WP (( \
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC & EXT WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 091207
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFpRMATION PRESENTED:
4 Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
c o
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
s
3
Department use only
City -of Northampton Status of Permit
Building Department Curb Cut/Dnveway Permit
,, 212 Main Street Sewer /Septic Availability
S _ $ Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 41 -587 -1240 Fax 413 -587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address
Map Lot Unit
Zone Overlay District
/o
Elm St District . CS Dtstict
i
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
V- N I ft �rl�tl�2oZ z.S s� Ate£
Name (Print) Current Maift Address: p /
`fl �� Sato " IUTIb
Telephone
Signature
2.2 Au4joirized Agent:
/L,6k doVk 0 1 013V
Na (Print) Current MaitKrg Addn3ss:
S*a ture Telepftne
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by rmit applicant
1. Building (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= 0 +2+ + 4 + 5) Check Number
This Section For Official Use On
Building Permit Number. bate
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
F PR i b
SECTION 5- DESCRIPTION O OPOSED WORK (check all and ca le)
New House ❑ Addition ❑ Replacement Windows Alleratkm(a) ❑ Rooting ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Docks [Q Siding [O] Other [ i
Brief pe, ption yf�Proposec�
Work
3� 0 - G " l knw Acct— C2l�u,�a se- �l c S h e' /GG� .2i- aeri waJl S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basemen Yes i No
Plans Attached Roll - Sheet
ea. If New house and or addition to existing housing, Complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
C. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
j e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Massbheck Energy Compliance form attached?
h. Type of construction
L Is construction within 100 ft. of wetlands? Yes No. is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? / Yes No
1. Septic Tank City Sewer Private well City water Supply
SECTION ?a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
t)Q Tif rz LLA &M 13fL 02 as Owner of the subject
property
hereby authorize
to act on my behalf ' 11 atters helative to work authorized by thI& — bu'ilding pernit application.
Signature of Owner Date
/J `
I, I' ma ` l / Pie s l / L / � =G?� f , as Owner / Authorized
Agent hereby declare that the statem nts and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed der the pains and penalties of perjury.
Print flame
S*a ture of Owner /Agent Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R L: R
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(W area minus bldg & paved
# of Parking S paces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO �.
IF YES, describe size, type and location:
E_ Will the construction activity disturb (dearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Mh
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Lkensed Constru S upervisor. Not Applicable E3
Name of Lkmm Rower: CL me S
Liae"Nu ber
ly- � G, /I M
' E,, Date
Sig lute Telephone
9. Registered Home Improvement Corte actor. Not Applicable ❑
.1 gCL �J`M J M pC0y yM fj J q
Com nv No a Reg ist lion Number
oAa 4)0 /1
Address Doraation Date
Telephone7/,�yn eb2
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted *0 this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit
Signed Affidavit Attached Yes....... No...... ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, a vided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.E
Definition of Homeowner Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one hone in a two-vear ptrs d shall not be gLn-#A red a homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the baildine uem t.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you maw be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Mossachusetbs
Deparbnent of IndusbW Accidents
Offrce of Invey4wlons
' 600 Washington Street
Boston, MA 02111
wnw mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information \ Please Print Legibly
Name (Businesslocgart zation/lndividual): l ld> .Ct L 4` iL t I P, 0 Vt i\i t 1 NC,
` r
Address:
City/State;/Zip: , i j - L? 1 35 Phone #: q' 1 3 L 3 D 1, - T
Are you an employer? Check the appropriate box: Type of project (required):
1. E] am a employer with (0 4. [] I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. [] Remodeling
ship and have no employees These subcontractors have 8. 0 Demolition
working or me in employees and have workers'
g any city 9. (] Building addition
[No workers' comp. insurance gyp. insurance.*•
requ.ed-) 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. C1 officers have exercised their I am a homeowner doing all work 11. ❑ Plumbing repairs or additions
myiel£ [No workers right of ex on comp. exemption MGL 12.[] Roof repairs
insurance required.] t c. 152, §I(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required]
* Any applicant that check¢ box # l. trout also fin out the section below showing their wodnxs' oompmsatian poluy infarcmat io
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContkacaors that check this box must attached an additional sheet showing the name of the sub- contra tors 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. --4
Insurance Company Name: j� 1
Policy # or Self -ins. Lin #: C� (f Z—� (�` Expiration Date: v C
Job Site Address: L� CitylState/Zip: FI0 r' e nGe- 1 o 06 .;1-
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 a raider tkee pains and penalties of perjury that the information provided above is true and correct
Si ature: C q �, Date:
Phone #: �l -3 a
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
& Other
Contact Person: Phone #:
} VDAC
woRi M C(IOMENSAMN
AND
EMPLOYERS LIABHJTY POLICY
TYPE AR INFORfII ANON PAGE WC oa 00 01 ( A)
POLICY NUMBER: Msouo- 9S64L17 -o -os )
RENEWAL OF (S560UB-9MML17 -0-08)
INSURIER: HARTFORD UNt7EWWRITERS INSMANCE COMPANY
1. NCCI CO CODE: 430411
INSURED: PlN3Dl1 M
IDEAL .HM IINRROMMENT INC A H RIST
142 BMLE ROM 159 AVE A
GILL MA (1354 Pt? BOX 391
TURNERS FALLS MA 01376
leisured Is A CORPORATION
W.2r = t 2nd !deI ?t' !'ttV are Stht n In the SchWige sj attached.
2 The Pdky pw6od is from I i -i 8-09 to i i -18 -i 0 12!M A.M. at On lnsared`s nnaMing address.
3. A. tl 0P-KERS C MPEMMTMN INSURANCE: Part One of the policy applies t0 the Workers
Cwnpensakion Law of the $Nib*) listed here:
MA
,a. EmpLUYERS LIABILITY INSURANCE: Par# Twa of the polky applks to work In emh state listed In
rmn 3A. The lfmfts of our f kblrky undw Port Two am
Bodfly Injury by Atxlderll: 9 600000 Mich Aceldent
Smi ly Injury by Disease: S 500000 Policy Un*
Bodily Injury by Dtssasm 9 50I M Each, Empkoyee
e. OTHER STALES INSURAIMCE Pert Three of the policy applies to the states. If arty, listed here:
COVERAGE REPLACED 8Y ENDORSEMENT tam 20 03 06A
D. This pollay Includes thsae er+dorsemta,ts and schWLqw
SEE LISTrNG OF E SE11ENTS - EXTENSION OF INFO PAGE
4. The p<at ;f::. for k L s &WmIrsed by wir 1, 1 1allmls of Fh-,Im ClassNoW*m. Rates and Rating
pleas. Al mgtdted JrMMMdun 16 Wbp& to WgbzgM and chi by Blldlt to be rra:le- ANNUALLY.
DA'M OF MUE: 12--113-09 DR ST ASSIGN t MA
OFFICE: OWL* O DA MD t1SG 26L-TL
pfa0DUCE1t A H RISr
,n
Jlt
- - -, �r BUaTC� O ill irig 'vr.T.'�i l� ari ta.Tl �` S
. One Ashburtonlla - ;e r Room 1301
Boston. Massy c huselts 02108
Home Impro vem ,ai
Registration- 146402
Type: Private Corporation
Expiration: 4/22/2011 Trt 281491
IDEAL HOME IMPROVEMENT lNC. `
JAMES ELLIS — — - --
142 BOYLE RD —
GILL, MA 01354 — -- - -__�
Update Address and return card. Mark reason for chnn-
Addrew r Renewal Employment
DPS -Cr '� �Ad- C8f0 &DBSLtFOR7giCA ?QS2t2Q0&
tilaxs.(chu�ett.� - Delru trncnt of Public ti,tfet�
y Boar(1 of Buil(lin�
Rc'Fulati(rn., :(n(I Jtandard.
License: cS 91207
JAMES P ELLIS
142 BOYLE RD
GILL, MA 01354
Expiration: 10116M12
,( nuni�.ianrr
Try: 32�
City of Northampton
` Massachusetts _
.A
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address:
Contractor
Name:
Address:
City, State:
Phone:
Property Owner
Name:
Address:
City, State:
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
Date
CCr -
�►�
Property Address:._ ' 1 �
Contractor i
Name:
Address: ! 1 V Veck
:i 1
c i , sue: r' t 1 I �, i� A o ( `-
Phone: L t - 3
Property Ovuner
Name_
Address:
City, State: — I I o Y-c yic
(contractor) attest and affirm that the building I intend
ta,iTGutate %-tom not lagcnaqy open-air (knob and tube) wiring in the spaces to be insulated and
that 4 have provided the property owner with a copy of this affidavit-
Con sign
Date
I
I
I
t L000£98£4 }uauranojdwl awoH I B60: L L M 170 t-O