43-149 (2) s;\....\ The Commonwealth of Massachusetts
......,.._. Department of Industrial Accidents .
_
Office of Investigations
600 Washington Stree.
•14.= _ Boston, 4‘ 02217
WWW.Mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ti
Please Print Lec
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Name (BusinessiOrgar.laationtindividual): `; iH —. /I 1 C/ r ;i&- 1, (._ I i ui i. t / , tk- 1 i L
Address: --).\
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Cv/State/Zip: M(hearyttirt i k4 (-106 Phone rr': L /13 3T) '4 i I C/ -4-C -
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Are you art employer? Check the appropriate box: ' Type of project (required):
am a er.rloyer with . (I 4. 77 I am a general. contractor and. i . ..
, 0. New constracrion
have tur to Me stib-cootractors __
,
en-Tioyees Gauls andlor part-tme).''
isms on the attached sheet Remodeling
2. , i am a sole proprietor or partner-
These sub-co=actors have
ship and have no employees ; ; S. , ; Demolition
e.rt ioyees and have workers' ; '
worrig for me in my capacity. i i 9. 7 Building addition
.
[No workers' comp. insurance con n insurance.. 7
required:1 5 77 We are a corpora an d it 10.L Electrical repairs or additions ,
..._:
3, ..; i am a homeowner doing all work office rs have exercised their 1 i .'l i Plumbing repairs or additions ;
i -'grit of ex.emption per iviCI... ; ■
m.yself. [No workers r
' corq,, . , ;.? '
Roof reairs
: p
4
c. 252, ,5:(4), and we have no ; ,Ily /), ) 4 1 216::_____
''.1.-S1.11.211Ce reqz.lired.] t
i 3. , Other ASV/. '
er*oyees. [No workers'
comp. Insurance required.I
4Ay applicant that cheeks box 5 I r also f,r, cut the 5000 below showing their sr.... C.37r*CaSatian pohcy infoi
.' Hornecwheis who sunmit this affidavit indicating they are doing all work and :her hire outside coritraciors roust sub:rd new a±tidavit indicating stich.
:Con=tors that shook this box rri-st attached -= additional sheet showing the name of the sub-contactors and ante whether v. those entities have
employees. If the sub-contactors have employees, they must provide their workers' cots policy number.
...'
ant on employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. .--
-(-■, ( .,:_ -_ , '(:,77.-t,'
insurance Con Name: `'\,,, ,C.;'1.1 T - N k ----: C f,■-::. , rnk, ck,
Poiicy # 0: Self-i.a.s. LiC. #: — C \,,
L g - — - Expiration Date: /( i 2_ i 2_
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Xliob Site Address: \ \'' (1,.), \NMI Cps. ` City1StateZip\ Jc t 11 (--C Al .6 9 I')
Attach a copy of the workers' compensation policy decinration page ir showing the policy num-ber and expiration date).
:To:lure :0 secure coverage as required under Section 25A 3:1VI.C-i., c. 152 cart lead to the :Imposition of criminal penalties of a
tine up to $1..500.00 andlor one-year irrqnrisoametn, as weli as civil penalties in the form of a STOP WORK ORDER and a :me
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
_,-
Sig .,., ( /0 , C 1-11
Date: / ti/ sa/ 71 (
.t.: #: L i I - -.-3
Qfficidi use only. Do not write in this area, to be conwieted by city or town official.
o ol
Ci ty ;,■ ;;Li or Town: PermitiLicense # .i
'
issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 11
1 6. Other !,
Contact c- Person: Phone
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k
SECTION 5: CONSTRUCTION SERVICES .
5 Licensed Construction Supervisor (CSL) /1-1/ a__
t jr�ztC
4 Let A. . License Number Expiration Date
Name of C,SL- Ho be ; s L ist CSL Type (see below) _ A.-� IC
L ,� i'1 f V 5 c "
A dr • Type Description /
"" 1 4 . p U unrestricted (up to 35,000 Cu. Ft.)
R I Restricted t &2 Family Dwelling
Signature
L i
i M Masonry Only
2,1J ` RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I, Residential Demolition
5.2 e Home Improvement ontractor (HIC) / -\/\
HIC mpan Name or HIC Registrant Ni I Registration Number
- L y-�, e....L j'u, A All e,. . l
Addr ss y 1 0
,A/ v' 2'� `�03 ).t : . 4 ( Expirtetion Date
Signature lure el epnone I
SECTION 6: 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 building permit.
Signed Affidavit Attached? Yes Nc 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
°
V I 1 :F.
1 (Y =��. 0 - - as Owner of the subject property hereby
�
authorize t. 1�f►[�Ji i i- i..14. . to act on my behalf, in all matters
relative to work a' .■.ized by thi .ilding permit application.
f/
Signature of Owner Date
,.��+ SECTION` b: OWNER' OR AUTHORIZED AGENT DECLARATION
I , ll" J e? ✓ c, ,, , as Owner or Authorized Agent hereby declare
that the statements and informati t e foregoing application are true and accurate, to the best of my knowledge and
beha / •
::: or Auth r Agent Date
7 /
(Signed under the pains and penalties of ury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations l 10.R6 and 110.R:5,-respectively.
1 2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) '
j Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open _
4
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. El Demolition El New Signs [D] Decks [Q Siding [0] Other [D]
Brief Description of Propo d �j + ■ ,
Work: '� 1'1 c -\''' ' �jl?�GN ' ) iC' f i(. 1 ii 1
Alteration of existing bedroom Yes .j No Adding new bedroom Yes \ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. 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
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. 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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.4 /
I, / / - i, ' ° L. , as Owner of the subject
property � 1'
hereby authorize C__,(1 r J 1 - V• - Q e.,14 - 'o 1h Y1LCZ..
to actt on Ty behalf, in a tt rs ative to work authorized by this building permit application.
Signature of Owner / Date
I, �' / 14/1? 2 fif2 , as Owner /Authorized
Agent hereby declare that the stateme and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed undetthe pains /
ains and penalties of perjury.
Print N!a /�/f/ y /, Signature of Owner/Agent ( Date
Section 4. ZONING All 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 1 %
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW ' ,i' YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO `___1111 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained o Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO *
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO t
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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Department use only
EIVED " City of Northampton Status of Permit:
RE Building Department Curb Cut/Driveway Permit
FEB 212 Main Street Sewer /Septic Availability
W • 3 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans,
o pt - s -587 -1240 Fax 413- 587 -1272 Plat/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
(� ( - Map Lot Unit
v-srl Zone Overlay District
Elm St, District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: c c�
JJ `1 I f' %� j l�/ '� , i t O /
Name jPrint Current Mailin As • e4s: 5 a
////,/,_, Telep
Signature
2.2 Authorized Aqent: fo
Narrl nt) , n /% j Current Mailing Address:
f ` % ; ./ ' , ' i 3 3 3-:i
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCT N COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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 = (1 + 2 + 3 + 4 + 5) ( Check Number ■P7 9 55
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0692
APPLICANT /CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611
PROPERTY LOCATION 113 WHITTIER ST
MAP 43 PARCEL 149 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1/72 � B"
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION & AIR SEAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102169
3 sets of Pla / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
FO ATION PRESENTED:
pproved 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
litio s
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.
113 WHITTIER ST BP- 2012 -0692
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 - 149 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0692
Project # JS- 2012- 001218
Est. Cost: $2266.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 105850.80 Owner: GOGGINS WILLIAM MICHAEL & KIMBERLY FINN
Zoning: SR(100) //WSP II Applicant: MARK LANTZ
AT: 113 WHITTIER ST
Applicant Address: Phone: Insurance:
74 LYMAN RD (413) 320 -7611 WC
NORTHAMPTONMA01060 ISSUED ON :2/7/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL ATTIC INSULATION & AIR SEAL
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 Signature:
FeeType: Date Paid: Amount:
Building 2/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner