22B-025 (4) 25 CORTICELLI ST BP-2017-1289
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22B-025 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-1289
Project# JS-2017-002142
Est.Cost: $1300.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(so. ft.): 11064.24 Owner: AIKEN CHRISTOPHER
Zoning: URB(I00)/ Applicant: MARK LANTZ
AT: 25 CORTICELLI ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST #200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:5/9/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:AI R SEAL BASEMENT
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 Occu.anc si!nature:
FeeType: Date Paid: Amount:
Building 5/9/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-20(7-1289
APPLICANT/CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST 4200 EASTHAMPTON (413)529-0200 0
PROPERTY LOCATION 25 CORTICELLI ST
MAP22B PARCEL 025 001 ZONE URB(10O)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FII LED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: AIR SEAL. BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102169
3 sets of Plans/Plot Nan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN,FORMATION PRESENTED:
approved_ Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:ys
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
Den clition Dey
Sl? . re of B. dim O- cial 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 40k Contact Office of
Planning&Development for more information.
Department use only
‘� City of Northampton Status of Permit:
,.iU�� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
r\4 < s Room 100 Water ell Availability
\ % Northampton, MA 01060 Two Sets of Structural Plans
�/ phone 413-587-1240 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
1.1 Property Address: � �This section to be com�pleteddby office
a5 C.ork 1 c-al 't t Map aLot CLv)5^ Unit
Zone Overlay District
�\o( Fr (...9.- I�A
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C C\ s A1kEy, aS ( oc ; cQ \ ; Avu , -Ell oct),.<R
Name(Print) Current Mailing Address'. (� -'1
C ?\, \L.__
GI10 - ukdS ' / tF1 \
Telephone
Signature
2.2 Authorized Agent: /� G o.0o /
m�li- L-o1x,�2— IVO 0) ec,�Can'f O)/ £ 5�'h"-nilui ry114
Na P t)) ,I ^/ yyy111 C.urrentlnailiinng Address: l
lav
S nature (((ffJ �fj Telephone
SECTION 3-ESTIMATED C STRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
\ '\ Q)-0
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection f(
6. Total= (1 +2 +3+4+5) 1 3 00— Check Number /4773 / 0e
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House pi Addition ❑ Replacement Windows Alteration(s) D Roofing C
l�I Or Doors 0
Accessory Bldg. I I Demolition ❑ New Signs CO Decks ❑ Siding [0] Other[Eli
Brief Description of ProotoPoseg \ f ""i.5 5190/- 1
Work: .C1.C11.(' 4 n
11. [ \ YVAP SI )) �kivik ' J .
Alteration of existing bedroom Yes _(�\ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Ye tr 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
I, C `
1'\ (`i ti 1l t i_R 1'\ , as Owner of the subject
property it/// /�
hereby authorize Col Fi!%/Y7 e J" f/d"uy'I1I4/JLC
to act o behal in all ers rela e to work authorized by this building permit application.
/er 5/5 /17
Signature
/of Owner Date
N\I, \ t 1 P r\'f– Lo 2— ,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.
Thi (`V L ½
2Print Na
a275 5 ) ti
Signature of Owner/Agen ///3 Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \y Not Applicable 0 7
Name of License Holder m rtr tey1 Le-, h 1 Z c .55/ - I Oak/ 9
License Number
\`(4ii \ RONSON.N)-- Mi' 7 �a6)-4\6`cy41J1\l 'Y-n
Ad /di% Ol/o-
drees Expiratio Date
1</.. y, i yt3 sag OoO
Signatureelephone
9.Registered Home Improvement Contractor: Not Applicable 0
C t>2y 14c Y Q Q Cr \ '(YN o.x.(it f (o dP 7 0
Company Name Registration Number
\A CS Q\ 1 .b\5w..�C 51' d, -.);\4-101-.„31-\N WV 445 Il 1
Address r� Expir tion Date
t�
Telephone 113-5al'04.00
SECTION 10-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 (1\ No 0
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,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 10833.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,oris 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 home in a two-year period shall not be considered 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 building permit.
As acting Construction Supervisor your presence on the job site will he 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 may 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 Massachusetts
Department of Industrial Accidents
=As--l 5 Office of Investigations
1 Congress Street,Suite 100
• _='— Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information pPlease Print Legibly
Name (Business/Organization/Individual).Co Z y 3bry t. Ire e!�[J(/fold 1�(!-
Address: A% 0 Q \ 2 ev S o. ( \s" ( Sj-
City/State/Zip: C.o,-S-0H I N 111C Phone#: 9 3 " S a - O a
Are you an employer?Check thea.propriate box: Type of project(required):
I.® I am a employer with 7 4. 0 I am a general contractor and 1
6. 0 New construction
employees(full andior part-time).` have hired the sub-contractors
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 S. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P ry 9. 0 Building addition
[No workers' comp. insurance comp. insurance
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] c.152.§1(4),and we have no <
employees. [No workers' 13.q Other AI_n Alia�3
comp. insurance required.] _
'Any applicant that cheeks box#I must also fill out the section below showing their workers'compensation policy information.
•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 comppolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. len)II •
Insurance Company Name: CD1171.1 .Pn 7m / '/1nj (oM)h n/
Policy#or Self-ins. Lic. #: (M L - $-y 5 37 3n- 0/ - /I Expiration Date:
NCl/
( ///
Job Site Address: 'T`M WC rf �--QI lCity/State/Zip: r( Cl/A( fy){)
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 certif 2 the pain and penalties of perjury,that the information provided above is true and correct.
Si•nature: / cave' >'" Dat': 5 5 / I
r>�
Phone#: et/3— �9-tV7 UC)
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
6.Other
Contact Person: Phone#: