38B-199 (2) 21 MANHAN ST BP-2019-0012
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B- 199 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildino DO NOT HAVE ACCESS TOTHEGUARANTY FUND (MGL c.142A)
Category INSULATION BUILDING
V ILDING PERMIT
Permit# BP-2019-0012
Project JS-2019-000016
Es[ Cosi $4900.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa. 111: 10193.04 Owner: HEADY LYN C
Zoning: URB(100)/ Applicant. MARK LANTZ
AT: 21 MANNAN ST
ApplicantAddress: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON.7/512018 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL, ATTIC INSULATION AND KNEEWALL
SLOPE
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 7/5/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
DepaMlentuse wily.
Status of Permit.
-,rM-58
Curb CWDrivawey Permit
SeveffSepticAvailabNly
1. Water/Well AVa AWW
0 Two Sets of Structural Pima
ph ne8 -1272 PbdSite Plans
NONTHAMPTON.MAIIM 011ier$pedfy
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH
�Aj ONE OR
TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 2.
1.1 Property Address: Thisssection to be completed by office,Da,'1 mq�1Yn j'y A Map 39Lot (L ! Unit
�IvUt��^ ��uN Ih[i U �66 zone overlay District
Elm SL District CS District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
L' o rh(1 alab6
Nam (Print) Current Mailing Address: l
Telephone lyS- j'�'7 o H )
at re
2.2AWhorized Aoent:
� �r� Ltit+�Z IScO (J�clSank S1' �aoo FM�r.,.Dfl a +]7�
Name riot) / Current ailing Adtlress'. �
1/ 4)�- Sa�-oal�Cl
Signature Telephone
SECTION 3-ESTIMATE6 CONSTRUCTION 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 / o
4. Mechanical (HVAC) l� J V l/
5. Fire Protection
6. Total=(1 +2+3+4+5) OO Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionerllnspector of Buiklings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION&DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows AIteration(s) Roofing
Or Doors ID
Accessory Bldg. ❑ Demolition ❑ New Signs MI Decks r] Siding ED) Other I®
Brief Descri tion of ro osed
Work:. t 6f) t PA.r�rf'I r gym,4a- -
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Be. It New house and or additlon to extedria housina, comolete the followfrim
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?
I. 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 fl. 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, L)i w R 2 4� ,as Owner of the subject
propertJ I
hereby authorize O 2'yT•(yQ�
t act on my b f, in all mall rs relative to work authorized by this building permit application.
;.6
of Owner Date
�y1 c� `�7, 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.
MfiCI;k �.m n� 2
Print Nme
!� 6 1
Sign ture ofO n gent Date
City of Northampton
s.
> Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main street •Municipal Builtl ng
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c40, 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:
(Please print house number and eet name
Is to be disposed of at:
xq\Df"' \' NN V—VP— (.cr^1j41A {lain S1� '6Y CCtN 0. l\
(Please print name and location of facility) ki n 6L tp f
C�dn
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
IIG
igI— �t
tJre of mit App cant or Owner Date V
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
ul www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annticant Information /� Please Print Leeibly
Name (Business/Organiu(nuiion/ladividual):C ')Z-V I ) 0l'4j(w)fq r1 LL
Address:
Cit /State/Zi i" N it Phone#:
Are you an employer'Check the mpNn to box: Type of project(required):
1 1'Ram a employer with 2___ 4. [31 am a general contractor and 1 6. [3 New construction
I.
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ry 9. [3 Building addition
req workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
1❑ 1 am a homeowner doing all work officers have exercised their 1l.[3 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL c. 12 ® Roof repairs
insurance required.] 152,§1(4),and we havno IOther JAS t,��W'f 1�'(�
employeM
s. [No workers
e
comp. insurance required.]
:My applicansthaz checks box gl most also till out the cation below showing their worken''compenseian policy information.
Fioenawtwrc who submit Nis amdevit indiceing they are doing all woo,and Nen hire outside contractors must submit a now affidavit miliceingsuch.
:Comracmrs the check this box most attached an additional sheet show ing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-conlracton have empkgccs they most provide their xorkerscamppolicy number.
1 am m employer that h providing workers'compensation Insurance for my employees. Below Is the polky and job site
information. II 11 /
insurance Company Name: C D n 7, ]
Policy#or Self-ins. Lic. #:_y(o ' -S Expiration Date:_l/
Job Site Address:2,\ City/State/Zip: ��t rn 01 bb'J
Attach a copy of the workers' compensation policy declaration page(showing the policy number and�te).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead m 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 5250.00 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.
1 do hereby ce the pal and penalties of perj that the b(/'ormatlon provided above is true and correct.
i /` f l Date ]
Phone C —
ojfichd 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 or Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
111
ACIOMY CERTIFICATE OF LIABILITY INSURANCE °"'E'" °° Y""'
4I2M2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE ODESES
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 pDllcWles)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and cone lords of the policy,certain Policies may require an endoreemem. A Mtemenl on this carts icale does rat cantor dgm to the
certificMe holder In)leu of such andoreemerd(s).
PRODUCFA xAue: MEN DDRY
The Dowd Agencies, LLC EHOxE F :413-43]-1110_
14 Robala Road .413437-1010
Holyoke MA 01040 "N m-nevididmed,orn
..COZYHOM-Of
INSURERS)AFFORDINSICOV!RANG HAICI
INSURED INSUPERA:Seledivelnsuranceof SDuth Carolina 19259
Cozy Home performance LLC
180 Pleasant St.
Easthampton MA 01027 aaLaERc'.
INWPER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:223905154 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.
I115P PE°F INSURANCE PoLICY XUMBFA MXNWYEFY MNNdYMYP NWg)8 Uers
GENERAL LIABILITY i S] N1]13018 N1]QO18 EACH OLCUPRENLE Sir="
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PERSONALSADVINJUPV 51 CWS
GE NEPAL AGGREGATE 133aD,OD
GEN L AGGREGATE LIMIT APPLIES PER'. H ODUOTS.COMPRW PGG s]m0[O]
� POLI°Y Xppo X LOC 3
AUTOMOBILE LIABIUTY A 91.581 V1M01B W]R019 ICOMBINEp SINGLE LIMIT 51 ttN OH
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ANY AUTO EDGILY IWUPY(PAY tenon) S
ALL OWNED AUTQSI '�DILY INJUPYIPs
X�SCNEOULED AUTOS PROPERTY pAMAGE
X HIFE.AUTOS IFPo,ay1mY) $
X NON OWNED AUTOS 3 _
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4 UMBRELLA LIAB X ,NCUR S'PMI 1117R019 N11ID11 EACH OCCURRENCE szoo.
ISACESSUAB —II CLAIMSMPDE AGGREGATE f3o0.'O
L DEDUCTI&LE 3
X RETENTION g $
WORKERS COMPENSATION TATLL OT
MDEMPWYMS'UAMUTY
ANY PWYMROWPANNERIEXECUTIVE O'i NIA =LEACH gLCRENT
°FFICENMEMREREXCLLGG'
IMNAPIRM In NM E L.DISEASE EA EMPLOYE S
m under 09CPIWION OF OPERATIONS red, EI DISEASE POLICY UMn S
DESCRIPTIONOF°PERAMNS/LOCATIONS/VEHICLES(A hAC D101,PWXbmI RemaM1s&IWUM,IImm pew Is reyu',tll
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE HATH THE POLICY PROVISIONS.
Cozy Home Performance, LLC
180 Pleasant Sl ANN
° aaDREnRESExTgnvE
Easthampton MA 01027
0799&2009 ACORD CORPORATION. All rights reserved.
ACORD 25(3009A9) The ACORD name and logo are registered marks of ACORD