29-251 (17) 61 OVERLOOK DR BP-2019-0047
GIS 4, COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-251 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
Permittt BP-2019-0047
Project JS-2019-000062
Est Cost $2400.00
Fee $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa. ft.): 18120.96 Owner: CLOVER REGAN
Zoning: Applicant. MARK LANTZ
AT. 61 OVERLOOK DR
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:7/1012018 0.00:00
TO PERFORM THE FOLLOWING WORK:INSULATE CRAWL SPACE
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 N 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 Shmature:
FeeType: Date Paid: Amount:
Building 7/10/20180:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
S_ -,t w lLl.la`ftL7'�
r. . DepaMrontuseonly
City of No ham ton Sulbu of Permit
JUL -WWO D part ant Club CWDavirisay,Permit
212 Mai Sir t Sewer/Sepbc AVabbN4
.� _ g00 Weter/Well AvadeWllly.
-i aAMBUDnIsa. 1060 Two Sete of Structure!Plan
p one 4A1133--5�87-1240 Fax 413-587-1272 Plot/see Plena
Ober Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION (O-r7 �L�7
1.1 Property Address:\ This section to be completed by office
I',\ �4 PI \ (- )).r Map Lot >s 7 Unit
0)0� Zone_ Overlay District_
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C�yen Sal�QetLo .F Dr h{��IvA��
Ne(P- ) Current Mailing Adtlress:
J Telephone ( _ l _C O _O,
Signature \W J l o
2.2 Authorized Ainent: Igo 1�,�'�A1�� 5k �OV
MA"<<y L ��� Z �a5�hg. P� 'hF O)oa,7
Name( int) Current Mailing Addr ss'.
Sig at re Telephone
SECTION 3-ESTIMATED CON41RUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1'-`BU TT' (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3«4+5) 1y Check Number
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature:
Building Comm' onerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 8-CONSTRUCTION SERVICES
8.1 Llcensed Construction Supervisor: Not Applicable
' ❑ Q
Name of License Holder MPlA Lin A Z If .1�(
License Number
Addres .T_ Expiretio Date
�/� 113 - J 9-
Signature elephane
9 Reci stered Home Improvement Contractor: Not Applicable ❑
Cr,2v I�,rY R nerd ,, mp,rsr 2 1 (od.-? 7 0
Company N me Registration Number
�ScG ale^ � � S � Iq
Address y Expir lion Date
Telephone 413-Sal-00,30
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c. 152,§2SC(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....... No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwelling 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 10835.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,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 combructs 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 hesshe shall be
responsible for all such work performed under the building permit
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 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
6C
CERTIFICATE OF LIABILITY INSURANCE 1 4/2241120182018
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: N the ce tifl me holder is an ADDITIONAL INSURED,the policy(lea)must be endorsed. H SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain Policies may require an endorsement. A matement on this M"Mcam aces rat cooter rights to the
certlBcme homer In lieu of such enaoraement(s).
PRODUCER COW
CT MET,C.
The Dowd Agencies, LLC M",ED ENT. FAX
14 Robala Road41343]-1010 Am :913437-1410
Holyake MA 01040 NL - mwnr0 tlaetl.cum
MaR ID.:CO2YHOM-01
INBMEa 9 AFFORDING COwai .JC1
INSURED INSURER A'.Selective Inum nce of South Carolina 19259
Cozy Home Performance LLC INSURER a'.
1B Pleasant St
Easthampton MA 01027 NBUREN D'. _. ._
INSURER°'.
INSURER E' _
INSURER F'
COVERAGES CERTIFICATE NUMBER:223405154 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.
IHS TYPE OFIX811fl°XCE FOUCYNUNBEx X OLV VYY MW➢NIYIII
LIMITS
• 'GENERAWABaTY RIXnes LIPRo10 Y9/M1B EACHOCCURRENCE 41 PA,aJ
X OOMMEROIALGFNEP.LL LIABILNV SPP I $.No
CLAIMS-MADE J UR j MED E%P(A anMn SIE.
I PER60NK6ADV INJURY S1WO00)
GENERALAGGREGATE EEO]D,CW
GE :'GPEGA}E LIMn APP LIES PEP. PROOUCTS-CONNV0F.GG SELCO.OX
DULY
'. X PRO. XILOU S
• AUT°MOBRF UABIUTY A N.N. <lt]/A1B U1]Rm9 COMBINED SINGLE LIMIT bl��
IEamaaeml
Y AUTO BODILY INJURY IPx gponl 1 5
B ALL OWNED AUTOS BODILY INJURY(PxvcbM)l S
X SCHEDULED AUTOS PROPERTY DAMAGE
X I XIPEDAIROB ',
'(Po,ccbM) S
X NOX.owryeD Auros j
T,
A X I UMBRELLA LIPS I X OCCUR 1 S 2H0111 M9IIDIB UVQ01B E1,CM OCCURRENCE 62,000m0
—~ EXCESS UAB CLAIM9MADE AGGREGRE 52a]OA
DEDUCTaLE _ - S
X RETENTION $
WgNKEFRODINEISATIOx I U' F.
ANDENFLOYEAS UAEUTY
ANY PR°PPIFUCH"IPTNEFONECUTIVC /X EL EACHAC°IDENT
C3
FFIDERMEMBERE%CLUOEO? H/A
MNiBF1ofY lR ryla EL OISFA$E FA EMPLOYE E
IOESCPIPTION OF OPEflATIONS Nbx E DISEASE POLICY LIMIT IS
DESCRIFTIO N OF OPERATIONS/L°cATDxSIVEMICLES LARINN ACORD IN,ANI NNI PNTINJI9 mmegw IF MJ/MI
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
Cozy Home Performance,LLC
180 Pleasant St. 7;REPRESEWAVVE
Easthampton MA 01027
®198&2009 ACORD CORPORATION. All rights reseri
ACORD 25(2009109) The ACORD name and logo Bre reglmered marks of ACORD
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteratlon(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Domolltlon ❑ New Signs ® Decks [❑ OtheY
oN
Brief Descript1ion of P5osed AWork ) t -n t dn
1�et,'Ckx
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
so, If New house and or addition to existina housing, complete the following:
a. Use of building '. One Family Two Family Other
b. Number of roams 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 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 CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. bv-a Cp T" (, 01 V-. , ,as Owner of the subject
property f1''�1 �
hereby authorize CO 2y $ D 4l �r�
.'r' f\J--
tomy behalf, tf, l atte work authorized by this building permit ap Iication.
on
V7 6J )
.......... Date
Aa \y Date
I, T� a \4 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 t pains and pen It es of perjury.
M r `--A n
Print Name
'7 5 � �
Signatu of Owner/Agent Date
- The Commonwealth of Massachusetts
Department of industrial Accidents
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 //�1 Please Print Legibly
Name(Business/Organization/Individual):�� L� _ (y (rJ1A r)(A
Address: \"Is Ici a ` Q r G c �� Y :)toll
City/State/Zip: a Iv A Phone 4:
Are you an employer?Check thea propriate box: Type of project(required):
1.EkI am a employer with 4, ❑ I am a general contractor and I
6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. [3 Demolition
workingfor me in an capacity. employees and have workers'
Y P tY. 9. [3 Building addition
req workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 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❑Roof repairs
insurance required.] c. 152,sxl(4),and we have no I
employees. [No workers' 13,�Other J W I))
comp. insurance required.]
•Any applicant thin checks box e I most also fill out the section below showing their workers compensation policy information.
'Homeowners who submit this ameavo indicating tMr ere doing ell work and then hire outside contractors must s ll nsit a raw atndavit indica ingovit
;Comractors that[hook this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employes. Huse sub-csntrxmrs have emplolecs.then must provide their workers comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below Is the policy call site
information. II / /
Insurance Company Name: Cott i"'1"4� 1 �•t pt elrl n / 4 �U�Yjb✓t t� _—
_T_—
Policy#or Self-ins. Lic.#:_y iv h-k-5 � ) , O/- /_/ _ Expiration
Date:
lobSiteAddress:fir, City/State/Zip! qLd
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 a 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 ce the pal and penaldes of perjury,that the information provided above is true and comet.
Si �! -Z � Date'
Phone 4.
Offictal use only. Do not write in this area,to be completed by city or town official.
City or Town: Perniit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical]Inspector S.Plumbing Impactor
6.Other
Contact Person: Phone#:
Massachusetts
( c
c
Q
DEPARTMENT
OF BUILDING INSPECTIONS
212 Nein Stx et •Municipal Building
NOLCTa ton, NA 01060 'rsYj�".y�l'13
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:
1i(()i f A-� bc NogAf JA Lw
(Please print house number and street name)
Is to be disposed of at:
6M KL, os ViD ® Mp4 c;"N
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
S
Sig ature of Perm plicant or Ow er 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.