37-083 (11) 266 GROVE ST-920 BP-2019-0218
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 37-083 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pennit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0218
Proiect# JS-2019-000355
Est Cost $1200.00
Fee:$65. PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sy. ft.): Owner: Johanna Stacy
Zoning: Applicant. MARK LANTZ
AT. 266 GROVE ST -#20
Applicant Address: Phone: Insurance:
180 PLEASANT ST #200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:8/2112018 0:00:00
TO PERFORM THE FOLLOWING WORK.•AIR SEAL, INSULATE HATCH , ADD
T'CELLULOSE
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:
FeeTyue: Date Paid: Amount:
Building 8/21/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
z A/ coY�
Deperlmsnt use only
City of Northam ton R EC�I !,I—
DEPT
�'
Building Depart ent V Permit
212 Main Stre t
Room 100 AUG 1 7 2
Northampton, MA 106 Ofrat Plans
phone 413-587-1240 Fax 13- OF BUILDING IN -
NOPTHAMPTON.M
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PropertyAddressThis section to be completed by office,
a b Co C5cb,f x. 3} J�ap Map _ Lot o F3 Unit
V GONN �r1JN "fl Zone Overlay District
vy Elm SL Dlmdc — CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
" (O GfOV`e. 7� 1�.a.0 VVIY��t`PTSLty 1rt1^
Na e(Pn ) Curren Mailing Address:
Telephone –1 ta LI 1
ISiaturs
Authorized Agent, / \ R � °�c...(� },may
Nel-x /�.fnTZ 1`60 �12a5A�� 5� � 131n'D
Name riot) Current Mailing Address: I
Z
Y1 3- 5 ,41 0UO
Signature Telephone
SECTION 3-ESTIMATED CO TRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1_fig (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) �C70 Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signatu (�
Building Cc i loner/Inspector of Bindings
Ihasbrouck @ northamptonma.gov
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signe U-31 s 11121
t Siding [3] Other
Brief Description of Proposed\ \\ n
Work:ceNPS�Swat�nD Qrf� $.t n� /�511c 1!\5J T Q� tz7MJ
Alteration of existing bedroom_Yes V� No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement `Yes _No
Plans Attached Roll -Sheet
Se. If New house and or addition to exletina 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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In, 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, �'nllArt\a J"1 GCV .as Owner of the subject
prop 'y
```` n
hereby authorize CD A'Z 'C d of n CL
to act n m half,in all relative to work authorized by this building permit application.
bjl
Sig 6 lureof Owner 1 Date
ve
1, i ' " 1, K ^A 1�( Z 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 andpenalties of perjury.
n�Z
Print a e
b lb 1
Si nature of Ov nt Date
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) QSISJi411�J'_
N''' Z _ License\umber F,pimtion Date I
Snc iCSl.11oldcr
I list C\:.l'.pe(uc nelowl Y
1)PC � Description
j C Unretnned(Buildings un to 35.000 cu. 11.)
C \
`�`•T��Oi M/}� Ty''t �Q` � � ,ff� _—_ R R trict•J I1-7 family Dwelling
C tf llw n. Si ite.ZlD V9 � Ma.ntry
Rc Roofing Co,ming
- - --- -- %S 1 U'indow ane Siding ,I
- -_---
SI I Solid Fuel Bunting Appliances
Dr)�j'S�`"t Q:� _LnS1Lk. rv1 2y�ty'frl( M . I Insulin ion ;
Telephone 6mai uldl r ci 1) D01111161113
52 Registered Home Improvement Contractor(BIC)
Lt:1 ) 7U - -- 4 sal-9. _
II11i7L��Z( �,�! L,{- _. lK lic_iurmion\umher repiratiun Doe .
I IIC l' nipam \acne or HIC Refi'oant Sone
L 8\ZaAni 1� 1)
1,0.undsneat rQ9. ._ -5.92
t'mnil address
f Ati-thwm,n},)tv -Mf\ Sll'> `II I-SJ i_�h;1i�
Cit /Town.State,ZIP T",p c c
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 ..........� \o _.. .... ❑ i
SECTION 7a:OWNER A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� 1,as Ownei of the subject property, hereby authorize-Ca27 NOrne- rit1o '(hnfltA
10 act on trybehalf, in all matters relative to work authorizer}b y this buildingpermit application.
Prim )wner's Kame(lilectronie Sianatu •) ate
SECTION 7b: WNFR'OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains mid penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
i
P -+
rini0vner' or,%uthoriaed Agcni> imelElecromc Sienawre) late
NOTES:
.. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered co manor
(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 can be found at
%wInformal on the Construction Supervisor License can he found at aww nrus aoy des
When substantial work is planned. provide the information belox':
I mal floor area(sq. d.) _ 6ncludinc garage.finished basemenuattics,decks or porch)
Gross living area(sq. ft.)_ _. Habitable room count
Number of fireplaces_ _ _ Number of bedrooms
Number of bathrooms _ Number of half/baths _
Type of hewing system_ Number of decks/porches
Type of cooling system _ Enclosed --Open—_
3. ^Total Project Square Foo[aee"may be substitu[ed for"Total Proiec[Cosi' I a o 1
-� a CERTIFICATE OF LIABILITY INSURANCE °"E'MM' 1111
ACORO bnuzota
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 ISSWNG INSURER(% AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the DerlMca s holder Is an ADDMNAL INSURED,the policy(les)must as endorsed. N SUBROGATION IS WAIVED,subject to
the terms and CoMNlons of the policy.certain Policies may require an andoreement. A statement on Use ceitNNAte does not cooker rights to the
certllce a holder in Neu 0 such endon emen ts).
.0. cw NZAnT Ma Conm
The DOWd Agencies,LLC PXOxe A%
14 BOOaa Road 41343]101041343]-1410
Holyeke MA 01040 m-nNDW5doWd.wm
IDA COLYHOM-01
IHaIIRBRB gG9PG1NO COVERAGE NgIL•
d6UREa INeuRE,A;Selective Insurance of South Carolina 19259
Cozy Home Performance LLC
100 Pleasant St. IxaupUle
Easthampton MA 01027 wwaeR c:
INSURER O:
meURER
INSURER P;
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 MY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE FISURANCE 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.
IITGIRq T'PEOF INSIIppHCE PoIILYN BEp M YYY C CYP 11iRT6
• GENERALUABWTV i5 zDeN. a17R°10 a1]/1016 EpCN OCCURRENCE 5160 W]
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0.NMSJMOE OCCUR MED E%P f15
PEpBCHAL sq°vI W11Rv s+0oc.
_ 'GENERALAGGREGATE $
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GEN'L AGGREGATELIMIT APR-IES PEP'. PRODU=r WMPAPAW f5°W 6O
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A ALIrWOM11EUMMUTY AB1005Bt a17lM10 V17=19 COMBINED SINGLE UNIT fIYA,60
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A XI1IMBRELLALIA11 X -OCCDR 63IIeB10 1111.018 1 a11R018 EACNGCCURREXCE 53. 1O
F%CES6 WB CLAIM6,MADEAGGREGATE S3..
_DEDUCTIBLE i
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WORKERSCOMPENSATON W
AND WRLOYERV UABNTY YIN
Y PROPRIETgLPAR.EmEXECUTIVE❑
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DESCRIPTION OFOPERATIONS/LOCATONB/VMUCLES(AYRAh ACmml°I,bdMIW R—r &MCU.,Rngry ApGNrparANl
CERTIFICATE HOLDER rANCELLATION30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WALL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
Cory Homo Performance, LLC
180 Pleasant Sl. AN 0 uaG pePRE9adTAnvE
Ea6thampton MA 01027 �` ���{
A 11&1F Gkov//-
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009A9) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of/ndustrialAccidents
Orlee of Investigations
x 1 Congress Street,Suite J00
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information /� -/ Please Print LeeIbIV
Name Business/organintiionllmm.;dual):C z2 11)not f1f'/4've Wl4srla_
Address: \� ( S\' .es �.'T���t
Ci /State/Zi : h tv Phone 4: ' 0
Are you an employer?Check the a pmp"mte box; Type of project(required):
1.t�i am a employer with 4. 0 1 am a general contractor and I
employees (full and/or[fart-time).' have hired the sub-contractor 6. [1 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-connectors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. Insurance.,
required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 12.0 Roof r;pairs
insurance required.]' c. 152, ysl(4),and we have no
employees. [No workers' 13."er J v
comp, insurance required.]
*Any epPliMtNa choles baa el mint also till out th<smion below shawi�their uarken'camp<nsadon policy m1ba wion.
'liomwwnus who wbmit Nis affidavit indc aing they are doing all work and then hireomaide ccentactonmun submit a new amdovit iodicaingsuch.
;Con,mums Nat check this boa most outwitted en additional sheet showing No name of the sub-contactors and one whether or not those entities have
employees. if the sub-contractors have emplo}ecs,they must provide their workercomp.policy number.
I am an employer tkar Js proniding workers'compemotlun Jnsurance for my employees. Below Is the policy andfnb she
inf0meadon. I
Insurance Company Name: Con L,
,
Policy#or Self-insr^sLic..#: �{o ' // — Expiration Date: �. nr3
Job Site Address: rsu C•�fo✓e S+ d0 Citylstate/Zip:N,fl/' #4
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 ce the pain;andpenaftles of perjtary that the iniforetadon provided above Is true and eormet.
Official we only. Do not write in this area,to be completed by city or town official.
City or Town: Permitr[Acense#
Inning Authority(circle one);
1.Board of Health 2.Building Department 3.ChytTown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone A
e• Massachusetts
I :,
c
S
DEPARTMENT of BGLLDL G L SPECTIMS
212 Main Stx t •Municipal Building
0
Mortht ton, MA 01060
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..
Thedebrisfrom construction work being performed at:
U b �� lc�y� 5'1 9 aO ��e��t`Hn}11Jh�
lease print house number and street name) 9
Is to be disposed of at:
75�c s . \ a* Ic Ae� l l d b•S S) ti,11 c f er wrv1� t� n s,
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of PerrFiFXpplican7wner 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.