11A SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License\umbe- Expiration Date-
List CSL T\pc(ScCbelo")
C�
\o.and Sliv7e! I'\PC Description
U Unrestricted(Building-,up to 35.000 cu.
Sj R I Restrictol 1&2 Family D%wiling
('it\/To\�n.St.-tic.
M Maionry
Rooting Coverina
WS 1 Windo\� and Siding
SI: il Solid Fuel Burning Appliance.
Insulation
1'elephone Einailadd res's 1) i Demolition
i 5.2 Registered Home Improvement Contractor(HIC)
117(3
i CA ry\f- tc�10(Mix A — Expiration. Daie.
W Ilegis I'trailoit Number
I 11CCorripam Name or HIC Registrant Name
�MQLA
No.and Su-ect
tm!n
Cit /Town.Statb.r __ r
TP
Y
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. 2SC(6))
I 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 ..........A No...........
SECTION 7a: OWNER ACTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
11.as Owner of the sub ect property, hereby authorize r-,.Q3 Hzme-
J LH;_"V�- LA
to act on my behalf. in all matters relative to work authorized b�,this building permit application,
Print Owner's Name(E'Icctronic Signature) Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
B) entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
I contained in this application is true and accurate to the best of my knowledge and understanding.
/e-
Print Or\%nt!r*s or authorized Agent'sylime(11:1ectronic Signature) bate
-4
NOTES:
.. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor I
1 (not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guarant) fund under\4,G,L. c. 142A. Other important information on the HIC Program can be found at
Information on the Construction Supervisor!,!cense can be found at J12s
12. When substantial %kork is planned. provide the information oelou:
Total floor area(sq. ft.). (irciuding,garage, finished basemenvattics.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 heating system _..__ _ Number of decks/porches
Type of cooling system Enclosed --Open
3), --Total Project Square Footage— may be substituted for-Total Project Cost-
J --,, oon
The Commonwealth of Massachusetts
Department of Industrial Accidents
0
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /J7 Please Print Leaibly
Name (Business/Organization/Individual):_{ Z�M(- ,!''''P,''6r-Mj1xk__
Address: l O1�
4,5t4A � V
City/State/Zip: "5111_1Md 1f0V 4V Q1 - Phone#: .3'Syt c1" 0.- oo 0
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with _employees(full and/or part-time).* 7.
7 []New construction
2.rl 1 am a sole proprietor or partnership and have no employees working for me in 8. D Remodeling
any capacity.[No workers'comp,insurance required.]
9. ❑Demolition
3.D I am a homeowner doing all work myself.[No workers'comp,insurance required.]'
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
s
These sub-contractors have employees and have workers'comp.insurance
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ,�Other / t'l utc�
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks 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'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \
Insurance Company Name:
Policy#or Self-ins.Lic.#: -�S'"1 �� 1 i Expiration Date: tt� )
Job Site Address: ,q15� (2 4}Q.1' - City/State/Zip:�,u d S M- ck-M cJ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify 1he pains and pe/talties of perjury that the information provided above is true and correct;
Sip-nature: �`� r-'rte Date:
Phone#:
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):
I.Board of Health 2.Building Department 3.City,'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
171
Or Doors I
Accessory Bldg. ❑ Demolition ❑ New Signs [r-]i ec4s [[:3 Siding[0] Other
Brief Description of Proposed
Work:lrA\W,S 5,P-,Tk 66 P&6MIk i C k aeA Aic
.1 - VQNNkAVll.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If Now house and or addition to existing housing,complete the followina:
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,Ce' (0)i-e C(A\') �j as Owner of the subject
property
hereby authorize tk\f T�A— 414(W\A A(
to act on my behalf, in 11 ma relative to work authorized by this building permit application.
SiWture of Owner Date
1'�- 1141911 1 as Owner/Authonzed
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.
M P
Print Name
ar
ISignature of Owner/Agent Date
City of Northampton
Massachusetts A.L-
DEPARTMENT OF BUILDING INSPECTIONS �'• =tv°
212 Main Street •Municipal Building
Northampton, MA 01060 �sN"....3.....
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:
Sq 5-,A5+ G"+er -34 , J,'Cek MA
(Please print house number and litreet name)
Is to be disposed of at:
�.� Tf 6,5 . W,1 �M ( �J FTS �1 n41 ft l S
(Please print name and location of facility) �V
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Perm" plicant or wner 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.
DECEIVED -n/ G�T/��
City of Northai iptortU's
74 Building bepa men NOV 3 2 ,
212 Main Sti eet *77
I�- -
Room 10M3
n�F)ull DING IN, 3 s s
Northampton, M 018K,--TtW n IoN 'n
phone 413-587-1240 Fax 413- 87�4
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION &p ^ jq—(1/D
This section to be completed yy office
1.1 Property Address:
Map Lot V( Unit
I �h Zone Overlay District
Elm St.District CO District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cc.( C- 1 ; fiJS S�1 ��►a'� (jac'r 3� 6MA
Name(Print) Current Mailing Address:
Telephone Y13 ,.d,,0
CgInat-u're / 0
2.2 Authorized Auent: \ t JOO
Name(P int) Current Mailing Address:
`tl� - 5a.�-oaoo
Signature Telephone
SECTION 3-ESTIMATE CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. 6U ` �f 1 (a)Building Permit Fee
2. Electrical N r \1 (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) j
5. Fire Protection
6. Total=0 +2+3+4+5) �] 0 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
54 EAST CENTER ST BP-2019-0660
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IA-015 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2019-0660
Dniect# JS-2019-001078
EsqCost: $7000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: MARK LANTZ 102169
Lot Size(sg.ft.): 22825.44 Owner. COLLINS CAROLE
toning URA(100)/ Applicant: MARK LANTZ
AT. 54 EAST CENTER ST
Ap-olicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON.•12/5/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXTERIOR DENSE PACK, ATTIC AIR SEALING,
INSULATE ATTIC WITH 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 Sienature:
FeeTyne: Date Paid: Amount:
Building 12/5/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner