23A-112 7 PINE ST BP-2019-0893
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 23A- 112 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
Permit# BP-2019-0893
Project# JS-2019-001489
Est.Cost: $1700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 5314.32 Owner: KALISH ALEX
Zoning: URB(loo)/ Applicant: MARK LANTZ
AT.• 7 PINE ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST #200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:2/19/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEAL ATTIC FLAT, ADD VENTILATION
CHUTES, ADD 14" CELLULOSE TO ATTIC
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 2/19/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
�- Department use only
City of Northampton Stat s of F Drmit
Building Department F E B 1 4 201 S Curt Cut1E riveway Permit
212 Main Street Sew)r/Ser is Availability
Room 00 -1wat irNVel Availability
fUl!DING IMSPE
Northampton, MA W'09HA,,,,ON.MA 01 $ets Structural Plans
phone 413-587-1240 ax
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
A� �/T,
1.1 Property Address: This section to be completed by office
-7 � �� � c�� Map o�'3/+ Lot Unit
(�1ok e yy- A Q 1 O a Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
TA'\ ,a, \v,rN\\ 1�J� ��tea- 5� ALC
LC Ir\ll V" Q. n k4L_
;ignature
ame&(P'nt) Current Mailing Address: -11
Telephone
J 4 ' I
2.2 Authorized Agent: 1 `. / 0)Da.�
I'� I1� f ISSA x g i, too ^w 1N
Name(P'nt) Current ailing Address:
11-� - 5 &Cg - 0k®o
Signa re Telephone
SECTION 3-ESTIMATE CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building \ 1 (a)Building Permit Fee
2. Electrical 'l (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) 4 ) Q Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: / Z- 19- Z61q
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/ /� css L_ I oai b9 1 a to
M A k K n 72 License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
4 o AJ c(5An I s
No.and Street Type Description
fC ` U Unrestricted(Buildings u to 35,000 cu.ft.
A,5THAMAfQN% 11Tt V Or�.� R Restricted 1&2Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
W�3"5o11 VV.uQ m�rk��ny�ozUlYl�•C�h'1 I Insulation
Telephone E address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
Cozy Home p���of m C Q( f- HIC Registration Number Expiration Date
I Co p ame or HIC iiegis Name i
Q V)PciAAnt Sr t=aou ►MAc1c ed r,% homV ,�s1�
No.and Std —TEmail address
mN 010 c.7) 'All-W-0 0
Ci /Town,StA,ZIP Telephone
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.
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
CONTRACTOR OR OWNER'S AGENT APPLIES FO(nR�BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C O�!! In m&
to act on my behalf,in all matters relative to work authorized ty this building permit application.
4411- -41,� a,11I
Owner's Signature ate
SECTION 7b:APPLICANT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
0,q�z 4-, /." . I�
Contractor//Owmer s Agent/Owner ignature Date
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will na 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass,gov_ ldns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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" 7 U
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
NVorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Annlicant Information Please Print Leeibly
Name (Business/Organization/individual):_I
Address: / ('G S q o A, U
City/State/Zip: Fr�57�/WhYV I_rOIV IVI1 W hone #: Iq/3-Sniff" 0 00
Are you an employer?Check the appropriate box: Type of project(required):
1.14 1 am a employer with___employees(full and/or part-time).* 7. D New construction
2.a I am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10 Q Building addition
4.❑l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.M I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 1 .R Roof repairs
6.❑W e area corporation and its officers have exercised their right of exemption per MGL c. 144. Other 1)5L (c( /(j1 f J
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �^
Insurance Company Name: Lan � it Q�� J��L�EM f\t �l Co mA cin
y
Policy#or Self-ins.Lic..#: y ,- \\` 5 � 'U 1 ( Expiration Date: ) )
Job Site Address: A��vQ 51 City/State/Zip: (`Aty\" yy\�
Attach a copy ofth w rkers'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 tine 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 nderihe pains and pe alties of perjury that the information provided above is true and correct
Si nature: � ��' •�� Date:
Phone#: t'�13— 53`\ C}
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#:
City of Northampton
r Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building y�`•.,_ ��
Northampton, MA 01060 ssyti �1�
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:
--) P I q,-1 S �(k. YYvA Z))wo
(Please'3print house numb and street name)
Is to be disposed of at:
�c L l A C f Sly W) \ )�'-e,
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
re� /1 a'/)) 9
Signature of Per it Applican or Owner 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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all amlicabie)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[ ] Othertl�l]
Brief Description ofProposed
Work:�t5S ()Ig
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if New house and or addition to existing housinfa, 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, ;`1 A q V-VA'\ SNI-) as Owner of the subject
property �+ \`
hereby authorize C o2y, t'1 p-,).-
to acl on my behalf, in all m tters lative to work authorized by this building permit application.
Signature of Owner Date
I, fv\A�� L' n� 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.
Print Name
1�
SignatA of Owner/ n-t- Date
.. City of Northampton
Massachusetts
DETARTWNT OF BVILDINO INSPECTIONS
tJC+r;.}"xFl7fixs t£`sr; AtA u2,060
Property Address:
Contractor _
Name: =.
Address
F
}may n
City, State. f" m _, �- •a..
y�
iq w n
Phone<
Property Owner
Name: ::
Address'.
City, State: .
tcontractorj attest and affirm that the building f intend to
insulate does not have any open air tknob and tube?airing in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit,
Contractor signature�
Date