42-137 850 WESTHAMPTON RD BP-2019-1254
GIs 4. COMMONWEALTH OF MASSACHUSETTS
Map:Block:42 - 137 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-2019-1254
Proiect# JS-2019-002020
Est. Cost: $5800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(so.ft.), 29925.72 Owner: BICKEL BERTRAND
Zoning: Applicant. MARK LANTZ
AT: 850 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 0 WC
EASTHAMPTONMA01027 ISSUED ON:517/2019 0.00:00
TO PERFORM THE FOLLOWINGWORK.•AIR SEAL ATTIC, VENT BATH FAN, CELLULOSE
TO ATTIC, ADD THERMAX TO CRAWLSPACE WALLS
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 4 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 Occuoancv Signature:
FeeTvpe: - Date Paid: Amount:
Building 5/7/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Pax:(413)587-1272
Louis Hasbrouck—Building Commissioner
U
City of Northa pto
Building Dopa en MAS 6 7 19
212 Main Sti et
Room 100 vEcsi
Northampton, MA 106
phone
of 6 ��noNn p0'0
phone 413-587-1240 Fax 13. 8r�' A
ONLY.
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I -SITE INFORMATION INSULATION PERMIT
This section to be completed by office
1.10-ProvarN Atltlnes: r1 1� O 1 J � y,
05 (3 wl,34, A ^9761% s� Mapes Lot ' Y7 Unh
C)�(\u A"4 aUi6 ` Zone Overlay District
9• Elm St District_ CB Dlnrka
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: pp
( 9AC61,10(
NN (Print) Current Mailing Atltlres .
/ Telephone
gnslure
2.2 Authorized Aeent:
�ne�k LST' 2- o
Name(Print) «gnArtl �
d �as��Mokw mo oina7
�i3-sAI-oao0
Signature Telephone
SECTION 3-E MA D CON TRUCTION C09TS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Denmit applicant
r-115',lUftny.1\ \�� C �Q (a)Building Permit Fee
2. Electrical V J (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee _
4. Mechanical(HVAC)
5. Fire Protection
5. Total= (1 +2+3+4+5) 5 Check Number 1
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: - Not Applicable ❑
Name of License Holder: i..,,it Cr La n1'z, csc-Y od/6 9
License Number
11sop�} N mA /—"I!I, o
Atltlress Expiretion Date
9 � 3 - sd9 -Oa.O�
Signature Telephone
i.Ratilelismid Mom m I men r Not Applicable ❑
Wzy Il�rne � 4f�crw.� nLx /G 070
Company Name \ Registratio Number
I�xO �`eSSwY,T 5� �dl
Expiration Date
Telephone q);-60m- o'4
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,g 25C(8))
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...... ❑
Brief Description of Proposed Work
_ nn�` W A.Q- Tub : A r 3c<1 Amit Jfnk uck bA4���n �a� R3
Wll� �t P1�,c Aad (hefmP> �(1
((6v—) 4u- WA�t, '
as Owner/Authorized
Agent hereby declare Mat the statelbents and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penaJh'es of perjury.
A/' WW k L+7n rZ
Print Name
i
Signature of Omer/Agent / Dale
I, 131 rLLr S n� �/��� C ,as Owner of the subject
property .. //
hereby authorize CaeV � /7U
to act on my behalf, in alljrdda alive to rk authorized by this building permit application.
Sign re of Owner Date
City of Northampton
w
Massachusetts
DEPART r OF BUILDING INSPECTIONS Z
212 Mein Street *M cipel auilcung
\ Northampton, MA 01060 A"c
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:
`6S r3 ije,5-tY�,�O—E �d
(Please print house nu berantl street name)
Is to be disposed of at:
Ptl N cp-,) . tv,>N 'F!-e aeK.wi f t a )olrst�j nrA A -(A 0-� 'f\
(Please print name and location of facility) O 6 J Ay _ k V�h\
Or will be disposed of in a dumpster onsite rented or leased Vlfrom
: y
(Company Name and Address)
: sd �
Signature Permit Appli nt or Owner D to
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
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massilovldia
U1kW rkers'Compensation Insurance Affidavit: Builders/Contra"ors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING ADTHORITV.
ApRlicant Information q Please Print LcAbly
Nme(Bwiness/OrganizatioMndividuap: Cozy Hj Ms-) J�i°j'f(/t7Y1<j/YR_
Address: / ro P/Q45An S� �d✓O
City/State/Zip: f15rlt Ie l)lf/11 /11fW �1'n''1�Phone#: z113 -,$,;i9- 0,).07
Are you an emproyer4 Coma the nppropr ale box: Type of project(required):
I.j&lamaemployerwith__7__emphyms(fullandurpan-timet• 7. ❑New construction
l am a sole proprietor or pannershipand M1ave nu employees wooing
harem
-❑ ' 8. Remodeling
anca ant [No workdo'comv tnsurnow required I
s.M l am a homeowner doing an work myself[No workets'compinsurance required.l' 9. ❑Demolition
4.0 I am a homeowner and will be harm rracmrs to conduct all work on 10❑Building addition
g con ora property. will
ore that all comracmrs diner Hove workers'compensation insurance or are sole I.[]Electrical repairs or additions
pre,maners wim no employees. 12,❑Plumbing repairs or additions
5.M Iand.Imeral conoseor and l M1ave hired the subconman ..fired..,he.,.had sheet ❑Roof repairs
These sulrcontrahors have employees and have workers'comp.insurance: 13.[]
6.❑We are a comoretion and its officers have exercised their right of exemption per MCL e. 14.yry Other 175i''Q�tOA/
152,01(41,entl ae have no employees.[No worker¢'comp.diamond required.I
'AM applleannhat checks box NI most also fill out the section below showing their workers'compere d.policy information.
'Homeowners who submit this modish indicating tory are doing all work and then hire outside commodity most submit a new atTdavlt indicating such.
:Commapo that chxk this box..at anazhed do additional fleet showing the name ofthe subcomtadors and state whether or not those entities M1ave
employees. If the sub-mn,.ctors have employees,they most provide their workers comppolity number.
7 am an employer that is providing workers'compenamtan insurance for my employees. Below is thepoficy and job site
information. k.
Insurance Company Name: Cull lo'di i l�Q!\\ o,�
Policy k or Sel&ins.Lia k: -tt�1�\\S �A� Expiration Date: �J,- l Cj
Job Site Address:�� Shu,H'TUI'� Q/' City/State/Zip:T3,i w- me 010C
Attach a copy of the workers'coat nsation 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 ofa STOP WORK ORDER and a fine ofup to$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
I do herebycertify oder Joe pains and pe motes of perjury that the information provided aboveistrue and Correa
n ,( I 1��
Signature: �✓ ���;1 7 Date: .5
Phone N: X11 .[.dc1' Ude V
Official use only. Do not write in this area,to be completed by city or town ojfictaL
City or Town: Permit/License N
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 N: