22D-078 (2) 46 CROSS ST BP-2019-1411
GIS 4: COMMONWEALTH OF MASSACHUSETTS
lsan:BIOCk:22D-078 CITY OF NORTHAMPTON
Lot: 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit 8 BP-2019-1411
Proiect# JS-2019-002284
Est Cost:8850.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: MARK LANTZ 102169
Lot Size(sa. R.1: 19253.52 Owner: SPIEGAL HELEN
zoning: UlunoOYWSP(100y Applicant. MARK LANTZ
AT. 46 CROSS ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST 4200 (413) 529-0200 ()
EASTHAMPTONMA01027 ISSUED ON:6/18/1019 0:00:00
TO PERFORM THE FOLLOWING WORK.MASS SAVE, INSTALL 2' THERMAX IN
BASEMENT
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 W 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:
FeeTvOe: Date Paid: Amount:
Building 6/1820190:00:00 865.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-1411
APPLICANT/CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST#200 EASTHAMPTON (413)529-0200 O
PROPERTY LOCATION 46 CROSS ST
MAP22DPARCEL078 001 ZONE URA(I00)[WSP(100
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid .
Building Permit Filled out
Fee Paid
Tweof Construction: MASS SAVE,INSTALL Y THERMAX IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102169
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER:§
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
• Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Once of
Planning& Development for more information.
ORCity of Northampton Dep
Building Department
21Room 1Street0INSULATION
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 7 -SITE INFORMATION R N PERMIT
1.1 Property Address: This section to be completed by office
1�` crows Sk JUN 10 20191ap 210 lot 0-1 a Unit
Zone Overlay District
DEPr OF aMtpIND IN3'ECTims
NORTHgMPTON.MAOmpa St.Dist ict CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record:
e\e S 4� CrU55 s� Ngl�iw�tWy
Na nn Current Mailing Adtlres . r
g tura
Telephone S�Q '36?-o00
i
2.2 Authorized AgenY A f �I(� n
�r'}z ItrUNIPOAAg 4 06Tr14r1Yk AYa Ulo�1—
Nam PrinD Curren ailing Address: /
103-sag-0a.00
Signature Telephone
SECTION 3-ESTIM TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b vermitapplicant
1. R-"R (a) Building Permit Fee
2. Electrical W (b) Estimated Total Cost of
Construction from B
3. Plumbing Building Permit Fee /l
4. Mechanical(HVAC) UD
5.Fire Protection 1
6. Total=(1 +2+3+4+5) 5 Q Check Number 1)
This Section For Official Use Only
Building Permit Numb r: Date
Issued: p
Signature:
Building Commissioner/Inspector of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder r"(`V U41A L CSL" j as lbq
License Number
0 1 cA nIN Ula Irl)M 1J-0
Adg s Expiration Data
A J4
13-Sd9 -0
Sig azure Telephone
9. Registered Home Improvement Contractor. Not Applicable ❑
dozy Z7
, eC�ac n.e nth 4 a 7 0
Company Name Registuration Number
A ti'QSS Ask IISI�I
Atldreas Expiration Date
Telephone Y/3'Sd9-rk,Otl
SECTION 5-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.......U No...... ❑
Brief Description of Proposed Work \\
MASS S�k`N. ��b + �t,k- d." 'f>,vimgx i1J �4alr'fYnl Sr1) bona(
�stt�'t�g DSS S
,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.
V,grlc 1-", i
PrintNam
J
Signature of Owne ent / Dat
I, H le S J v L ,as Owner of the subject
property
hereby authorize 0 1'q 4
to act on y be If,in all 6i§Ars relative to work authorized by this building permit application.
Signature of Owner Date '
The Commonwealth ofMassachuseds
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
ulky'�O' Compensation Insurance Affidavit:Builders/Contractors/EkMricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aollieant Information / �7 Please Print lcrI
Name(Business/OrganirstioWl.divid.M): (oY /70Mf2
Address: / R'O oe/f45,4111 54 '4�7ofU0
aty1StateiZip: EW5tr/9mp1U1y MWOIOeslnhd, ii: y/3 -50- 0ai00
An you an employer?Check the'sMmprkre hos: Type of projed(required):
L�lamamllayervith�
employees(full aM/mpatt-time)• 7. ❑New construction
❑lren.sole proprietor.,partnership and nave nostracyees working rormain $. ❑Remodeling
mq capacity.(No wmkers'comp.imurance re,wrod 1
l❑l an ahomrowmr doing all work myself(No wodeni comp.Insomnia retained)' 9. ❑Demolition
4E I aura homeownerand will be hiring crameni ,to conductall work an no,proper,. twill 10❑Building addition
ensure that all contmcrorsaimer base imrkers''compenvtion insurance w ere sole I1.❑Elecoical repairs or additions
proprietorswith no emDloyea. 12.❑Plumbing repairs or additions
5❑I am a general romrnanatd I have hired the subamnnamors listed an the attached sheet. 13.❑Roof repairs
Thee subcontractors haveemployees and have workets'comp.insuin,c; I
6.❑W<uearoryomtionatd its omeers have exercised Chair right of exemgion per MGL c. 14.�Oth[r /15 VIQ7A)/V
153.§I(at.and we have ad employees.[No intercessional ...scattered
•Any applicanuhat checks box pl man also fill Out the section below showing their workers'care etmtion policy information.
s H.ners who subminhis affidavit indicating.hay are doing all work and then hire outside comrecmrs must submit a new affidavit indicating such.
:Cantrachms that check.nix has must atuched an additional sheet shown,the nun of the sub-commetors aid scale whether or trot those entitles have
emplmeee. If the subcotnmctors han employces,they must provide their workers'comp.fish,number.
I am an employer thatIs provlding workers'compensmlon insurance for my employees Below Is the policy and fob site
,nformodon.
Insurance Company Name: (of\N,n Q )fcoM 0
Policy d or Self-ins.Lic.9: b- 12,5 Expiration Date:
Job Site Address: 9` (CO5 S+I City/State/Zip:NfC4'IV4r✓ mA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL a 152,625A is a criminal violation punishable by a fine up to$1,500.00
metier 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.
Idoherebyrrify pi�t lbe pains andpe allies ofperjury thin the informatioaprovided above is true and correct.
Signature: Dmf
Phone k: U1\ _ saes,- c1ao'6 Y--
Official use carry. Do not write in this area,to be completed hr city or town official
City or Town: Permit/License 9
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.CityTown Clerk 4.Electrical Inspector S. Plumbing inspector
6.Other
Contact Person: Phone h:
City of Northampton
Q-A
Massachusetts L. �•.,k
DEPARTMENT OF BUILDING INBPBCTIONS
212 Main Street Municipal auil6ing
Northampton, MA OlOfiO
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:
tib Otos s �c . N or���Rio .i
(Please print house nu ber and street n e)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from: Q
Pll - 4,V%51, 1,,,,1V �e64rw� Yr �obs'}� -14A al;jlJ, &A d ;N
(Company Name and Address) /ir�1 A\"qj Lt^ `
Signa— tur�e of Permit App cant or Owner Date irk
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.