43-175 422 PARK HILL RD BP-2019-1500
GIS a: COMMONWEALTH OF MASSACHUSETTS
Mar,0 k:43- 175 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:INSULATION BUILDING PERMIT
Permit p BP-2019-1500
Proiect a JS-2019-002430
Est.Cost:$2800.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Siae(sp.R.): 370913.40 Owner: COOPER SCOTT R&SUSAN L
Zoning, Applicant: MARK LANTZ
AT: 422 PARK HILL RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST 11200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON.•6127/20I9 0:00:00
TO PERFORM THE FOLLOWING WORK:AI R SEAL ATTIC AND DUCTS
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:
Budding 6/27/2019 0:00:00 565.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
b/-/4- iSc7ll
Dep
- — ' City of Northa pto
.>' Building Depoff
a men
212 Main ) et JUN 2 6 20 9 S ULA TION
Room 10
Northampton, M O1 of BUILDING Inc CnoNS
phone 413-587-1240 Fe oe.inn loan ONLY---
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
Ll as Q qrk w 11 f�t Map _ Lot 15 Unit
I\ �Zone Overlay District
'C^ Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
me 'np Current Mai IngMai Ing AddresI
Telephone 13_ C '� s, 300
gnature J
2.2 Authorized Agent:
rind l- C"N\Z
Name( riot) Current Current Mailing
�IJ - Sa°�- odao
SignatureTelephone
SECTION 3-ESTIMATZ_OONSTRUCTION CO TS
Item Estimated Cost(Dollars)to be Official Use Only
Com leted bv permit applicant
1- IDII age PIT M\`� 78 a (a)Building Permit Fee
2. Electrical i (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee YF'
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number 1-(
This Section For Official Use Only
Building Permit Nu bar: Date
Issued:
Signature: t a-mg
Building Cummbsionerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \\ Not Applicable ❑
Name of Lionese Holder: M � LFnLL CSL- 011601
License Number
13L)M I.-0
AZds —� Expiration Data
Ik 14 J4 40-sdJ -0
Sig ature Telephone
. Re 1stered Home Im rovement Contractor. Not Applicable ❑
Compares Name \ RegistUrati5on Number
\SSO ��QSSgs� 5�� �r,S�C�r,.x.DAw MA O10 a-1 11
Adtlress SS Expiration Date
TelephoneW3.5o[74 00
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(il c.152,S 211
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.......Q& No...... O
Brief Description of Proposed Work
p:r si
I. TnP t�. a�\L 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.
tf`� ptf�c "4�Z
PrintNa
Signature of Orme em Date
L <'�j b1` � �OOO.Pi'.. ,as Owner of the subject
property r
herob orize O fi kw
t87
my a8,in alters relative to work authorized by this building permit application.
3i
Signature Owner Date
City of Northampton
S t�
•" 4 Massachusetts Fs4 cif
W as
' - � DEPARTMENT OF BVSLDSNG INSPECTIONS
212 win . icipal BuilQi
r ng
Nwi Ci
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:
I a.a B M 1z ));)I aA Nor�,q, �
(Please print house number and street name)
Is to be disposed of at: �,"
e11 (yrs�. iR h, 111 �c #�AuJ P,� l d I sl�ar�( a� ;� �r din ,, W v
(Please print name and location facility I
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
6d
Signature of Ple1nit Appli t or Owner Dale
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.
City of Northampton
Massachusetts
c
DXJ?Xa IffirT OF BMWXNG INSPECTIONS
212 Main $twat • Manitipal au 1 w
Northampton, Ma 01060 a
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"mconstruction, alteration, renovation, repair, modemization, conversion,
improvement, removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by reeistered contractors.
Note:/f the homeowner has\contracted with a corporation or LLC,that entity shasf be registered.
Typeof Work: ov 1 v \E.st.1Cost:l A,�:Oo
Addressof Work: 1a11 tirK 1 111
Date of Permit Application:
moo.
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.I.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of the owner:
y bA La L , A1, 46'4Ar,Y /N660. / 6,, 770
Da�T Contractor Name HIC Registration No.
OR:
Notwithstanding the above n;4
I h by apply for a building permit as the owner of the above property:
Date Owner Natneana Signator
_ City of Northampton
taassachusetts • f. -��
ffiPENTNENT 0E BUILDING INSPECTIONS
212 Naim sts t • A cipal B Ii nq
9 C
NontTavpton, M 01060
Massachusetts Residential Building Code
Section I I O R5.12
Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR I I0.R5,provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
i
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official,that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on thejob site will be required from time to
time,during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts
General Laws Annotated, you may be liable for person(s)you hire to perform work for you
under this permit.
The Commonwealth ofMassaehasetts
Department of IndoestrialAccildenn
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
U1kWCompensadon insurance Affidavit.Builders/Contactors/Eketricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / n Please Print 1<e'bIv
Name(Bmtnesst(hganirarioMndividua0: y Coz /7o/I')Q Aerf(/!!)Ti4tec.
f
Address: f 8-0 0145A11y" Sri r¢do0
City/state/zip: CW5t/i9mP7o/y MW 0f0`�hone#: N/3-.5aA9- 0.z00
Amerman eagrkyert Cask tae appropdam has:
Type of project(required):
I.®I am a employer onto_2_emplgm(full andia, hrotime) 7. ❑New construction
2.❑lamasolepropneororpannershipendba noemploy«awaking formem 8. Remodeling
cry equity.[No warless'com,imurmce required)
J❑lama homeowrsrdang all whys myxlf,IN.warant' onp mswaae regmi l' 9. Demolition
4.❑1 am a homeowner and will be hiring contractors in conduct all ways on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or arc sole I1.❑Electrical repairs or additions
propdemss with ou employes.
12.QPImnbing repairs or additions
6C]I arae general comraeoa 1 hive hired the subcontractors M1nM an the mluhe0 sheet.
Thou subcontractors subnt
coractors havee smployeeseM M1ave woyser%comp.imumrwe/ I3.r❑WIRoof repairs /
6.❑We ax carpormumand is omcers have exemixdlheir right ofesemptian MMOL c. 14. Other j!ISUjQ1t()N
152,g114k arc we love no pnployes.INo woyseK comp.inenap:e reouired.l
•Any applicant that chicks box r I must also rill out the union below showing then workers contravention policy information
a Homeowners who submit thin afndivit indicating they are doing all work and then hire outside contractors must submit a new amdavir indicating six h.
)Contractors on. ox mot check this bamcW an additional fleet showing the name of the sub-contrumrs arc slam whether or octose crams have
emplwees. Ifthe submnuacmts love employes.they amt howide their workers'comp.polity number
1 am an employer that is providing workers'compensation Insurancefor my employees. Below is the policy andjob site
Information.
Insurance Company Name: (.ot\lJ
l(%Q,n�ct\ 1(\t,SQMf\tl(Y CumD 90V
Policy#or Self-ins.Lie.#: yto-�'-�S�� j 'U( ' I I Expiration Data:
Job Site Address8x:i,,. R h� Nsl� R� City/State/zip: Uldb�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and xpirstion date).
Failure on,secure coverage as required under MGL c. 152,Q25A is a criminal violation punishable by a time up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby�ceyraf/y hire ffie pains and pe altles ofperjuy that the information provided above is hue andd cornea.
Signature: 7/'/'-- � � 7 Date: 6Idy/i"1
Phone#: "I1-�'
Olficlal use only. Do not write in this area,to he completed by city or town official.
City or Town: PermiOLicense#
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#:
I