35-231 (9) 28 BAYBERRY LN BP-2019-1512
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:35-231 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-1512
Proiect# JS-2019-002447
Est.Cost:$3900.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: MARK LANTZ 102169
Lot size(sa.R.): 41512.68 Owner: PARSONS PAMELA
Zoning: Applicant: MARK LANTZ
AT. 28 BAYBERRY LN
Applicant Address: Phone. Insurance.
180 PLEASANT ST#200 - (413) 529-0200 Q WC
EASTHAMPTONMA01027 ISSUED ON:712,2019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION
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:
FeeTyoe: Date Paid: Amount:
Building 7/220190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
BP ('F-'IsFz
City of No ha
CEIVE Dep
Building partment
212 Mai Street INSULATION
MaiRoor1 tr JUN 2 8 2019
N -587-1 4 M 01060 ONLY
phone 413-587-124�F�)F !1�SByn • nEcria s
nnT��AMPTON.MA 01000
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
c�� ur.� �cffy LtJ MapLot �JV Unit
�ol``rV�vorr M� O) Ob� Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2-.10wner of Rec�o I.
� n 11 rJ Pl� IJrrI�C-/INLN IVO r1"•M � Q/.
Na ring Current Mailing A ress:
Telephone 113 -5f tf-50,1,
Sig lure
2.2 Authorizetl A
ent,
yagKk 'y2 /2Ae6k11"'l A�*AIV &Pf OJV-7
Nam t)
Current Mailing Address: J or
ti13 'Sri 7-OdW
Signature Telephone
SECTION 3-ESTIMATE24CONTRUCTI N COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
7'8aitil ^\� 1 (a)Building Permit Fee
2. Electrical i J (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee �(
4. Mechanical (HVAC) Y�
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number I &k
This Section For Official Use Only
Building Permit Num r: issued:
ed:
Signature: -7-
Z"2019
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 Lithium Holder: �'�C f� LC�/\�L CSI,- Ir3l)(09
License Number
1 IalM1xia
Ad s Expiration Date
`fl -Sri 9 -0
Sig ature Telephone
S.Regiistered Home improvement CQntrador, Not Applicable ❑
(,3z--y (?erLr v'(\ I I "-)-) 0
Company Name \ Regist tion Number
AIR
5�f unix\m iw MQr o)l) 1 � SI��
Address Expiration Date
Telephone M-547-w )(1
SECTION S.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
I, MP rk ii ac%\'-- ,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.
_ h`w P 1•� 4an�Z
Print Nam
Signature of OwneflAgent Date
I• ,as Owner of the subject
property
hereby authorize �0� Name O'�l .fl W*a.L
to act on my behalf,in ell atters relative to work authorized by this building permit application.
Signature of Owner Data
/ Massachusetts
111 s
DEPART tar OF BcULDLNG LnSPECTLOnS \\\
212 Nein atra t • Municipal Building
Northampton, Mx 01060 ,rY eT
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"reconstruction,alteration, renovation, mpair, modernization, conversion,
impmvement, 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 registered contractors.
Note:/f the homeowner has contracted with a corporation or LLC,that entity must heregistered
Type of Work: Tr )N \` Est.Cost: 3
Address of Work: a% `yff��, wy*N,^ 4`'yq
Date of Permit Application:
1 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.L.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 f the owner:
61A 14, tnxrh LenY-t l6Y1#0gV 7.7 p
Dam Contraq o arae° HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
CN The Commonwealth ofMassachusehs
Department of Industrial Accidents
I Congress Sheet,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
UIFIA Compensation Insurance Affidavit:Builders/Contr cton/ElecMcians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant
Information Print
1
Name(Busine es gli izatian/Individual). Z. Q f
Address: f S-0 P/P45Ai7� Sf 'pe'(00
City/state/ZI p: E1?5Ti,'9mP10N 9//40/Od'Adtie#: y/3 5d9- Od00
Are you au empbyer!Chea We approprbw box: Type of project(required):
L®IemeemDlger was�emplgces(fall and/or pamtime)• 7. ❑New construction
2.❑lcon.sole proprinoror partnership sal lave no employees working lm me in 8. ❑Remodeling
an,capacn,.[No workers camp.insurwce required.]
)❑I am almmwwnm doing all wont myself[No workerscon,assutmee namme .l9. ❑Demolition
4❑lcon ahwrcowmand will ba wringwnnema to conduct all work on my paper, twill 10❑Building addition
ensure that all eonaacwneither lune wakericomwermon insurance or are sole I1.❑Electrical repairs or additions
proprietors with no emplgees. 12.[]Plumbing repairs or additions
5 I am a general canpa<mr and I have hired the sub<ont wet.listed on this aneched used
Theo aubcontmctorshave empigas and have workers comb inamov � 13.�ROof repairs
6❑We eseecmpwationand iu omarslave emxeised their right ofexmtwtim per MGL c. 14.wOther 1%L IQ4/t)N
132,0.1(4t and we have m employees.INo workers mrnp.immmm required.)
•Any applicant nat checks box al mmt aha fill..,,he section below thawing their workers compemalion poliq information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new amdsvit indicating such.
:Connectors that cheek this box most anachea et dwore an additional sheet the of the olve ntracmrs and sum ose whether or rot thamts have
empleyees. [ilk suE-centractors have emplanes,they mmt provide their workers comp polianumber
I am an employer chat is providing workers'comparmadon Insurance for my employees. Below Is the pollry askat site
Inforreadon. —t-
InsuranceCompanyName: C 'US1't"r(\Qll�q� yf\N2Mf\t��r �.UmPally
Policy tior Self-ins.Lia.p:y b-�S"�S�7 j '� I I Expiration Duepp:�� yyI I d I C1
Job Site Address:a� �AY til ffM �fJ City/State/Zip:lWC9�46- w a J6�
Attach a copy of he workers'eom neatloa policy declaration page(showing the pogey,number and expieation date). "
Failure in 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 m S250.00 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.
Idokerebyeaalfy nder epainsandpe, aidesofperaw that the information provided above true and correct.
n
S' m I ( 'L7_ feaeC/j,711fes_
Phone k:
Oficial use only. Do not write in this area,to be completed by city oriental official
City or Town: Permit/License a
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing l nspectur
6.Other
Contact Person: Phone h:
r Massachusetts
I l`-_A o� e
1 1 DEPAa2L6eT or BUILDING MSPECTIOSS �S L
`\ 212 Hain Street ee9 Lipa a 1i nq
Q� xortn t.' tm 01060
Debris Disposal 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 p11e��rformed at:
a`6 ��ybt rr l L N r��nli�r�, raA
(Please pont house umber and street nam )
Is to be disposed of at:
r kt?\'r\ w'l" *rc Ie(VI�b"F kt�.v .�5r�c hnA l�>s�o�t/� �' ;"J Ot; hn k
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and
ndd Address)
21
�— / ✓�
Kz
Si nature rmit Applic t�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.