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43-152 (5) 5 HAWTHORNE TER BP-2021-1390 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43- 152 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-2021-1390 Project# JS-2021-002315 Est.Cost: $6000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq.ft.): 44431.20 Owner: GONZALEZ KEVIN Zoning: Applicant: MARK LANTZ AT: 5 HAWTHORNE TER Applicant Address: Phone: Insurance: 180 PLEASANT ST #200 (413) 529-0200 () WC EASTHAM PTON MA01027 ISSUED ON:5/25/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATIONNVEATHERIZATION 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. i I � • Certificate of Occupancy signs . •• �` • i FeeType: Date Paid: Amount: Building 5/25/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner DeFOR`,o¢� o` City of Northampton >'` " BuildingDepartment / ` C a i' i • A*212 Main Street INSULATION Aiit Room 100 � Northampton, MA 014G_0 �� / "" ,--4.'' phone 413-587-1240 Fax 41,32587-272 �� ONLY _ _._.,-.._ :,itip,",„,,. ._ i ',,,M EC•�,��DVYP ____, APPLICATION FOR INSULATION FOR A ONE OR TWO FAMIL N&ING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address: 5 Gq f�om c 7(rrace Map 4_5 Lot /C Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e U j ✓1 C)Q11 Z�i►l e. Z- 5 �44wt� Ile Ierract Name(Print) Curre, Mailin Address: � i' � �27� 7ff., 9 Telephone Signature 2.2 Authorized Agent: A CA Ln A I"Z (' 2Ny dti alt/ftrXrmGr n a /8 O`�0045A9 L M5?lye , A/v ,2 Name r t) / Current Mailing Address: If 4`�Z� Vi-5d9 -zoo Signature Telephone SECTION 3-ESTIMATED CO STRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) i 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 40,4 i 5. Fire Protection 6. Total= (1 +2 +3 +4+5) ,Oo 40 Check Number (44 Li 1/ This Section For Official Use Only Building Permit Numbe P /a ,310 DateIssued: Signature: 5-2 -ZOZ) Building Commissioner/Inspector of Buildings Date © EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoerviso_r: Not Applicable 0 Name of License Holder: �\ q_ L.G�.\\-Z I 0 a)tO al License Number 1`dC) \eFSA...k 4 `LcS4( r '\•0.; mQ 'a� ��� '�` Addre Expiration Date `�I S ae1' Oci�O Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Ca 2.-y Home e c-bk sr(No,(\(9_ 1 k2a7 ? 0 Company Name Registration Number %$ o ��ei.Sc'( `3\ ybitAl Address Expiration Date IK 4s/C\ h \' 0N, (Yl f\ Telephone 11,51 t,.U 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 QU No ❑ Brief Description of Proposed Work I ;rsec-( f)t- ic- Notd. S a To eit+rc.,(celo,rx) Ins 3 icc k e des \41M1 ue -514' 11 2'TTiKA rrnax Knct t„lall vJ4/( I, /i. �` ,as Owner/Authorized Agent hereby d e that e sta ments 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. /4/,1"A 44471z_ Print Na L / i / oVid/ Signature of Owner,'Ill''.it I, k T i COYZCf i cz , as Owner of the subject property // hereby horize Co Z '�G.77 e A-6,-,v)4.4 C� to ac ' my behalf, in atters relative to work authorized by this building permit application. iir -Li .--------- 5 /0-1 Signature of Own- ".„....2„.....„7( Date The Commonwealth of Massachusetts li .— 1 Department of Industrial Accidents :Jel ,�=9 — 1 Congress Street, Suite 100 °._ : E Boston,MA 02114-2017 e�i www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Co z)f Hwy)e. e —rini n Address: Ito 01eii5In-k• 5l City/State/Zip: Q] „r -1-o0 "►/. Phone #: Li/3 ' 5 d9-O6).6 d Are you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with —7 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.1=I I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14. ]Other /..4,IS Tjr/rt/ 6.�We are a corporation and its officers have exercised their right of exemption per MGL c. TT 152.§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C.04') w QiA oa jr.,— le..W\rt _ Ike/ C�r`1��J Cs fy/ Policy#or Self-ins. Lic.#:LW'$9 5--57 3' 0 I- 1-5 ( Expiration Date: ) 1'• a.-a.1 Job Site Address: 5 NG u#106116' 7r(t Ce- City/State/Zip:/Yorilylvi fogn /;f3 010 62 Attach a copy of the workers' compensation policy declaration page(showing the policy number add 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 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. I do hereby certifyy der the pains andd pp nalties of perjury that the information provided bove is true and correct. Signature: ��'`� / " Date: 6 ,2\52/9,( Phone#: If)3 -Sd -0 00 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 � � Massachusetts A. -- '•. ` `. *.r ± -' � DEPARTMENT OF BUILDING INSPECTIONS z ` 212 Main Street •Municipal Building vA. - Northampton, MA 01060 j4111, 3 ,<‘'. 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: }t 4 oc-n e,., rraGt, (Please print house number and street name) Is to be disposed of at: 4Ac(Rc 'l*, 33Lt ,,s-‘\,,,,,,o,,, fei WocA4-%I...) k(Pleas i print na e and location of facility) `) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) /4/ A ,,,,,./1„1 Signature Permit Applic nt or Owner D ie 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. _— vj yr &...d. .......... .. . oCc0,M°ra, r S.•. Massachusetts 4, ifi E' m i # : DEPARTMENT OF BUILDING INSPECTIONS 9 P "' 212 Main &treat • Municipal Building ' 1. • ., ,. Northampton, MA 01060 V�''sr `14' 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, repair, modernization, 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 registered contractors. Note:If the homeowner has-contracted with a corporation or LLC,that entity must be registered Type of Work: 3' R.F, e t , C? C. 0� il _Est. Cost:C•� J Address of Work: S }IA +horns I ec rcCL Date of Permit Application: 5 A.0 ) 1 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.L. Chapter I42A. 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: I hereby apply for a building permit as the agent of the owner: ^-� aCP' Pc-,k=.s Ac c•,,k-2, 1 c. Da e Contractor Name 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 City of Northampton `�"� Massachusetts Os .I +t - a` DEPARTMENT OF BUILDING INSPECTIONS t Vries 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: Contractor Name: 02-- 1-k..)r( Q., 2f C-)rrnGIIN (A. Address: ` c6 0 Q) p.s� ..\- 5N' City, State: ` PN`�)- T1h 'N `r,(4c Phone: "t\ .' - j3 °l- 0 . 0'11 Property Owner Name: Address: City, State: I, /Mte /*//17' (c• tractor) atte and affirm that the building I intend to insulate does not have any open air(kno• -nd tube)wiring i' the spaces to be insulated and that I have provided the property owner with a cop of this affidavit. / 1:1A7 Contractor signature,/, p Date