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23D-139 Property Address: 7 /1Q`Y� 64 Zt , 7 - . Contractor Name: /70-1k (. (a41 /70.1-2 Aygrt,„taa.c. Address: A/ (71,v, u-.. / City, State: Ak4 "I/ 00 Phone: q) - S a-4 - 0-d)00 Property Owner , � e Name: i M ^ �v► 4- \ q t ' /TA r PA/v.4_ Address: � 1ATTACIC City, State: c Mf) I, h k- UM/4-U' (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. / Contractor signature ,I,,, ir,17 Date A/ 5/ Li deminmummonomminsuounw • • Office of Consumer Affitirs & Business Re<zu[ation HOME IMPROVEMENT CONTRACTOR Registration: 162770 Type: Expiration: 4/6.2013 __LC COZY HOME PERFORMANCT. LLC MARK LANTZ 74 LYMAN R.7., NORTHAMPTON MA C nderseer..12r). 2 ,3nstruction Superv:sor Spec:airy Lcense :35 32 102169 MARK LANTZ 74 LYMAN ROAD NORTHAMPTON, MA ()Or'. : 12/10,2012 • • '02169 BPI 11ED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER ATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. 0090063 -00 WC 009 - - 6606 3072 013 -82- 1110 -00 `INCORPORATED UNDER THE LAWS OF VAN I A .ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO.: OZY HOME PERFORMANCE LLC LYMAN RD C H A R T I S ORTHAMPTON. MA 01060 -4228 A Chartis company EXECUTIVE OFFICES: EXTENSION OF ITEM "_ OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 MA - . PRODUCERS NAME AND ADDRESS KEATING GROUP OF MA LLC WORKERS COMPENSATION AND EMPLOYERS 144 TURNPIKE ROAD LIABILITY POLICY INFORMATION PAGE SUI TE 150 SOUTHBOROUGH, MA 01772 -0000 M Ti S L LICY N LIABILITY I L I TY COMPANY RENEWAL 0074 ED 007453941 ETHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 r.. POLICY PER!OD 12:01 A.M. standard time at the insured's ,a lint address FROM 11/02/10 TO 1 1 /02/ 1 1 -M i A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease S 500,000 policy limit Bodily Injury by Disease S 500 , 000 each employee C. Other States insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV 0. This policy Includes these endorsements and schedules SEE EXTENSION OF ITEM 3D. OF THE INFORMATION PAGE - WC990612 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. I Premium Basis Rate Per Estimated CassWcal.Ions Code Number Toia Remuneration $10 OF Re Premium C Annual 3 Year muneration © Annual ❑ 3 Year I I EXTENSION OF 'ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES i $549 XP CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA. i � t !r.NIM UM PREMIUM $500 MA TOTAL ESTIMATED ANNUAL PREMIUM $8 _ 729 •_,cT :mt :• Dela& nIonm aclustments of premium shall be made: ',? Inc F .�idl'y� „aner:v Monthly DEPOSIT PREMIUM 9 114 /i0 PARSIPPANY 82 . ` ar�`:.....i .��c Dal•_ Issuing Office .- Authorized Representative WC 00 00 01/. .\ The Commonwealth of Massachusetts fir . Department of Industrial Accidents n, v " Office of InvestigaiionS 1; 600 Washington on Street _ Boston, 314 02111 www.mass_gov /din - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers - Apolicant Information Please Print Legibly r Name pusiness/Or tion/IndividuaI) v?Y, f- t,'t ✓) - . 1 ' -c_. E Address: -- ,r -. <,_ City /State/Zip: - '- . Phone #: `` �� . -- r _ • Are you an employer? Check the appropriate box: • Type of project (required) I_ Li I as a employer with - 4_. Q I am a general contractor and I employees (fall and/or part-time).* have ed the sub - contractors 6. Q New construction Z.. Q I am a sole proprietor or partner- listed on the attached sheet 7. Q R--modeling shin have no ploy ees These sub - contractors have. -g- Q Detholition working for -me in any capacity. o4_° -and.3zave woo' ers' . p: -�j 3 clifion {No workers' comp- insurance _ GS3BlCf. mcrrrar�P . _ --+___ requiredj 5. 0 We are a corperadon and its 10 Q Ele ttICaI repairs or additions • 3. Q I am a homeowner doing all work officers havext:rciseti their 11.0 Plumbing repairs or additions myself [No workers' comp_ right of exem per MGL I2. m . • . . f repairs insurance required.] t c: 152, §1(4), and we have no �" employees: [No workers' 1 � 1�1 % Other ,5 i/ ` comp. inn: ance regninecL] Any applicant that chi bax #1• must also fill out the section beiawsitowing their compensation policy information. t Homeowncs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Cautractnrs that chink this box must attached an additional sheetshowiag the same of the sub contractors and state wircther-ornot those entities have employees. If the sub -cant actors have employees, they must provide their workers' comp- poficy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. ._.-- -- - U 1 1 � Isstn -ance Company Name: N Ch Ch - C// V "- ': ' E ' _ � < `-' - � _ Policy 3Y- or Seif ins- Lie_ #: ',. "v '' `-, - , Expfranion Date: - (/// DI rob Site Address: ) /41( 4.1 g 1- City /Stir /Zio : f i-- 4 teach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). =allure to secure coverage as required trifler Section 25A: ofMGL'c_ 152 can lead to foe th osition of a penalties of a inc up to $1500.00 and/or one -year imprisonment, as well as civil .penalties in the form of a STOP WORK -ORDER and a free ;flip to $250.00 a day against the violator Be advised'that a copy of this stater: mat may be forwarded to the Of 'e of avesttQafions of thin DIA foi"in§taauce' covers a iiiificatlon: do hereb � certi under the pains- penalties o - .. - - 3 f3' P P � fP�1�9.fhaf - the informartion�rovrdedltbovp r<t raP_�n d rnrr�t .. j � enatLre: Date: / �7� /' sore - . - '7� - . . _ _ - Off use only. Do not write in this are; to be completed by city or town offzciaL City or Town: Permit/License trs Issuing Authority (circle one): I. Board of Health 2. Budding Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6.Other T Contact P erson: Phone ff: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor; Not Applicable ❑ / C� Name of License Holder : Mme'' L� Y) C72, / b / �J License Number 71 6 W - I 4 /z/a/2-0/d--\. Address 3 Expiration i� //2 4 / sa C3\ ' Signature Telephone 9. Reqistered Home Improvement Contractor: Not Applicable C3 14 6AA-' /7c0,77 Company Name Registration Number 4 / 1f/ Address �` Expirat n to Telephone %,. TO S .o • SECTION 10- 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 b uildii permit. Signed Affidavit Attached Yes !lam No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of 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. 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 the job 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 undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature _ �_ , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) _ 5 -,,,14 � New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing F 1 Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I] Siding [D] Other [K Brief Work: Description of Proposed 041 C (} _ c ik. , iccA 1142. Alteration of existing bedroom Yes (/ No Adding new bedroom Yes _ No ` ? Attached Narrative Renovating unfinished basement Yes No R-13 Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ' OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, COlsm"t' -• l� — , as Owner of the subject property -reby authorize � /` ibL.1 1.-1 o act on my behalf, in, in al l rs relativ o work authorized is buildin rmit application. ''g ature of Owner Date get_eali4A0 I, Y1 0% ` CA ' t , 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. Print Name _ %'1.'C G v /) l Signature of Owner /Agent Date ., F m-a-em"..".""4" , 0\1 Department use only �ec City of Northampton Status of Permit ` i p 2Q,, uilding Department Curb Cut /Driveway Permit V-)A 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability dF ; oca • hampton, MA 01060 Two Sets of Structural Plans pEP1• • . • one 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office • tv 1 4N 3 Map Lot Unit N , n n t /A r , Zone Overlay District " Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ( ame (Prin Current Mailing Address: 4.7 7 Ica. Telephone Signature 2.2 Authorized Agent: 1c4 -- n„ 4C, 7 �' / Name (Print) Current Mai Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building �f } (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) — 17 5'dO Check Number / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2012 -0384 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 90 HINCKLEY ST MAP 23D PARCEL 139 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out f��5 Fee Paid l /� Typeof Construction: INSTALL INSULATION 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 INF9RMATION PRESENTED: V 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 0/ ) /1 Signatu 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 Office of Planning & Development for more information. , . . 90 HINCKLEY ST BP- 2012 -0384 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 139 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- 2012 -0384 Project # JS- 2012 - 000606 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 14069.88 Owner: LEVIN BENJAMIN Zoning: URB(100)/ Applicant: MARK LANTZ AT: 90 HINCKLEY ST Applicant Address: Phone: Insurance: 74 LYMAN RD (413) 320 -7611 WC NORTHAMPTONMA01060 ISSUED ON:10/17/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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: FeeType: Date Paid: Amount: Building 10/17/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner