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31A-004 (3) Property Address: 3 I ,A Contractor Name: ra t z in e_ i aelci7/116.ne---(, Address: 7 / v_ //a I Y,T t City, State: t { Phone: 7 — yd,v-, 7,4/J Property Owner 13 i I , Name: // f Jev— (iLf Address: 3o 1 j 1 P s City, State: Ao,, cfifriii (contractor) attest and affirm that the building I intend t insulate does not have y 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 / Date 0 - - A CERTIFICATE OF LIABILITY INSURANCE DATE (M 20 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jody Dodge Berkshire Insurance Group, Inc. IA/CNro.Fat) (413) "3 -9913 FAX No): (413)774-3872 117 Main St. EADDRE , SS : 3dodge @be rkshireinsurancegrooup.com INSURER(S) AFFORDING COVERAGE NAIC # Greenfield MA 01301 INSURERANGM Insurance Company 14788 INSURED INSURER S :Continental Indemnity Company 28258 Cozy Home Performance LLC and Mark M. Lantz INSURERC: 74 Lyman Rd. INSURER D : INSURER E : Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER:11 GL/ WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR I) R WVn POLICY NUMBER (MM /DD/YYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PRRENTED PREEMIMI ESES S (RENTED 5500 , 000 Ea occurrence) $ A CLAIMS -MADE X OCCUR MPJ6905M 4/17/2011 4/17/2012 MEDEXP(Anyoneperson) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO [ LOC $ IFCT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION I TORY IMITR I ' AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE Y N / E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y N/A 11/2/2011 11/2/2012 46-845373-01-01 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION (413) 259 - 2402 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cozy Home Performance ACCORDANCE WITH THE POLICY PROVISIONS. C /0 Libby AUTHORIZED REPRESENTATIVE 74 Lyman Road Northampton, MA 01060 Jody Dodge / JODY -c).,„0 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD SECTION 5: CONSTRUCTION SERVICES ;I • 5 Licensed Construction Supervisor (CSL) 11/ 1 • 4: Lei v Z License Number Expiration Date Name of CSL Hcicer i ( 4 (— • . ,-■ x A ; " !' ^�� • ,a, � t� List CSL Type (see below) r'1 V t ,r e, -N <,.l C) Type Description ." Apr ype P Lt lc , Lk _ • C; Unrestricted (up to 35,000 Cu. Ft.) R Restricted l &2 Family Dwelling Signature L M Masonry Only ( ? RC Residential Roofing Covering Telephone WS 1 Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D 1 Residential Demolition 5? egistered Home Improvement Contractor (HIC) (�(7Z�/ Z'v -)-, , ld , w l �� __ HIC ompan ,,--0 'y Name or HIC Registrant Nam i. Registration Number Addrfss r I .V'lff..� f"yi) y/ _3)-(' .' f Expi tier: Date Signature Telepnone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) i 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 No SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ' ,>'(%�, , as Owner of the subject property hereby authorize ,Qi • - „h4A, --L. t ,.a v' G..0-._ to act on my behalf, in all matters relati e to wplk aut..rized by this buildit�_ermit application. l � i '' 1 - � t . Si. nature.fO Da SECTION _ 7b: OWNER' OR AUTHORIZED AGE! 'T DECLARATION I MC14 )--a) iNk , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf 'M -.C (.--- 1--- 9--, ' Signature a : . Owner or Authorized ent / d'IrO/ id-- of r D- e (Signed under the pains and penalties of penury' NOTES: I 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor . (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5,-respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basementJattics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces _ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks / porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" • R SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone . , 9 Registered° 'Onel mpr ovement Co to actor p,, " j Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION .10- WORKERS' COMPENSATION INSURANCE! AFFIDAVIT (M.G L c '152, § 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 ❑ No ❑ 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 • A SECTION 5= DESCRIPTION OF PROPOSED WORK (check.all appl cable) t - , New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [[] Siding [Il] Other [l] Brief Descrip ' n„ of Propgsed �� _�� � - 5 Work: A t t\3 -'s Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a of New house:tand,or'add]fon to extstinq hoes nq; complete ttie fotlowi q: 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 COMPLETED WHEIM OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, A J as Owner of the subject property I hereby au on ` . to act o y half, in r.. e - ative to w. k authorized by this building permit app 'cab n. Signature of Ow r //"( Date I, j r11 /4 wt,' , as Owner /Authorized Agent hereby declare that the statiments 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 /' i �' � /0 Signature of Owner/ • gent ` Date .. w. .• Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete information ``„, b" • Existing Proposed Required by 'Zoning I This column to be fillo'd is by Building Department I ! 3 ti l TM 9 4 Lot Size Frontage i , 1 ! : , --......„1: Setbacks Front 1 1 i 1 s i f 1 ° n Side L:i i R:' L:l ; R: ? I ; L_ _____I Rear = = i Building Height = (--- I i Bldg. Square Footage i E I _% 1 I Open Space Footage (Lot area minus bldg & paved l ! l parking) # of Parking Spaces . Fill: _ „_ _._ ___ ._ _.., _...__ w__ _ .. ,... ___ _ __, _ _ . _ __ _.__. _. _._. (volume & Location) ` # A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW O YES 0 IF YES, date issued:% IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book i Pages and /or Document # I F B. Does the site contain a brook, body of water or wetlands? NO ,f,,ie' DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO f !4 IF YES, describe size, type and location: a D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO IF YES, describe size, type and location: e;3\ E. Will the construction activity disturb (clearing, grading, e avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IC IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , - - — PORA .A° - alit . i2Jai Xf, --....-::4;: r. v°,:i ori*t4.4,,,P,:iiktitt lik .. : zkr,:<,,,,„1,,,,,,,,,,P-4trol.'- --Attuv;t,Aqez..;Mtfo4Ar',.'34iif.o4*.legWq.at file !PC ".r-1.:- r t ' / '- ....eXS4116■ %1 '..;i.6:.i4e.grAi.'ft-frit: '''; i ' ii;;T'.;:"'.17::::1.1;.'144,tf:4::4w.'.f:;.;:-...t.:,;,iliW417'4,*.li i e : ' .1.i -, ,,.,4.--k,A144P-'=;-'" •-lt.1:7., ;',..,;;;;' '*;•,,7-4°:',..A,SA9C`I .1■,G -,,,-, ,:+jefir":114 4'1 4w.bi 1 - ei ci• ' . =.p.' TI a ,,t 4:Via*1.071t..,t-v.:7`....':.' -••'•;'*7`., .17:Rjegf°7;1::::•+.7.,t,tibalt.,(: C f C65 fl' 1 • -ss\ ' Building C i 2 y l o2 Room oMNorthampton o a Do m i i ten Department T o r Street S ti r Northampton, MA 01060 , '_, r _ 2 f;t:Vae..4:t:311t1:Yr"64.-t:4 ,, '' . ' -:: ' ,1--;- r - , -- t'i.:':''' - ', - ::'''''-`;'-'1, , 8:14 S pecify 1 DWELLING - 7. ' P- f °;"; Y phone 413-587-1240 Fax 413-587-12 72 APPLICATION ' TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FA District be completed ....kPI.r::.2.,,fritigtatiikei„ This s000,0-,49WilrAC-*IPM AI TE l' iNFO : RMAT 1 9- : ; niNi-T§Y,,l'U=9! SECTION, l'4,'-,--,' ,712.07"Clif*"4-4tZQ:tx;-'-' ..V;.-.NfiOMIA'!45-''''''.r.:1-; 1.1 Property Address' A- '''';,Oi2Arlllt42!44,6tk$U5''YgWPAI,#,#M',Tn'',Z:;;;:-i.Alk-41''V,. '44,4,44'....7'..7-12Av',,,.,,,-0,,..1.7,,,..6-,•-'-', ' ' z& - ..) v N" 1 ...', -',-- ----'cEl . -,..'-',...-,..,,,%,. :-_ , . 6\ rNNP‘ I)) illi:.::!ijiiiii4'-';-:-' - rl cji-NkN-yry.Nit\s...)1-.4 • - sECTION 2 PRP, _ ,..,.,„ ikT, ...-,7,.,„,1.-.,..,..,,':'::-,.z„,,', r AGE '..;' P , „ Y . OWN Y 2.1 Owner of Record. - 30 1 `u\ ' - Name 1 - fil - -S°211 gos , , k (-- _ - 7 ....,..,), CT Sign ture 2.2 Authorized Agent: ailing Address. ..... ./...--"` LA ■ i\qk).4'-- - -I-2 ,, \ C -,, Na tint)h /II \ , hl.t\onMeainglcidress: ,y17,7 ,...4 v i ' Te . .._ , . , . . , - '-,...-', -:: Official .90y Signature t.':-...:_..i14661iON COSTS ,-, . : .....,..,-,--.. 0 Ril ::-SEC L;ESTI...ATED C E stimated Cost (Dollars) to • ..,,-.'..-.::, .. .. _.,_' ...„...„_ comp by permit applicant ,:.(.6)....6-61:joi,i67,74tt-12:,...,..,r5,,,,4.,„,..t,.:,.1.,-1,..,,_,T,..-..,.:::_,,,,,..:::_,. ,,.2.,;,:::,y,,..,,,..,..1,::;::,,,,,:i..,:,:,._,. Item f-8i _ - .*,;: -,, ':''''J''''- . .''.:_:_f---,—,,- ''- '''E ted Total .:P.9,,,,' ,, ,,,:::„..: : ;.., : : : :_i. -:!,:, ':,.-..., _ . , , , 1.:(1;9- C fi ":from -(0) -:.,, .::.,_ ; .„.!,..,..„.„. .,•::: s.: ,. : , • ,, , , , , 1. Building 2. Electrical 3 Plumbing • ;BUilding.p" . . „ ..; .... ,..._ _ ... . , ... ......„ , ...,.,". „.....,.. ,....:: . . 4. Mechanical (HVAC) ..... ::-.....,--. .. :-'.....: ,.,..,,_ ...._ ...-_, .,...„— - -,....... heCk . , ., , , 5. Fire Protection ' ) .... 5 0 -• • . ' -*.arioffiirat'use-071yr.:. _ Building Permit Number:.-; .... 6. Total = _( 1 4. ,2,., +_3+,4t5,r.: .,;.:lhij Section.. ,.....[:..,.; ,:.._ .......„... ...,,,.,..„; .,_ i „ ; ., ......:, , ,_:. ,, ., , . , ,„ , .., _ .. .........- .-,...,....- . . -...-....,,.„_, ,. ..... . . . , , . . „, ... , . ...,...„ . , ,..... ...„, _ , ... ,.. , _, .. ,.,.. . , .., ,. , .,. ,,-. ...,,„ - - . -'• — -,..,.. -,-, ' - - - ' - - . ._ .. .. ..............„,, ., . ... . .._ .„ „...,.. ,, ., . .. . , -S117- ,-,:- ' ' 'Buildin9-C°m' missidne'rlins:Pect°"f' Bu ' ' • ..,. , File # BP- 2012 -0745 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS /PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 309 ELM ST MAP 31A PARCEL 004 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DAT ZONING FORM FILLED OUT Fee Paid �6 Building Permit Filled out �,����!� Fee Paid 5 f./� (5 Typeof Construction:_INSULATE EXTERIOR WALLS L� New Construction Non Structural interior renovations )( Addition to Existing 11 , Accessory Structure �4 Building Plans Included: Owner/ Statement or License 102169 3 sets of Plans / Plot Plan THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Sig = •. - of Buildi : 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. 309 ELM ST BP- 2012 -0745 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 004 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 -0745 Project # JS- 2012- 001312 Est. Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 19340.64 Owner: BOOS SANG KIT Zoning: URB(100)/ Applicant: MARK LANTZ AT: 309 ELM ST Applicant Address: Phone: Insurance: 74 LYMAN RD (413) 320 -7611 WC NORTHAMPTONMA01060 ISSUED ON: 6/21/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATE EXTERIOR WALLS -copy of final Utility inspection required 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 6/21/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner