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35-207 (2) Office of''(' Busine 12c2watIon HOME IMPROVEMENT CONTRACTOR - Registration: 162770 Type: Expiration: 4/6.2013 COZY HOME PERFORMANCE _LC MARK LANTZ - 4 YMAN . _ \.C.:`,P, MA riderecretar:‘ - O•, "„;';;:, - 1 9P -onsTrotion Super/is Specialti _Icerise . :02169 =. IC MARK LANTZ 74 LYMAN ROAD NORTHAMPTON, MA 0107 • • 12 102169 - _ - _ - . . , . . , 4 . BPI =74 • The Commonwealth of Massachusetts l z., Department of Industrial Accidents (, Office of Investigations IC eArige.==1 600 Washington Street 4-' —9.1-- E - -, : Boston, MA 02111 `'' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Con tractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): 44!J2, Horne__ Pelican an 0_,() i Ltd_ Address: I c ' A 1 .c son+ ,sT7 - -k Sb t'k 4 City/State /Zip:bctS e i- w,. V CU ° 1Phone # :(q 521 - c aclO Are you an employer? Check the • ppropriate box: Type of project (required): I 1. I am a employer with (-, 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. E Building ° addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.11 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. "Other 1(I` O Q comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. ' 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: .1 ' I - a , 1 , • ! g1 _a 1,0 -a I f Policy # or Self-ins ic. #: — 't. � ` L' 1 Cl .— OI Expiration Date: i i / 2) i Z. k * 5 �C Job Site Address: �`1i ' r YS )( Q!� , City /State /Zip:(` e... 1, rr ` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c tify under pains ndpenalties of per' that the information provided above is true and correct. Signature: JL / '( Q. - A_ 1 G- . ' Date: (o /251/:2_ ro. 4111fr Phone #: 60'3)s • lJr 6(,) 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 #: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) / �-1 G `1 lam-/ 1 i2__ �� _ License Number Expiration Date Name of CSL- Holder 15n �� Rxt S. - I h as ( L ist CSL Type (see below) InSU1 OY1 10 Address Type I Description ����'4 U Unrestricted (up to 35,000 Cu. Ft.) Si g ature %%% ��� R Restricted 1 &2 Family Dwelling /4135 � . 0,400 M Masonry Only 1 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) rOZ7 1DVv1 L re4 f:› ,v ate c,i_ _, Li c.., /Co 4)'7 - 20 HIC Com.any Name or HIC Registrant Name Re Number 0 '' , A `i. i ' 1 7 4 /3 Addr ss � rt ./∎(t - ' )-(A— LY73) 5a9 • 0 aoc, xpiration Date Signature Telephone SECTION 6: 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 No ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OW, ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ' , 550 N 1 I, _V .. , as Owner of the subject property hereby v authorize a r_ _ , ► - €..['k trst,---c.-2 - to act on my behalf, in all matters relative to wo . thorized by this building permit application. v w.... � ` w ti 71) 40 Sig,na re of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION t I, �C,.( F- �� .. , 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. c r<k i ' / 1ff )-..__ Print . , , Si. 'at• of Owner o ' �thorized Age D.t' ur (Signed under the pans and penaltie of perjury) NOTES: 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 basement/attics, 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 "X V 4 3 0.0 I JUL 2 3 21 The Commonwealth of Massachusetts 1.. _. ' r ? Board of Building Regulations and Standards FOR uE; N ORTHi AMF w o � • , ' ... ., Massachusetts State Building Code, 780 CMR. 1O S B USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One or Two - Family Dwelling This Section For Official Ilse: Only Bwldtng p*mitNUnxber: Date Applied 13tulding Official (Pnnt1lame} Signature ORl PION ,.z.0 1.1 % k .:) d A ( 1.2 Assessors Map &c Parcel Numbers 1.1a Is this an accepted street? yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 1 Lot Area (sq ft) Frontage (ft) 13 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L e. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public D Private 0 Zone: -- Outside Flood Zone? Municipal L7 On site disposal system LI Check ifyesO 2.1 Owner f Record: ' ame (Print) City, State, ZIP No. and Street . _.. Telephone w Rolm!. Address New Construction 0 Existing Building 0 Owner - Occupied 0 I Repairs(s) Cl Altent on((s) D Addition 0 Demolition 0 Accessory Bldg. 0 Nuniber of Units Other 0 Specify: Brief Description of Proposed W •rk 1 \ 0\ ' ,. t A & t k.'3') CN ib1 _ lie! . . 4 uSIRK a 1 ill $:COW 4:: 15 :4# f 3 ;UC✓1T4lrit C .0 . Item Esti oss. • abor and Materials Official Use Ouily 1. Building $ 1 Buil Retrial l ee:: $ Indicate how f is deternun ed ' 2. Electrical $ 0 Standard City/Town Application Fee El Total Plo ect Cost (Item 6) x niulttpl ei 3. Plumbing $ 2. Other Fee $ 4. Mechanical (ITVAC) $ T.ist: 5. Mechanical (Fire $ Total All $ Suppression) � Check N I',.' Check Ad ultf _____Cash Amount. 6. Total Project Cost: $ ) ) © Paid in bull 0 Outstanding Balance Due: i ii File # BP- 2013 -0088 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 1238 BURTS PIT RD MAP 35 PARCEL 207 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE o k ZONING FORM FILLED OUT Fee Paid 664 n Building Permit Filled out � )� Q 4 Fee Paid Typeof Construction: AIR SEAL & ATTIC INSULATION b A( New Construction �"� Non Structural interior renovations / eCJ Addition to Existing Accessory Structure Building Plans Included: W Owner/ Statement or License 102169 3 sets of Plans / Plot Plan THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 A er*fr4 Si: ..re o Bu din: iffic 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. 1238 BURTS PIT RD BP- 2013 -0088 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 207 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- 2013 -0088 Project # JS- 2013- 000138 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 71002.80 Owner: KOSSON JULIE & MARCIA MERITHEW Zoning: Applicant: MARK LANTZ AT: 1238 BURTS PIT RD Applicant Address: Phone: Insurance: 180 PLEASANT ST (413) 320 -7611 WC EASTHAMPTONMA01027 ISSUED ON: 7/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:AIR SEAL & ATTIC INSULATION - INPROCESS 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 7/26/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner