24A-100 (4) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: m C h 2 /b,4 ?0 n j
License Number
Addr Expiration Date
ignature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
CO 2,v 14,--, p ro f-L 181A ?% 9
Comppa y N ame Registration Number
2 c 1,11.5
Address Expirlation Date
Telephone
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 building permit.
Signed Affidavit Attached Yes....... ❑ 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 10835.1.
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 9: STATE AGENCY AUTHORIZATION
Name and Address of State Agency with Property Jurisdiction and/or Ownership:
Name(print) No.and Street City/Town Zip Code
State Agency Contact Information:
Name(print) Title Telephone Number e-mail address
This Agency Contact,as the representative of the State Agency with property jurisdiction and/or ownership hereby authorizes
Name Street Address City/Town State Zip Code
to act on the Agency's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here El and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control ��11
X
Name(Registrant)Vi NCN PVV Telephone Number e-mail address Registration Number 0 a 110
Li IJ
Street Address `�% c c City/Town ' }� ��' State l�r� Discipline ( C. Exj�ir�tion Date
10.2 General Contractor
Company Name C,a3y NJCtL q ti ,) Mw)o / G o-k- 7 0 191
Name of Person Responsible for Construction KN �► �- 4,n�'� License No.and Type if Applicable
Street Address 1` City/Town State W) Zip Code
x - 'tI*S-'�a'3--7b Ii 1�7
Business Phone 1�` SIC,— ���,0 Cell Phone e-mail address �, «I .C
SECTION 11:WORKFRS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed
Affidavit submitted with this application? Yes*Z No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: CAMIS value of the Building $
(Labor and Materials) If not known provide request to DCAM via form at
1.Building $ httt)://www.i-nass.govZcam/CAMIS/camisUser.html
2.Electrical $ Total Contract Amount(see note 1)=$
3.Plumbing $ Building Permit Fee(see note 2)=$
4.Mechanical (HVAC) $ Note:Minimum fee=$25.00
5.Mechanical Other $ Enclose check payable to The Commonwealth of MA and write check
6.Total Cost $ number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding. Further,I am authorized to submit this
application on behalf of the state agency with jurisdiction and/or ownership of the subject property.
- - x
Electronic Signature(Please type name) Telephone Date
Title I Street Address City/Town State Zip Code
State Inspector to fill out this section upon application approval:
Name I Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors 17
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [l7] Other[dl
Brief Description of Proposed
Work: )S111i� ktQ, t'T l��rC j �-- �I� d2 r �?c,Li� 56��'� �jPe f b� ��1 . 4)�.
Alteration of existing bedroom Yes QX No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Ye No
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
1 C ( \; e)�j` as Owner of the subject
property
hereby authorize C O
to act on my behalf, in all rs relative to work authorized by this building permit application.
�G/--� � _�-�(� ► i 1 S
Sign ure of Owner Date
1 � vJ ��L �C� 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 Nam ,�
Signature of Owner/Ag Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW (P YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,/excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
ity of Northampton Status of Permit:
Ilding Department Curb Gut/Driveway Permit
12 Main Street Sewer/Septic Availability,
Room 100 Water/Well Availability,
am p ton, MA 01060 Two Sets of Structural Plans
L '
n o,,
r"�p oneA1 - 7-1240 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
This section to be completed by office
1.1 Property Address:
Map Lot Unit
\� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam (fj'rint) j Current Mailing Address!
f
Tele hone ro
Ja 4
Signature
2.2 Authorized Agent: _
Name ` �� Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTR TION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Bu 1 (a) Building Permit Fee S 5
2. Electrical (b) Estimated Total Cost of G{ r
_ Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number Q /0 7s
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0753
APPLICANT/CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST EASTHAMPTON01027(413)320-7611
PROPERTY LOCATION 175 NORTH ELM ST
MAP 24A PARCEL 100 001 ZONE URA000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to ExistinC
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
INF 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
e Delay
ure of Bu i ding ficial 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.
175 NORTH ELM ST BP-2015-0753
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 100 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-0753
Project# JS-2015-001458
Est.Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 22389.84 Owner: GIARUSSO JOSEPH M&SHERYL LAFONTAINE
Zoning-: URA(100)/ Applicant: MARK LANTZ
AT: 175 NORTH ELM ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST (413) 320-7611 WC
EASTHAMPTONMA01027 ISSUED ON:112312015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC 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 1/23/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner