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22B-025 (4) 25 CORTICELLI ST BP-2017-1289 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22B-025 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A) Category: INSULATION BUILDING PERMIT Permit# BP-2017-1289 Project# JS-2017-002142 Est.Cost: $1300.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(so. ft.): 11064.24 Owner: AIKEN CHRISTOPHER Zoning: URB(I00)/ Applicant: MARK LANTZ AT: 25 CORTICELLI ST Applicant Address: Phone: Insurance: 180 PLEASANT ST #200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:5/9/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:AI R SEAL BASEMENT 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 Occu.anc si!nature: FeeType: Date Paid: Amount: Building 5/9/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File 4 BP-20(7-1289 APPLICANT/CONTACT PERSON MARK LANTZ ADDRESS/PHONE 180 PLEASANT ST 4200 EASTHAMPTON (413)529-0200 0 PROPERTY LOCATION 25 CORTICELLI ST MAP22B PARCEL 025 001 ZONE URB(10O)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FII LED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: AIR SEAL. BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 102169 3 sets of Plans/Plot Nan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN,FORMATION PRESENTED: approved_ Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:ys 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 Den clition Dey Sl? . re of B. dim O- cial 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 40k Contact Office of Planning&Development for more information. Department use only ‘� City of Northampton Status of Permit: ,.iU�� Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability r\4 < s Room 100 Water ell Availability \ % Northampton, MA 01060 Two Sets of Structural Plans �/ phone 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 com�pleteddby office a5 C.ork 1 c-al 't t Map aLot CLv)5^ Unit Zone Overlay District �\o( Fr (...9.- I�A Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C C\ s A1kEy, aS ( oc ; cQ \ ; Avu , -Ell oct),.<R Name(Print) Current Mailing Address'. (� -'1 C ?\, \L.__ GI10 - ukdS ' / tF1 \ Telephone Signature 2.2 Authorized Agent: /� G o.0o / m�li- L-o1x,�2— IVO 0) ec,�Can'f O)/ £ 5�'h"-nilui ry114 Na P t)) ,I ^/ yyy111 C.urrentlnailiinng Address: l lav S nature (((ffJ �fj Telephone SECTION 3-ESTIMATED C STRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee \ '\ Q)-0 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection f( 6. Total= (1 +2 +3+4+5) 1 3 00— Check Number /4773 / 0e This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House pi Addition ❑ Replacement Windows Alteration(s) D Roofing C l�I Or Doors 0 Accessory Bldg. I I Demolition ❑ New Signs CO Decks ❑ Siding [0] Other[Eli Brief Description of ProotoPoseg \ f ""i.5 5190/- 1 Work: .C1.C11.(' 4 n 11. [ \ YVAP SI )) �kivik ' J . Alteration of existing bedroom Yes _(�\ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Ye tr 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 I, C ` 1'\ (`i ti 1l t i_R 1'\ , as Owner of the subject property it/// /� hereby authorize Col Fi!%/Y7 e J" f/d"uy'I1I4/JLC to act o behal in all ers rela e to work authorized by this building permit application. /er 5/5 /17 Signature /of Owner Date N\I, \ t 1 P r\'f– Lo 2— ,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. Thi (`V L ½ 2Print Na a275 5 ) ti Signature of Owner/Agen ///3 Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \y Not Applicable 0 7 Name of License Holder m rtr tey1 Le-, h 1 Z c .55/ - I Oak/ 9 License Number \`(4ii \ RONSON.N)-- Mi' 7 �a6)-4\6`cy41J1\l 'Y-n Ad /di% Ol/o- drees Expiratio Date 1</.. y, i yt3 sag OoO Signatureelephone 9.Registered Home Improvement Contractor: Not Applicable 0 C t>2y 14c Y Q Q Cr \ '(YN o.x.(it f (o dP 7 0 Company Name Registration Number \A CS Q\ 1 .b\5w..�C 51' d, -.);\4-101-.„31-\N WV 445 Il 1 Address r� Expir tion Date t� Telephone 113-5al'04.00 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 (1\ No 0 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 10833.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,oris 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 he 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 The Commonwealth of Massachusetts Department of Industrial Accidents =As--l 5 Office of Investigations 1 Congress Street,Suite 100 • _='— Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information pPlease Print Legibly Name (Business/Organization/Individual).Co Z y 3bry t. Ire e!�[J(/fold 1�(!- Address: A% 0 Q \ 2 ev S o. ( \s" ( Sj- City/State/Zip: C.o,-S-0H I N 111C Phone#: 9 3 " S a - O a Are you an employer?Check thea.propriate box: Type of project(required): I.® I am a employer with 7 4. 0 I am a general contractor and 1 6. 0 New construction employees(full andior part-time).` have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in anycapacity. employees and have workers' P ry 9. 0 Building addition [No workers' comp. insurance comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] c.152.§1(4),and we have no < employees. [No workers' 13.q Other AI_n Alia�3 comp. insurance required.] _ 'Any applicant that cheeks box#I 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 comppolicy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. len)II • Insurance Company Name: CD1171.1 .Pn 7m / '/1nj (oM)h n/ Policy#or Self-ins. Lic. #: (M L - $-y 5 37 3n- 0/ - /I Expiration Date: NCl/ ( /// Job Site Address: 'T`M WC rf �--QI lCity/State/Zip: r( Cl/A( fy){) 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$250.00 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 certif 2 the pain and penalties of perjury,that the information provided above is true and correct. Si•nature: / cave' >'" Dat': 5 5 / I r>� Phone#: et/3— �9-tV7 UC) 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#: