11C-026 (6) 4 STOWELL.ST BP-2017-1290
cls#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-026 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLc.1144(2�A)
Category: INSULATION BUILDING PERMIT
Permit a BP-2017-1290
Project# JS-2017-002143
Est. Cost: $2700.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
onst.Class_ Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ILJ: 8494.20 Owner: MIENTKA GISELE M&MARGARET A MIENTKA& FRANCIS A
MIENTKA
Zoning: URA(IOO)/ Applicant MARK LANTZ
AT: 4 STOWELL ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 0 WC
EASTHAM PTONMA01027 ISSUED ON:5/9/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC, ADD 6" CELLULOSE TO ATTIC,
INSULATE KNEEWALL FLOOR
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 5/9/2017 0:00:00 $65.00
212 Main Street,Phone(411)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File P BP-2017-1290
APPLICANT/CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST#200 EASTHAMPTON (413)529-02000
PROPERTY LOCATION 4 STOWELL ST
MAP I IC PARCEL 026 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 6,,BuildingPermit Filled out -Fee Paidf'
Tvoeof Construction: AIR SEALTTIC I)6"CELLULOSE TO ATTIC, INSULATE KNEEWAI.,L FLOOR
New Construction
_Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102169
3 sets of Plans t Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
A✓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
P- 'oliti,I Delay •
•
Signature of Buil, ng,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.
Department use only
\ City of Northampton Status of
h
Building Department Curbs of Permit:eway Permit
�� 212 Main Street Sewer/Septic Availability
0Room 100 Water/Well 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 completed by office
t\
*ow
Q\\ &} Map '`C Lot O ( (P Unit
I--csLNS MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C.-7'k 4: pP\ .p t \52\., 4 Skkwa RA. sk ,< A 5
Name Print) / Current Mailing Address i Li Li
'� ��.-� - C./�— Telephoned t .S �f - )
Sig ure
2.2 Authorized Agent: I ,� doa Q)Qa---)
/11 h r c71 -712_r 0-d /P5 S 44 5
rgslii4 tory inn
Name Pn Current Ma in Address.
9
'X 4/ 3- 5a-9-034)
Signature ( Telephone
SECTION 3-ESTIMATED CONSTR TION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildinga J� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
I
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) e.7UQ Check Number jCna etrGOC
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 n Addition ❑ Replacement Windows Alterattlon(s) Roofing n
—� Or Doors 0
f
Accessory Bldg. 1 Demolition ❑ New Signs [O] Decks ID Siding E] Other(El
Brief Description of Proposed m IL
work: 13, e.\ NHtS PAd bit (4.))\v‘( �P\#) c 1N•SkA Jr. 'NI-1\11A 'Fatc, STflre
Alteration of existing bedroom Yes_pc_
No Adding new bedroom Yes O( No S 13
Attached Narrative Renovating unfinished basement As No -
Plans Attached Roll -Sheet
se.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, 9 I ea.th— I ' l 1'e c•k.\CC" - as Owner of the subject
property '' \\� L y
hereby authorize C-07— Yf)Y'(\A- \ e1 `Coe(\cork0--
to act on my behalf, in all matte relative to work auT�Thhhorized by this building permit application.
Cy-a jilLzi ifr" \ 3/6//
Signa of Owner ` Date
111111
I, �P N, La y k 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.
Signedunderthe' `
pains and penalties of perjury.
th
Print Name i r
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable 0
Name or License Holder: M A(- F Lh A Z c 55/ - 100U G9\\ � \\ 11 License Number/ /
\ ! 0 ` 24,')051. */ c 1�f5frv'y 7Jty' 'H\Ys /�/ i0/ /�—
A�re/� Z� / ` Expiratio Date
, �e y/3 sa9 p�od
Signature / elephone
9.Recletered Home Improvement Contractor: Not Applicable 0
CnZ. I \jrn- vCr \\ cc,c,<.( Q. 1 to te• 70
Company Name Registration Number
\1-6Q Q\ 2y5�,r.�c 'S' c c,-5)- l-��: rny) AI,5 J ( 1
Address Expotion Date
Li Telephone ti-- 1-'MovOQ
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 (Ud No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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}our 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
-- = l
o:i!eI= Office of Investigationsel 1. 1 Congress Street,Suite 100
•{ =��i`=,�9y Boston,MA 0211 4-2 01 7
9' www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name(Business/Organization/Individual):CO 2. I-turn- . Q e.4(y[ys/)Ql f)(R
Address: \CISo Q e RS o,-0\s' S"1" -IY/ cQO
City/State/Zip: C "fn 1 oN Phone#: 9 1 3- 5 al - 03A3 3
Are you an employer?Check thea.propriate box:- Type of project(required):
L® I am a employer with 7 4. 0 I am a general contractor and I
have hired the sub-contractors 6. New construction
employees(full and/ori part-time),`
listed on the attached sheet. 7. ® Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
9 D Building addition
[No workers' comp. insurance comp. insurance.-
required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions
3.0 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.�Other 1 n5 uA
comp. insurance required.]
`Any applicant that checks box al must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new alhdavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not hose 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: COD )'t 1 a(VIM / 7;4N err ( r*ofnl
Policy#or Self-ins. Lic. #:_..46 - b-Y,5 3 7 3 - 0/ _ // Expiration Date:
"" ///
Job Site Address: `k S\aw 2\\ b� City/State/Zip: ul.r dl5 tni\ (3) OS3
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 certiif J the pains and penalties of perju ,that the information provided above is true and correct.
%Si•nature: / r Date: 5 5 /7
r
Phone#: 7/3— S d 9—lc)00
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#: