31B-175 (3) 37 HENSHAW AVE BP-2017-1342
GIS#: COMMONWEALTH OF MASSACHUSETTS
talc 31B- 175 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-2017-1342
Project# JS-2017-002225
Est.Cost: $3800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 11543.40 Owner BATCHELOR ANDREW
Zoning: URC(100)/ Applicant: MARK LANTZ
AT: 37 HENSHAW AVE
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:5/25/2017 0:00:00
TO PERFORM THE FOLLOWING WORK AIR SEALING, CELLULOSE IN ATTIC
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 5/25/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240. Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1342
APPLICANT/CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 180 PLEASANT ST#200 EASTHAMPTON (413)529-0200 Q
PROPERTY LOCATION 37 HENSHAW AVE
MAP 31B PARCEL 175 001 ZONE URC(I00)/
THIS SECTION FOR OFFICIAL USE ONLY: /
PERMIT APPLICATION CHECKLIST `
OSED REQUIRED DATE
ZONING FORM FILLED OUT (L
Fee Paid d'm'1It Ypq'J
Building Permit Filled out V'
Fee Paid
Typeof Construction: AIR SEALING,CELLULc - ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
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
INFQRMATION 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
/�.n Dela
�2 -77
Si•If;uil� f:ia 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 Permit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Waterfwell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Piot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
7.7 ProparlyAtltlreap: rt This, section to be completedlby office
1-k kms '^,GSW 'ri�n� Map ,�t{�7 Lit I Is- Unit
- (\d'IQid Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
F1P, IIC 14 03 c•Y' ete-a?Va
Jcti' CkR?Va Z'1 He<,5`t18YJ tt, CV„f-\ 4'cti
Named int) 7 Current Mailing Address:
Cel jam- 1 /``..-_ Telephone (0 ^' 43
J
Signature
2.2 Authorized Agent: aU
l—et ‘ 4,,, ei.\.54Xxx * Q QLOLD '‘'‘)
Name(P' Current Mailing Address:
+ 0.0't (�)0�7
l13 'S a.`�' 411
Signature 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
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) ..((��
5.Fire Protection L
6. Total =(1 +2+3+4+5) � �",, V — Check Number /4T(IJ/ /(,j
This Section For Official Use Only
ate
Building Permit Number: issued:
Signature:
Bolding Cmnmissionethnspeator of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
I
New House n Addition ❑ Replacement Windows Atteration(s) U Rooting C
Or Doors 0 ,
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks IQ Siding CI) Other 1�y\
Brief Description of Proposed V ((�1�� \, n /
Work: S\9r3 • 2 -. 's L. (at U) . w I 1 Ii * c_ Il) >, t.4‘ - kat5
Alteration of existing bedroom Yes_�No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Qt No
Plans Attached Roll -Sheet
Ila.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
I. Depth of basement or cellar floor below finished grade
k. Wilt 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
OWNERSiAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMtT
I, (-t 'r^1 0\S-( Y^./ C�`k-OreA,) ,as Owner of the subject
property (' 1 t ',,> /-
hereby authorize C—CI) \j `Z / 'FTJ-cc\. v� Jk.:`end)-N(l(I
to act behalf.* all matters relative to work authorized by this building permit application.
� t/ .. s1171r �
nature of Owner , `' 7 Date
1 fl -K I
I, Cmo-6+^0, 1 Z.. ,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.
4/ A_LAz
Print
SignNam /J v
Signature of Owner/Ag QeC' Cate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Nameol License Holder'. MP1t' L
� h h1 Z C35/ -- 17
License Number
Adores.
Expiratio iDate
r _ V - 9- i
Signature elephone
9.Registered Home Improvement Contractor; Not Applicable 0
C2 4)n\4 ;j tz (4\ {Y,c,c\1 Q 1 to3\-2 ? 0
Company Name Registration Number
\4 3 RUNS°,nk `3V ..c c, ))(.�.Q�sek; K � 11
Address Uv Expo tion Date
Telephone�„itt}}t3�S i'(jr{,Q(} I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-O.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resu
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 1;6 No O
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,r4 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}on 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 law's Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
A - Department of Industrial Accidents
Office of Investigations
ah : —�4 1 Congress Street,Suite 100
' Ni� ee Boston,MA 02114-2017
if de www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Ca - er-CA h
Address: \% \ C/NS ox \ Sr S a,t3l1
City/State/Zip:_kp,. N Phone #: H 1" 5 - Q•
Are you an employer?Check the a propriate box:
-'r 4. I am a general contractor and I Type of project(required):
.® lam a ( ill with / ❑
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
listed on the attached sheet. 7. ❑ Remodeling
2.ID I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
cora . Insurance.' 9. ❑ Building addition
[No workers' comp. insurance P
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, 81(4),and we have no
employees. [No workers' I3.51 Other 1d\yvA
comp. insurance required.]
*Any applicant that checks box W I must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they arc 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.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: CDn )a.'] �n 71./1 / ion / , (orty
Policy#or Self-ins. Lie.6:l y(e - b-Ys 3 � 3 - 0/ - // Expiration Date:teii/c4//7
Job Site Address:37 rI tr hflW Atq City/State/Zip:VI 0101Lt' (`(l-t\
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 S250.00 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 ,. .',the pain and penalties of perjurwthat the information provided above is true and correct.
i•nature: , email/ Date: S 7 1 t
Phone#: 7/3 — Sr)9 -lid 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#:
City of Northampton 212 Main Street,. Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150k
Address of the work: ',1 N ; ''i ttr t'L A r v I)+C'Irp11"e r
The debris will be transported by. ✓ , 1 v _ . 1
t
The debris will be received by: , .=r !: , , r So L_ --t,
Building permit number:
n /-
Name of Permit Applicant
r , ,
Date Signature of Permit Applicant
City of Northampton
PP�i i
• Massachusetts CUP/
DEPARTMENT OF BUILDING INSPECTIONS
p z ,z Ufa;n rth4mp Municipal Bu'ildiny
Naxit,amptan i€A b.if60
Property Address ___':). ./. ��'* . ->t . i2FLf`
._ i.L ..._ l.k.,.�........
Contractor
Name (,.0 w' '_ \171.111f,/ �S t t it 'rr'fi t , ( / / (4 ._
_ �++ _.�
Address ': f ' }� v, t,- - _CH; S4 l. .. c
City, State) (C", ,r{ ��{ luC,,il.t`.S Cb ( ill /4 L 1e ,,), 7
Phone:
Property Owner ``‘ 7
Name. tTi"t C`�C�=-.t.c..'; J))(CTL' it i t;. I
Address: ( }-t tl_ Iild,ct, l -' "`< ,... _
v
City, State. 11,, 4-1r .1•. , r1f P71 .1`-1—
I. ��..— "- „--x""� (contractor) attest and affirm that the building I intend to
insulate does not have any 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 sgnature {
Date
1