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36-027 (4) 36 DEERFIELD DR BP-2018-0992 GIs#: COMMONWEALTH OF MASSACHUSETTS MaRBlock: 36-027 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-2018-0992 Project JS-2018-001804 Est.Cost:$2800.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sa.ft.): 13198.68 Owner: DENNO RICHARD R 1R&SARA A LAMERE Zoe Applicant. MARK LANTZ AT. 36 DEERFIELD DR Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 (413) 529-0200 O WC EASTHAMPTONMAO 1027 ISSUED ON.•4/3/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:MASS SAVE JOB -AIR SEAL ATTIC, ADD 11" CELLULOSE TO 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: FeeTvpe: Date Paid: Amount: Building 4/32018 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Zvyu.UR�t'p I Department use only C y o Northampton Status of Permit: B ildi g Department Curb Cut/Driveway Permit f, �A 12 Main Street Sewer/Sepbc Availability ,nsrE_cnorrs oom 100 Water/Well Availability A", ON "'"" ton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PlotlSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Q�� 1.1 Property Address. This section to be completed by office 3 (o �ezre\d� � � Map 367 Lot Oa?teUnit �o�e nlP J 1 J zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: R- hi 1 �b �ee F%e�o� 1) r F�X?n(k mil 0/06 a (Print) Current Current Mailin Address 1 Telephone 5 y Signaturei 2.2 Authorized Agent: MF1 ! 1-,"'\ 2— N ISo��[n5H�3 �Ana� D� M9 UlO�7 Na int) i Current Mailing Address. �\ U /i 11 . Jaa- gJ00 ignature Telephone SECTION 3-ESTIM D CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant (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 6. Total=(1 +2+3+4+5) QC7 Check Number This Sectlon For Official Use Only Building Permit Number: IDat ed'. r Signature' y�2I I F7 Building Commissioner/Inspector of Buildings 1 ` DdSe l� �o @ my wZyl-I�rnP. Cun-1 f EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations I Congress Street,Suite 100 y' Boston,MA 0211 4-2 01 7 www.mass.govldia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information �// � ePlease Print Lit lv Name (Business/Organizanntion//Individual):\ �"l..N 1-}')(Y1 ',/ Pl�9(rsrfblf)ll-- Address: () 1 ' I 6 e jl� (�j�����JJJJJ'�t 1 City/State/Zip: h N Tt Phone d: j" S J - Q Are you an employer?Check the a propriate box: Type of project(required): 1.q I am a employer with_7__ 4. ® I am a general contractor and 1 6. ® New construction 'employees (full andior pert-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-contactors have 8. 0 Demolition workingfor me in an ca acit . employees and have workers' Y P Y 9. ® Building addition req workers' comp. insurance comp, insurance required.] 5. 0 We are a corporation and its I0.0 Electrical repairs or additions 3.® I am a homeowner doing all cork officers have exercised their ;I.® Plumbing repairs or additions right of exemption per MGL myself. (No workers' comp. 12.® Roof repairs insurance required.] c. U2, sx1(4),and we have no 'qq �" II employees. [No workers' I Other J (}JL/ 4-(/JIJ comp. insurance required.] 'Any applicant that checks baa el must also fill out the section below showing thcn workers'compensation policy Information. 'Homeown<rs who submit Nis affidavit mdicsoma they ora doine xi work and then hire nutslde cmh, cvm,must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name or the sub-contracmn and state whether or not those entities have amployees. If the sub-contractors hate cmplmisa.they must provide their amkers'comp policy number. l am an employer chat is providing workers'compensation lasarance for my employees. Below is the policy and job site information. I / Insurance Company Name: C 17 n �a ) +':17n 7 e (UY)� 104 n t _ Policy a or Self-ins. Lic. ;_: H{o �[[�f 0/ - %/ _ Expiration Date(( Il a Job Site Address: 36 Deeef FCO! City/StareiZip: rANs'nU "1711 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 oferiminal penalties of a fine up to$1,500.00 and, one-}'ear imprisonment, as well as civil penalties to the form m 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 maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby cerdf' the pain and penalties of perjuryothat the information provided above is true and correct. L � Signature / � Date, J3,(jg-h /y i Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License is 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 Construction Supervisor License(CSL) C fY)Of�L 2— Llc,11vernier IL\pi:aian Dat `,a Cil. totter I uC'A. I p F'c bzlmv .� V stI Seca T.pe Dzsaription is lnre't il Bu 8 trtlin xun to x000cu u.) R t dd ,18 famll D��ell n� CIr, I un.ST....Xl� M i M,t,tu , li RC Roofinrz Comnng — U'F 4V'itdoa anal siding SI iohd I`uet Bumins Applmncc+ � 13' S�`1_03JU nAck r�S9znynt. alauou. — ! lblip.mnc Cmai fld) dre.l U U u Bion 5.2 Registered Home Improvement Contractor HICK Lb 3,7 ' �O { rQ2 Hci me N( fU! mq(1( L„ _ IIC R t adnn Rusher Cpl n! Dnc I11( ( ,pan, Na I luC Rc i u I A,ar< 1`69 g e� ��]+ _SJ I' J1�. ___ - -- myc -mxs<9 Zy he r-fe c-a- �_. v dd"', ZkthrnmO_j-UivYlj' Sd.`Ld-J•�- Cry/Town Staff ZIP Ielrrhone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e 15:. §25C(6)) ! Workers Compensation Insurance affidavit must be con piciedand submitted with this application. Failure to provide this affidavit will result in the denial ofthe Issuance ofthe building permit ! Signed Affidavit Attached'.' Yes _.....� Vn__.._.. ❑ ! SECTION 7a: OW\ER A THORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1.as Owner ofthe Subject property, heabp authorizeQi�-24 Off'i_p f4,,{✓)pr(�l ,( _._ to act on Ind behalf in all matter relative to work authorized b)'thi5 building permit application. 3,&s�1_ nm(finer I Arent (Illca onic Signore) Ume SECTION 71h: OWNER' OR AUTHORIZED AGENT DECLARATION Bp entering my name below. I hereby attest under the pains and penalties of pzljury that all of the information contained in this application is true and accurate to rite best ofm} knowledge and understanding. IJete NOTES: .. An Owner who obtains a huilding permit In do his he; own work, or an ower who hires an unregistered contractor (not registered in the Home Improvement Contractor LIC) Program). will not have access to the arbitration program or guaranty fund under M.G.L. a 143A. Other important information on the HIC Program can be found at NmP.OlaiN.gos a lnRrrmation On the Consvuction Supervisor License can be found at ,viin dps When suhstantial mark is planned,provide,the information beto,, I otal floor area(sq_ if ('mcicdin Garage,finished basement attics,deck or porch) Gross living area(sq. it.) Habitable room count _ � Numbers of Cueplaces dumber of bedroom, Number of bathrooms Number of halt/baths � IApe of heating when S inderofdecksr porches Type of coal ag sNdin Enclosed Open_ 13. 'Total Project Square Footage" may be substituted for"Total Project COST' SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs M Decks IQ Siding 0] Other Brief Description of Proposed Work: hP55 Sfl JE ��h Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Rall -Sheet sa. 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 . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWN`/ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ��_ I, 1 1 ( V)0h T) N 3 as Owner of the subject property hereby aulhonze C.O 2� �Jp'p P. �Q O( ihAf�[I to act on my be alf�, in all matters relativeu� work authorized by this building permit application. � Signature ilifOw\\ner —tt - Date Moog— 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. InIr� Print NN C U 6 Sig iature of Dwher/Aisnf Date A� CERTIFICATE OF LIABILITY INSURANCE ;,;zo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder is an ADDITIONAL INSURED,the polieylies)must be endorsed. N SUBROGATION IS WAIVED.subject W the temp and candidata of Me Policy,certain policies my require an endomernent. A statement can this ceNf cats does not Border rights to the certificate holder in lieu of such eadomemen ls). PRODUCDONTACT ER NAME'. MaL Conroy Cases J. Dowd and Sons Insurance Agency Inc. 14 Bobala Road uSxuo>En1',41331 32_100 _ Fuc 4]a-437-141 0 EMAIL Holyoke MA 01040 ADORERS mconrO @dpwd.com_ pR6tlucBt caeipMER ID x:COZYHOM-01_ INSURE&51AFFORDING COVERAGE NMCP INSURED INSURER A:Selective Insurance of-South CdIDh 19259 Cosy Home Performance LLC &SJRER B: 180 Pleasant St. Easthampton MA 01027 INSURERC: _ IxsueER D INSURER E'. NSURERF COVERAGES CERTIFICATE NUMBER:1140375167 REVISION NUMBER: THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MYTH RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR A°BLSLBA- MLCV Ell, 3WLR ryPECFIN$UMNCE POUCYNUNBER Df000 UNITS GENERALUMBhITY 5 32069]9 4/17/2017 4/17/2018 EACROCCURRENOE $1,000,0°0 - -DnMASErPPEO xe 'Eloo,o°o % COMMERCIPL GENERAL LIABILITY .PREMISES DOEao CLAIMS MADE _ OCCUR MED FXA OF,—XIsml 510,000 PERSONAL d ADV INJURY 51,000,000 GENERAL AGGREGATE 63,00°,000 GAEL\ EE VEP PRODUCTS-COMpIOp AGG S3 000,000-- _.- POLICY x Pao R LOC AUWM°BILELIA&LUV A 9100582 4/17/2017 4/17/2018 COMBINED SINGLE LIMIT 51,000.000 -- IE+ d-P - FNV AUTO BODILY INJURY Pe Porwn E ALL OYMED AUTOS BODILY INJURY N—YOUN O S V SCHEDULED AU70EPROPAGE _. .PS-1) 5 A HIRED Au.os (P.,Moace�o x NON OWNED AUTOS UMBRELUSUAB xpCCUP 5 2306979 4/17/N17 4/17/2010 EACHOCCURRENCE 52.000,000 B CESS UAB CLAIMSMAOE AGGREGATE _ .33,000.000_ DEDUCTIBLE S RETENTION $0 'E Man PRSCO.BGRUAREN AC SILL, DTH. ND EMPLOYERSLIABILITY _ O"OMITS.. ER ANYPROPR E70AEARrMEE%EOUTVE O NIA EL EACH ACCIDENT E OFFICEEMEMBER ESCLUDEO+ —- - - - - - - IMenNlorylnNH 11 MINUNIMAIM, FL OISEAS_E-EA EMPLOYE DMBATI°N OF OPERATIONS OMcw EL DISEASEPOLICYLIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ANDY ACORD 101,AIMMO M RMYMO,S PAP111,If mon spew Ie NXINO, CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED COZY Home Performance LLC IN ACCORDANCE WITH THE POLICY PROVISIONS. 180 Pleasant St. Easthampton Ma 01027 THOiIZEOREFRESENTATNE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ( '. of\on ?pton In accordance of the provisidrs of biGL C40 S54 i ackno.Meage--r a.as a condition of the building permit a: s -es- „ tre c r�a�cr activity governed by this Building Re r^t sha ce ^sed 0—r a r �de•ly ucensed solid waste disposal facility as de��nea cy Pl c '11 S '51) Address o`the work The debris will be transported by C The debris will be received by Building permit number Name of Pe,rrrt Albobcar't Date Signature Cf Penn it Applicant `. x. In accordance of the Provision!, of VG Sx _a:ecge;h,at as a condition of the building permit a alfcrs resu a from the cc-,sruchon activity governed by this Buiicing Per _shad be e issec 't e prcoe ly licensed solid waste disoosa `ac lit r. � de`red by MGI c 111. S 150A Adtl'es5 Of NOK The debris will be transported by The debris will be received by i Building perm@ number. _ Name of Permit App] cart ' Date - Siora'.ura o' Permr Acc''cs