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23D-014 566 ELM ST BP-2018-0993 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory INSULATION BUILDING PERMIT Permit# BP-2018-0993 Proiect# JS-2018-001805 Est.Cost: 55200.00 Fee: 565.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: UseGrouo: MARK LANTZ 102169 Lot Size(sq 13): 18687.24 Owner., MENDONSAMARISA zoning URB(100)/WP(3)/ Applicant. MARK LANTZ AT. 566 ELM ST Applicant Address: Phone: Insurance: 180 PLEASANT ST 4200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:4/312018 0:00:00 TO PERFORM THE FOLLOWING WORKAIR SEAL FLAT, 11" CELLULOSE IN ATTIC, R19 IN SILLS, KNEE WALL SLOPE 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 Occuoancv Signature: FeeTvpe: Date Paid: Amount: Building 4/3/2018 0:00:00 565.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 'h3i of Northampton Status of Permit: But din Department Curb CutlDriveway Permit 1, ' 212 ain Street Sewer/Septic Availability Room 100 Water/Well Availabliry 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 g o- 1 1.1 Properly Address: This section to be completed by offlce 5 m\ sk Map -,3p Lot 40tUnit p t`a\w 4i�� h� \ p) J b Zone Overlay District 4 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Mai f ,So' 0\eyl �oTJ Sbe tLm Sk �oc�hw ��ot mfl Nam rint) �/� Current Mailing Atltlress'. a Telephone sign ture 2.2 Authorized Agent: maf� Nam Print) Current Mailing Atltlress: 4 _ 5c3.�1�(7�lil Sig afore Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bLpernmt 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) 5 2" Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: at, ZI lam_ Building Commissioner/Inspector of Buildings Date @ CO/1-1 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) The Commonwealth of Massachusetts Department of IndustrialAccidents Offic Inv Congress ss Strest,Suite 1 1 Congress Street,Suite l00 Boston,MA 0211 4-2 01 7 ul www.m"s.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /' n / ePlease Print Legibly Name (Businesslorgmizantion/Individua0:l n �l 11ll'1'Ffa_ IJ �( ( IV)(I nLe- Address: \% 0 \ , �o.�� "-1P �13l1 City/State/Zip: LN Iv L Phone Are you an employer?Check the stpropriate box: Type of project(required): L® I am a employer with_ -7_ 4. ❑ I am a general contractor and I 6. ❑New construction \employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P lY 9. [3 Building addition req workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. No workers' cora right of exemption per MGL y [ p. 12.❑ Roof repairs Insurance required.]' c. 152,§1(4),and we have no I Other,/ 1 _ r) employees. [No workers' •�S G'A comp. insurance required.] •Any applicant that checks box a I most 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 atrid.o indicating such. Contractors that check this box most attached an additional sheet showing the name of the sub-contractor and state whether or not those entities have employees. If the sub-contractors have employees,they must powme their workers comppolity number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. II / Insurance Company Name: COP 7tj 1�rt l 'Ll�QJYI n CO/t1'J6 n)f Policy#or Self-ins. Lic. #: I�Iv -' .S 3 - Ul - /j Expiration Date:�!ht�7 'Wa ' ,,,,y/ Job Site Address:SC+C 5_ltrl S} City'State/Zip;/lli'r' >411 �Z///0✓140 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 a 152 can lead to the imposition ofcriminal 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 ofthis statement maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby cerlif the pat.ni and penalties of perjruydhat the information provided above is true and correct. Signature: Date' Phone#: 3 — -5 ' 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 Pelson: Phone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CSSL"IQ�l6r} la) irJ �iSf (Y) v;.t.eN:,inner lapimuonDuce \ J S . 1 I l r V : I 1 1 (S Igtc D.xa:ption �fl � 1 r:. Otlr4: 'dr:apL, J.oaocu.li, i B R i'.: : IKaI ntkDxellir, _ R( 11,111, (ottrine 'PC i"ne SIS,)hd Fcel BOr:tln^ Anpllance1 y13�S -0.�-oU ._ct�(k �.7saZr,�m(-�_M i lelcp'unc F.utuu aad rr� JcawliGon 51 Registered Home Improvement Contractor(Hi( i�.1-) 7u _ u, S �l �q2 }_jtIICR -:i' roi, Uule toner to ui t� II ( �pm A near III(' udr. � Cry/Town Stats 71P mutt „ ' SECTION 6:WORKERS' COM PEN'SATION INSURANCE .AFFIDAVIT(M.G.L.e. 152. § 25C(6)) j Workers Compensation l nsurmice eCfidavlt rust be completed and submfrcti with this 2pphcat1011. Pail Lire to pl'ovide this affidavit will result In the deniai Ofthe Issuance o'the Scildin_permit Signed Affidavit Attached' Yes_....._.ro \o.. __. C SECTION 7a: OWNER A 'THORIZATION TO BE COMPLETED WHEN OWN ER'S AG ENT OR CONTRACTOR.APPLIES FOR BU'ILDIN'G PERMIT 11.as Owner of the subject pi oparry.hcreb)autho.:u C-(j L Y�gI'Y11.. p f 4o !4-u6-LA-- _ m act on m� behalf. In,ail matters relative:o work amhodzee b) Pis bi,,Air_p rig t applicator. Pr'mt 0, 11, art.: nmuml Dmc SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby aucst ander the pain,and penalties otperjury Iiia;all oClhe ln SECTION S-DESCRIPTION OF PROPOSED WORK(check all appllcablel New House ❑ Addition ❑ Replacement Windows I Alteration(s) ❑ Roofing ❑ or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs I❑] Decks ED Siding LI] her(fA Brief Description of Proposed work:rna,° ° Ade yob! P f c'<-- cim Ilr Ccu-logf -'e [ 1`1 'aid S;))6 f"T'0\ sy Alteration of existing bedroom_Ves_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet Ga.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? K 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, (nNC I "1) Meh J as Owner of the subject property herebyauthorize CQZ e�� to pct ry behalf, inal rs relative to work authorized by this building permit appli tion. Sgnat re of Owner \ Date I, h"� (' Y� l—�Oi t\� 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, mA 4 PriX Signature of Own gent Date acoRo® CERTIFICATE OF LIABILITY INSURANCE '"MmDm m 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: If Me certificate holder is an ADDITIONAL INSURED,the polley(Ies)must be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of fire Policy,certain Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER GAME'. MaI CORLO Salves S. Owd and Sons Inenrance Agency Inc. PHONE AM 14 Bobala Read nc NII413-4T]-Into_ _.._ -L 3-437-141 IF Holyoke MA 01040 A.M. mco�@dowd.com_- _ _. USTRq uid C _CO_YHOM-01 ZusTOM INSURERISI AFFCROING COVEpgGE INSURED INSURER ASelective_ Insurance of _South Caroli.19259 Cozy Home Performance LLC - - -_- INSURER B 180 Pleasant St. Easthampton RA 01027 INSURERL INSURES D. .OR E' PER F: COVERAGES CERTIFICATE NUMBS R:114037 510 TN REVISION NUMBER: THIS IS 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 WITH RESPECT TO WYKH 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. NSR TYPECFINSURANCE e60L 9UBR POLICY NUMBER MIIDNEYW MMIDD LIMITS LPA A GENERALOABILITY 5 ]ID69I9 4/1)/301) 4/17/2013 EACI OCCURRENCE 51,000,000 OAMSOFFY)RENTED -- - _ COSMERCIALGSNERALLIABILITV PREM( ES AA-um . $100,000 C11.1MADE ODOUR MED IXP(Any one lrersw)_ 510,000 PERSONAL A ADV NJJ _S 1,000,00D GENERAL AGGREGATE _33,DCO,000 LGGP ESA-E_M'=>X ES-`C P PRODUCTS-COMPIOp AGG 53,000,000 POLICY % PRp L¢ $ A CT AUTOMOBILELMBILITY A 93005n2 4/17/2017 4/17h013 COMBINED SINGLE LIMIT 31,000,000 (Ea xc3en ANY AUTO —.. __— BODILY ILURY 11.1 X1.11mn) $ _ ALLowNED AUTos ' BoolwSIrvJu "s SLIPPY lvawaml S - SCHEDULEDAUTOS FROPERTYOAMAGE S HIRED AUTOS LPolew�nM NON OWNED AUTOS $ S UMBRELLA LMB X OCCAR E 2206919 4/1]/201] 4/1]/2018 EACHOUDRRENCE 5;000,000 F%CESSOAB FANG ACE AGGREGATE $2,000,000 _DEDUCTIBLE RETENTION $0 E ACR%ERSLOMPENSOMIN I- O - __. ER AND EMPLOYER$'IIABILIT" YIN TORYUNITS . BE ANY PRO'S EE.O,TNERE%ECUi vE� NIA EL.EAC CC E TC, CE IMyanOnNX1 ELDSE S EMPLOYEP�$ _- OEBCRaIDNOFOPERATIONSCelw EL DISEASE-POLICYOMIT 5 CESCAILONIOPERATONSILOCAnONBINBHICLES IA-PIACOROrm,AYOlpensl WmeM1S SCMCuk.l(men spau is nyuVWl 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 WIN THE POLICY PROVISIONS. 180 Pleasant St. Easthampton Me 01027 AUTHCePFD REPRESENTATIVE " ©198&2009 A CORD CORPORATION. Alinghtsrsearyed, ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Cita of Nonhampton _'!3 ,lain streeL, Northammon. 11,¢1060 Solid Waste Disposal Afficim 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 Perma shall be disposed of in a properly licensed solid waste disposal fac1ityas defined by MGL c 111 S 150A. Address of the work The debris will be transported by. The debris will be received by. Building permit number: Name of Permit Applicant 4"/-- Date "--Date Signature of Permit Applicant 3