24C-141 (5) 90 FRANKLIN ST BP-2018-1202
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:24C- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv' INSULATION BUILDING PERMIT
Permit BP-2018-1202
Project# JS-2018-002149
Est Cost$1100.00
Fee, $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sp.ft.): 9452.52 Owner. GOODMAN IAN
Zoning:URB(100 Applicant.- MARK LANTZ
AT. 90 FRANKLIN ST
AAakant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON.-5/1&2018 0:00:00
TO PERFORM THE FOLLOWING WORK.INSULATE SILL BAND, INSTALL VAPOR
BARRIER OVER DIRT 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:
FeeTvpe: Date Paid: Amount:
Building 5/16/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
T�
Depaflme-rd use ONy
p o I Status of Permit:
,>
mer t Curb CutlDrivaway Permit
212 Main St Bet Sewer/Septic Availab"
4 MAY I JR01610 Water/Well Awflablity,
\� Northampton, M 011 60 Two Sets of Structural Plans
ph, 41 -567-1272 Plomits Plain
NORr14411APIION,lklk a SPed6'
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO rF/AMILY DW)pELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by offlrx
Map Lot 1411 Unit
lo J zone Overlay District
Elm Si.District Ca DlstrWi
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDRGENT
2.1 Owner of Record:
1 I)\ �can� liU S� �or lw Pte{\
Nam Print) Current Mailing Address'.
" Telephone ' 41'3
-Signature U
2.2 Authorized Agent:
NE(Print) Current ailing Adtlress'.
H\3 5a i 6d�0
Signature Telephone
SECTION 3-_ESTIMATEdCONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit arrolicant
1. BD'AsiQg •l n5 J\ 1V (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Ln U
5. Fire Protection
6. Total=(1 +2+3+4+5) \ l Check Number 4-711
This Section For Official Use Only
BuildingPermit Number: Date
Issued: ` QQ
Signatur �✓ le
BuildingC rrAissionerlinspedor of Buildings Date
Ihasbrouck @ northamptonma.gov
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION b DESCRIPTION OF PROPOSED WORK(check all aDDllcablel
Now House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs M Decks ED Siding Ip] Other
Brief Description of Propos d I rnti t1 Save
Work \K, \�'c¢.. girl\�oc.r�Af �ne�r.\\ Y1Pac bHr11�. o� v. O'C' (�(��J�f / "��,
Alteration of existing bedroom_Yes��No Adding new bedroom Yes C \ No
Attached Narrative Renovating unfinished basement Yes _S� �No
Plans Attached Roll -Sheet
Its.M New house and or addition to existina housing, complete the followina
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?
I, Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. 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, `A N G W X W\k:J .as Owner of the subject
property r
hereby authorize 01
to on my beha in wl maters relative to work authorized by this building permit application,
�—, 1 v-�A✓`^� 5 1 6 1 `(�
ignature of Mner Date
I, M P\c\f-. `LP'rN — ,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.
Print Herne�
l
Signature of Owner ent Date
UK
acoird CERTIFICATE OF LIABILITY INSURANCE °°'E'M4124/2018/2rz018 Y'
o1a
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, EI(TEND 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 the cor ificate holder Is an ADDITIONAL INSURED,the P licy(fes)must be endorsed. H SUBROGATION IS WANED,subject to
the terms and con llllons of the policy,certain Policies may require an endorsement. A statement on this certificate tices not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER Naas OT Ma TiOnro
The Dodobala Agencies, LLC PHONE .413437-1010 ('A No 413437-1410 _
14 BObala Road rluL -
HolyokeMA01040 ADDRESS: mconroydowdcom
P ODUCERIUr C.OZYHOM-Ot _
IXSURan ED AFFORDING COVQigGE NAICY
IN9VNED INwRER A:SaIEWUNe N.J...Of SOUth(iar°IDa _ 19158
Cozy Home Performance LLC
180 Pleasant St. INSURER e: _
Easthampton MA 01027
INSURER
INSVRERE''.
INBVREA FTI
COVERAGES CERTIFICATE NUMBER:223405154 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 NTH RESPECT
TO VVTT ICH 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.
WE Rte - POLICY ER POLICY E%P pYliS
TYPE OFIXSURANCE POpCYXUMBEA MAnNVYY YYY
GENERAL UUMLlTY S 23X9]9 C/1]Q010 M1]YaVl19 EpCry GCCUPRENCE SI N],WO _
X�CO1MMERLpL GENERAL LIABILITY UEIAISE (Eearu :Z.
A
CIAIMSMAOE OCOUR MEOE%P(A',—) E11.,
PERSONALa AOVINJURY 110:) V
GENERAL AGGREGgTE SBWCN9
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPA)PAGG E3D =
POLICY X I PECTRO X LOC S
AUTOMOBILE UABIOTY 91W582 VP/3010 V17=19 COMBINED SINGLE LIMIT $I SCS
(EeecclMml _
ANr nIRo _tt SCOLY INJURY IN,PeIw^) S
ALL OWNED ACRES SODaY INJURY(vel eaaelul a
� X SLNEDULEDAUTOs
X TREDADLOS PROPERrrml DAMAGE
OPERTE
X NON-OWNED AUTOS Ia
_ S
X UMBRELLA LIAR X OCCUR S33ff+93 "ITS 17OGUA EACH OCLVREENCE $30.tl X0
EXCESS LIAB CLAIMS AGE pGGREGgTE S2,U]],XO
DEDUCTIBLE S _
X RETENTION E S
X°RHEAS C°MPEHSAl10H °i p9TP1?. OTH-
EAPLCSNUREVABLRY Y/N 5-
ANVPROPRIETORPARINEP/E%ECULIVE❑ N/A EL EACHgCCIDEN( S
°FFILENMEMBER E%OWDEDY
DERS ,In NEDEL.DISEASE-EA EMPLOYE E
y deunSA III
DESCRIWION OF OPENATIONS delwv EL.DISEASE-POLICYLIET E
DESCRIPTION CF OPERATONB/LOCATIONS/VEHICLES(MWh ACORD 1G1,AOOXIoml%mans YIIMUIe,II mmsPse Is nqulM)
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
Cozy Home Performance, LLC
180 Pleasant St.
Easthampton MA 01027 AULxORMEO RFSREsmranvE
®198&2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009N9) The ACORD name and logo are registered marks of ACORD
L-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) L S S 1_' 101.1_.1,r)
'12— 1 en,,rAumher Pnpimuon Date
V I(SLII lls
fit CSl.T1 (.�:bcln.�l
Vo,an�if 1LQ�P—`s -- 5� _. �C7� - _ F f)pu Dettription
�GPst�o,Mp� a ry F 01(J\7acd(Ilrnreapin,35MO0ca.11
R
R t mu Iti I unYl Uwcllinv
, Ctrl roto.Star.Ll V9 AAS vin
oc R0,11111"('o"' re _
1, SI Solid Feel Bnrnins Applianms
y, U _met.k� ,ur :
I I lphil..unc Cmai1 a.W rts. 1) D n 1'0r
5.2 Registered Home Improvement Contractor(HIC:) _Lb a7 ,1,)
Q,cs2;�_}{kir �_�Zf �`U( n�f_:L _ '11(12 ''( adon AuroneF'unaf...t Dila
111( (ontpam A t ,,or I IIC Rsg, n nt Arose
1X9 qe� �f, Sar X311
V 'a 1 svccc t roto ador ..
I£ Fhtht,rr.DMf\
C ip/1 own. Stall LIP I
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. § 25C06))
Workers Compensation Insurance affidavit must be completed and submitteei with this application. Failure to provide
this affidavit will result in the denial Of the ISSLlanCe Of the bcilding permit.
Signed Affidavit Attached" Yes e
SECTION 7a: OWNER A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR.APPLIES FOR BUILDING PERMIT
1 1.as Owner of dtz subject progeny, hereby authorize C�2 471�C..uj C4 1 nrifjil�_
to act on m) behalf, in all matters relative to work author;md mthis building permit applicmion.
Ira U))nzr s Svn (I(lectronic 1i_nmuns) Dere
SECTION 7b: OWNER' OR.AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all ofthe information
contained in this application is true and acctnam to me hest of my Knowledge and understanding.
r'ttU tner so 9uthtrin JA¢ nt ,mcll`ICUr ucl' n:ewyl Uate
NOTES:
.. An Owner who obtains a building permit to do hls,hei Own work,m an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), mill not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
) )w.ma s a Information on the Construction Supervisor License can be found at w nu�s ups_
?. When substantial`wa or a is planned,provide the information below:
Total floor area(sq, ft.) (mciudinggarage,finished basemenvattics,decks or porch)
i Cross living area(sq. ft.) Habitable room count
Sumber of fireplaces `,umber of bedrooms
`,umber of bathrooms Nunt'ozr of hal.*%baths
hype ofherin scacm `:umber of decksi porches
T)pe of cooling system dnclosed Open
"Total Project Square foO[age'"may be stbs[ituted for 'Total Project Cosi' 1F 1 l
The Commonwealth of Massachusetts
u,p
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
AoDdcant Information Please Print Legibly
Name (Business/Org�im(�'tiionnndivldual): iJ Z-V ]'{') Idf t�Yt�btivl(y-
Address: \ 0 ON ` it itG t
City/State/Zip: h Iv Phone#:
Are you an employer?Check theappropriate box: Type of project(required):
I.® 1 am a employer with ----77 4. ❑ 1 am a general contractor and I
\employees (full and/o .- have hired the sub-contractors 6. [3 New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These subcontractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ® Building addition
[No workers' comp. insurance comp. insurance
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 an a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions
myself. o workers' cora right of exemption per MGL
y . P c. 152, §1( ),and we have no 12.12.[] Roof repairs \\
insurancee required.] 4httitJti
employees. [No workers' 13.M Other IlV\\
comp. insurance required.]
Any applicantthet checks box 91 must also fill not the section below showing their worker,compensation polity information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a naw affidavit indicating such.
Contractors that check this box of 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 workerscomppolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
information. ) /
Insurance Company Name: ('_/Y),q4 � ✓tt
Policy#or Self-ins. Lic.#:_Lt�3 - 0l - / _ Expiration Dateee:�_1/ d
Job Site Address:Q� f rxt.\(-�i J SN *%* City/State/Zip: `1vi 0- H�cj 10(,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dale).
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/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 cew. the paint and penalties of perjury+that the information provided above is true and correct.
S' t �! �`-'� Date*
Phone#
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.CitylTDwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
'"` Massachusetts
x
�� � DEPARTMENT OF BUILDING INSPECTIONS
212 Nein Street •Municipal euila ng
Northampton, M 01060
Debris 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 150A.
The debris from construction work being performed at:
CV, q C' r1 \i N "\x \y Uc� uV M
(Please print house number nd street name)
Is to be disposed of at:
-ice e' \% o \ eksC-N ak ��e lovJ
(Please print name an location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
y� (Company Name and Address)
Signature of Per it Applican or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.