24D-280 (3) 165 CRESCENT ST BP-2018-1297
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-280 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permir. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv7 INSULATION BUILDING PERMIT
Permit0 BP-2018-1297
Project a JS-2018-002309
Est.Cost: $17000.00
Fee: $110.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa. 11): 13808.52 Owner. NOVOTNY RICHARD J&ROBERT J NOVOTNY JR
Zoning: URB(100) Applicant. MARK LANTZ
AT.- 165 CRESCENT ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST 9200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON.6/7/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:EXTER 10 R DENSEPACK ATTIC AND KNEEWALL
INSULATION, AIR SEALING
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 4 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 6/7/20180:00:00 $110.50
212 Main Street,Phone(413)5874240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
:r-47"J"a),
Department use only
i City of Northampton Status ofperma: .
� . Building Department Curb CtMDrfvemy Permit
212 Main Street Soarer/Septi:' h
` ;. Room 100 WateWfen Availabikty,
Northampton, MA 01060 T"Sob OfS;Ud ply
phone 413-587-1240 Fax 413-587-1272 PkWSlte Plane
t Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION EC -1 VEp p_ ,g + �9 7
1.1 Property Atlons": his motion to be completed by office
165 CfeSCe„f 54 JUN - 5 2Map til Lot -- QO
(„ qp /� //�� Unit
Nd4h'i+vt•Afv MA oecr Oe mm-DING,IMA:rnso Overlay District
U M1'ORTHAMPT
In co District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner ofWord: \\� r�� "}\ QId�
Na (Pring — HAS Cees '2 1� 5{ �}njA'1A
Current ailin Atltlress
J t3°$�-3 "r�—..
nature Telephone
2.2 Authorind Agent:en
'n'*y ` AryX7 Est5lrw 4§uu tr A 4)027
Name Pnnt) Current Mining Addirdirs,
K
— + )- Sa�- Qaop
Signature v Telephone
SECTIONS-ESTIMA CONSTRUCTION CpgTg
Item Estimated Cost(Dollars)to be Official Use Only
Com feted b rmit a Iicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee f
4. Mechanical(HVAC) i
5.Fire Protection
6. Total= 1 +2+3+4+5) it Check Number
Thus Section For Otgclal Use only
Building Permit Numb Date
Issued:
Signal
BuiWi nmmissionerllnspectorof 8uildmgs Date
goy
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION e-DESCRIPTION OF PROPOSED WORK(check all applicablet
New House ❑ Addition ❑ Replacement Windows AIteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signe 1171 Decks ❑ Siding CI] Other I�
Brief Description of Proposed 1�
Work: Mp}J Save A - lfx-�cr.ar tenScPhcks� Al' tkrva�hnu. JrlSy��Wr- AiIY,(I;
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No �-
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.If New house and or addition to existina housing,complete the followlna:
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 stones9
f Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L 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, Y�\"1krA kA Ny as Owner of the subject
property r
hereby authorize Q k I �X Mr1 f\0"-
to act nmy shelf,in all tters relative to work authorized by this building permit application.
V)
Signat 6reof OwnerDate
M
I, \ t 1T1C1,15— LAA 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.
rvl fl �-i Al
Print N
ti
Signature of Owner/ t Date
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License CSL)
(Y)P, 2— _ _ kenseVumhcr �spirnion Dute
\ n ICSI. II+Wa
adot."a 0,EQ 1+pc L) scr:ption
i \ . ]t
r Ln :v .pati{ Imi in 35.000 ca.it.)It R ai'� t IIA fam� U+wllin
Alaic,/IP V. _ Ma,orn
'i RC Real inz Co+aine
N'S Wi slue:md nidne -
SI1 Sohn l'ucl Humin_,Appliance
K13 531 03JU rcv'li, aZ-" M , m
r L.Id hone 8nvn , 1) U m union
(� 1� »() -_ . y S i.
51 x
Registered Home Improvement Contractor IHICi qq '.
�..Qzy__io-r&--ptc V L.r- _ lJ( RIgIlo nlpn Aumper L6innionlXa, .
Ilit (ompal, AUn nr11I( Reglies ntAai,
1f'D Q1e. ,r, 5i 1, 3u1 -- m c�C 2y�ozyho z uh—_
\n and'I", I nac ndress
ti h
City/Fown. Sta9
, 71P
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. it 25C(6))
Workers Compensation insurance affidavit must be comp)ned and subinincd with this application. Failure to provide
this affidavit will result in the denial Of rite Issuance of the coining permit.
Signed Affidavit Attached' Yes_. ......I; \u........-_G
SECTION 7a: OWNER A 'THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Las Owner'of the stb,ject property, hereby authorize C,�j29 _—
m act on m behalf in all matters relative to work aullionzed bt this building permit application.
T CN l e n e _ C/y�
- --—._
I esu O++ner's V tm (FI '.:epic 1i n:nur<) Usle
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest Under the pains and penalties or periury that all of the intbrtnatlon
contained in this application is true and accurate to the best of my knowledge and understanding
rittll na'.. ' 4uthmecd AL CIJ tont lEann C'enuu:rq IYatc
NO'PES:
.. An Owner who obtains a building permit to do his net own work, or an Ownel'who hires an unregistered contractor
(not reeistered in the Home Improvement Conn'actoi(I IIC) Program). will nor have access to the arbitration
program or.;uaranty fund under M.G.L. c. 142A. Other important information on the I HC Program can be found a: .'
q : o In[brmation on the Corso action Supervisor License can be found at o++w.mosS�n,dps
J
When subsiamslsiwork is planned,provide the information below
Total floor area(sq. ft.) _. _ _ . ._ (:ncludine garage,finished basementuttics. oecks or porch)
GI'oss living:area(sq.ti.l_ Habitable room coup[
Number of fireplaces Auinber of bedroons
\umberofbathrooms _ \umber of halfbaths_ _ _ ___
Itpeofmating ,Icm _. Numberofdeckvporche
Tope ofcooling system unclosed - Open
3. 'Total Project Square Footage" may be substituted tot"Tonal Project Cosi' 00 ` +
AcoR& CERTIFICATE OF LIABILITY INSURANCE
ananola
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), AUTHORED
REPRESENTATNE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT: H the ceDlacats holder Is an ADDRIOIUIL INSURED,the policy(Ies)mud be endorsed. N SUBROGATION IS WANED,sublect to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not conter rights to the
esrtiHcate holder In lieu of such endoreament(s).
FRooucwAME', MaryCorm
The Dowd Agencies, LLC PRONN,SAN.g13J3]-1010 we mmU413-437-1410
14 Sobala Road AA,
Holynke MA 01040mwnro dowd.wm
T Ms o COZYHOM-01
_ NSURERS AFFORDING COVERAGE HAICI
INSURED esumeA A.Seleorw Insurance Of South Carotim 19259
Cozy Home Performance LLC IxsuRER B.
180 Pleasant St -
EasthamptonMA0102] INSIIRERC:
WSUms D'
INSUREFI E: _
XSURm F'
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 WITH RESPECT
TO WHICH 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.
IXBII PoLICY 7W; :LIMITSPEOFINWRANCE POLICY XUMBFA• GENERAL LIABNTY 1522reen AI12Ru15URRENCE SI oN.soCOMMERCIAL GENEPALLABILUV SSW,WO _CLAIMSMADE rOLCW ore rYM) 31SM0LBADVINJUPY f1 W]A'MAGGREGATE $360m0
GEHL AGGREGATE LIMIT APPLIES PER PPOSUCTS-COMPAPAGG SSCW WO
POLICY%I PPO �,LW $
• 1UTOMOBILEUABIUTY A01.. AIP*DR 1 Y91MI9 COIEeMBINEINGLE n
$
160 W9
uudnll DSLIM
ANY AUTO BODILY I.US pFDnn) S
ALL OWNED AUTOS BODILY INJURY IPx—Mdl S
X SCHEOVLEDAUTOS PROPERTY DAMAGE
IX AFES AUTOS IPo,Yu]etl) 'S
r_
' X NON-OWNED AIR05
S
% 'UMBRELLA UA. IX ,OCCUR 53AC9N 9/[°10 V9R019 EACH OCCURRENCE 32 WJIXO _
EXCESS UAB ICLAIMS MADE' IAGGREGATE $t..
DEDUCTIBLE 'S
77
RETENTION S 3
NORERSCOMPENSAnaN I w CRYAU or -
• EMPLOYERS LIABILITY
PROPS I ETORIPARLUENNAGODTIVE YIN N/Ai EL EACH ACLIOENi 3
OR
D"'CERIMEMBER AMCLNCED? �I
(..q In NH) ELOISFASE EA EMPLOYE $
DEBCR4IION 0 OPERATIONS MWw
EL.DISEASE-POODY LIMIT 1$
DESCRIPTIONOFOPERATIONS/LOC ONS/VEHICLES(AIM[••CORD101,bftbmlrm*sao ..Xmme i*I UMI
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 Sl AUTNo MEDREPRESENr°nvE
Easthampton MA 01027 Q 1OW20M ACORD CORPORATION. All rights received.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114.2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AnnGcant Information Please Print Legibly
Name (Business/organimtion//Individuaq:�d 2.�4,( h),lrV)LJL-
Address: \ I P e e r
City/State/Zi : h N _ Phone#:An you an employer?Check thea propriate box: Type of project(required):
L I am a employer with --7 - 4. ❑ I am a general contractor and 1
employees (full and/or part-time).` have hired the sub-contractors 6. [3 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ® Demolition
working for me in any capacity. employees and have workers' 9 ® Building addition
[No workers' comp. insurance comp, insurance.'
reuired. 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ q ] officers have exercised their I I. Plumbing repairs or additions
1 am a homeowner doing all work ❑ g P
self. ' comp.m o workersright of exemption per MGL
y t p c. 152, §1(4),and we have no 112.[] Roof repairs \
insurancee required.] x.`Ritut�
employees. [No workers' 13.QOIher JR-t
comp. insurance required.]
Any applicant that checks box#I must also till out the section below showing their workerscompensation policy information.
'Homeowners who submit this affidavit indicating they are doing all wor1k and then hire outside contractors must submit a new atidnit 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-comosecas have emplolees.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. I
Insurance Company Name: CO/1f r.1 p:1rt � . ''1 _fh"11111'V �iL�1'��i✓t tf _—
Policy#or Self-ins. Lic.#:_4l0 ` �1-�' S -�- U - /j Expiration Date:pp/1� // d
Job Site AddressCity/State/Zip: \�of'x1`Is�YON mA o111b0
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 dap 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.
1 do hereby certif the pain and penalties of perju dhat the information provided above is true and correct.
Slymawre - /! �"-' Date
61LylIY
Ph #
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#:
yds..-- sic
.�' Massachusetts e2 > <<
ti� c
i
DEPARTMENT OF BUILDING INSPECTIONS
212 Nain Street •Municipal Building JdC�
Northampton, MA 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:
16S CIR-5u,N 0 Noce
(Please print house number and street name)
Is to be disposed of at:
'ScnS� w,�l\ � IYMJdeA YL�M St�t l`r0�r@
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
G v1
Signature of ermit Appli ant 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.