29-039 (2) 73 PIONEER KNLS BP-2019-0225
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map�Block:29-039 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2019-0225
Project JS-2019-000365
Es[ Cost'$3500.00
Fee, $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa.ft.): 13198.68 Owner: TOBIN JOHN R&BEVERLY C
Zonine: Applicant. MARK LANTZ
AT. 73 PIONEER KNLS
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 0 WC
EASTHAMPTONMA01027 ISSUED ON:8122/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.•AIR SEAL ATTIC FLAT, ADD 6" CELLULOSE TO
ATTIC, WEATHERIZE DOORS
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:
Dri,cnay 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 8/22/2018 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
-:PA) svr
R E On Status of Permit: Department use only,
Building Pal ME t Curb CuWrivewa.Permil
1AR
V m, eelSearq/Seplc Avallabli[y�fC WaterANal Availability
Npton, MA 0 060 Taro Sed of SinxlurM Plana
p on -5 -1272 Platloite Plans
NDRT AMPTON,M21% Oyler Specie
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property
Address. \1� This section to be completed by office
-) 3 U �n � A Y\b5 Map Lot Unit
Zone Overlay District
Q����1, oN rnP
Elm SL Digrtcd CB Digdet
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1�
A l N -)3 &30111r 1 y u��5 r Nof Q
Na Print) Current Mailing Address'. O I O 6 a-
- Telephone
Si nature 11 ll
2.2 Authorized Agent:\� Ito p�CaSN+tA �j�"7 d00 Q 5Y nti rh/1}UN IY�
Mf,rV �unT2 0
110d1
Na (Pri t) Current Mailing Address:
tiI'ts 5a �, poop
Signature Telephone
SECTION 3.ESTIMATED C NSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cam leted bv Permit applicant
1 Bcdd"'k k (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permtt Fee
4. Mechanical (HVAC) �O
5. Fire Protection
& Total=(1 +2+3+4+5) Check Number L
This Section For Official Use Only
Building Permit Number: Date
Issued:
Sign ure: /
Building C m ssionedlnspector of Buildings Date
Ihasbrouck @ northamptonma.gov
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows AIteration(s) Roofing ❑
Dr Doors
Accessory Bldg. ❑ Demolition ❑ New Signs M Decks M S{din ] O[he
Brief Description of Proposetl \ 6 (.t-���� 46 A#;(
workmE\}5 SAVZ J r/
Alteration of existing bedroom_Yes _No Adding new bedroom Yes C"I No
Attached Narrative Renovating unfinished basement Yes o'
No
Plans Attached Roll -Sheet T
ea. If New house and or addidon to exletina 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?
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 R.of wetlands?_Yes _No. Is construction within 100 yr. Floodplain_Yes_No
t 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
OWNERSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i
I, —TO\h n N UPJ �� , as Owner of the subject
property `\ (+
hereby authorize �,61'y ryz'mq, Pf("C� W'A-(\Ot-
to act ony behalf,in al matters relative to work authorized by this building permit application.
IL) 1
Signa re MOwner 1 `yy` Date
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.
Vt\Ar� Le.nk2
Print Name
6
Signaturd of Omer/A enf Date
. The Commonwealth of Massachusetts
Department of lndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electriebuis/Plumbers
Applicant Information Ple ace Print Leejbly
Name (Business/Organim('tiion/Individuaq:C 1Z-V 1:�)Ccd.e l�l'.1/rJ1GtVILR-
Address: \
City/State/Z N V,,N Phone #: 1' S 41 " 331`3 0
Are you an employer?Check the a propriate box: Type of project(required):
I. I son a employer with 4. ❑ I am a general contractor and I
P 6. C]New construction
employees(full and/or an-time).• have hired the sub•contrectors
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 far me in any capacity. employees and have workers' y ❑Building addition
[No workers' comp. insurance comp. insurance.•
required.] 5. ❑ Weare a corporation and its 10.❑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,,,��1,,❑rwws Roof repairs
insurance required.]' c. 152,§I(4),and we have no 13I Other l�✓I'r '( Y,
employees. [No workers'
comp. insurance required.]
eMY applicant Nucbxks box al must also fill mu oat sermon below showier Nair wm4n'compensation pollay information.
'Ho munmem who submit this affidavit indicating they me doing all wmk and then him outside contrMuns must submit a new affidavit indicating such.
:Conasctmn nut check this box must mashed m additional them showing the name of the sub-communors and stem hemer or not those enities have
esnplo)'eet Irthesub-wnnactorshave emplo)eM.thatman provide their workerscomp.policy number.
I am an employer that Is providing workers'compensation Insurancefer my employees. Below is the policy md)ob she
information. II II
Insurance Company Name. O n r�
Policy#or Self-ins.. Lic. #: 4(1a - IS 3 ) 3 " Q/ " // _ Expiration Date:—J/1 d
Job Site Addressj) r-fV. m City/State/Zip:j�0106d-
Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 S 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 c the patng and penahtes of perluryrthat the tnformadon provided above is true and comet.
S!C L ��� �/) Date If
Phone
#Official we 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 J.Chylrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
m ialat
oti
! Licenu Number H" imlinD
n att I
]:mm nl'CSL 14,It
IJst('S!.'ftpelxv,;b<lottl Y i
NC anA sI`re, \ I G�rJy( 11G�M T V a.i Yh Q (J �
L Inrevwww(Ru ldirzupto 35.000 cuIl
2 tr ? Family )
i
RCRon!ina Cotering
WS U'indow and Siding
SI' : Solid Fucl Buming Appliances
�1 Sj- _VNAl,� —
_)L&
22 �Isl(=i.M '. In.ulation
Telephone 1-mail addrl exi D Demolition
52 Registered Home Improvement Contractor IHICI -) 7 4 5 1 q
x_ moll( L _. I I( Itcgisvminn Sumher (cpinwt n Dric
I It( l tmpam Mow or IIIC'Regisimnl\an c
11KSL $12e,SAnk } >41Ail. - -- - '. mS s.Ezy
� \ and Su'cel r� Cmm ldnddrydrec.
,,ph, )—
City/Town.SIat4.ZIPZIP aephoTn< I '
SECTION 6: WORKERS'COMPENSATION I:NSURA NCE AFFIDAVIT(NI.G.L c. 152. g 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached" Yes ..........9 \o .......... ❑
SECTION 7a: OWNER A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.as Owner of the subject property,hereby authorize�r�2 1"I�P4)L nl r of (.L–
to act on m% behalf. in all matters relative to work authorize by this building permit application.
Pril Otcner's Namc l Electrome Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding
I Prim Ott ner's or.\ulhorizedA gcni s me Q'Icnronle Signnu¢el aze
NOTES:
.. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(H IC) Program), will W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at !
w ww ntac.eon tya Information on the Construction Supervisor License can be found at 1syy nrtss gOrdns
2. When substantial work is planned provide the information below:
Total floor area(sq. fl.)– _ . ..^. 6r.cluding garage, finished basemenvanics, decks or porch)
Gross living area(sq,ft.)__ Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms _ _. _ Number of half/baths
Type of heating system Number of decks/porches
Type ofcooling system_. Enclosed--open-
3. -Total Project Square Footage" may be substitmed for •Total Prosect Cosi' 3 S O O �
ACOA CERTIFICATE OF LIABILITY INSURANCE
dR412018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFRtEMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE ODES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSINNG INSURER(S), AUTHORUED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,tat PCIICV(")MUM M endorsed. N SUBROGATION IS WANED,suW to
the terms and Conditions of the policy,certain Policies may require an mnd mem. A atstemem on this LWBikate dost not cooler rttprts In the
certificate holder In Ilw DI such on lorsameut(a).
PRODUCER Mary C°r1
The Dowd Agencies,LLC INIONe 413437-1010 413437-1110
14 Robala Road
Holyoke MA 01040 mGq. dGAR1.wm
1. COZYHOMI
_ INew AFwRMWCOVERAGE xA.1
INMIREO
Cory Home Performance LLC ectiINSURER A:Selve Insurance of South Carolina 18258
180 Pleasant INAMR B:
M
Easthampton MA 01027 IxWeuREA c:
wwIMR D: _
INSURER E:
INSURER I,
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.
I�f TYPEOF IN6VRANLE Po CY NUYBIfl PD Y ' Po YYYY Ulan
A GENERALL4BILITY iB EXeWB Nt]R016 Nl]/N 18 EACX OCCURRENCE NIXO.
X
COMMERCIAL GENERAL LIABILITY SSCO.7
CLAIM&YADE _]OCCUR MEDSXP 13 1EGM
P....eADVINIURV II,.W0
GENERA-AGGREGATE $IGE.b
GFN'L AGGREGATEL1MnMWE6 PFA' PRCIX s CQNP.CPAGG "GKI
—1 PDLGY X PRP X .LCL f
• AUTDYDMWUABIUTY A 11.583 1 11.01, Ntbpts COM&NEDBINGLE LIMIT S1KO f0]
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UL
_ ANV PVIO ' ',BODILY INJURY{Po,gMn) Lf
_ AT 0.NED.XCG EDGILY II IPx ariGFrv) f
X SCXEDULE°ALTOS I PROPERTY DAMAGE
X HIPEDAUIDE ..(Pv rcNetl) t
_X NON.OWNEDAUTO5 t
_ E
X UMBREL14 WB X OCCUR '5 zxem, 41TG01B u11. EACHWCURRENCE f3.0.)
EACEMBLIAB CLAIMSMA°EI AGGREGATE f3M.0
L—.DEDUCIBLE --, I f
X RETENTION 31 t
WORNMMCDAR UA IUT - TA
AND ELPLDY0NJUABIURV
ANY OFFIWWMEMBEREXOLUDEOr ELuiIVE Y/❑H N/A E.L.FALX ACGDEM f
(Y1nEnn YIn HM EL.DaFASE EA EM%.OYE f
ye an.�,n.Lr,e.�
DESCPIRIONOFOPERAILY.pFbw EL.DISEASE POLICY LIMIT E
DESLRIPICNOFDPERATDNSIL TIONSIVEHICLES(A1M01,ACORD101,MBXb,WRpN&NXUIF.XmMagw b,p11,Mn
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 Horne Performance,LLC
180 Pleasant St AUTHO ,.,.R@RESSNunW
Easthampton MA 01027
A�
®1885-2000 ACORD CORPORATION. All ftma retarved.
ACORD 25(2009NS) The ACORD name and 1050 are registered markt of ACORD
City of Northampton
Massachusetts
x
DEPARIMENT OF BGSLDING INSPECTIONS i Z'
212 Win Strout •Wninipel euilairg c
NottTempton, D 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:
7 � Ka ,,u f )c no1� ) ,Wor
(Please PfInt house number and street namey
Is to be disposed of at:
z sM'Z\v h'n o\"A 6? b�q,)s� il\ �
(Please prim name and location of facility) F'l�g J`�� S( f1nik USS�OSe�
JN QS��,b.e
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant 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.