35-014 (9) 185 WEST FARMS RD BP-2019-0392
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 35 -014 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-2019-0392
Project# JS-2019-000632
Est.Cost: $5100.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa. ft.): 7100.28 Owner: MCDANIEL SCOTT
Zoning: Applicant: MARK LANTZ
AT. 185 WEST FARMS RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON.101112018 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VAPOR BARRIER, AIR SEAL,
CELLULOSE IN 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:
FeeType: Date Paid: Amount:
Building 10/1/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
_ _
RECEIVED �/sv�
SEP 2 7 Department use only
2 _Ry of Nort ampton Status of Permit:
Buildin De artment Curb Cut/Driveway Permit
BUILDING Main Street Sewer/Septic Availability
_.�
HAMPTON'MAP01060ROOm 00
Water/Well Availability
A 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 ✓r /# _ �O�
1.1 Property Address. This section to be completed by office
Map Lot ni _Unit
Zine� _ Overlay Cistrict___,.__ i
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1#Owner of Record: �� 6
0�\ q\(- n', f S �.� �fl r
(Pri Current Mailing Address:
Na71�
Telephone
/Skfniture 1 I
2.2 Authorized Agent:
��e�5�,,,� �k � �,��1,MP�r� ml� 0 ►0��
Na Pri Current ailing Agddress: �
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
_ Construction from(6)
3. Plumbing i Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =0 +2+3+4+5) 5 Check Number /
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
1
f
t
i
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r
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1
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Si mg[O] Other
Brief Description of Proposed
Work: S t 1 J\ t { >Q1 -4A A, f K4 AAA 6 if f� �
�Jtc ��i y3rf�
Alteration of existing bedrd6m Yesc No Adding new bedroom Yes .� No
Attached Narrative Renovating unfinished basement Yes (--N No
Plans Attached Roll -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.
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
as Owner of the subject
property
Vacty
rize
beha all ma r el ive t work au rized by this building permit application.
wner Date
I, rnpt C� +_C'�� 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.
Print Nam
)VOIA A 7/.( J
Signatur of Owner/Age t Date G
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
y' Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaulicant Information Please Print Legibly
Name (Business/Organization/individual): Y)LR_ _
Address:
City/State/Zip: H Tv Phone #:
Are you an employer?Check thea propriate box: Type of project(required):
1.1�I am a employer with 7 _ 4. ® I am a general contractor and 1
employees (full and/or Zart-time).* have hired the sub-contractors 6. New construction
2.® 1 am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub-contractors have g. ® Demolition
workingfor me in an capacity. employees and have workers'
y p ry insurance.-' 9. ® Building addition
[No workers' comp.comp. insurance
required.] 5. ® We are a corporation and its 10.® Electrical repairs or additions
3.® I am a homeowner doing all work officers have exercised their 11.® Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs ` 1
insurance required.] t c. 152, §1(4),and we have no 13. Other 5 V 1 h
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box b I must also till out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating the) are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must 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 workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. / J
Insurance Company Name: C Din �J.1 I (J,'nA")V
Policy#or Self-ins. Lic.#: t{(o Y_5 ' 0/ - // — Expiration Date:
Job Site AddressAYS W• City/State/Zip: (` �)Vv
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 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.
1 do hereby eerti the pain and penalties of perjurthat the information provided above is true and correct.
Sip-nature: Date:
Phone# — r
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
15•1 Construction Supervisor License(CSL)
n i Ussn__)oi
License\umber FXpiration Date I
\:une ol'C'Sl. I folder
List C'S.i.T\pe(see belo�\)
\u.and suect T\PC I Description i
j U i Unrestricted(Buildings up to 35.000 cu. ft.) i
R i Restricted 1&,2 Family D\keiling ;
Cit.i'fo��n. state.%IR M Masonr\
RC 4 Rooting Co\eriny,
- ..-- — -- - - -------- WS Windmk and Siding j
I
SF Solid Fuel Burning Appliances
Insulation
I Telephone Email address D i Demolition i
i
5.2 Registered Home Improvement Contractor(HIC)
L�-Y� 7U 4 s"1► �j
i C.Q - ! �Z� {�!rYltl(1(. i IIC'Registration Number Expiration Date
I I IICC'ompam Nang or HIC Registrant\time
No.and Street ElmatLddress
City/Town. StatI,ZIP I cie�honr
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 152. § 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. 1
Signed Affidavit Attached? Yes ..........Ito No........... ❑ i
SECTION 7a: OWNER A THORILATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
as Owner of the subject property, hereby authorize C— No rn _ '4.,�(fn A n LA
to act on my behalf, in all matters relative to work authorized by this building permit application. j
Print 0"ner's Name(Electronic 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.
Print M�ner:or;authorized Agent's 'time(Electronic Signature) Date
NOTES:
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
i (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the ELIC Program can be found at !
)tip+ .ma.,•e —0-La Information on the Construction Supervisor License can be found at ytiwtk.mass.gov dm
2. When substantial work is planned. provide the information below:
Total floor area(sq. ft.)__ (including Lgarage. finished basetnenuattics,decks or porch)
Gross living area(sq. ft.)^—__ Habitable room count
Number of fireplaces— Number of bedrooms
Number of bathroorns_ _ Number of half/baths_
Type of heating system _ _ _ _ Number of decks/porches _—
Type of cooling system.. _ Enclosed --Open
3. --Total Project Square Footage" may be substituted for"Total Project Cost" S /00
,Aco CERTIFICATE OF LIABILITY INSURANCEF74(MM/DD/YYYY)/24/2018
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 the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the 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 CONTACT
NAME: MB Conroy The Dowd Agencies, LLC FAx
14 Bobala Road •413-437-1010 •413 437-1410
PHONE
Holyoke MA 01040 AILFIAIg. mconro dowd.com
FHUUUH
7 rain ID r: CO2YHOM-01
_ INSURERS AFFORDING COVERAGE NAIC
INSURED INSURER A:Selective Insurance Of South Carolina 19259
Cozy Home Performance LLC
180 Pleasant St. INSURER B:
Easthampton MA 01027 INSURER C:
INSURER D:
INSURER E:
INSURER 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.
INSRPOLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
A GENERAL LIABILITY S 2208979 1 4/17/2018 4/172019 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY PR r n $500,000
_CLAIMS-MADE OCCUR MED EXP(Any oneperson) $15,000
PERSONAL&ADV INJURY S 1,000 ODO
GENERAL AGGREGATE $3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPAOP AGG $3 000 ODO
POLICY X PRO. ' X LOC $
JECT
A AUTOMOBILE LIABILITY A 9100582 1 4/172018 4/17/2019 COMBINED SINGLE LIMIT $1000 000
-- (Ea accident)
ANY AUTO BODILY INJURY(Perj$
PereoN
_ALL OWNED AUTOS
XBODILY INJURY(Per accident) $
SCHEDULED AUTOS
_
PROPERTY DAMAGE
`X HIRED AUTOS (Per accident) $
X NON-OWNED AUTOS $
S
A X j UMBRELLA LIAR X :OCCUR ',S 2208979 4/17/2018 1 4/172019 EACH OCCURRENCE $2,000,000
�— —+
EXCESS LIAB CLAIMS-MADE AGGREGATE $2000000
_DEDUCTIBLE r $
X RETENTION $
WORKERS COMPENSATIONWC STATU• H-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EX. Y/N E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE•EA EMPLOYEEl
tt yes.describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule.It more space Is required)
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 AUT110 IZEDREPRESENTAnVE
01986-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
1
City of Northampton
f• `� Massachusetts �v? - %,
I DEPARTMENT OF BUILDING INSPECTIONS
�. s a
212 Main Street *Municipal Building
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:
1165 k-Ij 110ns 0A N(X\ ln �A
(Please print house number and street name)
Is to be disposed of at:
1y(ILL 1-J 01 mu"� Ad 4pw)
(Please print name and location of facility)
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.