29-031 14 PIONEER KNLS BP-2019-0530
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:29-031 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-2019-0530
Proiect# JS-2019-000855
Est.Cost: $3300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa. ft.): 11979.00 Owner. DAUER JOHN A
Zoning Applicant: MARK LANTZ
AT. 14 PIONEER KNLS
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON:10/31/2018 0.00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEAL ATTIC, ADD 12"CELLULOSE,
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:
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 Sianature:
FeeType: Date Paid: Amount:
Building 10/31/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
— iartc use ori
City of No amL
S f
Building D artT 3 0 218 �P +n : .212 Main Str .5Room 00Northampton, MAnun DING iraPE I
7 �a'JOTON.MA o1 4
phone 413-587-1240 = ltt/ai#e Plans
011w 8 4
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ISP- 14 ^6'30
1.1 Property Address: l' \ This section to be completed by office
Map 074
Lot Q 2)1 Unit
Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
c'\-,c> >;�� 1 '�\Q'p r llS ,Q P)1X0'tMA o 16�i
i y Q �u�e4 f'JJ
N rint) Current Mailing Address:
JTelephone 1�
Signature
2.2 Authorized Ascent: 0-fPsv�r'A
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ' >,u 1 (a)Building Permit Fee
2. Electrical J (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) `��� Check Number PCIZ
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature: 10 3O 1
Building CommissioneNlnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 [0] iDecks [p Siding[p] Otherflll
Brief Description of Proposed II f
Work: S`!1'P►SS SAV2 NIA W-,1� 2nN Aydc W)2� � -t. 1V`P4 f,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existina 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
1, 01 U e as Owner of the subject
property
hereby authorize O2y HJ(�12. Q KyC VNCN4\CSZ
to a m ehalf, in all maft lative to work authorized by this building permit application.
gnature of Owner Date
I, ry-,?t rV L-�G�(��(� 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.
rnf\rk L�
Print Name
Baa �
Signature of Own gent Date
i41et'R0CERTIFICATE OF LIABILITY INSURANCE
sole
TVS CERT 11F" E Is 1 MWW AS A MATTER OF INFORMATION ONLY AND COO*"S 000 MGM"UPON 711E CERTIFTCATE NDLOEIL TVs
CERTNICIITE DOES NOT APIFI1lMATIVELY OR NEOJIT WELY AMEND,EXTEND OR ALTER TME COVERAGE AFFORDED BY 7ME POtlC1ES BELOW.
TVS CERTW$CATt OF INSURANCE DOES NOT COFNITTTIM A CONTRACT BETWEEN TNG M M M INWHENft AUTHORIZED REPRI SENTA TME
OR PRODUCER,AND THE CERTIFICATE MOLDER.
IMPORTANT It the owdh*W Roldw be m ADDITIONAL INBIJT M am poEc)Mal■rrt W .E WBROOATION M WANED ad a -Io aw lwm aM oondRlone
d oto poMeY.oertrin pop01■o nloY 1�g1Mre en wldarownoM. A olNw■wd on#"o■raAwA■doesnot coda tw"to ow owatow%OWN I"""a such wtdw■em■nq y.
PRODUCE" CONTACT
NAME
FAY
bu*sm r tnanramm atom It1ti tR+HONE.Elnl (877)934.1430 A� Nm (077)234-r4491
?ittal3a3A. BN 01203-4089 ATNKW
PRODUCER
CUSTO EA ID r
t 413)ii7-7 37 f INBURloq'b A"OPO ea CoVWM
" 6 b�'SUR A t:0atiawtal Zed+1■�itY Co. 7E9S•
CoA7/ �a • 2J+C iSvaER a
tba colo1I nwo ooa.
180 rloaamt St
wastham .tMo *A 01027-12s1< �rsuRElt°
■�sul�w E
C2% 1273 1480765 oisru Rs
VEGlamsfinVISION N METER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED NOTWITHSTANOW0 ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR WAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IN SUBJECT TO ALL
THE TERMS,EXCLUSION$AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
OWNWALLIAIITY fACZ-or-cum*toCE I
COMMERCbk4 GENII Kk I,Lm frlr LMAIAGE TJ RENTED
-CLAIMS PREMISES Fa:xwrtv+.T-
_.,.__,_-.......MADE DLLUR MED I
PERSONA-A ADV fWLIAv t
MNERAL AGGREGATE I
0EN L ADGMEG ATE LIMIT AP"S PER _..
.._ pR!?I7UGT8-r(,`MpClp Ana 1
pOLICY ':PnOJECT LOC
AUTOOM)BILE UA-A ITV I;,I;MLiINEdT$AK.iI f l 1411 I
ANY AUTO
ALL OW`&D AV t0' WJOIL.Y INJUnv-r,w P.— I
ti�EL�.li.E.:Y.AUTCp*.r BCVkLv INJURY •.r*;ati+^+ I
HCSh-+.'YWka"ET)AJ T O"R I
UMaRgLAUA6:. CK'x'LIR E.ACJt OCCUAREW.t I
.EA(:m uAE CLAMS-MApE
DEDUC TIULic
I
.RETENTION 4
AND Mp1.0"M UABILM YIN -oomplourookx:TDflYTL lIMT _ EP~,
Ei EACH ACCtOEar + 1,000,000
A'E�ccslmEc'
1�cuTroEawe�€eLwMnrR NtA 46-845373.01-14 W02/70t0 llllUMS
aftwommY I■Mp .: '.usE+�$a:-Ft4+tlP.,-.,'FF I =0000/000
R VOL*am in amw
spect7K1/000/000
DESS TWN OF OPS*AT*W t LOCATIDIW 1 VtH ICM IARtoh AaWd 101,AII/M WW 40"WM Schad a■.M Ito"400co N teau*WI
CERT- ATE
ow mom . SMOULD ANY OF 1`114 AWO OEEC*dlgD POUCW8 sE CAM"LLEO NP OW THE
390 p7+888
9XINRATIOk
OA OF,NOTICE WILL.BE DELNEIMWO IN ACCOROANIX WITH
THE POLICY
18rtb88{)h�o, M Olm-im AUTNORmm RORtAlNTATIV!
10 ummm 1,7933.16
ACM3E=11111R TeACOM moo ow am"am eglw■0 awn■at' GINW N ACONO CORPORATSRt AM#VM mnroW
The Commonwealth of Massachusetts
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/Contractors/Electricians/Plumbers
Applicant Information Please Print Lenibly
Name (Business/Organization/individual):C ;ter-i-�} {
Address:
City/State/Zip: 4. lV Phone#: 411
Are you an employer?Check thea propriate box: Type of project(required):
I. I am a employer with - 7 _ 4. ® I am a general contractor and I 6. ❑New constructionemployees(full and/or art-time).* have hired the sub-contractors
2.13 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
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.*- 9. (� Building addition
required.] 5. ❑ We are a corporation and its 10.[3 Electrical repairs or additions
q officers have exercised their 11.❑ Plumbing 3.[] 1 am a homeowner doing a!1 work $repairs or additions
myself o workers' comp. right of exemption per MGL
y [Al p 12.❑ Roof repairs
insurance required.] + c. 152,§1(4),and we have no
employees. [No workers' 13.®Other 111S�1cv1')�wJ
comp, insurance required.) 13.q
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating the)are doing all work and then hire outside contractors must submit a now affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees, If the sub-contractors have emplo)ecs.they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and Job site
information. ) jj� /
Insurance Company Name:-L D 1) t' •1 ;1 T n ( ?,��tm Q (U/�Y� ✓11 _
Policy#or Self-ins. Lic. #:_46 - I� s 3 2.3 - 01 - // Expiration Date:: �
Job Site Address: `t'\ \ �J���r ��0�1S City/State/Zip:49 e,-,CA_ rn$ 0)(16,�
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 23A 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.
I do hereby cer the pains annd naides of pc that the information provided above is true and correct.
r 01,
/ a
r
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.City/Town Clerk 4.Electrical/inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
2- License Nuinber Expiration Date
Mine of CS1.I tolder
List('S1.T-,pe(see belo%%)
\'o. and-slreel 1)PC I Description
U I Unrestricted(Buildings up to 35.000 cu.11.)
�'J'N(A
-n 2 Family Dwelling
M R 1 Restricted I&
\4 I Maionry
lic= Roofing Co,.eriny,
WS Window and Siding
SI: Solid Fuel Burning Appliances
Insulation
Telephone Dnailaddres,, 1) I
Demolition molition
5.2 Registered Home Improvement Contractor(HIC)
7 Q
HIS
' n
111CI Zcgistraflon\ iWil;e-r —Expiration Da-,
I 11('('ornpan\ Name or 111C Re isindrit Nunie
No, and Street
Einail address
tsi
City/Town.Stade.AP
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.J 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.
No........... [I
Signed Affidavit Attached? Yes ..........I
SECTION 7a: OWNER ATHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property, hereby authorize H13 me-
t'44(yn
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(h1ectronic Signature) -Date
SECTION 71b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that 311 of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Prinim ner or authorized Agent's me 0-:,lectronic Signature) Date
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(HIC) Program), will not 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
Information on the Construction Supervisor I.icense can be found at %k%vv,.mass.i.-1ov J12s
2. When substantial work is planned. provide the information belov,:
Total floor area(sq. ft.) (inciuding garage. finished basementiattics,decks or porch)
I
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 of cooling system Enclosed Open
3. "Total e
Project Square Footage" may be substituted for"Total Project Cost" 75
City of Northampton
X' Massachusetts
W:
DEPARTMENT OF BUILDING INSPECTIONS �
� 212 Main Street •Municipal Building b�.• ,QCT
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:
1'-\ Cl'7 C' 'Y-'M\ , 0,Y r\0-- mA
(Please print house number and s reet name)
Is to be disposed of at:
(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.