24A-199 (4) SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
2-
LicenscNumbc- Expiration Date
Jo
dame of CS1,I Ioldor
Lis
N't). a-n—dS-ircei Description
h U Unrestricted(Building,upto 35.000 cu,11.)
R f Restricted 1&,2 Family D%w1ling
M Masonry
�C , Roofing Covering
WS E Windo44 and Sidinu
SI: Solid Fuel Buming Appliances.
C7n-1) insulation
1'elephone
Email addrcA- 1) i Demolition
5.2 Registered Home Improvement Contractor(HIC)
7 Q
i �, rA in? A
IICRcgkztrafloii Number Expiration Date
I IK'C'ompam Name or Illi' Regisirant Nam,:
\o,and.. 11'ect
address
City/Town.Staft.ZTP
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 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,
Signed Affidavit Attached? Yes ...... ........... 0
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 C'�, HQz- r tv
J m �.L-j,4 - -------
to act on rn) behalf. in all matters relative to work authorized by this building permit application.
Print Owner's Name(Flectr is Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
B} 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.
1'r or.%uthorizcd Agent's tme(LIcetronic Signature) Date
NOTES:
1 An 044ner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor I
1 (not registered in the Honic Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guaranty fund under N4.G,L. c. 142A. Other important information on the FITC Program can be found at
ksk:.4 Information on the Construction Supervisor I.icense can be found at
2. When substantial %kork is planned, provide the information t)elox%:
Total floor area(sq. ft.) 6rciuding,garage.finished basennerivarrics.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/porchei
Type of cooling system Enclosed Open
3. -Total -Project Square Footagemay be substituted for"Total Project Cost"
J �
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aimlicant Information Please Print Leeibly
Name (Business/Organization/Individual): z�
Address: / rO y0
City/State/Zip: crr�5%/-/,�//'Jf>/0/,/ O� W/ Ihone#: -e1)3-,5c0- 0,,400
Are you an employer?Check the appropriate box: Type of project(required):
1.[MI am a employer with_employees(full and/or part-time).* 7. ❑New construction
I am a sole proprietor or partnership and have no employees working for me in
' any capacity.[No workers'comp.insurance required.] 8• ❑Remodeling
❑3.3.E)1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. Demolition'
❑4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs Or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.*
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.441 Other 1
J i <(LS)/V
152,§](4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \\
Insurance Company Name: i1`� ,(�Q��a\ fl G�CM f�t Comp em
Policy#or Self-ins.Lic. Expiration Date,:f J )
Job Site Address: � '1 1�o N �Q� l-2 T� City/State/Zip: 1y�N\ .Q�uh, tYl 0)Q�
Attach a copy of the workers'compe'hsatihn policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify linder Ae pains andpe allies ofperjury that the information provided above is true and correct.
Si nature: cv: 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
Northampton, MA 01060 .......
Debris Disposal Affidavit
In accordance of the provisions of IVIGIL 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:
3c, MV,r,0kN -f�ns� , N1CDYn60r\,
(Please print sen Atuber and strbet 'name)
Is to be disposed of at:
T(w4,, w ,�)
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
�7 1111AA
Signature of Permit**Oplicant 7/0,Vner 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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) I
New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing ❑
Or Doors 171 1
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Dec4s [M Siding[0] Other]
Brief Description of Propoged
Work:rCft-.Oi '51 A'd�,A A
lk '(fJ o.4 Qi "Kid 14J 0116
Alteration of existing bedroom Yes No Adding new bedroom-Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Sa.If Now 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?
& 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.
1. 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
hereby authorize CO ZY /7/6&W
to actmyb h 9 -m II niatters relative to work authorized by this building permit application.
vJ
Signature of Owner Date
M.AA L 2 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 pen (ties of perjury.
Print Name
�� Giy,�/{ /1L
Signature of Owner/Agent Date
City of Northampton ' A ,
r.: Building Department ,' f
212 Main Street ` '
Room 100 kia qNwx
E., i
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 _
9
y"+
APPLICATION TO CONSTRUCT,ALTER,R EPAIq,RENOVATE OR DEMOLIS H A C 4E OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION NOV 3 Q 2018 `g 0��
1.1 Property Address: This section to be completed by office
DEPT OF BUIL ii! ;C INSPECTIONS �`y,�./�
1 f., 1 e ^ NORTHAfMap)N.MA 01060 Lot / Unit
w o� rT4� Zone_ Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na rint) Current Mailing Address: �—
g Telephone
Si 3 �?co` 39
Signature
2.2 Authorized Agent:
A4 tis 7 to 'f 4.14 3� '16
Name(P- t) Current Mailing Address: /
Signature P
Tele ho/ J" A I/M-S'9
SECTION 3-ESTIMATEDI&NSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
11 Btrildiuy� ` •' (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
CZ
6. Total=0 +2+3+4+5) d Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
36 MURPHY TER BP-2019-0662
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma.a -Block:24A- 199 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-2019-0662
Project# JS-2019-001080
Est.Cog:$4100.00
Fee:$65.00 PE"ISSION IS HEREBY GRANTED TO.-
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 9365.40 Owner., Michael Byrne
Zoning:URB(100)/ Applicant.- MARK LANTZ
AT. 36 MURPHY TER
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 0 WC
EASTHAMPTONMA01027 ISSUED ON.-121512018 0:00:00
TO PERFORM THE FOLLOWING WORK:AI R SEAL ATTIC FLAT, VENT OUT 2 BATH FANS,
ADD 14"CELLULOSE TO 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 Depqrtment 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 Occuganpy Signature:
FeeTyve: Date Paid: Amount:
Building 12/5/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck--Building Commissioner