31B-052 (2) 42 NORTH ST BP-2019-0682
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-052 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor,,: INSULATION BUILDING PERMIT
Permit# BP-2019-0682
Project# JS-2019-001114
Est.Cost: $4300.00
Fee: $65.00 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor., License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 4660.92 Owner: CAVANAGH DONNA M
Zoning: URC(98)/ Applicant: MARK LANTZ
AT. 42 NORTH ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 WC
EASTHAMPTON MA01 027 ISSUED ON:12/27/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-Al R SEAL ATTIC, INSTALL 2 GABLE VENTS, ADD
CELLULOSE TO ATTIC SPACE
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 12/27/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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Building De artm nth
212 Main tre
DEPT OF BUILDING INSPEL`
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Northampton, MA 0 }
phone 413-587-1240 Fax 413-587-1272 _ 51
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APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE O/R TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION (6 rr r L R -w y,�)-
1.1 Property Address: This section to be completed by office
Map P2 Lot 6�;), Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 71
2.1 Owner of Record:
1,,,N,k,3C\ Gay atn�� '1�. 5� . 6��sc� ,M ,�, mlP
-11ame(Print) Current Mailing Address:
Telephone 1 C / I ' 4 5
2.2 Authorized Agent:
Yy\R r r" `-.�►n��— 0 1t s� r�RSk ti 0107
Name(Print) Current Mailing Address:
� "131 5a. - Oa0
Signature Telephone
SECTION 3-ESTIMATED 04INSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) V
5. Fire Protection
6. Total=0 +2+3+4+5) 3 C� Check Number
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature: 4 /2- 27-19
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [mi Decks [M > V 1,$Jd! [O] Othe
A 1 Brief Descripti n of Proposed "��
Work-.Bbl Nk �'oh , 1,s &CA �t1��c a,��� J���� AAA c���� P.3� � trifi( � 5
Alteration of existing bedroom Yes _No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement YesNo
Plans Attached Roll -Sheet
6a.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
c � V-\ as Owner of the subject
property— �
hereby authorize C k �-ek`�w\rzi\Lk
to act on my behalf,in I ma ers relative to workauthorized by this building permit application.
14,J 3 )
Signature of Owner Date
I, r I( A 1�( L.Gi �� 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 Name
Signature of Owner/ gent Date
City of Northampton
fMassachusetts
^X
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060 ss'•..... �10�
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:
Ha NyrAMP)s)-vi o)P
(Please print house number and street 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 orner 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.
'\ The Commonwealth of Massachusetts
Department of Industrial Accidents
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.
Ainlicant Information /J Please Print Leeibly
Name (Business/Organization/Individual):Z.\/ 1` rj/gc ,!`'P�'"f(/l"mvJ_
Address: J rO u S J9%l r 54
City/State/Zip: C,�51,,/+9/rJp/rON AW OI'��hone#: z1)3 'sot - Q,,4 0 0
Are you an employer?Check the appropriate box: Type of project(required):
1.O I am a employer with__employees(full and/or part-time)." 7. []New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity.[No workers'comp,insurance required.]
❑
3.�1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition
Q4.[]l 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.rl I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs
6.[:]we are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other f/}5(��� JO/V
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
•Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
+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: l�h`�'�(�Q��a ��er��1 k Y �oM cn v
Policy#or Self-ins.Lic.#: y to-�S15�� ) ~U 1 I Expiration Date:
/ � � - L), ) 9
Job Site Address:U i v O P4\ 5 City/State/Zip:f?l�Q1 nae A yV 44 ®fid 6/1
Attach a copy of the workers' compensation 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 ceerrdify ndeer' a pains and pe allies of perjury that the information provided above is true and correct.
Si nature: %�� /,�, " Date: HOZ 3
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#:
SECTIONS: CONSTRICTION SERVICES
r5.1 Construction Supervisor License(CSL)
i
(,SSL" 14 �Saq I�.�iO Or i
_Z, _ LicenseNuntbcr kNpiration Date i
Name ol'C'SL Bolder
! List CSI.T\pc(see bolo,+ X
7}pc Description
I No,alld tilt'eei
! UUnrestricted(Buildings up to 33.000 cu.fl.) i
-R Restricted 11,2 Family Dwelling !
i
RC-77 Rooting C'overintt
WS W'indotti and Siding I
SF Solid Fuel Burning Appliances
V),K_r— 2 tv�4 Q^A j 1 i_Insulation
Telephone Emai adds_ I Dom flition ----,
5.2 Registered Home Improvement Contractor(HIt;)
a-� 7 q. -
i ;f IC Registration Xumber Expiration Dale
111CC'ompam Name or 1110 Registrant Name
\o.and Sn•eet I:mai address i
11E A��nmD�
City/Town. Staib,71 P !rye�hunr
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. �
rSigned Affidavit Attached? Yes .......... \o........... 0
SECTION 7a:OWNER A THORIZATION TO BE COMPLETED WHEN -----I
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
!.as Owner of the subject property, hereby authorizeCr2-�t H,3 me_ �.�r�u(Yf�(,
0 & ,_w.._._._._.. ._._.. '
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(FIcetrom Sign•ture)—
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
t
B) entering my name below. I hereby attest under the pains and penalties of perjury that al I of the information
contained in this application is true and accurate to the best of my knowledge and understanding. i
; Print C)ttner':or authorized Agent's tma(l,lectronic Signature) i)ate
NOTES:
An Oµner 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.I.G.L. c. 142A. Other important information on the 1IIC Program can be found at
111n��.mutia.aul „:;4 Information on the Construction Supervisor I.icense can be found at v�w%UP;1ss,b,0v d128
2. When substantial tkork is planned. provide the information beloH:
Total floor area(sq. ft.)- i irciuding garage.finished basement/attics,decks or porch)
Gross living area(sq.ft.) _ Habitable room count
Number of fireplaces_ _ __- _ Number of bedrooms
Number of bathrooms - _ Number of half/baths—__,_, i
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" 300
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Property Address: /0
Contractor
Name: ISr ,i�ra I 06 e-I Le y-
Address:
City.State:
Phone:
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Property owner
Name: Y 1DY)&A
Address:
City, State: Jv
J?16 AJ � �(contractor)attest and affii :hat the building I intend to
insulate does not have any open air(knob and tube)wiring in the sp to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
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