16D-020 157 NORTH MAIN ST BP-2019-0766
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 16D-020 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-2019-0766
Project# JS-2019-001264
Est.Cost: $3400.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sg. ft.): 21475.08 Owner: John D.Dahl
Zoning:URB(100)/ Applicant. MARK LANTZ
AT. 157 NORTH MAIN ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 WC
EASTHAMPTONMA01027 ISSUED ON:1/3/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEAL ATTIC, VENT OUT BATHROOM FAN
ADD 12" 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 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 Sienature:
FeeType: Date Paid: Amount:
Building 1/3/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
7
'"- ity of Northampton
DE t
PECTIONS uilding Department
ORT nnP 01060 212 Main Street
Room 100
Northampton, MA 01060 "� a
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6P^/�- 7 l�iL/
1.1 Property Address: This section to be completed by office
-� C'� 4,0 Map 1.0 }
_ Lot "3O Jnit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: \\
Ty�n�► ��� rJ 7 U �� t� �C 11.E r�CA w1f\
Na (Print \ Current Mailing Address:
J Telephone U/ 3_ 3 3 6 d(/�
Si nature / / J
2.2 Authorized Ascent:
ti%yy . '� 2' Bio G)g"t a n} � �P ��C hh,.P�'��.►
Nana(Print) Current ailing Address:
Signature Telephone
SECTION 3-ESTIMATED ONSTR CTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1trth3ln� 1�� (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
6. Total=0 +2+3+4+5) Q Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: /-3-)q
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 [r-3) Decks [E] I Sliding[O] Other)(a
Brief Description of Proposed ,L, I �►
Work: MQIsS :4pt1C� h�• {�i! .✓t �L, V`A� ���f bti�}1>`�� ac�i� /d &&V
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 exietina housina:complete the totlowina:
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
I, i111 d� C" as Owner of the subject
property
hereby authorize 66t y h6,1V
to act on my h all tters relative to work authorized by this building permit application.
SigiKature of 0 er Date
as Owner/Authorized
Agent hereby declare that the stat ents 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/Age Date
City of Northampton
Massachusetts ?
wf 'ts
DEPAR7MWT OF BUILDING INSPECTIONS
y.
212 Main Street eMunicipal Building J•. :C��
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:
5 7 Ir)A IV 5+ pjuf'- 1 U
(Please print house number and street name)
Is to be disposed of at: 11 } S W,A �_ ����� �� s 1, � + t��
(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 Wmit Applica 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.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/gyp CSSL-loaib9 la do
M!r k K I,1"►nn ty 74 License Number Exprratron Date
Name of CSL Holder
14 o PJ M s An I s '1�1a O Q List CSL Type(see below)
No.and Street Type Description
{ ] 4 p U Unrestricted(Buildings u to 35,000 cu.ft.
C A.ST�R NPP,VN MT► (310 17) R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
C 1p, SF Solid Fuel Burning Appliances r
���-Joel �ro m�rk�mv�oZy 1Y1�.C�1y1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home mprovement Contractor(HIC) 01
Co; Nom t dor c i a.I 7 D ti 5 1
HIC Registration Number Expiration Date
I Co p t4ame or HIC egisqant Name
4 T)PAIJAn St dd00 ry,�►sk@Mycozyham.
No.and Std Email address
Ci /Town,State,ZIP Telephone
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.
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
CONTRACTOR OR OWNER'S AGENT APPLIES FOR
�BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C.O2'`f til M-t. NQ-s k,u(*W\a f\4 g
to act on my half,in all matters relative to work authorized ty this building permit application.
1 7 l.-
0 er's Signature I Date
SECTION 7b:APPLICANT 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.
Contractor//Owners Agent/Owner ignature Date
1. 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 nai 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
www.inass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including 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
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"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I 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 /// fJ Please Print Le¢ibly
Name (Business/Organization/Individual): C zy 1 Irj e Aer f6r- )6i'71Ck
Address: J 8'0 hole 45,4A � S� U(y0
City/State/Zip: C1t51/-W V),r01V MW 0/'� Phone#: #J3-Std 9" 000
Are you an employer"Check the appropriate box:
Type of project(required):
I.[&I am a employer with_employees(full and/or part-time).* 7. ❑New construction
1 am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. ❑Remodeling
❑3 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition
❑4.❑t 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.❑1 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? f/
6.❑We area corporation and its officers have exercised their right of exemption per MGL a 14. Other f�S t/I Q l�?/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.
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: C�n�',(�Q��a �C1 t�QMf\t Y Como AnT
Policy#or Self-ins.Lic.#: -�S �5�� 3 'U " f Expiration Date: 9
Job Site Address: -_� A a City/State/Zip:_ /p w— mil a)U 6
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�ceerrtify underjhepains and pe allies of perjury that the information provided above is true and correct.
Signature: Date:
;�/ 'r /4
l
�'
Phone#:
Oficial 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#: