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18C-149 (2) 18 WARBURTON WAY BP-2019-0820 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 149 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-2019-0820 Project# JS-2019-001354 Est.Cost: $1900.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 0.00 Owner: BREDBURY SETH Zoning:URB(100)/ Applicant: MARK LANTZ AT. 18 WARBURTON WAY Applicant Address: Phone: Insurance: 180 PLEASANT ST #200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:1/18/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-AIR SEAL ATTIC, ADD 3" CELLULOSE TO ATTIC, 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 Signature: FeeType: Date Paid: Amount: Building 1/18/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED =�I/SU���id�l/ City of Northampion JAN 1 7 ; Y Building Departm nt CurbC Peemit € g ; t 212 Main Stre r �- DEPT.OF BUILDING !(- Room 100 NORTHAMPTO77 N Northampton, MA 01060 Turc!' of5 tut :Plans •$ _} phone 413-587-1240 Fax 413-587-1272 PlbVW PIa ` ti APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 0 P, 1 ? f a)b 1.1 Property Address: This section to be completed by office 1 % w C% C D U � N �, Map ( OC Lot 1 q ` Unit y Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e(Pdqt) Current Mailing Address: Telephone _i1 3 c4 _ 015 a Sig re J 2.2 Authorized Agent: Nam (Print) Current Mailing Address: "�'p V� - San- ©a.o SVgature Telephone SECTION 3-ESTIMAT CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1111ding \� 1 (a)Building Permit Fee V 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4cb 4. Mechanical(HVAC) 5. Fire Protection jqp 6. Total=0 +2+3+4+5) a Check Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: 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) E] Roofing 0 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [M Siding[I Other 64 ✓�'3Jt, x� Brief Description of Proposed Work: V,�6 9 �1ft Digs0 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 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 I, 1 J�'j as Owner of the subject property \ (� hereby authorize to act on my behalf, in all mattrs relative to work au orized by this building permit application. %�1 Signature of Owner Date NEI 1, mIZ(Q)�, 1,^ A2, 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. `Pnld!�= �Icl t1 Print Name 1 1 Signature of Own gent Date City of Northampton ,s s, QiMassachusettsrt DEPARTMENT OF BUILDING INSPECTIONS y. 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: (Please print house number and street name) Is to be disposed of at: I kx-. (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) J y Signature of P66it Applica or Owner Dat 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 IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 kvwww mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aaalicant Information Please Print Leeibiv Name (Business/Organization/Individual): Coz.\1 /`'/Qmc) ,/'e/"form 1 � Address: J rO 454/i � 5� �`,(Oo City/State/Zip: C/�51 f�'e/nO, )/'7111 MW O/�hone#: y/.3 'Sof - (91140 0 Are you an employer?Check the appropriate box: Type of project(required): 1.IM I am a employer with 7__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 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 1 l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.rl I am aeneral contractor and I have hired the sub-contractors listed on the attached sheet. g 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. Other ) 'QJ N 152,§1(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: (,O f1`�1(1 c2�� ` —1-fA QM n t�Y Como em v Policy#or Self-ins.Lic.#: t` - Expiration Date: Job Site Address: !�i Yk�, 4�1 City/State/Zip: 0%0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and hpiration 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 nder a pains and pe alties of perjury that the information provided above is true and correct. Si nature: / v / �� Date: ` 1 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#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C55 L` I 0 o i m A.k K License Number Expiration Date Name of CSL Holder L 1 � o 10J ms An-� s f 1tr�OQ List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) f A5TN,ANPi*QW MP 1rr3101:7 R Restricted 1&2Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding . SF Solid Fuel Burning Appliances 413"sa q1 Ud(�� m�rkC�my�oZ�►�wme.c�M I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) rX'Y? 0 y 5 I Co;y Home ' of m4 a C?_ HIC Registration Number Expiration Date I Co ame or HIC e is ant Name p CIA An S 400 MASkQr_MyCO2 J\ia sQ..WYkn�\ No.andStrfet Email address MN QQJ;7? Ci /Town,Sta ,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 1,as Owner of the subject property,hereby authorize CO 1'L ►J1QM4. N l ku("MAA 4 9 t act on my behalf,in all matters relative to work authorized ty this building permit application. Owner's Signature Oale 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. I�,%\\N � Contractor//Owner s 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 11al 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.mass.gQv/oca Information on the Construction Supervisor License can be found at www.mass.gov/das 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"