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39A-064 (2) 75 LYMAN RD BP-2019-0846 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39A-064 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-2019-0846 Project# JS-2019-001398 Est.Cost:$10000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sg. ft.): 51400.80 Owner. WILLEMS MAURICE&CHERYL Zoning: SC(62)/URB(38)/ Applicant. MARK LANTZ AT. 75 LYMAN RD Applicant Address: Phone: Insurance: 180 PLEASANT ST 4200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:2/19/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-EXTERIOR DENSEPACK, THERMAX ON CRAWLSPACE CEILING, 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: FeeTyne: Date Paid: Amount: Building 2/19/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner �ti V City of Northmpt nP r= Building De rtm nt Cuda 212 Main tree JAN Room 100 3 Northampton, A0406@0 � b phone 413-587-1240 ax� ���� .' '�� r rna APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING f SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office -7 5 i—���n �1 Map Lot O� Unit n Zone Overlay District. _ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �e,rN 5 Ly mti iNwW44 F�y' "P Name(Print Current Wailing Address: (_Nkr_J Telephone l ) SlVature,4V 2.2 Authorized Agent: N (Print) Current M ling Address: Signature Telephone SECTION 3-ESTIMATED ONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1.'13aik< (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) © Check Number This Section For Official Use Only Building Permit Number: Date Issued: g Si nature: 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Sid r-3] her Brief Description of Projosed , f n� +w,� Work: 7►,�SS Sp't�fZ ►bb I. -0>)�-64C h CAS�CA`N6 ��{IrVne JYN ��p1 VJIVAa— 00�% hue, 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 housina,complete the foliowina: 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, f V V 1 I-P as Owner of the subject property hereby authorizeto ac on my behalf, in all m r relative to work authorized by this building permit application. i/t, a. Signaturqlqf Owner Date 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 p\eJnalties of perjury. Print Nam 4 '� Signature of Owner gent Date City of Northampton Massachusetts �s:• �. '`c'� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 ss""•.•• j�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 constructiioln work being performed at: vnvi 4A (Please print house number atid street name) Is to be disposed of at: (Please print name and location of facility) ' v Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) /,/" "'J 'n-A .Z Signature of P it pplic t 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. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) rnA�RK �.A�+ Z css�- �oar �9 i a ►o � License Number Expiration Date Name of CSL Holder -L l � o P/-(q 5An 4- s�- 1d'a O Q List CSL Type(see below) No.and Street Type Description ],_ p U Unrestricted(Buildings u to 35,000 cu.ft. F A S T P;p� op k% M T► 01 o I-) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding p SF Solid Fuel Burning Appliances r H13"5d1 OJQJ. mftrkemycoZyhome.an I Insulation Telephone Email ad ess D Demolition 5.2 Registered Home mprovement Contractor(RIC) O y ICozNom dor G HIC Registration Number Expiration Date ICo&r)arLX t4ame or HIC egistrant Name Q eC11An-f s 4400 Mar1C('Myco2yK10WA. ON\ No.and Std Email address MR 410x'7 411-SM-0 gQ 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 C.o2'`f ►inrnt, NQr kv(Wna A 4 to act on my alf,in all tters relative to work authorized by this building permit application. �q_ Owner's'Signature D 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 D e 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 ng 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.i!ov/oca Information on the Construction Supervisor License can be found at w w. a.s.g v� /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" �(� OU The Commonwealth of Massachusetts Department of Industrial Accidents 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. Anulicant Information Please Print Legibly Name (Business/Organization/Individual): co ZT//Gme Address: J $"O GS417 � S� �"400 City/State/Zip: /�5%f%�/Y1,��0/V BIW M-'' hone #: 413-6 cj 9' a,�0 0 Are you an employer?Check the appropriate box: Type Of project(required): I.IE l am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q 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. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other / `J Lr�Q /(�N 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: Co-fr� Q�� �Cl L�em(Nt JC Y L� c Policy#or Self-ins.Lic.#: y b-�S'A /5� 'V i 1 I Expiration Datee:I � ) 19 Job Site Address:7s �T��n� /�// City/State/Zip:+l►Uj` �Ul-v Inn 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. Ido herebyi ndeer a pains and pe allies of perjury that the information provided above is true and correct. Signature: Date: 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#: M & S ELECTRIC, INC. 119 ELM STREET HATFIELD, MA 01038 (413) 247-5330 February 13,2419 Wright Builders, Inc. 48 Bates Street Northampton,MA 01060 Re: Cher Willems Residence—75 Lyman Road, Northampton MA To whom it may concern M&S Electric did not do any wiring at 75 Lyman Road,Northampton MA, but per visual inspection there is no"knob &tube"wiring in the walls/attic/basement at 75 Lyman Road as per M&S Electric. Submitted by: Stanley Symanski President M&S Electric Inc. License 417278A