24D-058 (2) 181 PROSPECT ST BP-2019-0873
GIS 4: COMMONWEALTH OF MASSACHUSETTS
MwBlock: 24D-058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Catceorv: INSULATION BUILDING PERMIT
Permit BP-2019-0873
Project JS-2019-001458
Est. Cost: $5400.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(so. H.): 3963.96 Owner: RODRIGUEZ JASON
Zoning, URB(100)/ Applicant: MARK LANTZ
AT. 181 PROSPECT ST
ApplieantAddress: Phone: Insurance:
180 PLEASANT ST 4200 (413) 529-0200 0 WC
EASTHAMPTONMA01027 ISSUED ON:3/5/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.EXTERIOR DENSEPACK OF ENTIRE HOUSE - 2
APARTMENTS
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 3/5/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
eect0 tlW'NO1dWtlH1eON �— • F� „
stawoBd$M DNID11fIB dD'Jd30 l--�V �I/'-
/ pp �l DepeMlent use only
61�' City tlPfUrih mpl n Status of Permit:
�T Building Delp rim t Curb CuuDriveway Permit
ani reef Seder/SepticAvailablty
WalerMall Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloUSite Plans
Other Speify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I
1.1 Property Address. This section to be completed by office,
p 1 \ \�p� Ir ��� QCri CA -0e Map ayn Lot ot;� Unit
Zone Overlay District
Elm SI.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ;In 17 iT 5�'1"SINN
�Ie
1 Z G4 hIli JR Iij 1'ALA 5lis
N e(Pring Current Meting Address'.
Telephone
Si nature IJ
2.2 Authorized Agent: n 1' I, •I'
t+lA c� L-ii �2 I`6U `•�t55gr1T z' £1)•b'�'�q'6ry ly0 Owy)
Name(Print) Current Mailing Address:
y)1 -say nao0
Sig atu a Telephone
SECTION 3-ESTIMATED CO STRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. ul (a)Building Permit Fee
2. Electrical -1 (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee /f
00
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) rj O Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued: p
Signature: 3
Building Commissionecinspecror of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C55 L-1 0a j
Mb9 1
AkK kP A✓r TZ License Number E%plmuOnDee
Name of CSL Holder List CSL Type(see below)
/ b a J0 R64rl, s f 4200
No.and Street Type Description
FASTNAMP�JN M16A ^ U Unmsniated(Buildings u m 35,000 cu.ft.
VjO� / R Restriesedl&2Flurry
cayrrown,State,ZIP M Maimay
RC Hunting Covedn
WS Window and Siding
SF Solid Fuel Burning Appliances e
N13 sd1 OdJO mnvke�ycolylome CGn 1 hutduon
Telephone Email address D Demolition
51 Registered Home Jmprrovement Contractor(HIC) 1 a 7 O y 5 j
CO Z-Y Nome ! C f0 0"AM Cie- HIC Registration Number Erzpirsuon Date
F{I Co aty�Name or HICµegisgant Name
I CI UIQ,C,i nY' $t 400 MPe`G(:MVCO2i h�M4.(Oyy�
NoNo.ander (3%0 Email address
Mp,
rJ
Ci ?own,Sm ,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 ofthe subject property,hereby authorize Cp2.--/ 1iOM4-�Qr�'olMaA(,4-
to act on my bels f,in all matters relative to work authorized y this building permit application.
O er's Signature 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.
>1 a15 X1'1
Connacmr//Owner s Agcm/Owner igneturc Dete
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),wil I pp(have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important informmion on the HIC Program can be found at
wwiv.mns,ggv/ncn Information on the Construction Supervisor License can be found at www.mascgov/dna
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 ofcooling system Enclosed Open
3. "Tocol Project Square Footage"may be substituted for-Total Project Cost" 3 S y Q
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wintlows Altemtion(s) Roofing ❑
Or Doora D "�L
Accessory Bldg. ED Demolition ❑ New Signa [OJ Deeka [p . itling[D] Other l ll g
41V oN
Brief Description of Proposed I
Work: Mi Cale !A• V>At ; r iii1i+1
1
ncK af' e(t}ifC h��5c [1W0 Ae�'m..r�5
Alteration ofexisting 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 followina:
a. Use of building One Family Two Family Other
o 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 wetiands9 Yes No. Is construction within 100 yr. Floodplain_Yes No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes —No
t Septic Tank_ City Sewer Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT ORCONTRACTORAPPLIES FOR BUILDING PERMIT
1, CA 1— Z as Owner of the subject
propert n/ ,,�
hereby authorize CD�1 h1 g Y 4T Tof myV
to act on my behalf, in all matters relative to work authorized by this building permit application.
3s
Sig Wr of OwnerI
-}1Date
1, MAf k �q✓1/ Z 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 an penalties of perjury.
✓n lark 1,5
Print Name
a s 5
Signature of OwnerlA Date
City of Northampton
e-?' Massachusetts
c
z
'I DEPe TMENT OF BUILDING INSPECTIONS '
\ 211 Main Street aMuniciPal Heilaing 1F
NoxNamp[on, IM 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c40, 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:
1161 t Qcz) pceA 'aN iq
(Please print house number and street name)
Is to be disposed of at:
KA \( eti n ,)\ lg-< O,iMpdCA �(Jrc� � , 1 ,,A Aie�,)IvtA 6-f ;nOSI, A�f
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from: �7
(Company Name and Address)
&4 A'/-),
Signature of Pe itof Pe it Applt or Owner Date
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
!,firloms'Comineureatim.
I Congress Street,Suite 100
Boston,HL4 02114-1017
www.massgov/dia Insurance Affidavit:Builders/Contracten(ElecMcians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoolieant Information // Please Print Leeibly
Name(Bwlnns/OrgmixatioMndividual): Cozy H� MQ tjerfUrmS&X-
I
Address: f rO iel(45,4/1 � V
City/State/Zip: ri5t//9mPAoN ill/1 /�a�noDen: vl3-5oi9- OddO
Are you an employers Check rhe approprure boa: Type of project(required):
l.olatneemployerwith employaw(fulland/organ-lime)• 7, []New Construction
1❑lamasole Dropnetor or partnership and lave no employeaswohing forocam 8. Remodeling
inycepacity.[Noworkersromp.insurance required.]
3.0
l an alwmeowner doing all work myself(No workeKmmp.insumm,required.] 9. ❑Demolition
4.❑1 am a homeowner and will be hiring eammustme to contact all work on any pmpeny. 1 will 10❑Building addition
ensure that all contranors either have workers'compensation imamate or are sole 1 L❑Electrical repairs or additions
proprietors with no employees. I2.[]Plumbing repairs or additions
5 1 am a general communistic!I have hired the subcontractors listed on the anmbed sheet. 13.[—
These Roof repairs
sub-comincrors have employees and have workers'comp.insurancer�qq w
6.❑we are a emproman anal its officers have exemised their right of exemption per MGLc 14.4ra rhhef /�/SV1Q�/��/
152,41(4),and we have no employees.INo workers comp.insareme required.]
•Any tunicanuhamixcks box of must also fill out the swtion below showingtheir workers'compere&ion polity irdamation.
e Homeowners who submiuhis affidavit mdeanno,they are doing all work and then hire outside contractors most submit anew atTdavit iMicating such.
:Commctors that check this box must anached an additional sheat showing the name aloha sub-rannectors and state whether or not thou entities have
employees. If the sub-commcmrs have employees,they must provide their workers'comppolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is dtepolicy and fob site
information,
Insurance Company Names Ol)v
Policy#or Self-ins.Lic. I Expiration Date: ` O 11'- 191
Job Site Address:MS IIt'sk'qt l16City/State/Zip:�.ICI�,/s¢tt1N/ M4 l3)0b 0
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 51,500.00
and/or one--year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violation A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
I do hereby cerdfy ndn epi andp�fraides ofperi dial the tnformadon provided above is me and correct.
signature:�� /�' 7 Date, a.16 IIS
Phone#: 3- 5,-c\ Ua 0 16
Official use only. Do not write in lists area,to be completed by city or noun 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
b.Other
Contact Penon: Phone#:
f
Dlassachusetts � Y
3 i
ra:saan�.vr or sa,:�.ozxc zassacrzres xF�`�
Property Address:
Contractor
Name
Address:
City, state: L a Int, i �!`
Phone'
Property Owner
Name:
Address
City, State:
I, ]" 111 2 ( "I !contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy o`this affidavit.
CO=t�Ctpr
fes—
Date /
i(4n