42-011 (3) 959 WESTHAMPTON RD BP-2019-0921
GIS 9: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:42-011 CITY OF NORTHAMPTON
LoC-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-2019-0921
Proiect# JS-2019-001539
Est-co st:$10000 00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group MARK LANTZ 102169
Lot size(so f J' 32016.60 Owner. BRUNNER DAWN&J CEMBURA JR MAIL TO' JOSEPH 1 CEMBURA JR
Zorn= Applicant: MARK LANTZ
AT.• 959 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 O WC
EASTHAMPTONMA01027 ISSUED ON:212612019 0:00.00
TO PERFORM THE FOLLOWING WOM-EXTERIOR DENSE PACK 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:
FeeTVpe• Date Paid: Amount:
Building 2/26/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED ( Ti��/
Oeperlmerll use onlY;:,
FEB 2 S 2019 City of Northampton Slaws of Permit
Building Department Curb CutmrNeway pemJt
212 Main Street Sei1'er%3BpgpAvalleNLiry" p
DE T OF GUU D16G INSPECTIONS Room 100 WatedWell AvellabililY *
NOITHAMPTON.MA0106) - k
orthampton, MA 01060 Ywo Sets pf Swctura{Piens
phone 413-587-1240 Fax 413-587-1272 PfoVSiI'e lens _
(rifler Specify -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ACNE/O RR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
Thri section to be completed by ofRh§
Cl Property Address _L
y5q ue` f1S MJ7�JU A ,Mep -__ Lof Unif
N'(Ynu au Gloea Zoe QyedavDsdcy
Erle SL 01a1dkt SP
BECTON 2-PROPERTYONTIERSHIPIAUTHOROFDAGENT, '
2.1 Owner of RecoLd.
��1oSeo1, CeFin v �r 959 1ledF�tAv �A �drn� mN
Nerne n ) Current Mallmg Adc..;
Talephene Y,3--ol70 lyv t
SI re
L Asthorlaed Anent
mfyy l.Fr` 18 6 y It45R n�' s+ fAs}�I,�a dnr mA
Nam ring Current Melling Address:
III_
5 9 -4W—
Sgreture Telephone
EC ON T STRUG N C
Item Estimated Cost(Dollars)to be OTrV iUse Only
cam leted bv caurnita licant -
1. Bugdirlg \,� O (e)Building Pemdt Fee
2. HeGrical (b)Estirtleted Total Cost of -
Aonstrudtion from 6
3. Plumbing Building Parrett Fee �f
4. Mechanical(HVAC)
S.Fire Protection
6. Total= 1+2+3+4+ 1 Check Number
':Thla Secllon For Ofgclal Use on
Date
Building Penult Number Issued
.Signature:
Binding commissmnenlnapadorof Bu ldhga Date
SEC ION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CSS L" I oa I b9
✓nAkK 77— License Number Expiration Date
Namicof CSLHoIdc, LL
IVQ Pl<as An�' sList CSL Type(see below)
No.and Samt Type Description
U Umesuicted Buildin u to 35p0o cu ft
£A5TPkrvlQhN mfl R Restricted 1&2 Tandy Dwelling
Cny(Ibwn,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Stoma
SF Solid Fuel Burring Appliances
4I3-549 OMQ, mnik�my<ozvhone c6 manlae°^
Telephone Email D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 (42k*-),?
(ea.77 O 11 5
COZ-Y Hom It f01m4412 HIC Registration Number Expiration Date
715',C— aryt Name or HIC .gisWame�
219 ziIFG SAnY sgand00 ry Loa �pmQ Car
No.and S' et mail a—E dress
Sas+wGrn�uN ma 0102.' 111 i_-5d.R-Ua40
Ci Town,Sta ,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE,AFFIDAVIT(M.G.L.c.152.§ 2506)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure m 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 p It NQ
to act
%on�my behalf.in all matters relative to work authorized y this building permit application.
w6er's S' nae - ate
SECTION 71m APPLICANT DECLARATION
By entering ray 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. q
Contractor//()waer s Apr&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 pp(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
ssww, ya Information on the Construction Supervisor License can be found at www mass ,ovfdns
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.)_ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathe oms Number of half/baths
Type of heating system Number of decks/porches
Typeofcoolfng system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost" J 10 (�GQ
SECTION 5-DESCRIPTION OF PROPOSED WORK fcheck all aoplieablel
New House ❑ Addiden ❑ LD.aom
ent Windows Alteration(sI ❑ Roofing ❑
❑
Accessory Bldg. ❑ DemoflUon ❑ 117] Decks fO 51 In /d] lherQl
Brief Desoi
;ppr,flop of ro
Wont:i aaiy�. n'W��cK clr / sril /l f:LohA Aar/ (Juyv
Alteration of existing bedroom____Yes_No Adding new bedroom Yes No
Allaohed Narrative Renovating unfinished basement _Yrs _No
Plans Attached Ro1I -Sheet
So.If New house and Or addition 6 Ondstfing lousing,complete WE folbwina:
a. Use of building:One Family Two Famly Other
b. Number of rooms in each family unit: Number of BatMooms
c. Is there a garageattached?
d. Proposed Square footage of new construction. Dimensions
e. Numberofstodes9
f. Method of leac'ng7 Flreplacesor Woodstmes Numberof each_
g. Fnergy Conservation Compliance. Masecheck Energy Compliance form attached?
h. Type of coaruWon
I. Is ownructlonwithin 100 it ofwetluni _Ne, IscorrstructlonvdNinf00yc gcadplaM_Yes_No
j. Depth of basement or cellar floor below finished grade
k. Will bWding conform to the BulWing and Zoning regulations? Yes_No.
I Septic Tank_ Cry Sewer_ Pdvalewell_ Citywatar Supply_
SE6TI6N7a-OWNERAUTHORRAnON•TOBECOMPLETED WHEN
OWNERS
JAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, %�SP�� 4Q /J.,✓,/h 1 '� as Owner of the subject
property'
hereby authorize CR Z�/ Mi/h/ f/irH`/ w,anL
to a on my half,In al are relative to V70M authorized by this building permit application.
neWre of Owner Date
1
I. Y�11Pf l� k.0� Z .as OwnenAulhodzed
Agent her y declare Ihal the statements antl information on the foregoing appllosticn are tme antl accurate,to the best of my knowledge
and belief.
Signed under the pal and gqenaldes ofperjury.
mA (`k L��iz
Prinl Name � '
SignatureofO edAi Dale
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
V1\.-Iuerg'Cvsrupengaatima
I Congress Street,Suite 100
Boston,MA 01114-2017
www.mass.gov/dia
Insurance Affidavit: Buflders/Contractors/Electriciana/Plumbers.
TO BE FILED WITH THE PERNII'TFING AUTHORITY.
Antificantlinfinninatitan
/)L/ n Please Print Lea'bly
Name (Business/Organizationnardividual): C O Z- / �Mo
Address: J rO GSAi' S,s rpt✓U
City/State/Zip: cd5%f/9m,4110/y M/I U/�hone#:
Are you an employer?Cheek the appropriate box: Type of project(required):
L®lamaereployerwith 21 employ.,(fail under pan-vire)^ 7. New construction
2❑I am stole mratitmo,p rovaripind have no employees wmkmg for mein 8. Remodeling
airycapocan, [No wmkers'comp imumnee required.]
3. lAm.homeowner all work myself INo workms'comp.misnomer,regmred.I' 9. Demolition
❑ mowner d
4 D lama Mmeowner and will lie hiring contractors to conduct all work ono Twill IOQ Building addition
my sole Ito .
creme that all cotvmcwrs either lane workers eompmaation nsurm�ceor are I.[]Electrical repays or additions
proprietors with no employees. 12.C]Plumbing repairs or additions
5.❑lam a general commeter and l have hired I N subnac
tonmrs lovedmaxivolood shcet 13.11Roofrepair,
These sub-cuntommshave employees and have workers comp.insurance:
6.MWe area corporation and its officers have exercised their right ofexervana,per MGI.c. 14.�Othef j�J✓�QfiUN
152,01(4),and we have no employees.INo workers compinsurance required l
^Any applicant that cheeks box al must also fill out the action below showing their workers'comami
penon policy information.
a Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors.,submit a new amid.,,,indestat,such.
hCommcmrs that check this box must..had an additional sheet showing the name afore subcontractors and mute whether or not thou values have
empleyaee. If the subcontractors have employees,they must Provide their workers come.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: C opt {1 Q
Policy#or Self-ins.Lic.ft: to lr,-�1`ls lA j -( 1 ' Expiration Datee:�r � � - J.- 1 CI
Job Site Address: RSA 01Je5T/IO r�'�f�/ n/I City/State/zip: rem, ! /n Q X 106 -J-
Attach
Attach a copy of the workers' compensation poBcy declaration page(showing the policy number end expiration date).
Failure to secure coverage as required under MGL c. 152,g25A 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 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 herebyder a pains and pe allies ofperjury that the Information provided above is true and correcL
Signature: 17,71's > > Date
� 1
Phone#: NI� - 53� Ua0
Official use only. Do not write In this area,to be completed by city or town oJjlciaL
City or Town: Pesmit/License h
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Counter Person: Phone at
City of Northampton
rdaasachusatta %
D "TN or BUILDING IdaPL'[TIONa y(`�vl
112 N i. 9t .t • M .il-L
pe'cNc¢((tan, I 010601I
Property Address;
J� "I
Contractor
Name
Address:
City, State:
Phone:
Property Owner
Name: l
Address: -) l �n Pi ]( Tfl U1 PA,
City, State:
I. J`nom. 1!� �(" '�' (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 ropy of affidavit.
aa �davit.
Contractor signature / ,7/:
Date
t