The URL can be used to link to this page

24A-089 (3) 10 DICKINSON ST BP-2019-1101 GIS#: COMMONWEALTH OF MASSACHUSETTS M=Block: 24A-089 CITY OF NORTHAMPTON Lot,-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category INSULATION BUILDING PERMIT ermit# BP-2019-1101 Proiect# JS-2019-001786 Est Cost:$65.00 Fee.$65.W PERMISSION IS HEREBY GRANTED TO.- Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq.ft.): 5227.20 Owner: BARAJAS-ROMAN MAGALY&MARIA ELIZABETH BARAJAS-ROMAN Zonine: URA(1001/ Applicant. MARK LANTZ AT. 10 DICKINSON ST Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:419/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:EXTERIOR DENSEPACK, AIR SEALING 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 q Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 2M 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 Occuoancv Signature: FeeType: Date Paid: Amount: Building 4/9/20190:00:00 $65.00 212 Main Street,Phone(413)587.1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner rc— a City of Northampton- - ---- ,,a� -' Building Depame 212 Main St et APR 4 20 9 Room 10 sU ��© � Northampton, M 01 r CrONS phone 413-587-1240 F - `l2' ""1050 ONLY APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY /J— Q/ Ill U If SECTIONI -SITE INFORMATION INSULATION PERMIT 1.1 Property Address. This section to be completed by office 6 17, Ck�nSo n Map A -I, +- Lot Q 7 r Unit Zone Overlay District �N Imo ' m Elm St.District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record; YX G� �Jgfti 4 IQ 7;ck;u6( n �1 Akllj ,36—vy OV, ow Nam rint) p� Current Mailing Adtlress: J Telephone Signatund 2.2 Authorized Aceent: tnAskl s. v2 Ivv.Y `a� £PS��a� Okp TM7 Name(Print) Current Mailing Atltlress'. 4c `W, SO- MJY) Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1.'iSoAdiag 11�nJ�n �''N (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= (1 +2+3+4+5) 1 l) Check Number This Section For Official Use Only Date Building Permit Nu er: Issued: 4 42 Signature: 1-V-GV(9 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \\ Not Applicable 0 Name of License Holder: mA�k LAf�T �- (51, " 10 a ) L01 p, License Number I�ld �d-U Address Expiration to Signature Telephone 9.Recilistered Home ent Con .� tra r: Not Applicable 0 CU Z`/ Hjrn2. t �,trht\L9� Comoanv eme Registration Number 1isoQ\e SSa�� s' � RotR�or� m #1SI3,� Address Ezp rat n Dale Telephone SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(l 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. Signed Affidavit Attached Yes....... No...... 0 Brief Description of Proposed Work `C d'Cern sC dR�eeno�� PlQ ��r5 , 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. Fly A ry Print SignatureofOwner/Agent Date I, Mt\<�ti�\I C�"'r A�Q7 • �-b M�l� as Owner of the subject propel Q hereby authorize COZ to act on my behalf, in all m rs relative to work a orized by this building permit applicatio /r� � Z2 Z� 9 Signaturq5df Owner Date �� The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia V\Porkers'Compensation Insurance Affidavit:Builders/Contradors/Electricians/Plumbers. 'fO BE FILED WITH THE PERMITTING AUTHORI TV. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): -7zY h/0A7Q ,✓'P/'{OC-✓I'lhl;e.L I Address: / r0 .'9� ( 5 /) / 54 00 City/State/Zip: fiil5tf%✓fM1)A71v nVA W-''�hpHe 4: v/3 — 5ai 9- 0.JO0 An you an employed Check the appropriate We: Type of project(required): 1.®l am a employer with_. employ'ces(full and/or pzmtime)• 7. []New construction 20 am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling any anal.[No workers compinsurance required.( 3❑lamahomeowner Lin Il work If. No nd 9. ❑Demolition Ling mase I comp i,nmann reya� I' 4.❑1 am a homeowner and will IN,hiring uppradons w conduct all vork on my properly. I will 10❑Building addition room that all contractors either have workerscompensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 l am a general mtnmcmr and l have hired the subcontractors listed on the attached sheer . pairs These sua- lrcospors have employees and have w'orkeri twor nsurance: 13❑E]Roof reI 6.❑We are a corporation and its officers have exercised their light ofexemption per MGL e. 14,2011yor /7Ji'�Q7iUN 152,$10),and we have no smplo eet.[No workers'compinsurance required.] *Any applicant that checks box 91 mum also fill out the section below showing their workers'compensation policy inamianon. I Homeowners who submit this alfidavit'mdicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such. :Contmnou that check This box must aneched an additional sheet showing the name of the subs end d state whether or not those entities have employeeslffhe sob-conlractors have emplomes.tbey must provide their workers comp.policymsmber. I am an employer that is providing workers'compensation insurance far my employees. Below is the poh'cy andjob she information. �n�Emn Insurance Company Name: l9n fk(\Q.'1 v IOMLl1� Policy N or Self-ins.Lic.#:--L1,bJD j V 1 - I Expiration Date: \J,— I O1 Job Site Address: )i J-.rt OAC tNh�N 5t City/State/Zip: rv{ Uv 1314LU Attach a copy ofthe 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$250.00a day against the violator.Acopy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do herebyify pndu/the psa s and pe/aaies of perjury that the information provided above is true and correct Signatum _ /r/7 Date Phone 4, ',11 Set c\- UaC Official use only. Do not write in this area,to be completed by cl y or town official City or Town: Permit/Licease g Issuing Authority(circle one): L Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: _ City of Northampton +" Massachusetts 1 • Jt. v '�( i DEPARTMENT OF BUILDING INSPECTIONS 212 Nein Street oN icipal Ralltl ng Northampton, NA 01050 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: ll1 (Please print house number and street name) Is to be disposed of at: W �( Ay1\ �c (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: 1� 1 (Company Name and Address) kA r --J� y0��1 � Signature of Permit A plicant or Ow6dir D t� 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. i - City of Northampton � c. AAVYY amp ov,,P a Prooeny Address Contractor ihmne. Ali ess Gt>q State, I Pno,e Property Owner Varve Cit,. state 1, ;tont ror'. alteni arc adi rr t`ratthe nuildt,g n end to s-angoes-ot have any'men e}r,knob anC he.;wi tic n re spa es 10 he insulated a^d that i have l prmdaC the property Oona—mw A copy of ins affidavit e^.Yd i n2fUYE v3i3 G