31A-078 (3) 276 ELM ST BP-2019-1394
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-078 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: INSULATION BUILDING PERMIT
Permit# BP-2019-1394
Project# JS-2019-002238
Est.Cost:$3300.00
Fee:$65.0o PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: MARK LANTZ 102169
Lot Size(sa.R.): 13634.28 Owner. MESSER PERRY&JUDITH
Zoning:URB(100y Applicant: MARK LANTZ
AT. 276 ELM ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 () WC
EASTHAMPTONMA01027 ISSUED ON.61512019 0.00:00
TO PERFORM THE FOLLOWING WORILAIR SELA ATTIC AND BASEMENT SILL BAND,
ADD PROPA VENTS, 12" CELLULOSE IN ATTICE AND WEATHERIZE DOORS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector or 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:
FccTyoe: Date Paid: Amount:
Building 6/5/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
City of North a pto
Building Dep: me
212 Maih St at
JUN - 3 201 I
Room 10 SULA TION
- Northampton, 01
�t2�C LTIONS ONL Y
phone 413-587-1240 Fa 41T5�.{�lglory ^.�n: ,oso
° '
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY 6,1(q- (.3 Q
SECTION I -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: m
This section to be coplete by office
Map N /� /r
+ Loty Unit
N
11ff Zone Overlay District oel �VIJ '/�c` Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
C_t t11me 5 S4 r ma
Na (Prin Current Mailing Adt .
Telephone y ,j_ 33s -as�o
Signature
2.2 Au prized Agent:
MN0f.- L^rv�1- 1150 Q�MSg113( fA .rv��,,t., MR OIOd"�
Na e(Prinp Cu
nent Mailing Adtlress:
AHn,-5 a^-
ig ature Telephone
SECTION 3-ESTIMATED LONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I.-BaMdin�. q (a)Building Permit Fee
11�Sv��IIOJ 'T � � J l7
2. Electrical (b) Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+ Check Number d
This Section For Official Use Only
Building Permit Number: Date
Issued: �, p
Signature: /O- y-X/
Building Commissioner/Inspector of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
6.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holds UA L C5 L- 1 U 16`i
License Number
Ad s Expiration Data
-0
Sig ature Telephone
. Re is erect ome
Improvement Contractor. Not Applicable ❑
�U Z7 1"�Jfty- , eVLW'6"Lq— 11-,3177 0
Company Name Registration Number
1 'ecsq-k 6� �r•15(ly. lw WxQ' OlQ3-1 y 'SId`�
Address Expiration Dale
Telephone Y/3-SdY-(Ha7tl
SECTION 5-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.
Signed Affidavit Attached Yes.......T, No...... ❑
Brief Description of Proposed Work
Mt%7 " 54—` 3A'. Q„c ae,l n uc t bwe1 it stll ..t Asa Gp'h ��n�5
ASI 'Te Lil1��o�d- +a
O �
I, MP tv V a Aj— 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.
h. Aft --rt1��Z
Print Nam
5 3�
Signature of Owne gent Date
I, ,,� '/ K/'�" ,as Owner of the subject
property (�
herebyauthorize COZY VAOfhe iT4ul'NWI`�.L '
to act n beh in all Matters Tlative to work authorized by this building permit application.
Signature of Owner Date '
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
ulkllCompensation Insurance Affidavit:Builders/Contractors/Electricions/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoolicant Information n Please Print Legibly
Name(Business/OrgmiratiOW[ndividual): Corty 1,1011,101)9(2fOff 'P!'furIY15/7C�f_
Address: / �-O P1PbSAn � 54 radoo
city/stateizlp: FW5r11eAV1oN 47x90/0 7Ph,mll: y/3-540- 0-WO
Am you m empbxr}Cksek roe appropriate hos: Type of project(required):
1®l urea employer in-7 __amplosse,(full aWor pear-tore)• 7. []New construction
+-❑IamamlerWon orpenmrshipaMba memployeeswwking fornuin 8. Remodeling
any capacity.[No worker•comp.maturate required.I
3❑I amehomeowmrdoingallwoAntyself lNowakerscon, moveamou,nredl' 9. Demolition
4.❑1 am a homeowner and will be hiring cormaters to cmWwt all weak on my pmWrty. I will 10❑Building addition
ensure that all contractors elmor have workers'camphression commenceor are sole II.❑Electrical repairs or additions
propnetws with martial
12.[]Plumbing repairs or additions
5,C]1 son.§mares conamoveratd I have hired the suhemaromm;listed on tie attached s mes
TM1ese sub-contactor have etnployeea aid have workers comp.insurnce. 13.❑Roof repairs
6.❑Weueacon ontiotandirsoffcershaveexenamddhoraghtol'exemptipnperMGLe. 14.MOther 51,WA)N
152.§1141,and we hagsrmemployees.I Nowolvas'comp.imuraaena ma.l
•Any applicant that checks box#1 must also rill out section below showing their wwkeri compensation policy mirmanumn.
'Homeowner who submit this affidavit indicating they are doing all work and then hire outside restrictions mum submit a new affidavit indcating such.
:Cmtmtors that check this Iwx most atmchd an additional sbect showing the rwne of the sub-wnvrtors and state wnnne,or not those cremes Mme
emplgees. Ifinesubcontractor Mveemplgees,theymustpmvidetheirw erscomp.policynumber
I am an employer that isproviding workers'compensation insumncefor my employees. Below is the policy and job site
informadon.
Insurance Company Name:
Policy#"Self-im.Lic.N: 21, 'V1 ' I I Expiration Data:
II' J." 19
Job Site Address:d7 b E�Y'r> 'Oy City/State/zip:YV��avr MA O)Dw
Attach a copy of the workers'compensation policy declaaHon page(showing the policy number and expiation 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 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 oflnvestigations of the DIA for insurance
coverage verification.
I do hereby certify ader the pains and pe aides ofperlsoy that the information provided above is true and correct.
Sienmure: / w 7 Date'
Phone k: till - v, _ V��
Official use on0•. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License n
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 h:
i
City of Northampton _
Massachusetts L
DEFABTJID NT OF BUILDING ZNBPBCTZONS 7
"\ 212 Main Street •Municipal Building
eorNampton, M 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:
17 (o t1. . a� Nur��� l��r/ .
(Please print house number and street me)
Is to be disposed of at: ` • �
Li(
L `t %l -' V*' DM1
R \`-tM��
(Please print name and location of facility) \
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Pe it Applica or 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.
2019 WEATHERIZATION
mass save BARRIER INCENTIVES
Savings though energy effidency
Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing
Improvements.Before moving forward.Please follow all the instructions below to ramedlate your weratheNiation barriers.
CUSTOMER INSTRUCTIONS
1.Hire a mal fied.licensed contractor to evaivata and/or remedlatc the w nitMntustion b rmar(s).
2.Submit signed and completed copies of this form and a copy of the paid contractor immice(s)within 60 days of your Home Energy
Aasessmert to RISE Engineering,60 Shawmut Rd,Unit 2,Conten,shk 02021
Or email to Calg MaGUMAlnf ORIMenglneeMS tom.
3.The weetheri2ation incentive will be deducted from the customer co-payment amount of the weathadstation work.A rebate check
will be Issued In the event the amount exceeds the customer's co-payment amount.
a Complete the recommended weath.nturtion Improvements,
CUSTOMER INFOPMATON
Customer vamaPerry Messer Client a or site ID: 484927
site Address 276 Elm Street oty: Northampton swop KA z .. 01060
etx wlu..iJ
phof)e Numbber: 413-335-2 70 Email: PMESSERrdlCOMCASLNET
Cusfomae/Homaownar 6lamture• X M/�.�- Gatto su4
To determine if there Is any active knob and tube wiring,the contractor will evaluate the fell a ilhg eeU whereeliglble Mean Saw'
weal erintion recommendations have teen made
®Attic Ploor DAttic Wall OAtlie Slope DESTemer Wall Deasemem 00tlwr DOMar'
I have performed m r,inspection and determined there is no active knob,and tube wring in the areas selected ball
NAttiCFbor ViAttiCWell 11(suiC6bpe i3f:MNIOr Wall Mparemam DOlnar: ❑Other'
borewwo:iwreLcrawedifp'.
kI Mw read and agree W the Terms and Conditions on Me back of this farts.
Contractor Nems,
,wd. /60 /UuA?W MA/it. Sl- ZIP: O/Obi
Company Name: "1401hy '20 NpAI-1 Llmnse Number: Jr YS
Commctor Signature X ,.a.lx /aav Otli S
ALCHANICAIC SYSTEM BARRIERb(f, 04—
High Carbon MonOYwet Cortractor Is to se,,aro re-evaluate the selected maehenical sysum(s)and mdum we Carbon monoxide level,
as measuratl n the undlluteo flue Oas,to below IDO na,mer million(ppm).
Draft Failure;Contractor Is to correct the draft i-.nu selected fleMsZ Refer w table on reverse for aocknal draft ranges.
- -ting CO Poo: Pais.CO ppm: Edatirg Drift pa: RMisea Draft pa:
Heallp syatarrr I '�
'tatvaartt..w I�—�
outer.
SpI a"Connector is t000mect the spillage offlue galas In the safected m achanieal systam(s).Must nM spill akar 60 wcOndsof opwadon.
D Heating System O Hot Water Heater O Other:
O 1 Week,performed my inspection and have comeeted tM bums noud n the area sekeeted above.
D 1 have read and agnate the Terms and Conditions on the bark of thas form.
Contractor Hams:
Address Cies Stall ZIP,
Company Nems License Number.
Contractor Signature: Data:
Continued on back
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