30C-074 (2) 564 BURTS PIT RD BP-2020-0101
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:30C-074 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-2020-0101
Proiect# JS-2020-000174
Est.Cost: $2700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 33541.20 Owner: Vicki Goldlust
Zoning: SR(100)/WSP(100)/ Applicant: MARK LANTZ
AT. 564 BURTS PIT RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413)529-0200 Q WC
EASTHAMPTONMA01027 ISSUED ON.7/26/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR SEAL ATTIC FLAT, VENT OUT BATH FAN,
WEATHERIZE BULK HEAD DOOR
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 7/26/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
b1';2—a0-10g
Dep
OR
City of Northampton
Building Department JUL 2 5 2019
212 Main tree
SULATION
!� V Room 100 nFaT F r�un_oiNc INSPEc ,oNs
Northampton, A 01 Cd�tlTHAMPTON.MA 010(;0
phone 413-587-1240 Fax 413-587-1272
ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address:
This section to be completed by office
5(QLA C'�u r�t P I 1�� Map Lot V ` Unit
,p1 Q"n(-k Yr1 P Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: nn
C � GQN A � S6q 8vrfs56q8
Na a(Print) /� Current ailing Address:
✓"" ILr Telephone
Signature '�/3- 335- 11115
2.2 Authorized Agent: n 1I
hnAk LAA) tZ ��� (?1e�5>��� 5� itAh4l�i , mo Ojai
Name(Print) Current ailing Address:
�&/ f�-J, y►3-511°1- oil 00
Signature Telephone
SECTION 3-ESTI14TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 13 tI"91 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee /n
4. Mechanical (HVAC) (�
5. Fire Protection
6. Total = (1 +2 + 3+4 +5) '� v Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: -"Z5"7?619
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
—]SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: M�1(-� l mA L CS I-_ I�Jl16
License Number
6 I Allo 1a-,3
Ad r s Expiration Date
,00 4 --� J., —GINO
Sig ature Telephone
9. Registered Home Im rovement Contractor: Not Applicable El
6v 2y Nuri- 1 (11317.) 0
Company Name Registration Number
Address Expiration Date
Telephone y�3�5�9-UU
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....... (11 No...... ❑
Brief Description of Proposed Work
MF1)5 'S At )JO). (�,� �,c,�1 Al ,JC � ��� P► ��1 la►� (k�lv�� l 1�P11� cr, 6��1����,�
C-N 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.
Yrs p,rbc LCA Z
Print Name
713
Signature of Owne gent Date
I, r' I G ✓ 1 as Owner of the subject
property
hereb authorize �0 NO�e � r�
to a on my beh in all r tive to work authorized by this building permit application.
Signalure of 5wrieY Date
City of Northampton
Massachusetts ��?S' e
I }t X
DEPARTMENT OF BUILDING INSPECTIONS �`•
212 Main Street •Municipal Building
Northampton, MA 01060 rsy ••, ...
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:
-5('L� (�Urk's e)-� QA 03Q-t1Lt me
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
01 h5p
Signature of it Applicant r 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.
'\ The Commonwealth of Massachusetts
0 Department of Industrial Accidents
a a I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aaalicant Information Please Print Leeibly
/l
Name (Business/Organization/Individual):
Address: / rO �2/f G S An /d
City/State/Zip: 6> 51AleAl0a ON MW 0/0� Phone 3-5a 9" ddb d
Are you an employer?Check the appropriate box: Type of project(required):
1.1&1 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. E]Remodeling
any capacity.[No workers'comp.insurance required.]
' 9. ❑Demolition
3.a 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10 E] Building addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.[:]Roof repairs t
6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Others�S V'Q►/(�hI
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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: C olrk)(�Q 0 a Qmn t� y ComA A()v
Policy#or Self-ins.Lice.#: b-�S"�5�� 'U)l i Expiration Date:: "I 1,- I t 1
Job Site Address: 5 G / 43/�� C'lrur h �� City/State/Zip: M(z I YO o 106
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.
I do hereby/certi�nder to pains and pe alties of perjury that the information provided above is true and correct.
Si nature: i/ Date: I
Phone#: %-\\31 K,�"\.- U-),C;
Official use only. Do not write in this area,to be completed by city or town offrciaL
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#:
.�. SSS . • s�,
Massachusetts
c
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building" be
done by registered contractors.
Note:If the homeowner has-contracted with a corporation or LLC, that entity must be registered
Type of Work: �nSv���', >� f�AhS S�� Est. Cost: a.�0�
Address of Work: 5&Li
Date of Permit Application: 7la"9115
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own pen-nit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A. SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Ib) -_/ z4n 1 7 7 '
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature