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30C-018 (4) 495 BURTS PIT RD BP-2020-0126 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30C-018 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-2020-0126 Proiect# JS-2020-000203 Est.Cost: $438.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 40118.76 Owner: GUERTIN SHIRLEY Zoning: SR(100) Applicant. MARK LANTZ AT: 495 BURTS PIT RD Applicant Address: Phone: Insnir once: 180 PLEASANT ST#200 (413)529-0200 0 WC EASTHAMPTONMA01027 ISSUED ON.81112019 0:00:00 TO PERFORM THE FOLLOWING WORK.-AIR SEAL AND ADD TO BASEMENT 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 8/1/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Dep Building Departm -- -A , 212 Room tre �VE, �SULATI® AL AlRoom �00 __-T Northampton, ,MA 1060„ i �. phone 413-587-1240 !Fax X13 -11122019 ONLY PFP r�� r^ APPLICATION FOR INSULATION FORA ONE t�M�bd �r �IN ONLYI�- SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: This section to be completed by office ►-i 5 �V A5 P A tz � Map Lot � Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: h N (Prin) Current Mailing Address: �� Telephone4 qj Signature 2.2 Authorized Agent: V`�>_15� ►--h C�Z Name rint) Current Mailing Address: -0d. o Signature Telephone SECTION 3-ESTIMATEd CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant (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 = 0 +2 + 3+4+ 5) Check Number a ?6 This Section For Official Use Only Building Permit Number: DateIssued: Signature: 131 7010 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�►('� UrmA L C5 I-- I U11,09 n` License Number lU 1a-o — Expiration Date 1Lo-1 / Sig ature Telephone 9. Reciistered Home Im rovement Contractor: Not Applicable ElCy27 1-13r�- , k1 (0IT) J Company Name Registration Number Address NI Expiration Date Telephone`7/3"54-0q�Jo 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.......U No...... ❑ Brief Description of Proposed Work Mit S 5 S"-A A '" \nA c\AA tC CT' fip Si,l b�ine� iN P C'V `- �.c�� 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. `rte p, PrintName Signature of Owne gent Date I, 5A Y-/,- C-ru e,,- i'/v as Owner of the subject property hereby horize VA�)�Q to a my behalf, in all matters rel�#ive to work authorized by this building permit application. Signature of Ow r Date '\ The Commonwealth of Massachusetts Department of Industrial Accidents a o 1 Congress Street, Suite 100 Boston,MA 02114-2017 r' www mass.gov/dia NVorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): co;w x Address: / rO 41-114 5,4A /" V �C'✓U City/State/Zip: FY5r1-W 1 I)()1r✓N 1,V ©la's hone#: -q/3 Are you an employer?Check the appropriate box: Type of project(required): I.Jo1 am a employer with_employees(full and/or part-time).* 7. [:]New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F�1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10❑ Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5 M I 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 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.4 OtheC �il�i{(� �u/V rs I 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. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �'n\�QM n t�YC o M C)4i Policy#or Self-ins.Lic.#: to-`6"� 5 � -� 'U 1 ' [ J Expiration Date: � ) �` I Ol Job Site Address: 415 43V' 1 S / �+ t�f City/State/Zip�/►-))tel Vy(1 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 certify nderfre pains and pe allies of perjury that the information provided above is true and correct. Si nature: / Date: Phone#: `�1 K c� C3:YC Official use only. Do not write in this area,to be completed by city or town 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 6.Other Contact Person: Phone#: ...� . .z .... ....,,...t.. ...... SNS S.G Massachusetts _ r• Fu DEPARTMENT OF BUILDING INSPECTIONS " M 212 Main Street • Municipal Building yJy cb� 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:_'l �\ \ ,S� Est. Cosd L13 Address of Work: IS5 80_�5A4 �/ 90 �ry Ml Date of Permit Application: 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 permit(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: A 2, V 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