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17A-166 (3) 44 KIMBALL ST BP-2020-0750 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 17A- 166 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-2020-0750 Proiect# JS-2020-001293 Est.Cost: $6200.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO.- Const. O:Const.Class: Contractor: License: Use Group:. MARK LANTZ 102169 Lot Size(sq.ft.): 33410.52 Owner. MACDONALD ADDIE Zoning: URB(100)/ Applicant: MARK LANTZ AT. 44 KIMBALL ST Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 (413) 529-0200 O WC EASTHAMPTONMAO 1027 ISSUED ON.12/23/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.EXTERIOR WALL INSULATION, WEATHERIZATION 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 12/23/2019 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dellual? City of Northampton ccI .� Building Departments t 212 Main aA eet , SULATION Room 1 DEC 2 Northampton, 0 060 201 phone 413-587-1240 rax - 272 ONLY F FUI "'Liz APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING/ONLY SECTION 1 -SITE INFORMATION INSULA TION PERMIT 1.1 Proaertv Address: This section to be completed by office Map -7/+ Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: ::�i� �a�ic- FC 1-14 Telephone Signature 2.2 Authorized Anent: ACA z 2, 11111P,151-1,7 Name y Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED C4STRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by permit applicant (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee /n 4. Mechanical(HVAC) (moi 5. Fire Protection 6. Total= (1 +2+3+4+5) 211-� Check Number 3 This Section For Official Use Only Date Building Permit Number:_ Issued. Signature: �0 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES —7 8.1 Licensed Construction Suoerv1lsor: Not Applicable ❑ Name of License Holder: '1'W>{N r� G�,<\V2— _ J O ad(, 1 License Number tev -S �Nvj m idl i0 )io A 4Expiration Date "Sd 13ao CI Signature Telephone 9.Realstered Home Im r v ment Con r tor: Not Applicable ❑ C- i H r�4k tfSA A 0- --1 6117) 0 Company Name Registration Number k$ (�, �� 4 Is lit Address n Expiration Date �Pt5'c�h 3,. , (YI�C Telephone��3'Sd'1'��.tl� 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....... No...... ❑ Brief Description of Proposed Work Rx�es;� as Owner/Authorized Agent hereby d6okfe that asta sr 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. Print Na ignature of OwnerA4ent Date I, TT I Q. t\�1as Owner of the subject property hereby authorize ,�)2 Ho NNc.� to act o y behalf, 'iti al afters relat. a to work authorized by this building permit application. Signature of Owner Date The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aimlicant Information A Please Print Le ibl Name (Business/Organization/Individual): �+l Address: �`6 0 Q�SA in� 5� City/State/Zip: Phone #: y/3 " 5dqOk)d Are you an employer?Check the appropriate box: Type of project(required): ].[:]I am a employer with —7 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. ❑Demolition 3.❑I 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.M 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 L 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other /��(//�jT/rJ� 152,§1(4).and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 4 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is tl:e policy and job site information. \\ 11 Insurance Company Name:COAV) w eJT a �>n AVy1n AV C�')r\�P C\oy Policy#or Self-ins. Lic. #:�( -\$Li S 2a 3-0 1- 11 Expiration Dater , a, � � U s.y V-.1Job Site Address: 11 mNb \A 11A City/State/Zip: o MA QW6 0 Attach a copy of the workers' compensation policy declaration page(showing the policy number anV 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. 1 do hereby certify) tder the pains and�nalties of perjury that the information provided above is true and correct. Si nature: �'( Date: 1 ) Phone#: Y)3 'S,�q'okl d 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#: City of Northampton . . t Massachusetts J( .1. DEPARTMENT OF BUILDING INSPECTIONS M 212 Main Street *Municipal Building -»� Northampton, MA 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: (Please print house number and street name) Is to be disposed of at: VV (PleasEf print na e and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature Permit Applic n or Owner Dale 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. v+ vj v+. r�vr vraw�� vvaa ✓ Massachusetts A c. N X DEPARTMENT OF BUILDING INSPECTIONS r 212 Main Street • Municipal Building Northampton, MA 01060 sdyq �� 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: Est. Cost: (a �00 Address of Work: Date of Permit Application: 1AAi110� 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: All) Datd Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereb ,apply for apermit as the owner of the above property: z /o-) -7 J) �Klll�_ � Date O«ner Name and Signat e rte DATE(MM/DO/YYYY) ACCORD CERTIFICATE OF LIABILITY INSURANCEF 6/11/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Mary Conroy The Dowd Agencies, LLC PHONE FAx 14 Bobala Road 413-437-1010 tA/C,No):413-437-1410 E-MAIL mconro dowd com Holyoke MA 01040 ARA_R95 .. Yom_._._._ PRODUCER COZYHOM 01 CUSTOMER ID X: INSURER(S)AFFORDING COVERAGE NAIC i INSURED INSURER A:Selective Insurance of South Carolina 19259 Cozy Home Performance LLC 180 Pleasant St. NsuRER e Easthampton MA 01027 INSURER C INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:423967460 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER D/YYVY MM/0 YY A GENERAL LIABILITY S 2206979 4'7020'9 4/17/2020 EACH OCCURRENCE $1 000000 DAMAGE TO RENTED X $500,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) i CLAIMS-MADE OCCUR MED EXP(Any one person) li$15,000 PERSONAL$AOV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGO i$3,000,000 POLICY I X PRO- X LOC S A AUTOMOBILE LIABILITY A 9100582 4!'7i2019 4/17i2020 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Par accident) $ X NON-OWNED AUTOS S $ A X UMBRELLA LIAB X OCCUR S 2206979 4/'712019 4/17/2020 {EACH OCCURRENCE 1 S2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 r....., DED:ICTIB-E S X RETENTION $ WC WORKERS COMPENSATION STDTH• AND EMPLOYERS'LIABILITY Y/N 1, TORY LIS .Ek3--- - ANv PROPRIETOR/PARTNERIEXECUTIVE[--7NA E.L.EACH ACCIDENT _ $_ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) L---`" I I E.L.DISEASE-EA EMPLOYEE $ If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cozy Home Performance 180 Pleasant St. AUTHORIZED REPRESENTATIVE Easthampton MA 01027 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD