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32C-235 (10) I I WILLIAMS ST BP-2020-0919 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-235 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate og rv: INSULATION BUILDING PERMIT Permit# BP-2020-0919 Proiect# JS-2020-001568 Est.Cost:$5000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sg. ft.): 5532.12 Owner: TUROMSHA WILLIAM J Zoning: URC(100)/ Applicant: MARK LANTZ AT. 11 WILLIAMS ST Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON.2/12/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.INSULATION AND 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 Sienature: FeeTvpe: Date Paid: Amount: Building 2/12/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �� Dep City of Northampton V Building Departments-/ ` 212 Main Street FEB � 2 ULATION .i Room 100 20 Northampton, MA 01060 oFe phone 413-587-1240 Fax 413-5" p ONLY !r,INS N.req n CTioNs APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: This section to be completed by office 11 N'111't� � Map Lot A 3 S� Unit Oppd Zone Overlay District Elm St, Dictrict C113 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: GSA \, Name(Pr i t) Current Mailing Address: u �';' ✓ Telephone �)3 - Shy - A�� S Signature 2.2 Authorized Agent: Name t) Current ailing Address: X/ Vl3-s)9 -a O6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical HVAC 5. Fire Protection 6. Totai= (1 + 2 + 3 +4 +5) S Check Number This Section For Official Use Only Building Permit Number: �" �'` . ` ate Issued: Signature: ALI �a ao Building Commissioneonspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Vv'v;1 Ok- LAN�� 10 JJ L 1 License Number la I U )d.0 Addre y Expiration Date Signature Telephone 9.Registered Home Im r v ment Con r tor: Not Applicable ❑ ( 2- }- r��l C9. I6,J7'? Q Company Name Registration Number I$ CN 1 spu154 /S/dl Address 141 n Expiration Date Telephone���' �1'0 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.......QJ No...... ❑ Brief Description of Proposed Work 1N\k!'vt'Nh biW"k qtr~ \d�o�v� s���i S u e�. ' d pts d., �,�1 n�k ��-_ ��►�19 as Owner/Authorized Agent hereby d6elife thaNheents 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 a1oa� ignature of OwnerA4ent Date I, 1y A V11�',�ry���� as Owner of the subject property hereby authorize C n Z �U S to act on mybe �Ih all ma rs relative.to rk authorized by this building permit application. � b Signature of Owner Date 2019 WEATHERIZATION mass save BARRIER INCENTIVES JarnWe tMougft enetyy eltrc'rtH y 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 remediate your weatherization barriers. CUSTOMER INSTRUCTIONS 1. Hire a qualified,licensed contractor to evaluate and/or remediate the weatherization barrier(s). 2.Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)within 60 days of your Home Energy Assessment to: Pro-Wit Barrier Incentive,c/o CLEAResult.50 Washington St.Suite 3000,Westborough,MA 01581 or email to: prewxoffer@clearesuk.com 3.The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. 4.Complete the recommended weatherization improvements. Customer Name, __.WILLIAM TUROMSHA __ Client#or Site 1D: 3950172 &3950174 Site Address: 11 Williams St 1 &2 City:_Northampton __ ____ _ State: . MA _ZIP:01060 Phone Number. 413-586-4005 __..____�._.__.__..— Email: CustomiWHomeowMrSlpnature: l`�' _ Date:&fA4AM14 c�Zd Af To determine if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mass Save weatherization recommendations have been made: l Attic Floor JAttic Wall U Attic Slope U Exterior Wall J Basement _1 Other: J>�I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below. I(Attic Floor Ig Attic Mall QrAttic Slope IllExterior Wall VBasement ItOther:11I " =JNJQ s i)Other.,_ ❑ 1 have read and agree to the Terms and Conditions on the back of this form Contractor Name: b a u 1 Address: 2�i/ '�!�C�_ __- ^nn _ City:ru s'17[�1jE�„1+ State:._zip: 010 12- Company Name: License Number: _+DAME— ContredorSlgnetwe: � �P� Data: High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level. as measured in the undiluted flue gas.to below 100 parts per million(ppm). Draft Falkue:Contractor is to correct the draft in the selected fkmKs).Refer to table on reverse for acceptable draft ranges. High Carbon Monoxide Dra" Fadwre Existing CO ppm: Revised CO ppm: Exist"Draft Pa Revised Draft Pa: Heating Sydem Hot Water Heater Other: SpISe9a;Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation n Heating System ❑ Hot Water Heater 0 Other:_ ❑ 1 have performed my inspection and have corrected the items noted in the areas selected above. U I have read and agree to the Terms and Conditions on the back of this form Contractor Name: Address:__,_ - __ ___ ____ _____City:____ State ZIP Company Name: _—_-_ License Number:-- Contrsetor Signature: Date; Page 1 of 2 continued on back (page 1 of 2) The Commonwealth of Massachusetts Department of Industrial Accidents e 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. Aimlicant Information - Please Print Le ibl Name (Business/Organization/Individual): P -f Address: �`6 Q Ie�SA�� 4 City/State/Zip: rJ Phone #: Are you an employer?Check the appropriate boa: Type of project(required): I.Q I 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 3711 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10E] Building addition 4.[]l am a homeowner and will be hiring contractors to conduct all work on my property. l 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.F1 we are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other /n3(/��jT/r/� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. 1 Insurance Company Name:CoAk,) N Q 1\T 1Y1���Y11r\Ir�p C, Policy#or Self-ins. Lic.#:�(p-$y S�7 3' Expiration Date: (' &o Job Site Address: \\ N,`1�� � 5� City/State/Zip: Ik%4�pt mP Q) 0 6() 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 certifg der the pains ns and p�nalties of perjury that the information provided hove is true and correct. Si nature: �L Date: a` Phone# 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 �s sy Massachusetts y 2S T DEPARTMENT OF BUILDING INSPECTIONS �, 212 Main Street •Municipal Building yJi �a 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 d street nam6) Is to be disposed of at: k(PleasEf print na e and location of facility) Or will be disposed of in a dumpster onsite rented or leased from.- (Company rom:(Company Name and Address) Signature Permit App lic nt 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. SSS SSC Massachusetts [[ cf/ ' A N Y DEPARTMENT OF BUILDING INSPECTIONS " 212 Main Street • Municipal Building svti cam Northampton, MA 01060 Sp T_% 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: Q k�� Q Z-4 Est. Cost S�� Address of Work:N\ h,J' Date of Permit Application: alyy a-y 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 buildingent of the owner• g pe i th iG a r /6 2 0 to Contractor me 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 ,eco 6111/2019 CERTIFICATE OF LIABILITY INSURANCE DAT D/YYYY) �� 6/11/2 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 endorsements . PRODUCER CONAME:NTACT Mary CO The Dowd Agencies, LLC PHONE - FAx 14 Bobala Road 413-437-1010 ANC No):413-437-1410 E-MAIL mconroy0dowd.com_ ,Holyoke MA 01040 Ap9RES§:.-_ PRODUCER COZYHOM-01 _ CUSTOMER 1D 0; I INSURER(S)AFFORDING COVERAGE i NAIC R INSURED INSURER A:Selective Insurance Of South Carolina 19259 Cozy Home Performance LLC 180 Pleasant St. INSURER e: Easthampton MA 01027 INSURER C INSURER D; i - INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:423967460 REVISI,0N 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 TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, IMSA ADDL SUBR POLICY EFF POLICY EXP I LIMITS LT TYPE OF INSURANCE POLICY NUMBER M/ MD A GENERAL LIABILITY S 2206979 4P,7!2019 411712020 (EACH OCCURRENCE I$1,000,000 DAMAGE TO RENTED S 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) CLAIMS-MADE OCCUR i MED EXP(Any one person) $116,000__ PERSONAL&ADV INJURY $1,000.000 GENERALAGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OP AGO $3,000,000 POLICY! X11 PRO- X I LOC f $ A AUTOMOBILE LIABILITY A 9100562 4!'7/2019 411712020 COMBINED SINGLE LIMIT j$1,000.000 4(Ea accident) ANY AUTO - BODILY INJURY(Per person) I S ALL OWNED AUTOS BODILY INJURY(Per accident) s X SCHEDULED AUTOS PROPERTY DAMAGE $ (Per accident) X HIRED AUTOS j X NON-OWNED AUTOS - -- I$ A X UMBRELLALIAa X OCCUR j S 2206979 4!'7/2019 4117!2020 EACH OCCURRENCE $2,000.000 EXCESSLIAB CLAIMS-MADE AGGREGATE $2000,000 --- _._._ DEDUCTIBLE S RETENTION $() . $ WUHKERS COMPENSATION WC ST,;U- DTH• I ER AND EMPLOYERS'LIABILITY Y/N TO LIMITS _ ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT !$ OFFICER/MEMBER EXCLUDED? ( N/A (Mandatory in Ni E.L.DISEASE-EA EMPLOYEE, $it yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DEBDRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additions[Remarks Schedule,N 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