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18C-020 (2) 285 HATFIELD ST BP-2020-0933 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-020 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-2020-0933 Proiect# JS-2020-001586 Est.Cost:$2500.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License:, Use Group: MARK LANTZ 102169 Lot Size(sa.ft.): 8145.72 Owner: CZARNECKI STANLEY J E Zoning: SR(100)/ Applicant: MARK LANTZ AT. 285 HATFIELD ST Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:2/19/2020 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 Signature: FeeType: Date Paid: Amount: Building 2/19/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587.1272 Louis Hasbrouck—Building Commissioner Dep City of Northamptgjq, Building Depart men 1 ` 212 Main Street Room 100 6,INSULATION Northampton, MA 01060 1� �_ ... phone 413-587-1240 Fax 4 -587-12e�o I rONLY APPLICATION FOR INSULATION FOR A ONE OR ti o DWE ING ONLY SECTION 1 -SITE INFORMATION INSULAIJON PERMIT 1.1 Property Address: Q This section to be completed by office Map ) O Lot 64� Unit G Zone Overlay District Eim St. District_ CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ' 2.1 Owner of Record: a tint) Current Mailing Address: NaZ Telephone �' ,•�� 1 �� 5 Signature 1v 2.2 Auth"ed A ent: /rt, Name;Pt) Current ailing� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by permit applicant S V� (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 = (1 +2 +3 +4 +5) cj © 0 Check Number This Section For Official Use Only Building Permit Number: -q / DateIssued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: l Not Applicable ❑ Name of License Holder: 'iy;t!' - LA,\TZ 10 ad(, 1 License Number Addre Expiration Date 911 ,5 13P Signature Telephone 9.Realstered Home Im r v ment Contractor: Not Applicable ❑ C CS 2— � e 1�a7I;1 0 Company Name Registration Number %!a CN AspulsM �� y /5/it Address 1J n Expiration Date (Y) Telephone� %'D�.l�� 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.......0 No...... ❑ Brief Description of Proposed Work P1 r c fit. c� '► �I a;� ��, 4� g� n�;{ -� ons- c h as Owner/Authorized Agent hereby d e thatllheents 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. /",4 Print Na 7 L c� ignature of OwnerAlfent Date I, 'SA". -N a 1-1 Ir YV �,�) as Owner of the subject property rr hereb u o ' e to a oo ehal in all ers relative to work authorized by this building pe mita lication. 1.�� , 3' ignature of Owner Date vr. ..j w+. r.w� v•w..j.. vw•• SSS s�G ✓ Massachusetts �A W DEPARTMENT OF BUILDING INSPECTIONS x M 212 Main Street • Municipal Building Northampton, MA 01060 sst-yy 7y,:)^`1 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: P5 / 24) Est. Cost: S Address of Work: 1,6 5 P-40JA tr N04 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: 4/,3 �' 61 )) L�D�� l b 4,7'7 0 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 City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building xvti C�� N Northampton, MA 01060 J. 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 street name) 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 Name and Address) 1411 -✓� J 3 Signature Permit Applic 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. The Commonwealth of Massachusetts Department of Industrial Accidents 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. A licant Information Please Print Leizibly Name (Business/Organization/Individual): eA.+,r Address: In bmiqn� S� City/State/Zip: O Phone #: D3 " jagk d Are you an employer?Check the appropriate box: Type of project(required): IQ 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 $, ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 ❑ Building addition 4.[]l 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.E]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.F_1 Roof repairs L 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other /�3��jT/(/r✓ 152,§I(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,the} must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ++-- 1 Insurance Company Name:cp►1�e�) N Policy#or Self-ins.Lic. 3 20 3- Expiration Date: _-� (- Job Site Address:��S N^� 0i #W r- ]]�City/State/Zip:!" r4W4prx, NO 0 l o9d 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 certifj der the pains and pgnalties of perjury that the information provided above is true and correct. Si nature: `�`{ �/ Date: ^� ) 3 U Phone#: YJ3 'S4q-Ua() 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#: C.s � ACC? 611 CERTIFICATE OF LIABILITY INSURANCE DAT 1/2D(VVVV) ��. 6/1,/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). CONAPRODUCER NAME; Mary COnrOy The Dowd Agencies, LLC PHONE FAX 14 Bobala Road O Nd Ytj. 413-437-1010 (A/C,No):413-437-1410 E-MAIL mconroyQdowd.com___ _ Holyoke MA 01040 PRODE�� CUSTOMER CER IQ►;�.- COZYHOM-01 USTOM _ INSURER(S)AFFORDING COVERAGE NAIC Y INSURED I INSURER A:Selective Insurance Of South Carolina _ 19259 Cozy Home Performance LLC 180 Pleasant St. INSURER B Easthampton MA 01027 i 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. ADDL SUBR POLICY EFF POLICY EXP ILT R TYPE OF INSURANCE POLICY NUMBER D/YYYY MM/D LIMITS A GENERAL LIABILITY B 2206979 4!'-7/20'5 4,'1712020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY + ! PREMISES(Ea occurrence) $500,000 CLAIMS-MADE OCCUR ;MED EXP(Any one person) s 15,000 i PERSONAL 8,ADV INJURY $1,000.000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $3.000,000 POLICY X PRO X LOC f $ A AUTOMOBILE LIABILITY A 9100582 4'7;23'9 4117,'2020 COMBINED SINGLE LIMIT (Ea accoent) $1,D00,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS j BODILY INJURY(Per accident)Is X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ E X NON-OWNED AUTOS 1$ A X UMBRELLALIABX OCCUR S 2206979 4!'7/2019 4117!2020 EACH OCCURRENCE 82000000 L._ -..---------_._ EXCESS LIAB �L CLAIMS-MADE. i AGGREGATE $2000,000 _ _ DEDJCTIBLE II S X RETENTION 5 WORKERS COMPENSATION WC LIMIT OTFI- AND EMPLOYERS'LIABILITY TORY LIMITS...__., ANS PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT I$ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL.DISEASE-EA EMPLOVE�I$ If es,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT S 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. I Cozy Home Performance 180 Pleasant St. AUTHORIZED REPRESENTATIVE Easthampton MA 01027 C 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD