46-037 (2) 178 ISLAND RD BP-2020-0978
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:46-037 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-2020-0978
Proiect# JS-2020-001500
Est.Cost:$9800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sa.ft.): 7143.84_ Owner: SARAKOSKI JOHNNY
Zoning: Applicant: MARK LANTZ
AT. 178 ISLAND RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 (413) 529-0200 0 WC
EASTHAMPTONMA01027 ISSUED ON:3/4/2020 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATIONMEATHERIZATION
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: Rotiah: 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 3/4/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:.(413)587-1272
Louis Hasbrouck—Building Commissioner
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City of Northampton - -
.;��° Building DepartmepO
. ` A 212 Main Room Oto reetr B 28 INSULATION
.k
' Northampton; MA94
- phone 413-587-1240 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
CJ
Map Lot 3 7 Unit
J� Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
h n ` hl 1 4s s n�l 1�a� Gr/O n�hh►VD /NV.
N (Print) Current Mailing Address:
Si nature Telephone 6 y6—553—/1Ol
2.2 Authorized Agent:
Name(`A%r}nt) Currree�ntn} aili4ngA/dddre(sss:
r�/ /C.✓L f //✓J✓� / 1 V 0
Signature Telephone
SECTION 3- ESTIMATED CO STRUCTION 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
Coristruction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2 + 3 +4 +5) d % Check Number
This Section For Official Use Only
Building Permit Num er: Ap, do r 17 DatIssed:
Signature: 3- 2 - ZO2-0
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction 1
Supervisor: \ Not Applicablee, ❑
Name of License Holder: yy,{� S� 1A-,(NTZ __1 0 ad(,
License Number
"ev 't�,Vj m gid) iu)ay
Addre ll Expiration Date
Signature Telephone
9.Reallstered Home Im r vement Contractor: Not Applicable ❑
Z K) e f\o- 16,17'? y
Company Name Registration Number
1!R (�, bu\,5iNy� h\ 4 /5)1 d, (
Address NJExpiration Date
M Telephone
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
cr~,n)� I N cfP�wl��h� �c►► , '
as Owner/Authorized
Agent hereby Aelelfie th—aftheents 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 /
L
Signature of OwnerAA4ent Date
I, " "�.� - /f1 ��'v�/�✓ as Owner of the subject
property /!
hereby authorize Z
to act on my beh , i al afters relative to work authorized by this building permit applicat, n.
Si ature of Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
a
1 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.
Anplicant Information Please Print Le ibl
Name (Business/Organization/Individual): P <+r
Address: 1160 Oke ti A n1 4
City/State/Zip: vJ Phone #:
Are you an employer?Check the appropriate boa: Type of project(required):
1.0 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. ❑ Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10 ❑ Building addition
4.❑I 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 I I.[]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 o, 14. Other /17,1
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.
*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 emplo}ees.they 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:Cor%Vl N e n& a �n d1C►'Y1n A
Policy#or Self-ins.Lic. #:' (p-14 S:37 3-0 J" 11 Expiration Date:
Job Site Address:l74$ 151 C,J 9,4 City/State/Zip: V 1�4v M14 01 o )
Attach a copy of the workers' compensation policy declaration page(showing the policy number a d 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 ,der the pains and pQnalties of perjury that the information provided above is true and correct.
Si nature: "/ �% Date: d` �r
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
t Massachusetts
pp y
.T DEPARTMENT OF BUILDING INSPECTIONS
�16 V 212 Main Street •Municipal Building
� t Northampton, MA 01060 n'Nn,
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:
(Pleasd 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 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.
� L
,4coCERTIFICATE OF LIABILITY INSURANCE DAT D/VYYY)
si 61111 1/2reo 19
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
I certificate holder in lieu of such endorsement(s).
ONTPRODUCER NAME; Mary Conroy
The Dowd Agencies, LLCFAx
14 Bobala Road 413-437-1010 Aro NO);413-437-1410
PHONE _
Holyoke MA 01040
E-MAIL_oEU� mconroy0dowd.com
PRODUCER COZYHOM-01
CUSTOMER ID#:
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: _
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.
INSRADDL SUBR POLICY EFF POLICY EXP -�1_11111111711'sLT TYPE OF INSURANCE POLICY NUMBER MM/D
A GENERAL LIABILITY S 2206979 4!'-7120'9 411712020 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
X
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $600,000
MED EXP(Any one person) $16,000
CLAIMS-MADE OCCUR i .._ __
PERSONAL&ADV INJURY ($1,000,000
GENERAL AGGREGATE I S3,000,000
GENt AGGREGATE LIMIT APPLIES PER. I PRODUCTS-COMP/OP AGG $3,000,000
POLICY I X 1 PRO X LOC $
A ! AUTOMOBILE LIABILITY A 9100582 4'T23'9 4/17/2020 COMBINED SINGLE LIMIT
(Ea accident) {$1,000.000
ANY AUTO BODILY INJURY(Per person) j S
ALL OWNED AUTOS BODILY INJURY(Per accident) S
X SCHEDULED AUTOS PROPERTY DAMAGE $
X HIRED AUTOS (Per accident) }
X I NON-OWNED AUTOS $
$
A X I UMBRELLALIAB X OCCUR S 2206979 41'7120'9 4117!2020 EACH OCCURRENCE $2,000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE $2,000.000
DEDJCTIBLE S
X RETENTION $
WORKERS COMPENSATION WC STATU- 'OTH-
AND EMPLOYERS'LIABILITY I TORY LIMITS EFS.�
Y/N
ANY PROPRIETOR/PARTNERIEXECUTIVE N/A E L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? L�
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE;S
II yyes,describe under
DESCRIPTION OF OPERATIONS oelow EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace 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
' SSS r/
Massachusetts ��2 C,'
N t
DEPARTMENT OF BUILDING INSPECTIONS
ro
212 Main Street • Municipal Building yJ`
Northampton, MA 01060 ssajy
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 r\ t�tr,��1'��� Est. Cost I 0
Address of Work: 17 ,51 ti INA F—A
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:
ahC dO z /ca 7 v
Take 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
WrN- 2018 W E
ATHERIZATION
mass save BARRIER INCENTIVES
Sarongs rMoupin•ne=rgk•M2ieni.y
Used 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 pualihed.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:Pre-Wx Barrier Incentive,c/o CLEAResult,SO Washington Street,Suite 3000,Westborough MA 01581
or email to prewxoffer a.clearesult.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 •• •
Customer Name: John SierakOWSki Client u or Site ID: 3950185
Site Address: 178 Island Rd Cim Northampton 01060
State: MA ZIP:
Prone Number. '+r,o+. Email: SSzamosi@gmail.COm
Cttstomer/Honreowner Signature: __ oatr Z 6 2�
KNOB AND TUBE WIRING t
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.
RAttic Floor ILAttic Wall ❑Attic Slope &Exterior Wall MUsement ROther:crawlspace
IR i have performed my inspection and determined there is no active knob and tube wiring in the areas selected below
X Attic Floor IC Attic Wali ❑Attic Slope 11Exterior Wali (Basement kOther:GrCt W I&P-46 C ❑Other:
IK I have read and agree to the Terms and Conditionsonthe back of this form
Contractor Name. Nbl+haA fC
Address
1�� -1"hq(/LPTv11 State�tr-_-LIP: 2
Q�U7
vY
Company Name: M 1 Z
jol Lp�f �eC�(1� License Number: Z(4S —A
3
Contractor Signature: Dew
High Carbon Monoxide.Cortr:ctar is to sernce and re-evaluate the selected mechaniczl system(s)and reduce the carbon monoxide level,
as measured m the undiluted flue gas.to below 100 parts per million(ppm).
Draft Failure:Contractor is to correct the draft i•the selected flue(s) Refer to table on reverse for accept:)le draft ranges.
High Carbon Monoxide Draft Failure
Heating SystemExisting Co ppm m Revised CO ppExisting Draft Pa' I Revised Draft Pa
_
Hot Water
Other:
Spills";Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation.
0 Heating System 0 Hot Water Heater O Other_
O 1 have performed my inspection and have corrected the Mems noted in the areas selected above.
❑l 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:
Contractor Signature: Gate.
Continued on back
(page 1 of 2)