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31B-286 (15) 129 MAIN ST-FIRST CHURCH BP-2020-1138 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31 B-286 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-2020-1138 Project# JS-2020-001908 Est.Cost: $4600.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 31755.24 Owner. FIRST CONGREGATIONAL CHURCH OF NORTHAMPTON Zoning:CB(100) Applicant: MARK LANTZ AT. 129 MAIN ST - FIRST CHURCH Applicant Address: Phone: Insurance: 180 PLEASANT ST#200 1 (413) 529-0200 O WC EASTHAMPTONMA01027 ISSUED ON:5/21/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:I N S U LATE CHAPEL CRAWL SPACE SPRAY FOAM AND VAPOR BARRIER 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 5/21/2020 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dep City of Northampton,Z .,� Building Departments '� ? 212 Main Street a INSULATION ! Room 100 r x'11" Northampton, MA 01060 `. p c phone 413-587-1240 Fax 413-587�;(°g' 2 o ONLY APPLICATION FOR INSULATION FOR A ONE OR TWdFAcnMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Ad ress: This section to be completed by office Map Lot Unit J21 Zone Overlay District Elm St.District CB District i SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Namer Current ailing Address: � t) Signature Telephone SECTION 3-ESTIMATED CO STRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building LI C/_,r1 (a) Building Permit Fee 2. Electrical �� - c�`-�� (b) Estimated Total Cost of Construction from (6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection uu 6. Total= 0 +2 + 3+4 + 5) Check Number Q� This Section For Official Use Only Date Building Permit Number: '"✓rr J'� Issued: Signature: / — `yw 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: t��t� ��Z n V(, ) License Number Addre y Expiration Date 7 1I r5 O� 2--/J24 Signature Telephone .Reals reme Improvement Contractor: Not Applicable ❑ 2- H1.)M c P e r�4t C.9, I �J7 ? 0 Company Name Registration Number 1 !a (�, R�tr's 4 /S/d Address 1i nn Expiration Date 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 J / Z g Z L A ,as Owner/Authorized Agent hereby dbehirre thaftheents 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. /V'4 4, Print Na / Signature of OwnerAifent Date 1, , as Owner of the subject property �� hereby authorize Co ZY 'T6/ri P AOH��M,10/71q 6k. to act on my behalf, in al afters relative to work authorized by this building permit application. Signature of Owner Date City of Northampton Massachusetts h ; DEPARTMENT OF BUILDING INSPECTIONS z . 212 Main Street •Municipal Building yvti `D� 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: w\\ C � '4�,N d �V (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 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. '\ The Commonwealth of Massachusetts Department of Industrial Accidents F" I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia ki Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/individual): 1 ? P of Address: City/State/Zip: tJ Phone #: y/3 " 5 d9_0"y Are you an employer?Check the appropriate box: Type of project(required): I.Q I am a employer with employees(full and/or part-time).* 7. E] New construction 2.M I 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.❑I am a homeowner doing all work myself [No workers'comp.insurance required.]' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 E] Building addition 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: L 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.q Other /.11,1 T_IaAl 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 must also till 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. Insurance Company Name: coy�k l W S�Ak -,� `Xn 1Q W1 C�)rt(J Policy#or Self-ins. Lic. Expiration Date: Job Site Address: City/State/Zip: 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. 1 do hereby certify der the pains and7naltles of perjury that the information provided above is true and correct. OVY Si nature: Ev'< Date: Phone#: 78 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#: 1 0 75/18/2020 (MMIDD/YYYY) ACC?R" CERTIFICATE OF LIABILITY INSURANCE 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 CONTACT NAME: Diane LaFleche The Dowd Agencies, LLCPHONE FAX 14 Bobala Road 413-437-1062 A/c No):413-437-1462 E-MAIL Holyoke MA 01040 ADDRESS: dlafleche@dowd.com PRODUCER CUSTO'ER1p#: COZYHOM-01 INSURERS AFFORDING COVERAGE NAIC N INSURED INSURER A:Selective Insurance Of South Carolina 19259 Cozy Home Performance LLC 180 Pleasant St. INSURER B Easthampton MA 01027 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1486494555 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 AO L SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDDNYYY A GENERAL LIABILITY S 2206979 4/17/2020 4/17/2021 EACH OCCURRENCE $1,000,000 RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500,000 CLAIMS-MADE F1 OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $31000000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 POLICY X PRO X JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per acci erk) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ A X UMBRELLA LIABX OCCUR S 2206979 4/17/2020 4/17/2021 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000000 DEDUCTIBLE $ X RETENTION $ $ TU WORKERS COMPENSATION RY WC ST MIT ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE� E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ H yes.describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) FOR SAMPLE ONLY 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(2009109) The ACORD name and logo are registered marks of ACORD