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11A-004 (7)
BP-2022-0405 17 EVERGREEN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: I I A-004-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0405 PERMISSIONIS HEREBY GRANTED TO: Project# 2022 GARAGE Contractor: License: Est. Cost: 17500 MARK LANTZ 102169 Const.Class: Exp.Date: 12/10/2022 Use Group: Owner: SCHUMANN HOBBS DAVID B& LYNN Lot Size (sq.ft.) Zoning: URA Applicant: MARK LANTZ Applicant Address Phone: Insurance: 180 PLEASANT ST#200 (413)529-0200 0 46-845373-01-12 EASTHAMPTON, MA 01027 ISSUED ON:04/20/2022 TO PERFORM THE FOLLOWING WORK: SHOP SPACE ABOVE GARAGE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $113.75 212 Main Street, Phonc(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1 The Commonwealth of Massachusetts f Ip Board of Building Regulations and Standards APR 1 9a. FOR '.4 Massachusetts State Building Code,780 CMR 2f FUSE_mUNICIPALITY ppRepair, Building Permit Application To Construct, Renovate Or Iae ni- Revised Mar 2011talz1,h a One- or Two-Family Dwelling ' ;;:,,; This Section For Official Use Only Building Permit Number:SO- .Z 3- ` 0 5 Date Applied: /� �LJit DONu /`SS �/ i -ZO'ZOZZ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 P roperAddress: �S 1/Assessors Map& Parcel Num1 p1,c6 4--• I�Jb if (J(1''I 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 :oRecord: r b ee�- 101.2 Lt-c-,S t MA- Name(Print City,State,ZIP �- S pc", 6k.. c63 2t`1 S9 oC> No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building K Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work': 5 Lno(p $pc f e_ cc bG�e_ --a `� ['.l o> C,rx..(..L -s-,v �Ss21.- - v_ U ..r i A a_A-oL 1 a.' 'L <<^-�-. t ✓Z?,-sY�l o << SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ �/ I _ 4.Mechanical (HVAC) $ List: 4 CC, ) K t 5 ()-,S 2- t I, 3 5.Mechanical (Fire Suppression) $ Total All Fs: $ t U . t 1 Check No I Check ount: I f C punt: 6.Total Project Cost: $ ( )- 57 ( (Paid in Full 0 tan ' ance Due: City of Northampton 4'4Nti�`" Massachusetts ��S • c,�` �. ( G „. 3 ,ii.ff,,...„ . !! DEPARTMENT OF BUILDING INSPECTIONS ? 212 Main Street • Municipal Building J� Northampton, MA 01060 J'.1 3,7\"�`� PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. I. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s) and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new / replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit - public land by DPW / private land by Building Dept. 13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. City of Northampton �Ct j Massachusettsth DEPARTMENT OF BUILDING INSPECTIONS SyrI, - • t7 -;.- U --- 212 Main Street • Municipal Building Northampton, MA 01060 / CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: �,...ps-i-r' l e' r �`'su-L�- St"" Location of Facility: - .ems 4- 0/A. L The debris will be transported by: Name of Hauler: v5-4 ke-c---- C-L\N I Signature of Applicant: Date: ( G0-L _ The f onunonwealth rif AI, cachrasefts e -- Department of Indwi rirtl Accidents Pr Ealjahlff d I forigreAs Street,Sa1te 100 =.=cz�._ _W Boston, M:10211 d-2017 .",.. ► ww_mass.gnvidirr 11 oiI crs'C urnpeusaliun Item railer .41frda%it: I)uilders'(•ontractursrElectririjnsePlumber^s. tit HE: 1 IL1:11%A I ill I lIM:PtE1tt11117St:all"ilIORIi 1. .%ppliraat lufierenat- Please Print Ixeihli Milne Itiu,Inss ttiltira C.t authin Intl,idurll: j )- . y� () $ „- ("LC Address: 1?C) 1 / S �- (5f. CityfState.Zip: "I��i, , 4v->1 Phone#: Ye_ g G Zero Arr sue an clap toyer?('dark the atpitrapr6d4 Type of project(rrquitledl: 1 ant .:ti p AFycT with ettiploreon(full and or parr—Lim: 7.*New Construction %' 1 am a xirc pit/mica";or parts Ttflap and lrata'twv cn1preloc'!Y L[life for me in 1!I- El Remodeling 1/ LLalt c-ipataty_ Nu w caanp.ut,uran. Rgiuri.Ill 9. ❑ Demolition ±.0 1 ant a lwnncaoWra7 lk hag old wur►anywIt.!Nu Nurl:tm'Lump_na,tlrnwi:ra uiral-I- 10 D Luikimg addition #❑I ant a Iarrnctutot r and will he htrirty trlatrraatnre to utlnclnct all weak urr ray tr tutis-rty_ I will n .•murr ihal all ctnuna-lurs cithicn-Ju�c%whets comptauuliuti ite,ur.ur r t� ire su1C 111.J Electrical repairs or additions prupwet ra with nu c�nplarvec�_ 12.0 Plumbing repairs or addition, .4.0 1 ant a gcaocrall uentractur And I In+e Meld the alub-euntr,ururs Listert on the:oteadsad:,ltcc.•t. Ihc,c,.ub-ctamuracton,Iaatc a nployce. and ha%cwu a••rlcr cwnp.nuurjncc.• I3❑Roof repairs 14.0Othet till 1k c an curpuratism and ita<oaken hat c cstat:ised then right]of ext.-yttrium per}►1t,L c. 152. 11 At.and tite Ica%e au eitalelcyecs.ISu%arils'ctanp.msuranee ramrod.' 'Am apptit.-ant Thai clwwks I midi ahsu tiii.Iut ris xctioat&Ickes I,Ituu ing their uoriters•cunlpctasariun tI,:,Iei ntfwrnatrarn.. *Ilaancvw acne why,Wlnnti tins attt.da,rt nulicatrrai they ar\^doeng all%urk and then hire uois it co ttruclura anlor.,uhnat a rat%atlidm It Iredicnita¢Awls. that tbttik this hot Inasl;at.w•I.-il;In ad.ail urna:l%hell sbtnwinp the nann:of the snt►,ctnunr•urns and.twee w healer t•n nut tlntse.entitle-,Law anpl:uycLn._ It the sub.c,.aleactuta Isa',ettgrlo cep.tile!, nunA prt w idcllrcir v,orlcT,'comp.tsllw t iauinIs r.. l atilt aM e'mpltiver that is prreridine leaders'carrpta stiun iarnrvince for mI,employees_ Below is ilk policy urrd;oh Arte information. Insurance Company Name: CcM-"ti,f_01 c,t Policy#or Self-ins.Lie.#: Kb gc13 .3 T) " U( l 0 Expiration Date: 1 / -(2_-2- kb Site Address: fl g' '* (Q.l•• City;'Statt 2'ip: LP 2�t /I/1� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date►. Failure to secure coverage'as required under M(iL c. 152,§25A is a criminal violation punishable:by a fine up to$1,5111J_1111 armor one-year imprisonment,as well as civil penalties in the form Iola STOP WORK ORDER and a tine of up to$254I_0N l;e day against the violator.A copy of this statement may be fortivarded to the Office of Investigations of the DIA for iaautalltc coverage verification. do hereby certify tinder the mitts and penalties of petjtrr that the information provided obesee is true and correct.. Si aturti: , — ��'! Dale.: `(itq (?.— Phone ft: t--.i3 s- C1 v Official xsr oak Dv not write in this area.to be completed by cite'in-town official City tier l rw►n: Prrmitl iecasc to Issuing:tinhorn~ (circle one): I. Board of Ilealtb 2.Building Department 3.('ity!Tuwn Clerk 4.Electrical inspector 5. Plumbing Inspector 6.Other ('ontaet Person: Phone#: SECTION 5: CONSTRUCTION SERVICES (Z t/i o / ZZ 5.1 Construction Supervisor License(CSL) .t L" _ �- 1i‘_L- (kZ License Number Expiration Date Name of CSL Holder f o-ZI 6 r( �_ C J c n f_K:_ ,( ./1t S List CSL Type(see below) No.and Street � 7i- Type Description Ct ci,)4- /v.r T V h ' /v A- rJ(J 2_ ._ U Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Lit -/ U Lot} I _ Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 19 o5 2 ` -1.(( (i / U / Li' HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name Si? P1 usc+-4- S7- No. d Street 1 Email address City/Town,State,ZIP c2 f 0 2)- Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.125C(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 42K- No .❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize �`� (1"" (` `& Cam-, �C_�' to act on my behalf,in all matters relative to work authorized by this building permit application. b Ci v-, tiZ (717) ',(;. L(7117/-1- Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information containe in this application is true and accurate to the best of my knowledge and understanding. / / 72-2...__ Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YYVY) 9/27/2021 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 have ADDITIONAL INSURED provisions or 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 The Dowd Agencies, LLC NAME: Diane LaFleche FAX 14 Bobala Road IA/c.No.Ext):413-538-7444 (Aic,No):413-536-6020 Holyoke MA 01040 ADDRREss: dlafleche@dowd.com INSURERS)AFFORDING COVERAGE NAIC S INSURER A:Nautilus Insurance Company 17370 INSURED FOAMUSA-01 INSURER B:Commerce Insurance Company 34754 Foam USA LLC 180 Pleasant Street INSURERC: Easthampton MA 01027 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:47882776 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. ILTR ADDL TYPE OF INSURANCE INSD SUBR WYD POLICY NUMBERPOLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY NN1310702 9/1/2021 9/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY BJGBYJ 5/5/2021 8/5/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Peraccen accident) $ AUTOS ONLY AUTOS ( ) X HIRED X NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY , AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR AN1246304 9/1/2021 9/1/2022 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER TH- AND EMPLOYERS'LIABILITY Y/N STATUTE R _ ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? n N/A - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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. Foam USA, LLC 180 Pleasant Street AUTHORIZED REPRESENTATIVE Easthampton MA 01027 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingtq -&Jre t-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC 41 =M i :e•' ation: 190521 FOAM USA,LLC 180 PLEASANT ST SUITE 200 '' E E'ration: 02/01/2024 EASTHAMPTON,MA 01027 A • ©/ W `di4 — s.4e III Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:LCC Office of Consumer Affairs and Business Regulation Realstfatlen S Expiration 1000 Washington Street-Suite 710 1A0d21''. .i,1.02/01/2024 Boston,MA 02118 FOAM USA,LLC '• :. '- 0 MARK LANTZ '/ 180 PLEASANT ST SUITE 200'`-t __ .`,/ ,,a,,,,.d4/ cr.4' EASTHAMPTON,MA 01027.;. - Undersecretary Not valid without signature Commonwealth of Massachusetts �� Division of Professional Licensure Board of Building Regulations and Standards Construction,StipW'Viapr Specialty CSSL-102169 p�pires:12/10I2022 MARK M LANTZ • 1. 180 PLEASANT STREET', .p EASTHAMPTON MA 01027' Commissioner •✓ice Construction Supervisor Specialty Restricted to. CSSL-IC-insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govidpl