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17A-265
Property Address: 0 E cST , r , Contractor � �� # c Ac G r� Name: � � Address: --(( C.- c... City, State: i' (/ ZiV �I X 44 0726 6e) Phone: (13 43 leD - (t, Property Owner / Name: Cr#2`�c - 'T' C Address: 5 -0 46‘).7p._____ City, State: / I, £t 1 / ∎a (contractor) attest and affirm that the building I intend to insulate does not have any of -n air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature it,&,L,g 1-1----- Date g ____________ `'.1SSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. 0090063-00 WC 009 -93 -6606 3072 013 -82- 1110 -00 INCORPORATED UNDER THE LAWS OF ' Li VAN I A e ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO.: C; ' COZY HOME PERFORMANCE LLC C H A R T t 5 74 LYMAN RD NORTHAMPTON, MA 01060 -4228 A Chartis company EXECUTIVE OFFICES: EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 MA U I =: PRODUCERS NAME AND ADDRESS KEATING GROUP OF MA LLC • WORKERS COMPENSATION AND EM PLOYERS 144 TURNPIKE ROAD LIABILITY POLICY INFORMATION PAGE SUI 150 SOUTHBOROUGH, MA 01772 -0000 N SU RED iS I PREVIOUS POLICY NUMBER _;MITED LIABILITY COMPANY RENEWAL 007453941 DTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 �h1 2 POLICY PERIOD 12:01 A.M. standard time at the insured's I mailing address FROM 11/02/10 To 11/02/11 BEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident • Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH' NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 M 4 i The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Classifications Code Number Tot Remunerati $100 OF Re Premium ® Annual ❑ 3 Year muneration © Annual 1113 Yea •FE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $549 • XPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA t ' PREMIUM $500 MA TOTAL ESTIMATED ANNUAL PREMIUM $8,729 • �uLCa: r_d below, .nterim adjustments of premium shall be made: LI I r- Semi - .Annually Quarterly Monthly DEPOSIT PREMIUM D9/14/10 PARSIPPANY 82 / !sous Date Issuing Office L� Authorized Representative WC 00 00 01A i1:ev'd 01/38ii The Commonwealth ofMassachusetts _ .-r— Department of Industrial A M =. t r.-1- 7 Office of InvestigationS 1— ' 600 Washington Street _a =�9 —" - Boston, M4 02111 v"7::, www.mass.gov/dia . . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AD olicant Information PIease Print LegilaIF Name ( Business /Or izdrion '`� • ��i' Pr y % y t°_ � ✓ f �.- ' <. � Address: -- ;-Y, ,, ' z - '' i t G __, / City/State/Zip: , ° '- .=- v�_,t Phone - #: /�� J-= — - Are you an employer? Check the appropriateboz: T e of ro'ect _ • i l 4 .- I am a general contractor and I � project (required): 1- L3 =p i - am a p ❑ 6. ❑ New construction employees em (full loyer and/or with part time).# have hired the sub-contractors 2_. E1 I am a sole proprietor or partner- listed onthe:attached sheet 7. ❑ RemodeI7n� ship n have no. Ioyees These sub - contractors have .g. [C Deunolit on working for me in any capacity cuililoyee and sage workers ' : ;tdifioa workers' comp insurance - comp. incrrrancr I _ 9 t - -❑ re ed 5. ❑ We are a corporation and its 10 ❑ Electrcal repairs or additions ] officers have xercise their 11 .0 Plumbing r 3 _ I am a homeowner doing ill work ❑ mg epairs or additions 4 myself [No workers' comp. right of exemption per MGL I2' Roof insurance required.] t c: 152, §1(4), and we have no ❑ ?EP to [No workers' 13.0 Other cmP gees. • comp. insurance ref;l . Any appii=nt that checks box ml ffixst.also fill out the section belawshowmg the r odcexs' comp=sation policy ieonnauoii: t Homeowners who submit this afftdavit.inc ie: iing they are doing all work and thin hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box mustattached an additional sheet shu ng the name of the subkco nttactors and state whethc-ornotthose =tides have employees. If the sub - contractors have employers, 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 gird job: site information Insurance Company Name,, _r _ . - ,� i Poll # # ' --- _ / Policy or Self -ins. Lic- � F- i -� `-± � • -4 - Expiration Date: - % ::. Job Site Address: 9 V Oa. k E., Cit /State/Zip:' r'hrai- .a 44 Attach a copy of the workers' compensation policy declaration page (showing the policy number and espir date). Failure to secure coverage_as required 'uudeir .Section`25A ofNIGL c_ 152 caii lead - to the i ilposiiion of cnn al penalties of a Rice up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK -ORDER and a fn+e )f up to $250.00 a day against the violator Be advised 'that a copy of this statement may be forwarded to the Office of nvestinatrous of the DIA lir ins xi ice coverage vet caifon do hereby ,certify under the pains-and perui'! ties ofperjury information provrdedsibove. true and ' orr c .1_ __- innattre: Date: (��.�� _ hone #: _ t ` '"T:. _ V _ Official use only. Do not write in this area, to be compleied by city or town offictaL City or Town: Permit'Lir•pnse # y _ __ Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical Inspector 5. Plumbing Inspector 6.Other i- ' V Contact Person: Phone #: f, 4.1. ' SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : h eAvk Le l V p..l 6 License Number - i24 • t J J l 1 ' Address Expiration Date Signature Telephone 9. Registered Home Imarovement Not Applicable ❑ c 2 / / �w1� a4 C al 0 Company Name Registration Number 74 (y am Ask ( t) � 3 Address ExpiratioriDatat Telephone .S. 7-0.20o SECTION 10- 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 k No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. El Demolition El New Signs [O] Decks [p , idi g [p] Other [I �+ ll 1 1 1htV/47f1�6 — Brief Description of Proposed A" L' ij�k S `r - S Wit ` I — . � S� �oh� ' v \ J Work: �'1 �S S �er1l� 5$45 � 9, OVYY Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C 14 )v , CC A S'1 , as Owner of the subject property hereby authorize '3 2. Nom, L .LC.—• to act on behalf, in allj afters relative to Work uthorized by this building permit application. It Signature • S ner Date I, etnk Q ' Ci J /1h4/J14! , as Owner /Authorized Agent her-by declare that the statements and informatio n the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under pains and penalties of perjury. .iL l- -fi Print Name A4/-‘141r400 4i,K O e21) Signature of Owner gent Date r s ..,. u t m Department use only ' . City of Northampton Status of Permit: REC E� Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability 5EP 2 " Northampton, MA 01060 Two Sets of Structural Plans hO : 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans BuI LDING 1NSPECT Other Specify PPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 1 0 B b It,, S Map Lot Unit IF O cs42..1n c.,Q /H A Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: CGt Name (P ' t) Current Mailing Address: �) - 9 3 I z Telephone Signature 2.2 Authorized Agent: m/24_ At. Mr-liet4 Name (Print) Ct en Maili Address: oj/b CCA 3- 7(') Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /� / , d / J / (a) Building Permit Fee 2. Electrical /` , � r ^l v (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 04.55- 6. Total = (1 + 2 + 3 + 4 + 5)�� C Z5 a Check Number 3 _ 5 This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner/Inspector of Buildings Date , File # BP- 2012 -0258 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611 PROPERTY LOCATION 78 OAK ST MAP 17A PARCEL 265 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out !!22 Fee Paid � 3 Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102169 3 sets of Plans / Plot Plan THE FO G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Penult With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission - Permit DPW Storm Water Management - moliti s • 4 elay Signature of Buildi g fic Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 78 OAK ST BP- 2012 -0258 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 265 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-2012-0258 Project # JS- 2012- 000406 Est. Cost: $1600.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 13503.60 Owner: CONTI CYNTHIA Zoning: URB(100)/ Applicant: MARK LANTZ AT: 78 OAK ST Applicant Address: Phone: Insurance: 74 LYMAN RD (413) 320 -7611 WC N O RTHAM PTO N MA01060 ISSUED ON: 9/15/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 9/15/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner