44-053 1114 FLORENCE RD BP-2019-0394
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-053 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2019-0394
Project# JS-2019-000634
Est.Cost: $9000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 130680.00 Owner: DION ADRIAN
Zoning: Applicant: MARK LANTZ
AT. 1114 FLORENCE RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST #200 (413) 529-0200 () WC
EASTHAMPTON MAO 1027 ISSUED ON.101112018 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXTERIOR DENSE PACK, AIRSEAL ATTIC, 6"
CELLULOSE TO ATTIC, WEATHERIZE DOORS
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 10/1/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
��
RECE su ��v�
IVED
S
EP 2 8 201 Department use only
City of Nort jjiveway
rmit:
BUllding De Permit
I.a 21 2 MainUILDING INSPF sAvailability
AMPTON,P,AA01
�- Room Availability
\fit` Northampton, MA 01060 Two Sets of Structural Plans
7." phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
/ '
SECTION 1 -SITE INFORMATION /.'" V
1.1 Property Address: This section to be completed by office
'v
110 �1�r �� CR, �—d Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
dj �t 1'� �I�('-e'(\LL 2l 11)6 glob
Na a(Print) Current Mailing Address:
) 1 Lam. Telephone � ) .. au 01.�
ignature
2.2 Authorized Agent:
Name(Print) Current Riailing Address:
H 115- Sal-Or'10
Signature Telephone
SECTION 3- ESTIMATED CONSTIIIIUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building `hv�r`�l�p�' r (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Feefo 4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) V Q Check Number •�
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: f
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
y,...� ....a
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [Q dn5 �idiing[p] Other'
Brief Description of Proposed.
Work: InQSS S�V'-L ��b'- 4 2A f6'r 06 A
(� DOUf3
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, n A C, '�''J as Owner of the subject
property `
hereby authorize C 0 Zy i�10 Y`n� Q_ffCayAAA0_
to ac on my beh in all mat ers relative to work authorized by this building permit application.
J ���-� I
Signature o Owner Date
r�TZ as Owner/Authorized
Agent hereby declare that the statements 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.
n(�,D�C)�_ �--rn 2-
Print Name
Signature of wner/Agent Date
City of Northampton
.S .. s;..
Massachusetts 5
DEPARTMENT OF BUILDING INSPECTIONS S x
nr
212 Main Street *Municipal Building
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:
1��`1 ���� ayi NxWtj 13N rq
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant 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.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
L Cl
Licerisc NL1111bC- Expiration Date
\ame ofc`Y.I folder
List CSL ripe(See belo%N)
No. and Sire'elL )PC I Description
h l (.'rirestricted(Buildings up to 35.000 cu. 11T I
R Restricted 1&,2 Family D,�elling
Y-0-
Cit\/J omi. Stale
\4 Masoiir\
RC Rooting Co,,eri ng
WS Windo„ and Siding
Sl' Solid Fuel Burning Appliances
tl\ S__6,1- QKS �j zy ( t-- ^,,r\ I InsulationInsulationN-La-- -b
TelephoneL-I'mail address 1) Demolition
5.2 Registered Home Improvement Contractor(HIC)
7 Q
CQ,, Ht�, -Regis ---N-
1[1(' stratiollNum-ber I'Apiration Date
I 11CCompam Nainc or HIC Registrant Name
No.and Street i7i�,Zi address
7-11A)
City/Town. Statl.ZIP I,ie Thune
SECTION 6: 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 .......... No........... 0
SECTION 7a: OWNER AtITHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the Subject property, hereby authorize cr Horne ke4,4(fnA 0 LA —_____
to act on my beho' in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNFR' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Z-1
Print(%ner*,;or authorized Auent' me 0:1ectronic Signature) Date
NOTES:
.. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
i (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 IIIC Program can be found at
%%�%w.111 lss.-o ,,:a Information on the Construction Supervisor I.icense can be found at 1%.1111'ss.,140V dI2s
When substantial work is planned. provide the information below:
Total floor area(sq. ft.)_ __ (including garage.finished basennent/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces_. Number of bedrooms
,Number of bathrooms Numberofhalf/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"
' i0o
s
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
' Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information l f� Please Print Legibly
Name (Business/Organization/Individual):�v 2 �1 -t'Ji��„ 1�/ Q! �(�(rt y)(y-
Address: � `j�` �•`J`.1
Cit /State/Zi h N Phone #: 0
Are you an employer?Check thea propriate box: Type of project(required):
1.[�I am a employer with 7 _ 4. ® I am a general contractor and 1
employees (full and/or dart-time).* have hired the sub-contractors 6. New construction
2.® I am a sole proprietor or'partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub-contractors have g, ® Demolition
workingfor me in an capacity. employees and have workers'
y p �'• . 9. ® Building addition
[No workers' comp. insurance comp. insurance.•
required.] 5. ® We are a corporation and its 10.® Electrical repairs or additions
3.® 1 am a homeowner doing all work officers have exercised their 11.® Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.® Roof repairs
insurance required.] ' c. 152, §1(4),and we have no 13 !;4 Other j ns LA �)Wemployees. [No workers'
comp. insurance required.]
*Any applicant that checks box q 1 must also till 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 employees.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. )_
Insurance Company Name: D n -0 n ?�7 UYA (U e)1 __
Policy#or Self-ins. Lic. #:_y 5 ,3 - Q i - j — Expiration Date:_ LL
Job Site Address: i�\`'� c� nCQ ti�� City/State/Zip: Tvrl InA d ga.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the.DIA for insurance coverage verification.
1 do hereby eerd the pain and penalties of perj7that the information provided above is true and correct.
1,6-
Signature; !+
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#:
ACCWTLIP CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
4/24/2018
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(les)must be endorsed. H 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).
PRODUCERONT CT
The Dowd Agencies, LLC PHONE Ma ConroyFAx
14 Bobala Road •413-437-1010 No):413-437-1410
Holyoke MA 01040 • mQonrQyQdowd.GQm
PHU
T MiR ID,: C07-YHOM-01
INSURER(S) AFFORDING COVERAGE NAIC a
INSURED INSURER A:Selective Insurance Of South Carolina 19259
Cozy Home Performance LLC
180 Pleasant St. INSURER 8:
Easthampton MA 01027 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:223405154 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 TYPE OF INSURANCE LIS POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A 'GENERAL LIABILITY IS 2208979 4/17/2018 41172019 j EACH OCCURRENCE S 1 000 000
X COMMERCIAL GENERAL LIABILITY S 500,000
I PREMISES(Ea occurrence)
CLAIMS-MADE J OCCUR I MED EXP(Any oneperson) $15.000
PERSONAL 6 ADV INJURY S 1 000 000
_^^ GENERAL AGGREGATE $3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPCP AGG $3 0D0 ODO
POLICY X PRO• X : LOC S
A AUTOMOBILE LIABILITY A 9100582 1 4/172018 4/17/2019 COMBINED SINGLE LIMIT $1000,000
-- (Ea accident)
ANY AUTO
-- BODILY INJURY(Per person) $
_ALL OWNED AUTOS
BODILY INJURY(Per accident) 5
X SCHEDULED AUTOS PROPERTY DAMAGE $
`X HIRED AUTOS (Per accident)
X NON-OWNED AUTOS $
A X UMBRELLA LIAB X OCCUR S 2208979 4/172018 j 4/172019 EACH OCCURRENCE $2000000
EXCESS LIAR .CLAIMS-MADE AGGREGATE $2,0D0,000
_ DEDUCTIBLE $
X RETENTION - ,$
WORKERS COMPENSATION WC STATU- H-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $
ElOFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE S
'yes.describe under ---
DESCRIPTION u0 OPERATIONS hebw E.L.DISEASE.POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more specs 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.
Cozy Home Performance, LLC
180 Pleasant St.
Easthampton MA 01027 AUTHO IZED REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/U9) The ACORD name and logo are registered marks of ACORD