25-007 (10) City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
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
i\A
(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)
111d6
Signature of P&6it ApP71 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-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [M id'ng[❑] Otherl(o
,i T►7 ry
Brief Description of Proposed
Work: �P15`� `��iTe, �C11J- J
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 existina housina,complete the followina:
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
Q'A'Q x as Owner of the subject
property ,\ 1�
hereby a orize CO Z �''O)V'Jt. 6 �rTJs cr t`l�
to act behalf, in a ers relativ o work authorized by this building permit application.
1> fl G
ignature of Owner Date
inArV � �z
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.
it L La �z
Print Name
Signature of Owner/Ag-&d- Date
SECTIONS: CONSTRUCTION SERVICES
rS.1 Construction Supervisor License(CSL)
-Li v4__ 2- License\ hxpiraJon Date
\Linie ol'CI,I folder
List CSLT\PC(x:k:belo�%)
xo
\o. and Sitvm Description
-1(-�-� U (:nre,.itriewd(Buildings upto 35.000 cu.11.)
R Restricted 1&,2 Family Dwelling
CitJI m�11. State./I
.M i Masoiry
RC
Roofing Covering
WS 1 Willckm and Siding
SI: Solid Fuel Burning Appliances
In
k:lephonc Email addres;- Demolition
5.2 Registered Home Improvement Contractor(HIC)
a-� 7(3
CN,QL traiio
I IIC Compam Name or HIC Registrant\tinw i I IC Itenk 11 er Expiration Daic
\t).and . ircet.
Einatl address
City/Town.Statb%ZTP
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 ........... 13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I !.as Owner of the my
property, hereby authorize subject CQ1 HQmt— r �--)tMa4LA
---- - -
to act on � behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Elceironic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
contained in this a4pplication is true and accurate to the best of my knowledge and understanding.
'
/ab
me(Electronic Signature) Date
Print 0%%,ne I-r',,or.Authorized Agent's yn
11-1 NOTES:
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor I
i (not registered in the Horne 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 f IIC Program can be found at
Information on the Construction Supervisor I.icense can be found at -%k.nwssxov-dns
' When substantial work is planned, provide the information belo%k:
"Total floor area(sq. ft.) (inciuding,garage.finished basemenvattics.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"4
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
o Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aunlicant Information /j Please Print Le¢ibly
Name (Business/Organization/Individual):Z_y/( )mC� ,!4'(�r'{(/�.-m,'
Address: l P/e 4.54// � 5" A".4 00
City/State/Zip: fy5%f-/�?/,vV,r0/V MW Olaf Phone#: #13 -,5cO- 000
Are you an employer?Check the appropriate box:
Type of project(required):
l.C@ I am a employer with employees(full and/or part-time).* 7. []New construction
I am a sole proprietor or partnership and have no employees working for me in
8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
3r I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑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.❑1 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?
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.M Other /�1/5 Lk(L)N
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I 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 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: coi-A',(�Q n7A �(�Ltl Qmn 1 y Comp em V
Policy#or Self-ins.Lic.#: y b-�S"1 rj � "U 1 l i Expiration Date:
Job Site Address: Vi I ?t� of CC,nk (LA City/State/Zip: :', �CQ`Vri V mei 31
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.
I do hereby certify nder a pains and pe alties ofperjury that the information provided above is true and correct.
Si nature: -. -� �7 Date: t M 1
Phone#: `A1 �,— ���1- U c,(0
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#:
RECEIVED �vsUL�r���
�uitWor
NAV 2ham ton Status of PRDE partr ient curbC tn>t
C 9 t�4 2
212 Mai Str t Sr/� Iraltjf
PT .7F C l;i'f I��G INS, 5100
1060 Two c k .
uw � r ' ` �'•` ,
phone 413-587-1240 Fax 413-587-1272 PiotfSi !?It f "
Other SPp
3
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE
OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION �!7� /"/' (J,)"
1.1 Property Address: This section to be completed by office
^�
Map O` Lot 00 ✓ Unit
fz� �` u�v A Zone Overlay District
,\ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na Print) Current Mailing Address:
- Telephone
ignature l
2.2 Authorized Aaent:
2- A14
Na nn J Current Mailing Address:
Signature Telephone
SECTION 3-ESTIM ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) So S O Q Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
142 RIVERBANK RD BP-2019-0628
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma : 10 k:25 -007 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-2019-0628
Proiect# JS-2019-001028
Est. Cost: $6500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Uge Chomp: MARK LANTZ 162770
Lot Size(sq.1): 24001.56 Owner: NMER1 ALEXIS
Zoning. Applicant: MARK L6NTZ
AT. 142 RIVERBANK RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST 4200 (413) 529-0200 0 _ WC
EASTHAMPTONMA01027 ISSUED ON:11/28/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXTERIOR WALL DENSE PACK, 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 Denartinnt Fireplace/Chimney-
Rough: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
rtif ate of Ocgugancy §ignature:
FgeTvne: Date Paid: Amount:
Building 11/28/2018 0:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck--Building Commissioner