42-038 721,WESTHAMPTON.RD i BP-2020-0241
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-038 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-2020-0241
Project# JS-2020-000413
Est. Cost: $5700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq.ft.): 14984.64 Owner: KAGAN AARON
Zoning: Applicant: MARK LANTZ
AT. 721 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
180 PLEASANT ST#200 413 529-0200 WC
EASTHAMPTONMA01027. ISSUED ON.•8/28/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-AIR-SEAL ATTIC, ADD 12" ROOF VENT, 12"
CELLULOSE TO ATTIC, INSULATE RIM JOISTS, WEATHERIZE DOORS
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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: J
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THIS PERMIT MAY BE RE OKED BY THE CITY OF NORTHAMPTbN UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: (Date Paid: Amount:
Building 8/28/2)19 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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Dep
City of Northampton
'rA Building Department
2 2 Main Street IN
A'1Room 100 LA, IO�,:
Northampton, MA 01060 b
; n�TM phone 413-587-1240 Fax 413-587-1272
- � •• ONL-Y �
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY � btq—
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SECTION 1 -SITE INFORMATION INSULATION ������
1.1 Property Address: This section to•be completed by office
Lott Unit
7 ,)A ,.,Map
\L Zone- Overlay'Distridt
Elm St District �, CB District
SECTION 2-PROPERTY OWNERSHIr/AUTHORIZED AGENT
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2.1 Owne of Record:
am
�� � 7 � GJe � �'�w 12 r� �'°� •
Ne rint) Current Mailing Address:
Telephone LPN' 0 YO
ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
A'& 0�j -0 1
Sign ture Telephone j
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SECTION 3-ESTIM ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 3 Official Use Only
completed by permit applicant
a
1. uilding - �1 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fees
4. Mechanical (HVAC) / O
5. Fire Protection
6. Total=0 +2+3+4+5) S Check Number `�Oq
�I This Section For Official Use Only
Date i
Building Permit Number: Issued: i
Signature: f (6j"29"Z6l 9
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Building Commissio i er/Inspector of Buildings Date
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EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 9 Not Applicable ❑
Name of License Holder:rn'QI(�� l Z Us CS l-- I U 1�9
License Number
Cie PICA let 114 IQ 1 X,3
Ad r s Expiration Date
Sig ature Telephone
9:Registered Home Improvement Contractor _ Not Applicable ❑
Company Name Registration Number
� o Z ens ov,�< 6A, 5�(��,- ►�i:�.� r�4� Ol0�1 � is I a'I
Address 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.......% No...... ❑
Brief Description of Proposed Work
rr�3� 5�v e fob'• �,� ��� Arc AAA �a'' fovf dtr► ��� Ids �11�� � 'Ic
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I, mP f F 1.�,i1as 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.
Print Name
-J—
Signaturg of Owne gent Date
I, A 01'11 k5'!g as Owner of the subject
property J
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hereby authorize COQ No�2_ 9-e AW\Owo,
to act on behalf, i Ian matters relative to work authorized by this building permit application.
-gnature of Owner Date
.. . .z ., .... .....,....t.......
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS y;
212 Main Street • Municipal Building
Northampton, MA 01060 I sbyY j��
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
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The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and
subcontractors performing ii, ovements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
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Note:If the homeowner has• i retracted will:a corporation or LLC, that entity must be registered
Type of Work: 515 `� 1, Est. Cos ��Z
Address of Work:
c6�^► 0
Date of Permit Application:_& , \7
I hereby certify that:
Registration is not re uired for the following reason(s):
_Work excludedb law(explain):
_Job under$1,00000
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THE iR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCO TRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.1SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE iUlLDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION.
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Signed under the penalties ofperjury:
I hereby apply for a building 4rmit as the agent of the owner:
JJ I .
I y'hi Rr'K <6z 1 u 7 70.
Date Contractor Nain I HIC Registration No.
OR:
Notwithstanding the above n tice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
7 Boston,MA 02114-2017 !
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information f�JJ I Please Print Legibly
Name (Business/Organization/I!dividual):—� (jl
Address: f rO , 544 I
City/State/Zip: 5l f'� ,�A0/1/ ✓11� ®�® Phone#: q)3 `5�ot q"W
Are you an employer?Check the apropriate box: Type of project(required):
1.(M I am a employer with !employees(full and/or part-time).* 7. ❑New construction
2.[7 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No.workers'comp.insurance required.]
3.❑I am a homeowner doing all wolk myself.[No workers'comp.insurance required.] 9. ❑Demolition
4.[:]1 am a homeowner and will be Firing contractors to conduct all work on my property. I 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.!,E]Plumbing repairs or additions
5.n I am a general contractor and I I ave hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.- 13.[:]Roof repairs 1
! 14�[�Other I!��W6�.�t(,)h/
6.F1 We area corporation and its officers have exercised their right of exemption per MGL c. !
152,§1(4),and Nye have no emp'oyees.[No workers'comp.insurance required.] '
'Any applicant that checks box#1 must also fill 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 ant an employer that is provif workers'compensation insurance for my employees. BI low is the policy and job site
information. \\
Insurance Company Name: rA'� �Q n�a\ �'(1 G4 Q M(y k 2� comp.-,n v
Policy#or Self-ins.Lic. 5 Q I Expiration ate: J J I cl
Job Site Address:7 a.\ WC4'�, N A City/State/Zip: ,ar)k�\A6v MA o )0 tJ\
Attach a copy of the workers' compensa ion 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 cceerrijifyyndeer a pains pe alties of perjury that the information provided above is true and correct.
Signature: ✓� c L and Date:
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 on,
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other �!
Contact Person: 1 Phone#:
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City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS i
212 Main Street •Municipal Building b� X49
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Northmpton, MA 010601
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:
-)�'N a-'k "W
(Please print house num&r anid street name)
Is to be disposed of at:
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P4 A
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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Signature ofPermit A plica'nt or Owner D to
If, for any reason, the debris will not be disposed of as indicated, the Applilcant or Owner shall notify the
Building Department as to the location where the debris will be disposed. i
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