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35-031 (3) Awk- 12,6 ,SGo / l L lc C✓J�.v. - „ . l�-G-� �� ( LA-) 14 b 1.L G ! 4 - Ale C �� T r`J //(( a x Y K 6c i Y M f 4"O* Lt �x io d�LU f-�c,�ce�Is MAY OVA W(Kip- 61 AJ, s! U w0000 _off K S 212 M.IiL sLrt:f-, �MfLL'Ecirall GIG60 7-14-04E 1�V,\; -0 -rXE.N, �TTON A CKIN:OW-I DGEN-171 TT �j f a S 3 a c LI:s e=s ij o-w s L 11 e h o r-,,t 0 w m e�,L�e z!,:,- c 7 E 0 C-��f R 1C4..1 t0 Tire S=2�0" ac-,- az e,Son(s) aparcel on which resides or intends to be, a o,--e or twoflzlmzuy az-zacLed or.d.eached strz-,c--i,-re;S acce--Scj-�to szjch us- =(!Vcr fam 2111 r-I sl d person WLG coust-Licts more one hoMe in a IDe:7od sLall not be cc e r ed a home CWMef." T-he f,-F tLe Civy of Northampton wanzfs any persom(s)Who seek to - -- — -- L * - 1-n lne 'LIT e use thne hom�, C-,7�Mer eX2=PLOI:� LL; C-" C-Z L.Uelr 07� co=tr-,=--Cn Suoerlwlls-M�l tLat by doi. - s�vou become r—esponsible for complanct win state building codes and reguL.-fo us- T"he i=ec,. procesz-requ—Tres that the builldLng denzr=ent be nnT7ed to insper wcrx at v=-Gus st-azes, which include foundztionj Tootings (before bacIdUA se-notube holes (before vour). a rouSin buildipgjuspe�on(before work is CMC--ile-A. mzmecti�an-(ff reguL-ed) The buEd:= m."T.2ires these inspe ons.before the work is Conce-ale:t failure to secure these i=uectons can result in failure to obtain a Certificate of Occurmncv H the ham ec per mres Other trades to pe:=orm wore(ellectic'--1 p lu.--b in z&--gas) tL e -ble C.- er- e r tC, Z7-'-,-5ZIr;-that f- 7-4 Se-- --re their proper' tr_ZeS hIL r=,is 19 per=---ts C-or-j=czon to the buUdimg Pe. '- zu--- and that they get their r-- uired Lispectious-FaEH:-,e cjFiHe inai uidLai trades to se-'r:1-e the permits and ins�,d--dcms as _T made T the above_ sig-unture requesting exemption) 1 W� cad-.0 schedule 1 recuL-ed bL m- -- pections necessary for the building permit issued to me. Da e 7-- Add-, O�ace of In vest.-ctions -; 600 Uits.hinJton Street Boston, 111-4 02111 WTVW.Mass_1 of/dia Workers' Compensation Insurance .--ffidavit: Builders/❑flntractorsTlectricia,isi,Plumbers A gnl;C;?rit Information Please Print Leaibiti Fame (Business/Orzanizanon/Individual): SGo A//c /C��✓� ., r Cit✓/State/Zip: Ze u c c-# M4 U/° J—',( Phone L. V / 9 6 — 7 3 :`re you an employer? Check the appropriate box: Type of project (required): !.❑ I an; a employer with 4. ❑ I am a general contractor and I p J q ) employees (fuP and/or part-time).:� have hired the sub-contractors 6. ❑ New constuction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in anv capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and is 10.1 1 Electrical repairs or additions ffi o cers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ Myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t C. 152, F 1(4), and we have no employees. [No workers' 13.7 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contr-ctors that chec:c 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. ,C_ / Insurance Company Name: J - �` ����'`-'^ 1 Tr A v e Xel 1 y- 1 r A4 (r it G r) (o IC v 0 cf`a� X S r ru .Expiration Date: Policy�or Self-Ins-Lic. �: _ �1�rex ex- City/State/Zip: 1H 7 k t G/a 6 0 . Job Site Address: � �� ��. �� Ll 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 fire up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investieations of the DI_A f- assurance coverage venfication. I do hereby certify-u: , the at-the information provided above is true and correct. Signature: Date:-3 ./..3 / Plh o .ne fraciaLtue_.or�i� I?oatrt�ule�ulhis area tort e competed bv_citt or town o clot City, or Town: Perinit/License i Issuing-uthonty (circle one): i. Board of e2it: _. Bu-]din2 D ecl tMcui 7t-;,'Ti v rli, Cie— -.Eiectr;cal Tnspe,t;;r 5. P11-1 lbng IlsPector - 6. Other C:,nt:i;:t IjIll:ne=: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructions Supervisor: Not Not Applicable ❑ Name of License Holder: ✓ 6. " �e,-1, � s /- 6 License Number Address Exon Date Telephone 9.Registered Home Improvement Contractor „ Not Applicable ❑ Company Name Registration Number gfz%Address Expiration ate Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,:§25C(6)) Workers Compensation Insurance affidavit nXst be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin,g4permit. Signed Affidavit Attached Yes....... No...... ❑ 1.1 .....1-Iome:Own�r Egemptan 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-vear 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 f-1 Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [M Siding[p] Other[c] Brief Descn ion of Pro osed r R Work: o.+c Ptr s.. .� ✓oow. a 3 GaJdK w� 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 ejjSji6q bousin ., com lete,the`'fofiowin 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 � f-1-9 (/ -et c. 1 �; l' as Owner of the subject property hereby authorize �C 4 �1 ✓ — `C"CUs d to act on my behalf, in all matters relative to work authorized by this building permit application. ?"' Gov � Signatu wner ate S ( a tf c.lC C ri �..— as Owner thonzed Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my edge and belief.. Signed under the pains and penalties of perjury. o Print Name Signature of Owner/Agent Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size _ �/ G Frontage Setbacks Front µ Side L.__..._._._. R.-__,._. R ,_...._.. _.._..... µ.___ Rear Building Height Bldg. Square Footage Open Space Footage _ % _- (Lot area minus bldg&paved � -- Darkin ) #of Parking Spaces Fill: (volume&Location) - A. Has a Specia mit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued:'ii IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0---DON7 KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavatio Iliing)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City.of Northampton Status of Permit: ;Suit ag Department Curb Cut/Dr7yeway Permit," . 2i� Main Street Sewerlsept cAvalabtl ty Room 100 WatertWel Auailabilit 1 2 'thampton, MA 01060 Two sets of Structuraf Plans � J ph ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans r j Other Sperm.. APPLIC,41ION TO CONS-f kUCT-AtTILR,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro a Address. This section to be completed by office / g� R) Map Lot Unit v"O- 64l-A( Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: 0 'Coo--I V(,4-/Cl 12of Name(Print) Current Mailing Address: rluv-r-vct 4-?r� UtGCp2 Telephone 5 0 LIE 11 A 2.2 Authorized Agent: -Sco -If c r r 4 3 �� Lc��..,l� ��>• �v r7� �i�led Gld�' � Name(Print) Current Mailing Address: Lhs - q - Sig Telephone S CTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building o2 000 (a)Building Permit Fee 2. Electrical / o o (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) O O a Check Number This Section For Official Use.Only Date Building Permit Number. Issued: Signature: Building ommissioneR t6f of Buildings °` Date File#BP-2008-0842 APPLICANT/CONTACT PERSON Scott Nickerson ADDRESS/PHONE 197 NORTH LEVERETT RD LEVERETT (413) 896-3347 Q PROPERTY LOCATION 782 RYAN RD MAP 35 PARCEL 031 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out 4 1406 Fee Paid Typeof Construction:_CONVERT ENCLOSED PORCH TO 3 SEASON ROOM(12 X 20)&INSTALL WOODSTOVE CHIMNEY LINERS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 053156 3 sets of Plans/Plot Plan THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: 7� pproved 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 Permit 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 1 Septic Approval Board of Health Well Water Potability Board of Health -N� Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition elay Signature of Building Official 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. 782 RYAN RD BP-2008•,"')542 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -031 CITY OF NORTHAMPTON lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category BUILDING PERMIT Permit# BP-2008-0842 Project# JS-2008-001286 Est. Cost: $21000.00 i'ee: $105.00 PERMISSION IS HEREBY GRANTED TO: Coast. Class: Contractor: License: use Group: Scott Nickerson 053156 Lot Size(sq. ft.): 19994.04 Owner: KAZAKIEWICH ROGER A & Zoning: SR Applicant: Scott Nickerson !,,')!c r iI Address: - ---- -- Phone: Insurance: 197 NORTH LEVERETT RD (413) 896-3347 O Workers Compensation LEVERETTMA01054 ISSUED ON:41412008 0:00:00 TO PERFORM THE FOLLOWING WORD:CONVERT ENCLOSED PORCH TO 3 SEASON ROOM (12 X 20) & INSTALL WOODSTOVE CHIMNEY LINERS 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-: L')/� Rough: Rough: ,� /' 1) House# Foundation: : "�� �, Driveway Final: Final: Final: Rough Frame: Q, tT- V(,l ,d f Gas: Fire Department Fireplace/Chimney: Final: Smoke: Final: n k THIS PERMIT MAY BE REVOKED BY THE-CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIOl1S/ Certificate of of Occu anc Signature: FeeType: Dat aid: Amount: Building 4/4/2008 0:00:00 $105.002972 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo