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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