25C-051 (7) 59 LINCOLN AVE BP-2021-0132
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:25C-051 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2021-0132
Project# JS-2021-000211
Est.Cost: $6000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SCOTT NICKERSON 053156
Lot Size(sq. ft.): 12501.72 Owner: GINTIS VALERIE
Zoning:URB(100)/ Applicant: SCOTT NICKERSON
AT: 59 LINCOLN AVE
Applicant Address: Phone: Insurance:
PO BOX M (413) 896-3347 () SOLE PROPRIETOR
LAKE PLEASANTMA01347 ISSUED ON.81412020 0:00:00
TO PERFORM THE FOLLOWING WORK:PORCH REPAIRS
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 8/4/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
q
The Commonwealth of Massachus 3
FO
1 Board of Building Regulations and n r C97Rev'
C
Massachusetts State Building Code,780 �i 0�� CS ALITY
MOV 4,
Building Permit Application To Construct,Repair,Renovate a dMar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Buil di g Permit Number: y (' ate Applied:
EUIIJ
Building Official(Print Name) ILI, Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: / ^ 1.2 Assessors Map&Parcel Numbers
�.. /`1" d SG
1.la Is this an accepted street?yes—V--/'
es no Map Number Parce Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D' sal System:
PublicgJ Private❑ Zone: _ Outside Flood Zone? Mturicipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 �w�ner'o1
f Rec rd•
�IL'1
�mlP
Nae(Print) o City,State,ZIP
S61 [-in c a A Lf6(M (~
No. and Street Telephone E Address
SECTION 3:DESCRH'T N OF PROPOSED WORKZ (check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bid . ❑ Number of Units Other ❑ Specify:
B f D criptiono of Proposed Work /w- o rc
SECTIO 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 6 p 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ �
Suppression)
Total All F
Check No. Check Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstructionSuperviSupervisor License(CSL) S31 S 4
sea-111 /7,J
License Number Expiration Date
Name of CSL Holder U
OQ I o A M List CSL Type(see below)
No.and Street / ' Type Description
L� �f�K Q �� l� U Unrestricted(Buildings u to 35,000 cu.ft.)
City/Town,State,ZIP � R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
y/3 9 -33 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) .114311 9 `I
Sett A-1 A 4e u e— HIC Registration Number Exp6ratiofi Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Telephone
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 Issu of the building permit.
Signed Affidavit Attached? Yes .......... 6 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
n
I,as Owner of the subject property,hereby authoriz4& 'V1c.kt:5(,)
to act on my behal ma rs relative to work authorized by this building permit application.
Print Owner's ectronic Signature) Date
SECTIO :OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name I hereby attest under the pains and penalties of perjury that all of the information
contained in this and4ccurate to the best of my knowledge and understanding.
- �3
Print Own 's or Authorized Agent's Name(Electronic Signature) JDate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(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 HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dys
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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"
The Commonwealth of Alassachusetts
Department of Industrial Accidents
I Conjgress Street,Suite 100
Boston, A.L4112114 2017
www.mass.go�Adia
%N urkrrs' Conipcosation Insurance Afridavit:Gencral Businesses.
10M, [1t.E0 t1 t 1'H THF P'ULMITT1214G A L Tt OR1 's`.
AptAicant Information Please Print Leeibly
� � r�1� C / � 6d�
BuitlanizationName /_0L,
Address-
citylstawzir- Iti_ f l�-hJ ,n . ..I L Phi
Arc tuu ate umpioNerx Cliecl,the apprupriatebox: Business Type(required):
1.❑ l' a employer Wath tnplcaye (full said:' 6�.k Retail
pan-time).* 6. ®Restaurantt'Barl-Eating Estahliahrtwrtt
20 1 am a scale proprietor or parusc:., ,tr and have no 7. office and/or Saes(incl.real erste,auto.etc.I
employees working for me in any capacity.
[No workers'wmp.insurance required] 8. D N prof t
3.C: We are a corporation and its officers have exemised 9. D Enterumrnent
their right of exemption per c. 152,§1(4),and we have i(1.D Manufacturing
no employees. [No workers'comp.insurance required)*
t We are aterser-profit organization,staffed by volunteers. 11.D health care
Keith no t rtoyees. [No workers'comp.insurance req.] 12.[7 Other
*Any aMhLzai that d cks bux 41 mwa a6j,fill out ergo t€4m bdu*showing dknr policy mf narunt_
•*ti t$rL coqumate affiLvM 1watic exampled ncera sdvex-but dic cospuraiRm has other ansate:yeti,i*relies'Loinpaxsatiun pulii? 6 tettair a %ucie sn
urywivation,huutcf checkbuxmt.
I am an employer that is providin worliers'compensation havarance,for tart-employee%. Belt)*is rhepoftt�v in formatiorn.
Insurance Company Natne.
Insurer's Address:
City'state:Zip:
Policy#or Self ice.Lic_# Expiration Date.
Attach a copy o(the workrrs'compensation polio declaration pie(showing the policy number Mw expiration dste�
Failure to secure coverage ai requires t1 under Section 25A of NIGL c, 152 can lead to the imposition of criminal penalties of a
fine up to$1,500M andiior targe-ve*'i'renpnsonni w-as well as civil penalties in the forth of a STOP WORK ORDER and a tine
of uta to S250.04 a day main. k 10[ator. d-dr�tt-�r of this statement rmy fc ar d to the+O#�ee of
ttgations of theDIA tn, cc c;overa-ge verific;ation.
I cis hereby cerrif)-, r rhe pains and,pena lflea of perjury that they information provided tebove is true and correct
Sit�natua nate-, -' 1 221_/A O
Phone : �� 3 -
Official ic•ial use only. Do not wt�e in this arra,ur be romptemf by etity or fawn:r�+j iciaL
City or Towns. Permit/License
IssuingAuthority(circle erne).
1.Board of Htakh 2.Building Department 3.CitylTown Clerk. 4.Licensing Board 5.Sciectmen's Office
6 Other
Cantu Pers aa. Phone 4-
City of Northampton
Massachusetts
d DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building va
--Wa Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number _ is that all debris resulting from this work shall be disposed of
in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
�/Location of Facility: Y /� Il 4 - /' C.4
The debris will be transported by:
Name of Hauler: _S�t- 7�1 /`<< </er c c-1
Signature of Applicant: Dater -�