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25C-051 (12)
File #BP-2022-0779 APPLICANT/CONTACT PERSON:SCOTT NICKERSON PO BOX M LAKE PLEASANT, MA 01347(413)896-3347() PROPERTY LOCATION 59 LINCOLN AVE MAP:LOT 25C-051-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permi •. • it Fee Pa i• $42.00 Type o . DECK ADDITION New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved 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: § Findin Special Permit Variance* r 5,1 etitt r Received&Recorded at Registry of Deeds Proof Enclosed OtherPermits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 7 ao Si ture 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,Deparbnent 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 o Planning&Development for more information. or RECEIVED 1 e C mmonwealth of Massachusetts wi \ Boar of uilding Regulations and Standards FOR JUN 2 9 202501ass chus tts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Ap icati n To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 DEPT OF BUILDING INSPECTIONS On - or Two-Family Dwelling NORTHAMP[ON.nnH 0 i 080 is Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 P peerrl Address: i 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel 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 Yard Side Yards Rear Yard Required Provided Required Provided Required Provided A L �� no LI•4 c 3/ 1.6 Water Supply: (M7 1 c.40,§54) 1.7 Flood Zdde Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check ifyes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1, Qwperl of Recor , V er (or t3 _ 1 ` mp-CfN [hR ©LOL& Name(Print) City,State,ZIP (•in cot es 4/3 all9 --BIOS Vlertiv-t'ij Tail t No.and Street Telephone Email Address CeArN SECTION 3:DESCRIPTION OF PROPOSED ORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units / Other Specify:')-` 4 /o A x.a Brief Description of Proposed Work2: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $3 6 O p 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ �® 0 Standard City/Town Application Fee —. 0 Total Project Cost3 (Item 6)x multiplier x 3.Plumbing $ .....,?"- 2. Other Fees: $ 4.Mechanical (HVAC) $ __,,e----- List: 5. Mechanical (Fire $ Suppression) �- Total All Fees: $ Check No. Check Amourh V(. , Cash Amount: 6. Total Project Cost: $ c 0 6 0 0 Paid in Full 0 Outstanding Balance Due: City of Northampton >- Massachusetts '��_ n. r ur SLL. DEPARTMENT OF BUILDING INSPECTIONS �; 212 Main Street • Municipal Building ' ,?' `\t±! Northampton, MA 01060 +'P.. x'I°~` CEIVED S l 6., cd .-/ A.--e JUN 2 9 2022 2-p, f/Mej 76 A PROCEDURE FOR OBTAIN A BUILDING PERMIT FOR NEWPT of BuILDTN,tNSPECTIoNs 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY' ; k1 .01060 FENCES, GROUND MOUNTED SOLAR, ETC. I. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s) and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new / replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit - public land by DPW / private land by Building Dept. 13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) c 3 1 / 6 ,. 5-co # A [clee ed License Number E pirati n Date Name of CSL Holder 1 List CSL Type(see below) V No.and Street Q . Type Description r /• 4w( Q/3 'I Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,� State,ZIPc� � y�n Ni? Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvementn Contractor(HIC) Jr-?-3 f r ,`�3 SArte Af Ahw''G HIC Registration Number E irauon Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issua of the building permit. Signed Affidavit Attached? Yes No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 'J(_1}1. Alf f Ciffi' to act on my behalf ' relative to work authorized by this building permit application. Print Owner's Name rlectrontc Ignature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under s and penalties of perjury that all of the information contained in this application is true and accurat e best o standing. s e 2) /'2a- Print Owner's or Authorized Agent's Na lectronic Signature) Date 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/dps 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". CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD ?jJ SL 14 SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 5 212 Main Street • Municipal Building ,ter.' ,,. 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: Ye- `( ye‘ G'fr The debris will be transported by: Name of Hauler: .Sc- ff XZe e ''ao Signature of Applicant: Date: d �9 � ..., . The Commonwealth of Massachusetts P'Rig'WWI ft Department of Industrial Accidents 1 Congress Street, Suite 100 -.. laiv4,1am .kire Boston, MA 02114-2017 ,;,„ •-!;:-. .44- www.mass.govidia •,... 0.4 on VlOrkers'Compensation Insurance Affidavit:BuilderalContractorsiElectricia ns,`Plum hers. TO RE FILED WITH THE PERMITTING AtT110111TV. Applicant Information Please Print Legibls 1 . Name(Bustness'Orpunzation lodtvidua11:5Co lit e Address: AO 3.7C ifq CityState'ZipLAL,, ,/ ...,444,.1 Azol., 0/3112 Phone -=--: Y/) g71 ... ) Art yom ila employer?Cheek the apprupriate but: , Type of project(required): I.C3isma kryer with employees;lull and or part-tiniri,• 7. 0 New construction .',' ant a sole prupnetin an prallnerliaip and have no employees tkorions tor nor in g. 0 Remodeling an?,rapacity No workers'cow.insurance regannel„) 9.. 0 Demolition 30 I sin a homeowner-doing all*vent myself[No woekers'i:onigr„insurance required"' 1(00 Building addition 4.1:1 i am a lalmeownei and will Sr kunnc eontnkinry it,etindua.1 all WCAtic on in pracitity. I trk'tfl mum Thai all Llyntractur>cithet have rken -malurrn uesurancr ur are Ark I I I a Electrical repairs or additions proprietors With no employckm. I 2.EI Plumbing repairs or additions . .rj 1 ant a getter-al contractor and I have hotel the suls,contractors hated on the attached sheet E3 Thew sub-contct raors bane innployeres and have workers'cnp. I 3. Roof repairs omp.nnurance) I 4.1:3 Otbet We are a corixisation and at,officers have exert-need their right of exemption per PrAC)C r. i 152.,f II 41.,and we haven('employees.[No workers'cutup.insurance required.] i *Any appli...mt Ina tack .ls',..,... aunt aLso fill out the section below shot.uag their workers'compensation policv infonnalsom +Eknneour nen.u km ataimut Lan.aft-Wave rusLicatireg the)are doing all unri and then hire outside cordras-tors must submit a new affictis it indieung such. :Contractors that check this boa.must attaraard an addrmunal sheet shins trIF Lb.:name‘,1 the sutv,zraiti a.:t de,alui'Lac wiretile: ea not thou:entthe,h.v.,...• employee, if the A.IlY-contr.1,1.nr,brave employ ee%.die!.muse pnu Id, VI,r ur I 4 k en, ,.....'!711, 7, I ant an employer that is providing a-writers"compensation insurance for my employees. Below is the'polity and job.site in urination. Insurance Company Name: _ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City'StateZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under NIGL c. 152,-§25.A is a criminal violation punishable by i fine up to SI,500.()0 andOr one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. A co ' ' statement may be forwarded to the Office of Ins estigations of the DIA for insurance coverage verification. Ida hereby certify u re pains and penalties a • ' urination provided above is true and correct Signature: Date. 4 ff - - ----- Phone v.-. - EFI Official use only. Do not write in this area. to be completed by city or town official City or Town: Permit/License# Issuing.ku(hority icircle one): I. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector (a.(Mier ('otitAct Person: Phone#: Nov 17 05 ' 2: 1 smi . surveyor 1413) . 41 p.2 •I t i I I 1 J--* 1 \1e.iJuE Corr.: IRE pup :+TO DETEFYINB PHYSICAL _•2f.1•;,�:,� r�KtY FOR Ci8 B1 L811DING To a T t;Nt.HT W. i>kyL :,f,. , rrr� IrsuMNOE COY• , i+ ;vvSdTIOATWN ITi{NdC and BCRV�,rlt,li; "-t.EaG�" ; •+carcwstYc BOUNDARY To the beet of my E::. •isdge. in!,, ••`-'.y report that _, r6 BE uesD rot MS y�ECRNO O!lBNCaf I have a st;'-, i the••• ,• i:ra an ,+; the l,ulidin as locatEd on he p r-8 de3 !n:lrely within i 0F lot Ilnea a -st tit,' t no . building cf_:,} adi,:'; 4 premix r report that, DONALD ' to the 1,:r-: e' my !,:.. •..leti'ie, : . ':rd affecting J. thin property Sk4(TH 5' the tract shr•+s her-- sz>rept i,- s,;.31380 is:.10T- loe--v d in establi:. •Note:t~ _ ,1 jai v� This 'st i, c ^i?e�, •�A.,, ' —her sources of ar,+ infor _. ; is subject to -,i►' , , p .. .; MtTH V � City of Northampton Massachusetts 44/$ ._ DEPARTMENT OF BUILDING INSPECTIONS ? rv: 212 Main Street • Municipal Building Northampton, MA 01060 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born — (insert month, day, year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) (7I ) 4-- 6,7J D".1 �l or el ary nrss / )09/ 3/)ic 1-1"9.0 dcf ( ))r )fd '"/7 "are ey_A 13 i i Fr I ,\.‘ ,,,...„ tom✓ t c I � I `\ I ! i Pr t i�i I ^I-t ! C-Ii N . G 2 i� i 0_....7 decl -----0 Ill i 3 -Pf u I cuss frp 4o, Li TJco� .1 AVENUE NOTE: THE PURPOSE OF THIS PLAN IS TO DETERMINE PHYSICAL To ' -pJ E'1 w" BEDWA22- :}k• + aU$ -RL vc A. 4�A.: ENCUMBRANCES ON THE PROPERTY FOR USE BY LENDING INSTITUTIONS. MORTGAGE AND TITLE INSURANCE COM- and ?Al?N A Pi 1-se A. C of 8E TT PANIES.IT IS BASED ON A SITE INVESTIGATION.IT IS NOT To the best of my knowledge, information and belief, I hereby report that SURVBEY AND IS NOTC URFFICIENDCTo BE USED FOR THE I have examined the premises and that this inspection plat shows the buildings LAYOUT OF PROPERTY LINE 0' 'V,.. 'ECTING OF FENCES BY THE OWNER as located on the premises described, that the buildings are entirely within . OF lot lines, and that there are no encroachments upon the premises described by �kA�' buildings of any adjoining premises,except as indicated.I further report that, :' DONALD to the best of my'knowledge, there are no easements of record affecting g J. the tract shown hereon, except as noted. I further certify that this property SMITH is v o-r located in the established flood hazard area. No.31380 Note: S 9,4. This plat is compiled from other plans,deed dimensions and other sources of ''�/ONgt LAND S� information, is not to be construed as an accurate survey, and is subject to �, changes as a more accurate survey may disclose. :,•► OWNER: `.7FA0L.E.'' VU. FiErAJARZ . JR. ;' r:= .. A., PLAN OF LA ' • AT: (D '%.'71]�i.t; 7"�w Sr i i1� N�<. /►TE:�}; tz.3<r GALE: " = 50' bir, S.E. COUNTY BOOK OF PLANS: 4c-7 PAGE " NO.: 19 0 LOT NO.: FT PLAN NO. cl DEED 8 K: �:<< ` SMITH ASSOCIATES PAGE NO.: SURVEYORS, INC.