17A-157 (5) BP-2022-0781
61 FOX FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-157-001 CITY OF NORTHAMPTON
Permit: Acc Structure
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0781 PERMISSION'S HEREBY GRANTED TO:
2021 ZONING ADD AUX
Project# BUILDING Contractor: License:
Est. Cost: 55000 SCOTT NICKERSON 053156
Const.Class: Exp.Date:01/10/2024
Use Group: Owner: CIAMPA DOSTAL ERIC D& ELENA L
Lot Size (sq.ft.)
Zoning: URA Applicant: SCOTT NICKERSON
Applicant Address Phone: Insurance:
PO BOX M (413)896-3347 0
LAKE PLEASANT, MA 01347
ISSUED ON:07/01/2022
TO PERFORM THE FOLLOWING WORK:
ADD 12'X24'X5'MODULAR BACKYARD STUDIO WITH 1/2 BATH & 3'HIGH CRAWL SPACE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I i 1
'1 •
Fees Paid: $58.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Ab
t
S , The Commonwealth of Massachusetts
, lt - Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPAL[TY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 4 .. - 7 e/ Date Applied:
, ItSiAlLAK., .2 . ,... I '''Ir
Buildin /49•
g Official(Print Name � ' Date
) Signature
SECTION 1: SITE INFORMATION
1.1 Property 1d r � 1.2 AssessorsMap&Parcel Numbers
CO
this anaccepted street?yes no Map Number Parcel Number
1.1 a Is ber
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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
el,e44 L G arm pot 1 iermce , M,4 D if D(a—
Name(Print) //�� City,State,ZIP
Id Lii SOX fa/VMS , 4t”'9-1'-0 106 -eleiritCd tiod.6"
No.and Street Telephone Email Ad ss
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0''" Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg.BP. Number of Units I Other 0 Specify:
Brief Description of Proposed Work2:
c t., , L► 4��.a(� _ i.. fi. . t 0s" . .. .r,�!� r'/ie,114,r Ae/4 /✓�
SECTION 4: ESTIMATED CONSTRUCTION COSTS V
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ §!p 0 6 a 1. Building Permit Fee: $ Indicate how fee is determined:
/ 0 Standard City/Town Application Fee
2.Electrical $ 5- n O a ❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $/! O a an2. Other Fees: $
4. Mechanical (HVAC) $ /6' List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check No.\�(� Check Amount: Cash Amount:
6.Total Project Cost: $
sf' do 0 0 Paid in Full 0 Outstanding Balance Due:
E M City of Northampton
t '
s � Massachus -
• ', DE1'MENT OF BUILDI G I
NSPECTIONS
212 Main Street • Mun' ipal Building
Northampton, 01060
JUN 2 9 2022
6 D� cep✓ t ,„�cr.; MA010
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
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.
4
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 53/ - 1 16 ;/
License Number Expira on to
Name of CSL Holder
List CSL Type(see below)
No.and Street // Type Description
/" lC�t 44-K Mil o/J V U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,C State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
Y/3�S g�' �� Y� S� �' �e � SF Solid Fuel Burning Appliances
I1/L 3 q #� I Insulation
Telephone Email address •J 6174-4 D Demolition q
5.2 Registered Home Improvement Contractor(HIC) 3 // I/i /?3
Sq ra.1c �c 4 4u-. HIC Registration Number Expiration 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 ompleted 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 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 Ceti N I' // 4)
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electrdnic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and p s of perjury that all of the information
contained in this application is true and accurate to the best of owled understanding.
.0Ca Al/LCGeLOti 0
Print Owner's or Authorized Agent's Name(Electronic S' attire) 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
C /4,4,/ dam/
CLnd
7 0 t (AL Jr-
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
w
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS '
212 Main Street • Municipal Building J ;'
Northampton, MA 01060 1r
J'S lY
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: VA /47 `` 17 Ga f /1Ak- lP
The debris will be transported by:
Name of Hauler: !/ �C Le_do 4-7
Signature of Applicant: Date: 00
...
ii
, The Commonwealth of Massachusetts
- -H
14
Department of industrial Accidents
1 Congress Street,Suite 100
Boston, M.4 02114-2017
www.mass.gogidia
Workers'Compensation Insurance:liflidavit: BuilderslContractors/Electricians/Plumbers.
TO BE FILED WITH I HE i'L.li 111 IT IN C.%t filORITV.
Applicant Information Please Print 1.eeibls
Name(FlusincsaOrganIzation/Indivickial);5C*'If -b /k/4, Le r-..(4.-1...,
Address: /a 7c,, "/
city/stat,'Zip: t 4 Lt fleAdA, Iinit Phone #: (//3 8i 3-z v4
Are you an emptii:serl't heck the appropriate lint: 0/1 ti 7.- l',in-or project Irequired
I.E3 1 .1 CrIfirk.H,a with _employee:,i tall mad:or part-time 0 - -1 New construction
2 I.tin a sole proprieor t or partnership and hate no erriployees**oriole for the in.....itn-
t S. 3 Remodeling
any capacity No*otters'comp.insurance required.)
9. p Demolition
10 i=is ilium:ow:un-doing all work myself[No workers comp.insurance irquirni]"
I 0 c3 Building addition
4.0 I ran a homeowner and will Ise hiring oostuactors to conduct all work ou my ps'operry. I will
ensure lust all contra:tors caber hate workers"conmensution insurance OT 11,0 MAK I 1E3 Electrical repairs or additions
proprietors with no employees
I 2.0 Plumbing repairs or additions
0 I a aeneral contractor and 1 hiSVC intt'll the sub-coranicaors listed on the attachod sheer
13.0 Roof repairs
Mese sub-contraelois bust employees and hat e*otters'coin's.insurance.",
1 4.0 Other
o.C]Wc are a corisotainni and its officers hat c exercised their right of own:it:Rim per MU c.
l','2.§1(41 and tte hate no sanplo!ous.[No wtirkers'eianp.insurance required.), ,.*Air.appis..ani roaz Jocks but g I must also till out the section below showing their workers'compensation policy information_
1 "-I lo;naeow nets who 3ubinii this atlidaint utawatIng they are doing ali wort and then hire outside contras:tors must submit a new anfidaY it indicating such.
Contractors that check this but must attached an additional sheet show mg the name of the sub-contractort and state*holier ur not those entities has<
etruploycc-, it-.Ite tob-contraczors bate employees.they most pit,,,d,their -.totters"stamp policy number
. _ . _
I am an employer that is providing worAers'compensation instirance,fOr my employees. Below is the polio and job site
infOrmation.
Insurance Company Name: ___
Policy#or Self-ins.Lic.#: Expiration Date:
Jab Site Address: CityStateZip:
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, §25.1. Is a criminal violation punishable by a fine up to SI.500.00
aridd'or one-year imprisonment.as well as civil penalties in the fonn of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A caps la - s statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage. verification.
I do hereby eertili an e pains and penalties of perfauy that the inlirrtnation provided above it true and correct.
..•
Sieriarurc:
Phone#:
Official use aid). Do not ly rite in this area. to lye completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
-NOTE-
This PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSUED AS AN ACCURATE SURV
BUILDING LOCATION ACCURACY ES,NOT GUARANTEED
RECORDED.
160.00 ± fie
.".........„„def.,...---
BOOK 3497, PAGE 278 1
PLAN BK. 45, PG. 8
PORTIONS OF LOT #31 32
x1 i3-44
CO i '- o
0
0 0
0 0
I+ r It
NOTE: #61
SUBJECT TO EASEMENTS AND - ,
RIGHTS OF WAYS OF RECORD.
160.00'±
FOX FARMS ROAD
TO: FLORIDA CAPITAL MORTGAGE, NA &
CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTAT1ON ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY ; 250167
-NOTE-
SURVEYOR: -A
THIS GEE-
LOAN
� , AND DOES NOT CONSTITUTE
.0 of/44sS, -MORTGAGE LOAN INSPECTION PLAT-
/ RANEALL ��\ NORTHAMPTON, MASSACHUSETTS
PREPARED FOR
IJ IZER y ERIC D. DOSTAL & ELENA L.+ CIA ' PO
i35032
/ SCALE: 1"=50'
sa / DECEMBER 5, 2 08
�0 .s. Rv��° HAROLD L. EATON AND ASSOCIATES, INC.I
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET - HADLEY - MASSACHUSETTS
\e2,1.
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File No. 3
ZONING PERMIT APPLICATION (gi o.2)
Please type or print all information and return this form to the Building
Inspector's Office with the $30 filing fee (check or money order)payable to the
.:- City of Northampton
1. Name of Applicant: EI et.1 C1 C i CI-vri f 1
Address: 01 F4Likvis I2 • 0lO(a— Telephone: 't i S " 100
2. Owner of Property: �Pi1 coNd. c otl c erio D05"hl eeu �5--? �c
Address: 9'41^'& Telephone: Sa,s4e-
3. Status of Applicant: Owner ✓ Contract Purchaser Lessee Other (explain)
4. Job Location:
Parcel Id: Zoning Map#)1 —i67--o a I Parcel# District(s): U RA
In Elm Street District In Central Business District
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
PI "�-
5. Existing Use of Structure/Property: �<t'r raj,. -Fee,• of bauvja.•-d S fate-
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
2- I x -' x 1 s rn atvl a►' ba a�( � o vi
//le,iiittAin Illikram)I sptee,
7. Attached Plans: Sketch Plan V Site Plan _ Engineered/Surveyed Plans
8. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO V/ DON'T KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document#
9.Does the site contain a brook, body of water or wetlands? NO j DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission? NIA
Needs to be obtained Obtained , date issued:
(Form Continues On Other Side)
W:\Documents\FORMS\original\Buildinb lnspector\ZonincPermit-Application-passive.doc 8/4/2004
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: t‘I/A
Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location: Af//// A
11. Will the construction activity disturb (clearing, grading, excavation, or filling) ove 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
Department
EXISTING ` PROPOSED REQUIRED BY
YEci ce, r( P/ 4rm ZONING
Lot Size X 4 SOL (Z
Frontage )( '7-6 1?et
Setbacks Front
Side L: R: L: LJ R: f +L: R:
U � O
Rear, coo
Building Height
Building Square Footage
Open Space: (lot area
minus building I* paved q2G,/A cps
parking f/
#of Parking Spaces
#of Loading Docks ��11
Fill:
(volume Ft location) 0
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
I
Date: k �' , �� Applicant's Signature�!(�
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004