17A-157 (6) BP-2023-0375
61 FOX FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-157-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0375 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 KITCHEN&RENO Contractor: License:
Est. Cost: 100000 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: 04/03/2023
TO PERFORM THE FOLLOWING WORK:
KITCHEN RENO &DECK ON ACCESSORY BUILDING AS PER PLANS
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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: i i
• • Y
„ .52 . 'NT
Fees Paid: $650.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
�� I.
-*ro(can S
it
` The Commonwealth of Massachusetts
v, r, Board of Building Regulations and Standards MUNIF OR PALITY
i
i Massachusetts State Building Code, 780 CMR USE
`...
. ouilding Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
III One-or Two-Family Dwelling
I This Section For Official Use Only
Building Permit Number512 ZO23--O3'75" Date Applied:
tiv,o�i? /7/ 3-3 .ZCZ3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this anan — S accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
URA ,(flit (?Ct
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 apply:(M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage sposal System:
Zone: _ Outside Flood Zone? Munici On site disposalsystem 0
Public Private 0 Check if yes❑ y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:: / K '�
EicL -2' T°/ r / 6/4 /
Name(Print) City,State,Ziff � O `�
6 / /---;y tom. /2../ 1-03 -A/6 -63Yy rAri.,/1.f/./60.y4 4 • 6-4i
No.and Street Telephone Email Address
SEpON 3:DESCRIPTION OF PROPOSED ORK2(check all that apply)
New Construction Existing Building L'I/Owner-Occupied 1id'fRepairs(s) 0 Alteration(s) Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work22. 41j, pei,,,,nd 4s1' A.t. 4.. r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ RQ G c. 1. Building Permit Fee:$ Indicate how fee is determined:
/ 0 Standard City/Town Application Fee
2.Electrical $ /c Goo 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ / 2. Other Fees: $
%�/ GOo
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No/55D Check Amount:,
6.Total Project Cost: $ Ad DO d 0 Paid in Full 0 Outstanding Balance Due:
PlIF
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 33 /5. / / O 2
�� if Al/ ee✓ C H License Number E irati n Date
Name of CSL Holder
d
�t List CSL Type(see below)
�� M ��� Description
No.and Street
//
,Q '.J T
1 Unrestricted(Buildings up to 35,000 Cu. ft.)
L o t P
ot o l3 V — Restricted 1&2 Family Dwelling
City/Town,State,ZIP / M Masonry
RC Roofing Covering
WS Window and Siding
t' 3 Solid Fuel Burning Appliances
f`[ O 6cy 6 `3 3 Y -aril c(j coC'5 ►1t.�,./ I Insulation
Telephone Email address NI &Al D Demolition
5.2 Registered Home Improvement Contractor(HIC) /n 2.3//
SA,........" s_r H .,...e HIC Registration Number xpir tion ate
HIC Company Name or HIC Registrant Name -CAI 41
..0 r eV'q At d �tw.."
No.and Street Emil 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 completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuancece of the building permit.
Signed Affidavit Attached? Yes C� No .0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Own; of 1 e subject property,hereby authorize Sc o f ' /" e IsAio
to act on y b alf,in all matters relative to work authorized by this building permit application.
Print 0 : 's < e(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and hi perjury that all of the information
contained in this application i true and accurate to the best owledge and understanding.
v e -7) A!(G Arlo h 3 27 z 3
Print Owner's or Authorized Agent's Name(Electronic S ature) D e
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/dos
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"
11111
The commonwealth of Massachusetts
•Ni==. Department of Industrial Accidents
1 Congress Street,Suite 100
ctiZartialt Boston, MA 02114-2017
WWW.mass.goildia
‘$utters Compensation Insurance Affidavit:Buildersit'ontractorsdElectricianstPlu mbers.
10 BE ilLED WITH 1 HE Pt:1011111NC At TI1011111.
Annlicant Information Please Print Legibls
Name itiusiness:Organization
Address: PO
el3YX
cityistateizip:Ldir— 110i4 Phone P: Y/1 "if - 33v '7-
,
Are you ain employ re?Chtch the a ppruprlatv hot: IType of project(required):
i,C:1 I am employer vo.th employees(ftoll arniqn parttime 0 7. 0 Neu construction
2 am a:wile peoprictur in punneralup and have no ernployeex working itor me in S. QRemodeling
capacitY(Na workers'comp.insurance to:cooed.)
3.0 Demolition a haescoaalei doing all%mit myself.(No aork4ss'einnp.onaurance requireti.1'
10 0 Building addition
40 1 arn a homoovvner and vvill be luring contraddra to conduet all work on my property, I Will
at-htire lila all contractuts either have workers'compensation nenarance or an:sole I I C Lhx-Arical repairs or additions
pnapriettoos with no employees,
2J11 Plumbing repairs or additions
SO I am a gentn-al contractor and I ha.,e hared the sub-contracturs Listed cm the attaJaint ahem
3.1:1 Roof repairs
These aub-contractora ernployees and bast*miters'eamp.insurance.;
Other
na We are aompuration and its officers have exercised then Oen of exemption per WA_
152,§l141,arid we have ni ailploycvs.No workers'comp.inmaarice renunoLif
An oppticita that eitwki,box t,1 m12,1 ,Liu idi Otif the ieettim ham show Inv then wlifitTS'colitpea tn policy tnformatott.
Homeowner,who mabinct tin%affichoot inalicannu they arc doing all wor,and then hum otihidc collimator*must submit a view affudav truth:aunt;sts,:h.
Cc,nitetorb,that cheek this box most attached an ahhtional sheet above ing Ow name f the itractors and amine whether or not thuse tannic, e
onplul.,.Ix, tithe sub-eutikactues eiripluyeiN,they fltUai pnak.ide their workesa"comp..policy number
ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
•Insurance Company Name:
Policy or Self-ins. Lie.4: 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 MGL e. 152, §25A is a criminal violation punishable by a fine up to S1.500.00
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 this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify a mins and penalties ofperjury that the information provided above i.true and eorrect.
Signature: 111;: 3 2
Phone 4: Vrg ;Y
Official use only. Do not write in this area,to be completed by city or town official
( its or Tow n: PermitiLicense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
Massachusetts
" y. t1i *
DEPARTMENT OF BUILDING INSPECTIONS x`
212 Main Street • Municipal Building 4"..>
Northampton, MA 01060 Y
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: O. l- ,
The debris will be transported by:
Name of Hauler: f4 Ale f./G€C,�
Signature of Applicant: Date: 3A Z
III
City of Northampton
Massachusetts ,
;.
DEPARTMENT OF BUILDING INSPECTIONS -
' `"" +' 212 Main Street •• Municipal Building �j -.;
`—"""4 Northampton, MA 01060 §'!. A,',1 „
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)
-NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS YAND OTHERNO
SOURCES AND IS NOT
NO
TO BE CONS BUILDING LOCATION ACCURACY ES NOT GUARANTEED
RECORDED.
160.00'± fie-)
f i
BOOK 3497, PAGE 278 1' �
PLAN BK. 45, P 8 y�
PORTIONS OF LOT # 32
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NOTE: #61
SUBJECT TO EASEMENTS AND , d
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 QN
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: [T a Q THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
ZN of *Ss ._ —MORTGAGE LOAN INSPECTION P`AT—
RANDALLs` NORTHAMPTON, MASSACHUSETTS
E. I PREPARED FOR
'ZER " ERIC D. DOSTAL & ELENA L. CIAMPO
', #35032
SCALE: 1"=50'
\, sla4'4 , DECEMBER 5, 2008
° suRvt."( - HAROLD L. EATON AND ASSOCIATES, INC.
_.- ---- REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
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