32C-192 (6) BP-2023-1417
12 HOCKANUM RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-192-001 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-2023-1417 PERMISSION IS HEREBY GRANTED TO:
Project# LAUNDRY ROOM 2023 Contractor: License:
Est. Cost: 22500 SCOTT NICKERSON 3/6(49
Const.Class: Exp.Date:
Use Group: Owner: LLC ADB-1 PROPERTIES,
Lot Size (sq.ft.)
Zoning: URC Applicant: SCOTT NICKERSON
Applicant Address Phone: Insurance:
PO BOX M (413)896-3347 0
LAKE PLEASANT, MA 01347
ISSUED ON: 10/13/2023
TO PERFORM THE FOLLOWING WORK:
CONVERT PORCH TO LAUNDRY ROOM
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:
cior, ,
if i
Fees Paid: $147.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
I� \
FqO
The • 'nwe of ► ass chusetts
O • = ' - .lic S ety . d Ins ections
Massac a Buil. g Co.• (780 CMR)
Building Permit Application for a‘Y- HM' , other an a One-or Two-Family Dwelling
raj n
(This Section For• 'gal lse O y)
Building Permit Number:4 J'f1/7 Date Applied: :uilding Official:
SECTION 1:LOCATION/
No.and Street fit, City/Town Zip Code[)/D 66 Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Co used If Newonstruction check here 0 or check all that apply in the two rows below
Existing Building Repair 0 Alteration ld Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No CT
Is an Independent Structural Engineerig Peer Review required? J .,( Yes 0 No O�
Brief Description of Proposed Work(_ et vet 4 .. .( ex 1,-,T' ,�c /i /n I s
19,0
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):5q L
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) J (I K e-e
Total Area(sq.ft.)and Total Height(ft.) J
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 1-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3❑ R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6: CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA 0 VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Trench Permit Debris Removal:
Water Suppl Flood Zone Information:indicateSewage
Disposal: ,
dA trench w' not be Licensed Disposal Site C=Public Check if outside Flood Zone municipal
Private 0 or indentify Zone: or on site system 0 required or trench or specify:_
permit is endosed 0
Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable l Is Structure within airport ap ach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: _ Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
City of Northampton
*,fn r�r
Massachusetts '+
ii a
it/Ii; DEPARTMENT OF BUILDING INSPECTIONS s r g�
-.a 212 Main Street • Municipal Building �m a''
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. 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 & Hard copy).
3. Site Plan with location of proposed structure(s) and setbacks.
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 CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11. Trench Permit (if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
13. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name a.d Address of Property Ow per
„' '''' 4D8 - I f�✓ark-17-e3 u- ( to Cws-e...eC 5t -�Or P d2o'2_
Nam• (Print) No.and Street City/Town Zip
Pro erty Owner Contact Information:
4
i Ig Yfren'i!(/ t((j_S31_ .S' -a5 `r(3-S3( _S',2' (7/ 4geC' Coe sf reef.
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property wner hereby authorizes:
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1.1C Registered Professional� Responsible for ConstructionL Control(the professional� coordinating document submittals)
So-it i(Ic. '/` fa / il3 - al. SPI3 SdAt(CS4-eS'lt Vern-" /J 6
Name gcr�S N t)1✓ 14Tkeph� pTo/K / e-mail address Q/3�� Regis rtr on Number v / V
1 / /C L / D
Street Address City/Town State Zip Discipline Exp atto ate
10.2 General Contractor /
Sea !/ /(l (. 6,4 v t.•
Company Name
sf.) /74 A/ ittr4G+ 6 .S L c 3 /.,^ 6
Name of Person Responsible for Construction License No. and Type iffAApplicable
p
( '-be.4, 4, 17� /A4_ /P/i14, f^o. !�'[A CJ/ ?V 7-
Street Address / City/Town State Zip
-(//3 $46 - JJV _ 14K -Ur)/C1Tr e,A42./ . ce4.%
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes D No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ /f DOG , `--D
/ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 2, J'O o appropriate municipal factor)=$ .
3.Plumbing $ 5-, o 0 6 ,I i
4.Mechanical (HVAC) $ Note:Minimum fee=$14 7, (contact municipality)
5.Mechanical (Other) $ — Enclose check payable to
6.Total Cost $ e/2/ f p a (contact municipality)and write check number here
SECTION 13:SIGNATU E OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under pain penalties of perjury that all of the information contained in this
application is true and accurate to the best of o ge and understanding. c
Please print and ign name / Title Telephone No Date
. w 6 /AGE i 'st-r iw '
Street Address / City/Town State Zip Email Address
crqMunicipal Inspector to fill out this section upon application approval: Nam. 4.) ' 41 / 0 ' 3
Name , D to
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SII)1 YARI)_ SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
ion1.4 rf.
Massachusetts rf
f,, A *k
m ' t DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building �Z*•(
Northampton, MA 01060 �st., .1z' '�
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: VI /41 12, e ! (/^A /4
The debris will be transported by:
Name of Hauler: JCo „/ -r�t
Signature of Applicant: Date: /00/z 3
The Commonwealth of Massachusetts
Department of 1ndu.strial Accidents
11=x,
Si"musi-4 j3 I Congress Street,Suite 100
"".7'1!""•' Boston,A14 02114-2017
www.mass.gooldia
11 orkers'Compensation Insurance Affidavit:Budders/(ontractorstEkctriciansfPlumbers.
It)BE 111.1.1)WITH1111:PLRMI ITINGAt 1I1oR11
Aurilicant Information Please Print Legibls
Name rg,an:.1.1non X/c
Address: 9 0 73
City/State/Zina ev1v7- Phone#: V/i in 91
yew an eaxployeTY t holt the appropriate trot:
pe of project(required
la i employer st ohcrc (lull and or partgime).• 7. El New construction
2 I am a sole pruprietis or partnership and bmer no employees working for nx in 8. CI Remodeling
Any (No titekias'cannp..insurance rripared.1
9 0 Demolition
30 I am a huniemslta Jung all work myself.(Na Workers'comp insurance requiroti
0 0 Building addition
I ant a homeowner and will be hiring corium:Intik)conduct all stink on my property. I will
%mann:dud all contra:tura either frave workers"compeniatim insurance or are sok: II.c)Electrical repairs or addition,
pnspnetors with no 6-mpkiyee5.,
12.0 Plumbing rt./xiirs or addii ton,
50 ant a noteral eontructor and I lime hand the sub-contractors Listed on the attached sheet.
These sub-contractors hate employet-s and Ism r workers co' rm.insuran ; 13.0 Roof repairsce
l4.00ther
h.C3 Vie are a corporation and its officers'hart-mod then right or exemption per
§1141.and NI:ha orno ouployees.(No workers'comp.insurance regional
An applicant that chselts box NI nubs 46u till inn du:section below stowing then workers'eompermation policy info-mg:mon.
tlemeowners who sulnrin dos atridat a indicating they arc doing all work and than hoe outside cintLiwctuts moo stihnut a am afindae.it mdicatlittg uck
1.ontracYot,that check dui box MUM attached an adattional slice:show my thte name of the sub-contractors and nate whether th,r&w not those Millie*hate
It:he SLIb-Cl!ntractors ezeirduyect.,they neu,1 pro'. lh,ir workers"comp 1)=kt
l am an employer that Ls providing P4'orAtTA•compensation insurance far my employees. Below is the 1101 kir and job sire
information.
Insurance Company Name:
Policy or Self-ins.Lie.#: Expiration Date:
Job Site Address: City(State Zip:
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 c. 152.§25A.is a crinunal violation punishable by a tine up to SI.500.00
an&or 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 cop 'this statement may be forwarded to the Office of Investigations of the DIA for insurance
cruAerat2e verification.
1 do herehr certify liti01.1111:7—inditenalties of peritto.that the information provided above is true and correct.
Date
Phoned: 1" 3-- —3 3 y4
Official use mall. Do not write in this area.to Ire completed by city or town official.
City or Town: Permittlicense
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. ityrTown Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other_
t'ontact Person: Phone#:
Initial Construction Control Document
t,i
To be submitted with the building permit application by a
Registered Design Professional
iili v
.k' for work per the ninth edition of the
_llerssachusetts State Building Code, 780 CMR, Section 107
Project Title: Date: /c//e/2 3
•
Property Address: j.1,2 _ /V ;,4„ fro
vn f% Au/ '"'t (�'i m
Project: Check(x')one or both as applicable: New construction ✓fasting Construction
Project description: P r(-4 Cc)averft/t"
I MA Registration\umber:c/33,6Expiration date- 0/ ,am'registered design professional, and I have
prepared or directly supervised the preparation of all design plans.computations and specifications concerning
Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (78,0
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee}shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1_ Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3_ Be present at intervals, appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibilit*, regarding the provisions of 780 CMR 107_
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a"wet" or
electronic signature and seal:
Phone number:V/3-1? -33v4 EmaiJg.bti44 1-..4 ca 5,44cty . Cai"
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an'x'project desist plans,computations and specifications that you prepared at directly supervised.If'other`is
chooser,provide a description.
Version 0l 01 201S
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. • Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.) •
11 Specifications
12 Structural Peer Review
13 Structural Tests Sr Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Tele hone No. e-mail address v Registration Number
fii4t.% J/ 4ef �/eAeft..I MA_ 07-Wit�sL l
Street Address City/Town State Zip Discipline pir 'on ate
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
. I.,4 ii.:!4:4?:,,,,•:,'..,: :.,,,:,..
..
\,,,,\NA.--.A....._%...-_1-11.--_L__L--L.-:.L..._Li./ ////‘040 -/411
NNN\NN_
N / • r.; , i
A
4
y,
:: ., , \ [ .
MOM
°1i
PP
_:::____ - ., , ,
...
,,T... ..,:.'-:.:::„,
• ' Xd
' f.. ' '
,:....
F;,
, , , . . . : ..
`t
III .f:"'. �. I f xx
LII
,
I. i .
_I �_ 1 1 1 1 _,..�...,�_ 1 1. 1. .
1 t
....._.l -.. , �- _
. - "a
II
1 . . 3
I1
// ' i r /7/7-__r_r_r_r___
____ 1 .#
• 1 n
•
/S4.
.;..
*, .
j.
-1a-, uoJ \l a
• r
, e-f'?v CI) t
�nP ri72v
q -t
J
et
/ -"7-? 7/
/ 7 /
r_572.7 11'2/, 341 re), u
terJ 7.71/ I/ (/ v7ar ryliow
."4. J , 14 - 9r.,01 ") ��y ?5
a n na 7,7,../ /,/ - V /