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18C-062 (2)
B P-2 021-2 023 157 PROSPECT AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18C-062-001 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-2021-2023 PERMISSIONIS HEREBY GRANTED TO: Project# SHED ROOF Contractor: License: Est. Cost: 2500 SCOTT NICKERSON 053156157311 Const.Class: Exp.Date:01/10/202209/17/2023 Use Group: Owner: MORRISON, ELAINE SANDRA Lot Size (sq.ft.) Zoning: URB Applicant: SCOTT NICKERSON Applicant Address Phone: Insurance: PO BOX M (413)896-3347 0 LAKE PLEASANT, MA 01347 ISSUED ON:10/14/2021 TO PERFORM THE FOLLOWING WORK: CONSTRUCT OPEN SHED ROOF 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. Signature: • . 2 . C 'l • � i Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner • z -ok is C& The Commonwealth of Massach .efts / w. Board of Building Regulations and Land ds CT IC ,'HI'ALITY Massachusetts State Building Cod 789F R N �0� E Building Permit Application To Construct, Repair, ' -•• T0,4 olish a evis-• Mar 2011 One-or Two-FamilyDwelling Nni�1('in, we g On! Sp, This Section For Official Use Only �'I 07 so'oN$ Building Permit Number: g0-all •a ea,? Date Applied: _1(2111/2) Building Official(PrintName) Signature I I Da SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers J.S. } l�•-,�c�/ A. to 1.1 a Is this an accepted street?yes i/ 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/ (1 C 11riu t1' 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zont 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: L/a.► S VY1 0 ir"r i. nl /JOr -t t, i (Avv' 1 fort 11/4 0 I 0 i, O Name(Print) City,State,ZIP JS7 Pro?Pecf- Ave A) 9/L-.W -klii C)a'hrn ►'4t eoLiole ,l.coM No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Cam'Owner-Occupied-Er— epairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of/Proposed Work': Ce 0.51. /C cr... ..(4./ r,. I e Ali/Z7 -c .,:J € V 1747„..r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ a 2 a v 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 3 © a 0 Standard City/Town Application Fee ❑Total Project Costa (Item 6)x multiplier x 3. Plumbing $ , 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $Suppression) Total All Fees: $ h Check No. II Check Amount: '/ Cash Amount: 6.Total Project Cost: $ `a 1 0 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) rr 33 i�d 0t /.11 �C e 1/ - ies f,;I License NumberxpirDate Name of CSL Holder Zf'A .17 List CSL Type(see below) No.and Street 41 Description LAG p/(tAl A.1! MA d�3 y Unrestricted(Buildings up to 35,000 cu.ft.) jRestricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding y/.3` l ` N�3y / SF Solid Fuel Burning Appliances I f�ilIc rr� .wi. ( I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ,s? 3 // 9//4/6/3 SA"at. Il! IQ C HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name c fA' Q SA,ta 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 completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance o the building permit. Signed Affidavit Attached? Yes No...........❑ 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—)i"7Y to act on my behalf,in all matters relative to work authorized by this building permit application. to/1 Z/Li Print Owner's Name( ectronic Signature) Date SECTION 7b:OWNER OR AUTHORIZED AG ENT DECLARATION By entering my name be , hereby attest under the pains and penalties of perjury that all of the information contained in this ap tion is true and accurate to the best of my knowledge and understanding. Print Owner s or Authorized Agent's Name(Electronic 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 Information on the Construction Supervisor License can be found at 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" ,/,. 4,,,, City of Northampton Massachusetts --zy - 6 ()Pik * i '-- ' DEPARTMENT OF BUILDING INSPECTIONS 1 dt 4, ' 212 Main Street • Municipal Building wNorthampton, MA 01060 ''fyti. ,.,��° 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: l`t� (/< i / e / f t The debris will be transported by: Name of Hauler: S.( // / 4, /- Ay/0Signature of Applicant: ADate: � , /13 IA r 124 4:4 l` i -- I. of ) (1.7xLit c1aJt 7 S .: t," e // ' _ / Vk) 1 IL111 ii Max S f U g WI 17 ,• /t - 6 They Commonwealth of.tlu.8.Suchtt,,ett.. Department of 1n(ltt.triul.accidentts ! t: on,'re'.s Street, Sulk' BM Boston. .11.4 02114-111' 'ucie:mttS.'t.got.diu 11opkers' Compensation Insurance.0Wdasit: Builders Contractors Iiietricians Plumbers. iO IIF. HUH)1111 II I III. I'F.It1111 I I\(,Al 11101(1 11. 11'1,1ir:int information I'lcau I'rin[ it1 Jt itt.• lip: %re 5nu an urlpluaar' th,L the aptln.pn.rtt I pe of project Irequiredl. 1 —1u. .i _ . . 1 :C It L.11 rer.r.., or stltl.•.�:1. S; .4 tllllc: t 1 /am an empinrer that is prot•idin,,icorAern'compensation insurance/or ntr emp/pre•es. Be/ott is the policy and ioh site information. I'.'.1. 1.:5:. I'-\t'I :Ior: 'Mach a t:ul►s of the workers'compensation pudic, declaration pate(shim in U1e pnlicr number and ewiratio11 date). t '•ti...:� ,t••CI.._. ,1� t..:'...:�.I UII,L. VA I. . : _. •..-`III.lit ...- -. II::1�-. . ...:I:at._. 'A..1 i.t Ih 11l iRK 1 IRI)l.it r: a :Ir:C•-,t :i:' .- \,` _. '-I.•.,It..: .A .ot`t tills a'J(4.1II.I:' ll:.'S : . .•'I'•5,115:Ca1 i ' ti:C C)11 i.,. Vi I:1%l>:I•!,It:va,. t}:C i)I.\ IUI :Il�t.r al7.0 I do he'rehr certify under the pains and penalties of perjury that the information provided above is true and correct. I... 1 U/tiein/use null. Do not write in this area.to he completed ht'cite or temn official t ( it. or I IMIE Permit I.icense Issuing.\uthorits (circle Imel: I. Board of Health 2. Buildin Department 3.( itt -town(deck 4. I:Ieetrical Inspector 5. Plulubint; Inspector h.Other ( untat.-t Person: Phone C: The Commonwealth of Massachusetts Wit._ x_ , t Department of Industrial Accidents nsi_ 1 Congress Street,Suite 100 h ; =Inn a*N�< Boston,MA 02114-2017 www.mass.gov/dia MO Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual):SC� 114 Alt &/r d `. Address: 2 Q �c'X' M i Zit if AiLrA + City/State/Zip: /1 A 0/2 'i q _ Phone#: 03 — 896 " 21 V I-- Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am ployer with employees(full and/or part-time).* 7. ❑New construction 2. am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.1:I I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.EI I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�ROof repairs These sub-contractors have employees and have workers'comp.insurance? 6.11 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.['Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am 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.Lic.#: 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 criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A coop--'statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u�j�pains and penalties of perjury that the information provided above is true and correct Date:/O lam' �/ Signature: � / f C �- 23 V �- Phone#: / 3 — 0 �� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: