31A-150 BP-2024-0836
25 MAYNARD RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-150-00I 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-2024-0836 PERMISSION IS HEREBY GRANTED TO:
Project# RENOVATIONS 2024 Contractor: License:
Est. Cost: 200000 SCOTT NICKERSON 053156
Const.Class: Exp.Date: 01/10/2026
Use Group: Owner: KIEVAL KIEVAL DAVID J& EMILY GLASSMAN
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: 07/09/2024
TO PERFORM THE FOLLOWING WORK:
RENOVATIONS AND ALTERATIONS
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: 4/./..°°P
Fees Paid: $1,300.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
kyll(ikzn
onw alth of Massachusetts
r JUN oard of Bu din egulations and Standards FOR
2 giltp4huse is S e Building Code,780 CMR MUNICISPEALITY
1)Efui ermit Applicat' n T Construct,Repair,Renovate Or Demolish a Revised Mar 2011
NOg7yq/1.0NG O e-or Two-Family Dwelling
ro`v•M or,ONs Th' Section For Official Use Only
BuildingPermit Number: gfe 7j(/ Date Applied:
KUit.)
! IZs /1./ 7-8-Z)z j
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
- - ----------
1.1 Property Address: 1.2 Assessors Map&Parcel Nu ber
;LS MG .u„a ktA 1 Nteit-k..,p , MR i/ jcu
1.1 a Is this an Accepted street?yes j no Map umber 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) h o CliA k tf
Front Yard v 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:
Dow.4 4- ,1� K%evo•.1 00 Int �t" I Al 0i06D
Name(Print) City,State,ZIP
Mai buil Rd 617--421--4s6 I evit;tokkiev4Jeq,.+o:_t•celwl
No.and Street 1 Telephone Emlfl Address J
SECTION 3:DESCRIPT OF PROPOSED W K2(check all that apply)
New Construction 0 Existing Building Owner-Occupied Repairs(s) 0 Alteration(s) Addition 0
Demolition 0 Accessory Bldg.0 Number of Units 4 Other 0 Specify:
Brief D tpttion o foposed Wor L
o(/ . .`
l- 4 4- A ♦s- � .-, of pc. ie /Ks
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only '(Labor and Materials)
1.Building $ /co p p O 1. Building Permit Fee:$ Indicate how fee is determined:
l 0 Standard City/Town Application Fee
2.Electrical $
�j G G O CI Total Project Cost3(Rem 6)x multiplier x_
3.Plumbing $ 2p, 0 O 0 2. Other Fees: $
4.Mechanical (HVAC) $ _ List:
5.Mechanical (Fire $ --e— Total All Fe ,(1`
Suppression) Check Nol Check Amount. 3(St)
6.Total Project Cost: $ O 0, eat, 0 Paid in Full 0 OutstandingiBalance Due:
City of Northampton
• i . Massachusetts
Jj
DEPARTMENT OF BUILDING INSPECTIONS •
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
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 and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate(new/replacement windows).
7. Home owner's License Exemption Form(if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code—all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. 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 SupervisorLicense(CSL)
Sc�� �3/�� �p ra 2,6
!L cf..° License Number ira on Date
Name of CSL Hol er
9 rit ..s T '/1, A1 List CSL Type(see below) (>
I 7
No.an t et •
Type Description
C A fi6AJ,4,j m A d/J y� Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r SF Solid Fuel Burning Appliances
jI3_394 -33`f- SJ✓tfcIfre, .c.) I Insulation _
Telephone Email address , Cc,L. D Demolition
5.2 Registered Home Improvement Contractor(HIC) /j . 3/ 9 /f of-
SA SA w.e >—' A -e_ HIC Registration Number iration 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 completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssuan 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
T)oxv.61 Ki.e a' Gilt j 2-019
Print Owner's Name(Electronic Signature) l ate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of ry that the inf rmatio
contained in this application is true and accurate to the best of my knowl and erstandingG/ ?— y
ISGo N c ,,,,,,�
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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"
•
The Commonwealth of:lfassachusetts
='q1== Department of Industrial Accidents
1= 1 Congress Street,Suite 100
1.9 r,.r Boston,MA 02114-2017
+, r w►tirt�:mass.gov/ilia
11 rakers'Compensation Insurance Afda.it:Builders/Contractors/Electricians/Plumbers.
TO IIIL 1'11.ED N CID 1 la:I'ERMITII\G At THORITI'.
Applicant information 1 / Please Print Legibly
Name(Business'(hgant:uttion'Individual): S� // Ah a Gem'✓K.v
Address:) a
City/State/Zip:L! ��ur *(A Phone#' Y/3— ‘ - �Y
Are you an employer?('htck the appropriate bias: Type of project(required):
t.�1 a .i employer with empairyees quit andtw part•time1..' 7. ❑New construction
- I am a auk proprietor or partnership and have no emptoyers working for nit:in K. Remodeling
any capacity.(No%sorters'comp.inerrancy mowed.]
0
9. ❑Demolition
10 I am a homeowner doing all work myself.)'No wortai emit.insurance nquira1.1
10❑Building addition
•tea I am a hunk:owner and will he hiring&inns drs to conduit all Mork on my property. I M dl
ensure that all contractors either have workers compensation ttuuraner or an sole 11 a Electrical repairs or additions
proprietors with no employe.
12.0 Plumbing repairs or additions
50 I ant a general contractor and I have hint d the sub-contractors listed on the attached sheet i 10 Roof rC airs
ei These sub-esintraors base employer s and base winters'comp.insurance.; repairs
n_❑w rn-
e are a corporation and its officers have exised then nglu of exemption per MCI.c. 14.D Other
152.,¢l(41.and we dose no employees.[Nu workers'comp.Insurance required.)
'Any applicant that checks lox ri I mist steer till out the seeticm below show in their workers'compensation policy infix/nation
r homeowners who submit this afiida%it hrtdicathng they are doing all work and then lure outside contractors must subunit a new aftidas it indicating such.
:L-onlractors that check this Laos must arta.b.d an additional sheet show mg the name of the sutrcuntractors and state whether or not those eitaties have
cmph,%ee+. it tt:s sub-contractors h.',,cmployecs.they must prosidc their ut,rkers"ccsntp rdres number.
i ant an employer that is prodding workers'compensation insurance for my enrpkyees. Below is the policy and Job site
information. �t,� f/
insurance Company Name: SCE `, A/G. LA Cr to•-*A _
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City iStatelZip:
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 tine up to S1,500.00
and'or one-year imprisonment,a s+ell as ei+it penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A c•;' f this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify a the pains and penalties of perjuty that the information provided a ve is true and correct:
Signature: Date_ 6' ft 7—A- "
Phone»: / 1 3 — — 3 3 VV �
Official use only. Do not write in this area.to be completed by city or town officiat
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
SH
j,0� L-"1�O,y .. .SAS S/ni
Q' Massachusetts
:i *
�� DEPARTMENT OF BUILDING INSPECTIONS t t.
\,M',r,�i�>;t 212 Main Street • Municipal Building SJ'
\`' ''4 Northampton, MA 01060 ssN ���`'
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 Ile �(- L/ 6,-/14.4,
of CA-."
The debris will be transported by:
Name of Hauler: Seo A/c�1e,.1 ci y
0 0/
Signature of Applicant: Date:
City of Northampton
Massachusetts
L.
! • DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building `10`a
,..' Northampton, MA 01060 csfrh.
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
1, (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. 1 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)