23A-096 Niassachtro..qt - Deparnocnt 1.I Public '
• 7 Board of Boildiii„" RcLatiation. ..Ntai..1,ird
License: CS 96159
EDWARD J RICKEY
PO BOX 62
WILLIAMSBURG, MA 01096
Expiration: 7/13/2012
Tr., 19385
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Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 150840
Expiration: 5/3/2012 Tr# 294482
Type: Individual
EDWARD RICKEY & COMPANY
EDWARD RICKEY
56 RESIVOR RD.
WESTHAMPTON, MA 01027 Undersecretary
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City of Northampton •
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Massachusetts
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6 4 r , DEPARTMENT OF BUILDING INSPECTIONS
%� 212 Main Street • Municipal Building v. .1
V Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Mass: chusetts allows the homeowner the right under 780CMR 108.3.4 to act - his /her
construction supervi or. The state defines "Homeowner" as, " Person(s) who owns a .. cel on which
he /she resides or inte •s to be, a one or two family dwelling, attached or detach: • structures
accessory to such use a a/or farm structures. A person who constructs more th- one home in a two-
year period shall not be con 'dered a home owner."
The building department for the a of Northampton wants any perso - who seek to use the home
owner exemption, to act as their ow onstruction supervisor, to be . are that by doing so you
become responsible for compliance , ith state building co. - and regulations. The inspection
process requires that the building depart -nt be called to i : sect work at various stages, which include
foundation /footings (before backfill), son ube hole .efore pour), a rough building inspection
(before work is concealed), insulation insp= io. if required) and a final building inspection.
The building department requires these inspectio • before the work is concealed, failure to secure
these inspections can result in failure to o • ain . ertificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to • -rform work (elec 'cal, plumbing & gas) the homeowner will be
responsible to make sure that the tr. :es hired secure their p o'er permits in conjunction to the building
permit issued, and that they g- eir required inspections. :lure of the individual trades to secure
the permits and inspections - required can DELAY the project un such time as the proper permits
and inspections are mad:
I, understa , d the above.
(Home o - r /resident's signature requesting exemption)
I will call • chedule all required building inspections necessary for the buildins sermit issued to me.
Address of work location
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The Commonwealth of Massachusetts
Department of Industrial Accidents
° ° 4 Office of Investigations A
—7.61= . 600 Washington Street
. -..,� Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business / Organization /Individual): el 6- _
Address: g. B...„ 4
City /State /Zip: • 0/0 ?' Phone #: 5//3- 615 74 57
Are you an employer? Check the a opriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2.N2 I am a sole proprietor or partner-
ship and have no employees These sub- contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ►`4 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: /01/40/ Z.
Phone #: 0 5"-.7
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 1. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : (4,4uo est- V,Ct.1�y ?4/59
�/ License Number
P. e 6P- 24//./.6z.,,,..417 (/ 9924 7-13-20/2
Address Expiration Date
Signatu Telephone
9:.�Registe ed iGir e:Imptovemenfi =Contraetor_'7 `"_ 4 4 - ' °_ " pa. Not Applicable ❑
G-.G.rarar.se at Co.. /Sd 6 Yo
Company Name Registration Number
P , 4 A_
,&a 2 Vre2/ 2 Address F Exp
v .ddittle f . 9
Telephone V/3 /5 7
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c.152, § ; . .
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 of the building permit.
Signed Affidavit Attached Yes ❑ No N'
11:37.-: .ome caner. �
The current exemptio •r "homeowners" was extended to include Owner - occupied Dwellings of one ( or two(2) families
and to allow such homeown o engage an individual for hire who does not possess a license, a rovide : that the owner acts
as supervisor. CMR 780, Sixt a dition Section 108.3.5.1.
Definition of Homeowner: Person (s a o own a parcel of land on which he/she resides or int - : s to reside,' on which there
is, or is intended to be, a one or two family .. -11ing, attached or detached structures access. to such use and/ or farm
structures. A person who constructs more than a . • I ome in a two -year period shall a a t be considered a homeowner.
Such "homeowner" shall submit to the Building Official, a . form acceptable to the r ilding Official, that he /she shall be
responsible for all such work performed under the building a II it.
As acting Construction Supervisor your presence on the job site wil a . equ• - d from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compe • . ion) and • .ter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachuse • eneral Laws Annota - • ou may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes res.. ibility for compliance with the State Bui a • • , Code, City of
Northampton Ordinances, State and Local Zoning • •'s and State of Massachusetts General Laws Annotate..
Homeowner Signature
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SECTION 5- DESCRIPTIQN OF PROPOSED WORK (check all applicable) . ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing gA
Or Doors El
Accessory Bldg. El " Demolition ❑ New Signs [O] Decks [D Siding [O] Other ICI]
Brief Des iption of Prop sed _ n •
Work: — — ~� �� ■� CX C �,.w.e .
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes )G No
Plans Attached Roll - Sheet
�" k � - . � i':�' t4 �£",�yf�'�$9x�"'4�i'�" :.. , 'h°�?�"a. °xm''" �:.`?.�,. ,
sa ,lfJ4ew:hou o r adait to existi.nq housing ° complete the . following:
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. _ Dimensions
e. Number of stories? g
f. Method of heating? Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction /
i. Is construction within 100 ft. of wetlands? Yes ✓ No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade f
k. Will building conform to the Building and Zoning regulations? il. Yes - No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION TO BE COMPLETED WHEN
F
OWNERS AGENT OR CONTRACTOR. APPLIES FOR BUILDING PERMIT
I, X 'Lrz - crtr " i1 , as Owner of the subject
property
hereby author -7 1114/.4 RD R I C KE Y Jr CG.
to act on bIIalf ' : II matt relative to work authorized by this building permit application.
x X / e /0 /l/
Signature o wner Date
I, ,$D wA t n) Ric K E. ? # GO . , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
SOw,4RI0 IIck &r
Print Name
1 / /_', _ /
Signature of!,.- -r /Age t Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 7
Existing Proposed Required l Zoning j
This column to be filled in by
Building Department
,:...
4.. _ tom -
Lot Size 1 k -Or
Frontage ' s i _ 3
Setbacks Front
Side L:' ` R:` L:' ; R:i
Rear I
Building Height i ¢
Bldg. Square Footage , i % i l r €
Open Space Footage % _ g
(Lot area minus bldg & paved I I 1 i
parking)
i t i 's I
# of Parking Spaces - --
Fill: - _ _. __ _ _e__ W,. __
(volume & Location)
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A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO * DONT KNOW 0 YES 0
. ,
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Page; 1
and /or Document #1
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B. Does the site contain a brook, body of water or wetlands? NO ► 4S DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO *4
IF YES, describe size, type and location: e i
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO �®
IF YES, describe size, type and location: >
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 4 4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w t Dep- l � emt use only
City •f N•rthampton S t tu�p * *l k � '
1 2( g ild g I ►epartment Cur C er , � _ t
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1 �I 1 21 . Ma n S Sew e ttc fi r. a a l
{ i wiz_ _ �d -a"s° uv.- G „ - €`
� oo 1 00 1Nat 2el � ,
, .. p on, 0411036-5087- wo e -o fStr ra t o � r
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one 413- 587 -1240 Fax 1272 P--1° arcs
, .. r ,:::.:: ` -- #*^ , �'$"t` ` ri' d:,-� � dry k ---`. "„ J-.
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Other SPePI , ; „
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC TION 1 - SITE
Property Address:
This section to be com plete d by office
i 2 7/ d F' dot U ;
of ,, ;� '� .r , "
Zone Overlay District e`
Elni StDistr ct `' { . t CB District '' {'
SECTION 2 - PROPERTY OWNERSHIP!AUTHORIZED A GE N T
2.1 Owner of Record:
It-Lt-4/CE' j.,E R, l/ /Ga -
Name (Print)
/ Current Mailing Address:
1 / ( (" _. , 7f 0/062.
Telephone
Signatur y/3 • 5.5- '. 0A3.
370
s "
2.2 Authorized Agent:
�bw� .4JckE Ca �. e del , ,4A Olo9G
Name (Print) Current Mailing Address:
V/3 •695.7o5
Signature Telephone
S N 3 - ESTIMATED CON COST e; "
Item Estimated Cost (Do llars) to be Officia Us e Only
completed by permit applicant
1. Building � yG (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of�
Construction from 6)
3. Plumbing Building Permrt Fee:`
4. Mechanical (HVAC)
5. Fire Protection
6 Total= (1 +2 +3 +4 +5) ,SYQ. C. al
This Se For Offic U s hecke Onl '"
y
Date
Building Permit Nu mber::- Issued:.
Signature:
Building Commission /Inspec of Buildings - Date
/ /
/■
File # BP- 2012 -0391
APPLICANT /CONTACT PERSON EDWARD RICKEY
ADDRESS/PHONE P 0 BOX 62 WILLIAMSBURG (413) 695 -7059
PROPERTY LOCATION 291 LOCUST ST
MAP 23A PARCEL 096 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /O J ‘3
Typeof Construction: REPAIR VALLEY FLASHING & ICE/WATER BARRIER
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 96159
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition De .
/-/ I
Signature of Building • fficial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
291 LOCUST ST BP- 2012 -0391
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 096 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0391
Project # JS- 2012- 000621
Est. Cost: $540.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): 5967.72 Owner: MCCUTCHEON JILL & FELICE M LESSER
Zoning: URB(100)/ Applicant: EDWARD RICKEY
AT: 291 LOCUST ST
Applicant Address: Phone: Insurance:
P 0 BOX 62 (413) 695 -7059
W ILLIAMSBURGMA01096 ISSUED ON :10/19/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK :REPAIR VALLEY FLASHING & ICE/WATER
BARRIER
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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/19/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner