17A-209 (6) 119 NORTH MAPLE ST BP-2016-1256
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-209 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1256
Project# JS-2016-002160
Est. Cost: $10810.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sg. 1): 44431.20 Owner: DOHERTY JQJ N C
zoning: URB(83)/URA(17) Applicant: EDWARD RICKEY
AT. 119 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O BOX 62 (413') 695-7059
WILLIAMSBURGMA01096 ISSUED ON.4/29/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR PORCH FOOTING,RAILINGS & FLOOR
& REPLACE DECK�AILING & DECKING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.I 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 4/29/2016 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2016-1256
APPLICANT/CONTACT PERSON EDWARD RICKEY
ADDRESS/PHONE P O BOX 62 WILLIAMSBURG01096(41 )695-7059
PROPERTY LOCATION 119 NORTH MAPLE ST
MAP 17A PARCEL 209 001 ZONE URB(83)/URA(I7V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION_CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT i
Fee Paid
Buildina Permit Filled out
Fee Paid
Tvpeof Construction: REPAIR PORCH FOOTING RAILINGS&FLOOR&REPLACE DECK TAILING&
DECKING
New Construction
Non Structural interior renovations
Addition to Existing
Accessoa Structure
Buildina Plans Included:
Owner/Statement or License 96159
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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 Delay
7 jt:
Si ure of Bui dig 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.
- — Department use only
ity Of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
API' ROOM 100 Water/Well Availability
- No hampton, MA 01060 Two Sets of Structural Plans
i phoi 87-1240 Fax 413-587-121,72 Plot/Site Plans
S
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMQL-tSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
�y�.� Q�Q 6 Z Zone Overlay District
�� //�'"1
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
khln //9 rI rr .. � . mM 014 2-
Naa (Print)) / / Current Mailing Address:
/_\ 04, hA. � Telephone ,, r t r'
Signatu 7�� C{
o y b 3
2.2 Authorized Agent:
0/496
Name(Print) Current Mailing Address:
y/5-695-705,
Signature Telephone
SECTIO -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 8/p� 9 4 Check Number 1220
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES a NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing EDOr Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs j[3] Decks [2r Siding[O] Other[
Brief Description of Proposed
Work: -
Alteration of existing bedroom Yes J/ No Adding new bedroom Yes No
Attached Narrative Renovating',unfinished basement Yes _Lo," No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing. +,omplete 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?
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 Np. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WIHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to W&authorized by this building permit application.
K C6&, 7)o V. is • 16
Signa a of Owner Date
I° as Owner/Authorized
Agent hereby declare that theAtements 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.
�Dw�1Rry /z/c i«r
Print Name
4��,L�000r 42WAX .3 20/6
Signature of r/Agent Z Date
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 96/5-
License Number
O ___7�3/2�►/6
Address Exp'atio Date
iwa-695--zo.1
Signature Telephone
9.Renistered Home Imorovement Contractor: Not Applicable ❑
� Cc. /sz78Y4
Company Name Registration Number
Z M4 Q/o9G .5AL2_o/6
Address Expir do ate
Telephone
SECTION 10-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 of the building permit.
Signed Affidavit Attached Yes....... PrIll No...... ❑
. -Home owner ExeYn tion
The current e ption for"homeowners"was extended to jinclude Owner-occupied Dwellings of one(1�atthe
o(2)families
and to allow such owner to engage an individual for faire who does not possess a license, rovided owner acts
as su ervisor.CMR 780 Edition Section 108.3. J.
Definition of Homeowner:Person o�than
arcel of land on which he/she resides or in ds to reside,on which there
is,or is intended to be, a one or two family ling,attached or detached structures acce ry to such use and/or farm
structures.A person who constructs morea hom in a two-year period s not be considered a homeowner.
Such"homeowner"shall submit to the Building Offict od a form acceptabl he Building Official,that he/she shall be
responsible for all such work performed under the buildtM Dermif�-,
As acting Construction Supervisor your presence on the job s' ll be required 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 orkers' Compensation) d Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death) e Massachusetts General Laws tated,you may be liable for person(s)
you hire to perform work for you under t ' permit.
The undersigned"homeowner"cert' s and assumes responsibility for compliance with the State 'lding Code,City of
Northampton Ordinances, Sta nd Local Zoning Laws and State of Massachusetts General Laws Ann ed.
Homeowner Signa e
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all 'debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: lj9
The debris will be transported by:
The debris will be received by: '
Building permit number:
Name of Permit Applicant '
Date 3/2.0/6 Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
S.e www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 10,a& w 62
City/State/Zip: 9>:24 4/1774 Phone #: W.3-696-7os7
Are you an employer? Check the af propriate 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. E]New construction
2.,9 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 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.
1 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 MGIL 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.
Si ature: Date: O/4+
Phone#:
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#:
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