25A-052 (3) 49 HUBBARD AVE BP-2017-0248
GIS ft: COMMONWEALTH OF MASSACHUSETTS
Map-Black:25A-052 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Convert two family BUILDING PERMIT
Permit# BP-2017-0248
Project# JS-2017-000428
Est.Cost: $500.00
Fee: 565.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT NICKERSON 053156
Lot Size(sa. ft.): 4791.60 Owner: HAZEN KATHARINE T
Zoning: URB(l00)/ Applicant: SCOTT NICKERSON
AT: 49 HUBBARD AVE
Applicant Address: Phone: Insurance:
197 NORTH LEVERETT RD (413) 896-3347 O
LEVERETTMA01054 ISSUED ON.:8/30/2016 0:00:00
TO PERFORM THE FOLLOWING WORK: Convert 2 family to one family, disable kitchen and
remove stairway wall
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: FeeTvoe:
Date Paid: Amount:
Building 8/3020160:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
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Dept or euunlNG INSPECTIONS tef/i Jell rel+bl y
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APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1 SECTION 1 -SI`INFORMATION i
1.1 PronetYv Address. Th ecuon to be completed by amce i
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SECTION 2 -PROPERTY OPJNERSHIPIAUTHORIZED AGENT
2.1 Owner cf Record;
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Name la 1CurrentMaliny AdC s ' " /als
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2.2 Auth oorzed Aoent ,{ .r_ L - 1
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Canal) / In4
name{ r Cowen)r P lsi n;Address: A
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/ X73 $ > e `1 f
Siena - Tele,phone
SECTION 3-ESTIMA T?O CONSTRUCTION COSTS
I
1 !tem Estimates Cost ✓c lar s)to be 0:,5sal Use Only
completed ay perm`applicant
1 1. Buildingay d 1 (a ) Building Permit Fee
2 Elac em' / (I (6}Estimated i otal Cost of
_ Construction from{e)
Flumninc Su lding Permit Fee IS
i 5. Fire Protecrion I - I t j^
o. Total=(142.3+e-?) 1 rev I, Check Number_
This Section For Official Use Only
I Baring Permit Number a"G
I c, c.
1 Building C.-..miisicerInpe torof uidin,7 Data .�
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Email°1 °
Section 4 ZONING n11,neerr,ectic MustBeComoieted Fermi:Car Ee Cemed Due Tc- Incompletef nedon ��77pp
ting nose I Required by Z i S
Lis I _ t fit in Sy
Bund gD
Let Size
��_ - >._. -._� r-'- I
Froatze=
SetbacHs front
Side � L . R�. .Z ' . <
Rear — _ ett,,_
1 1
1 Bldg. Square Footage _ I % I .� I
Open FootageI
_ /
1 prwaa nus.dageca ed I
idi of Parking Spaces I --7—
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tvol�� L'tanont I a...__....�>�_f—"'= _-- ` ,
A. Has a Special Perini:/Variance/Finding ever been issued fo-/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date isued:ii
I
IF YES: Was the permit recorded at the Registry of Deeds? I
NO DON KNC'WYES C✓ I
IF YES: ender Book i Rage' end/or Document x'
B. Does the site contain a brook, bony of water or we lards? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 Date Issued: —,
C. Do any si=ns exist en the property? YES 0 NO 0
IF YES, describe size, type and Location: '
D. Are there any proposed changes to or additions of signs intended for the property r CS 0 NC 0
IF YES, describe size, type and location:
E. Will the co strucion activity ciistcro(clearing, Cradng,.excavation, or fining)over 1 aero or is it par of a common plan
tat will disturb curl c YES ' NC 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is requiree.
SECTIOal 5-DZSCRIFT ION OF PRC"POSED WORK(check all eoolicable)
�I j I
New House —I Addition U Replcoaniont Windows lrerarrion(s) IRoofirvg LJ
Or D cors C
Accessory Bidg. C Demolition L New Signs [❑] Decks '❑ Sidina I❑; Other;1=1
afterDewipfion ofProposed
-'
Work: E-- to { g 1---4.,, 1/) Jr 4 /ei„„ 7 �a1p‘ �C.��I� lt. 1 .5f. ,..
Alteration ofexistr /g bedroom _o No Addng new bedrom Yea No `
Attached Nasative Renovating unfinished basement _Yes _ No c W+E} r tj
Plans Attached Roll Sheet C ✓}cn tr.a-�1.htri
sa. If New hoIsB Brad oradthtion f ITEtna 6aoN.4fha cornoLs1is he follaWirm:
a Use of binding Ore Family Two Fam.Iv Other
b Number of rooms in each family unit Number of Bathrooms
c. Is There a garage attached?
r< Proposed Square footage of new construction. Dimensions
e. Number cf stories?
f Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance tilascheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ftof wetlands? Yes No. is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. WIII building conform to the Building and Zoning regulations? Yes No
L Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACT/OAR APPLIES FOR BUILDING PERMIT
L_- \].. ,}.1 Cl�� i:
SECTION E-CONSTRUCTION SER+l4CES
8.1 Licensed Corstruo:ion Suoerdscr: Ula:Applisa h:'e t
Name 07 License HplCer.
SCO 'It 7) A// 4 , Cl? 13 4
License Numbs:
M LA1, MM. ///d��8
Address r i✓ ) Expimoo Date
X113 - Ev3
Telephone
9.Redistered Mome Imoravem_nt Contractor Not Applicable E
/Ar nr n 2 95 } 3 / l
Company Name Registration Number
g
/ Ar�� �
Address Expiation Dale
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, §26C(6))
Workers Compensation Insurance affidavit must bornplet and subrnited with this application. Failure to provide This affidavit will result
in the denial of the issuance of the building pesTR
Signed Affidavit Attached Yes _ N .
/I; - 1addne ®weer E em taon
The cu_rent exemption for"homeowners"was extended to include Owner-occupied Dweilines of one(1) or nvo(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.351.
Definition of Homeowner Person(s)who own 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
structares.A person who constructs more than one home in a two-year period shall not be considered a homeowner
Such"homeowner"shall submitto the Building Oficial,on a form acceptable to the 3uildi g Ofilcial. that he/she shall be
responsible for all such work performed under the building hermit
As acting Construction Supervisor your presence on the job site wilt be secured from time TO time, during and upon
completion of the work for which this Hermit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting m Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this Hermit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Burls:L-1g Code, City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated
Homeowner Signature
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Annlicacct informanon Please Print LeTinty
•
Name (Business/Organ:za cn4ndividual): S <7a t 1 Ai lc t-"
p. _
Address: 1 . 72 '—{72 '—{ m LA L Y q 1/Crl , , V11 __ $"7`7"1- --
City/State/Zip: 0 I 7 U Phone in: `1 17 - S el 6 ^ -S 3 `l 79,
Are yon an employer?Check the appropriate box:
813.'pe of project(required):
1.7 I am sployer with 4. E I am a general contactor and S
.ployees (full and/or part-time).* have hired the sub-contractors 6. U construction
2. I am a sole proprietor or partner- listed on the attached sheet; 7. Remodeling
ship and have no employees These sub-contactors have 8. (—] Demolition
worldfor me in any capacity. employees and have workers'
9 1 I Building addition
[No workers' comp. insurance compinstance t
required] 5. n We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself ' o workers' right of exemption per MGL
Y � comp. 12.0 Roof repairs
insurance required] t c. 152, 81(4), and we have no
employees. [No workers' 13.❑ Other
coma insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
trio meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a um 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 worker'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 n' or Self-is.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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to .81,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fie
of up to 5250.00 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 ins .c.ce coverage verification.
I do hereby certify and/ pains and •=
City of Forthsimpton
Hassechidgetts
‘71 'ikltk
12 Main Nut-rune t _ciH 3 ng ,�3.
INSPECTOR
Louis'Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER E_ .1' TION ACKKNOW'LF_DGEVENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
jconstruction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a c e or ho ernriy c`wafPh^g, 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."
he building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations The inspection
process requires that the building department be called to inspect work at various stages,which include
foundation/footings (before backfill). sonotube holes_ (before pour). a roach building inspection
(before work is concealed). insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
City of Northampton 212 Man Street, Northampton, MA 0 050
Sold Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, 354, 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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant