31A-101 (4) g( BP-2003-0172
cls#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Buildine
Category BUILDING PERMIT
Permit# BP-2003-0172
Project# JS-2003-0324
Est Cost $20000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
UseGrono: Scott Nickerson 053156
Lot Smelsq. ft.): 12763.08 Owner: MARTYN AMY
Zoom, URB Applicant: Scott Nickerson
AT. 17 FEDERAL ST
Applicant Address: Phone: Insurance:
P O BOX J (413) 367-7533
LAKE PLEASANTMA01347 ISSUED ON:8/76/010:00:00
TO PERFORM THE FOLLOWING WORK.ADD SKYLIGHTS,REPLACEMENT WINDOWS,
REMOVE NON BEARING WALL& CONSTRUCT DOORWAY IN SUPPORTING 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 Shmature•
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/16/020:00:00 1287 $100.00
212 Main Street,Phone(413)587-1240,Paz: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2003-0172
APPLICANT/CONTACT PERSON Scott Nickerson
ADDRESS/PHONEPOBOXI (413)367-7533 d2&2g1,_33q-7
PROPERTY LOCATION 17 FEDERAL ST
MAP 31A PARCEL 101 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid z'
Tweet Constructiom ADD SKYLIGHTS REPLACEMENT WINDOWS REMOVE NON BEARING WALL&
CONSTRUCT DOORWAY IN SUPPORTING WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plana Included:
Owner/Statement or License 053156
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INWRMATION 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 Cc ion
`o x
ZZ.
Signature of Building Official 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.
Fc
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Champton
��f di artment
0 `V 212 ai Street
om 00
� Lcor a It oial $ ,},' pton, MA 01060
^^le BST Fax 413587-1272 t
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectbo b complpted,by offn:e�
1.1 Property Address: � s,
Map
Zone
Elm St. District �-'Ce District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner off"Record: K +6 rlw,m • 6 IS6Z
Ms„r itv °I Fe ty'rlai S-ht_ {erca O 06Z
Name(P D Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent
See ft -b Rc /,13L- ,r/ Lt,. W
Name(Print) Current Mailing Address:
- g13- 3c4 -0i } /
SigTF, Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
—completed by permit applicant
1. Building av O O (a) Building Permit Fee
� O
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) a0 000 Check Number 11110 �
This Section For Official Use Only
Building Permit Number: •D:?) 71- Date Issued:
Signature
Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
/ This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: U R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Puking Spaces
Fill
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?Sp
NO_[� DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page _, and✓/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ^ DON'T KNOW _
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. A there any proposed changes to or additions of signs intended for the property ?YES
No
I IF YES, describe size, type and location:
SECTIONS D� IJOOSEDV1k0R`K(cbeikoall:applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) i Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding( ] Other [ ]
Brief Description of Proposed Work: U01A fl- -Ni—,11 ire,
rcwaw.a_ c ,6 .,,.T...— `..n._f...r
Alteration of existing bedroom Yes?_No Adding new bedroom Yes x No (f.
Attached Narrative D Renovating unfinished basement Yes X No
Plans Attached Rall D Sheet D
gilftNe—Wih-O sV',aTid.CbWdditlofft o?ezi'gtf"n"housin com"1eteRhe'ff6IIoVvin
a. Use of building : One Family v�_ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c Is there a garage attached? A D
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 2—
f. Method of heating? Fireplaces or Woodstoves P1 O Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction ll
i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain _Yes K 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 WHEN
.OWNERS'AGENT"OR='CONT-RACTOR APPCIESt0R'BU1L01NO PERMIT.
I, yts, IV`[r.•f�Vi as Owner of the subject property
hereby authorize � D 6 1 � 4? _to act on
my behalf, in all matters relative to work authorized by this bMilding permit application.
Signature of Owner UDate O�ylo-�
I, ,fce 1f �• '�%c'Eeri "^ 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.
Sc. 7't -b a..l.-.
Print Name r'
ner/Agent Date
5EC��.73.. .0,N.
'8-.CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Nolder: SC6 I D �•r.li f t7
License Number
.Lc„4.E( Lee. * m& o /o-I
Address Expirat orate
Telephone
a _ Not Applicable ❑
Scott l� . �•�lcb cc_ — uve�w � / 6493-9
Company Name Registration Number
- SAn AS A 4[.��i= -4-;1111
Address Expiration Date
Telephone
SECTION 30-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... ... A No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hive who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel offend 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 Verson who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will 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 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for persons)
you hire to perform work for you under this permit
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and Stale of Massachusetts General Laws Annotated.
Homeowner Signature
q' fl
9 e 87.enev¢n:m.•
e
DEPARTMENT OF BUIMING INSPEMIONS J/
272 Main Street ' Municipal Building yl/
Northampton, Maes. OSOGO
WORKER'S CO
MPENSATION rNSURANCE AITIDAVIT
{1;censcrlpcsmifiec7 �
with a principal place of busuless/residencs at:
IV..... 4ye_cH RW 4tue.�H Ma U(ac'Y_(phoneY.)
{ctmxticiiylstatrJap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compen-=on coverage for my
employees working on this job:
/ rau�Ic�l �(�koi3- s'S9xp}Z -1-a _
(Insu r=Company) (Policy Nnmbe[7 trtioa Date)
( 1 I am a sole proprietor,general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation pohcies:
{Name of ConCraceor) {IvSurana:Company2oGcy Nmmlxt7 (Expiration Date)
(Name of Conexaetor) (tn.waucr.Compa>ry/Pobcy Number? (Expiration Date)
(Name of Contractor) (InStnance Company/PaiGcy Nnmher) (Eupiredon Date)
(Naznc of Contranor) (Insntauce Coutpa y!Tolicf Nurrai c) (Eapirtion I)nte)
(nnuL additimil x:><n J'c«m+ryr.-iwud�'w«rwam a*�^�^;w.e eli warywra)
O I am a solo proprietor and have no one working for me.
{ ) T am a home owner performing all the work myself.
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