09-010 (4) 410 KENNEDY RD BP-2019-1472
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map,Block:09-010 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)Catmorv: ADDITION&RENOVATION L V ILDING PERMIT
Permit# BP-2019-1472
Proiect# JS-2019-002386
Est.Cost:$379500.00
Fee:$2467.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KENT HICKS 66104
Lot size(so.ft.), 853993.80 Owner: SCHOLZ GREGORY
Zoning:RR(I00VWSP(I00 Applicant. KENT HICKS
AT.- 410 KENNEDY RD
Applicant Address: Phone: Insurance:
P O BOX 57 (413) 296-0123 O WC
WEST CHESTERFIELDMA01084 ISSUED ON.•612812019 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW GARAGE AND RETROFIT GARAGE AND
RESIDENCE
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 628/20190:00:00 $2467.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-1472
APPLICANT/CONTACT PERSON KENT HICKS
ADDRESS/PHONE P O BOX 57 WEST CHESTERFIELD (413)296-0123 q
PROPERTY LOCATION 410 KENNEDY RD -
MAP09PARCEL010 001 ZONE RR(I00)[WSP(100
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENC D RE [RED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
--
TvocofCon 'ore NEW GARAGE AND RETROFtE GApa AND RESIDENCE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 66104
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Beds 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 Stonn Water Management
_Demolition Delay
e / 6 lull
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.
ur- IV Department use only
City of rth Ste 0.'t'
r Permit:
Building spa ment 4 2019 curb uUDriveway Permit
_ 212 'nS UUN 2 ewe septic AvaaaNlly
ROO 10 afar ell Availability
Nolthampto wo s or Structural Plans
p t11LDINf.INSpnln( �MK
phone 413-587-124 F50gj
APPLICATION TO CONSTRUCT,ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMA710N
1.1 Property Address: This section to be completed by biles
410 l<6NNtDY zr) Map f� Lot 00 d. unit
L.-EtOS I MA Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2./1 Diviner of Record:
l ,R4fom SUidL2. Po Fox ps , LEtep& , r'tA 01053
Name(PMI Cunent il' Adtlress:
NI3• �IS111
Teleplvq
Si nature
2.2 Authorized AIgem:
( NT t'Y lcatS Y S� r W . CkE�le;L-D FMA
Nam m) Clu1rren)Mailing Address: OK�6 LL
-tt3. Azo
Signature l
Signature—r Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed brmitapplicant
1. Building b2,y r 2,610 (a)Building Permit Fee
2. Electrical 24 ,100 (b)Estimated Total Cost of
Construction from 6
3. Plumbing 5 r Building Pemdt Fee --
�'�, �{ �9
4. Mechanical(HVAC) �
5.Fire Protection
e. Total=(I .2.3.4.5 '3 1 9,50D Check Number
This Section For OMcial the Only
Building Permit Number: DateIssued:
Signature:
Bulking Commissionedinspector of Buildings Date
�iar� � �N7Ntc.1�Ca1SfRwc-T1�=N �Cor�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement ndows Alteratlon(s) Roofing
Or Doors SCI
Accessory Bldg. RL Demolition ❑ New Signs 101 Docks IBJ Sltllnel0l Other(Oj
Brief Des prion M Pro
Work:
X ' -
� C E R YLETOF IT OF CQ Gt{ CE; A IZESIbE�CE.
Alteration of existing bedroom_ Yes No Adding new bedroom K Yes No
Attached Narrative Renovating unfinished basement X Yes No
Plans Attached Roll -Sheet
Be.H New house and or addition to existina houslna, complete the following:
a. Use of building :One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?y
1'r i
d. Proposed Square footage M new construction. goo Dimensions ay K 3(7
e. Number of stories?
L Method of heating? Ear-NtAT RAMP 1 W app Fireplaces oKjj� Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Typeofmnstruclion V-PJ
I. Is construction within 100 fl.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes XNo
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_ X City Sewer Private well y City water Supply
SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 6 tefLg O.Y as Owner of the subject
property 1
hereby authorize <jetA'T- �T�C
to act on my behalf,in all matters relative to work authorized by this building permit application.
(0-Ro•ICI
Signa me of Owner Date
I, I<"-r [A1cxs 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 1pains and penalties of perjury.
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Print me
i
Synatureo(Owner/Agent Data
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Section 4. ZONING All Information Must&Completed.Permit Can Be Dented DmTo Incomplete Information
Existing Proposed Required by Zoning
Thi,column ro be fillniin by
Building Dep,nmem
Lot Sin 5.. _;k i al.SF SA..tr1E
Frontage 1 10$pT SgMC-
Setbacks Front AXOPr aPP" SAME LJ
Side L: aZ i R:�,'tb. L:SAN* R:— 0 0
Rear
Building Height r�a� ®f O
E
quare Footage '20 0 ,a+pace Footage %minor bldx&p .d
M of Peking Spaces r3
Fill:
vdumeal.acarion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 10 YES O
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book [777--] PageC-7] and/or Document Nj _
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued: i_
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0
IF YES, describe size, type and location:
E. Will the construction aeUvity disturb(clearing,grading giWavation,or filling)over 1 arae or Is it part of a common plan
that will disturb over 1 acre? VES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW Is required.
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Ncmeof Lieenee Holder: KENT ,41uc9 [,S -obblo`I
License Number
(n34 Metu t �, CNESIHZFIELD ,/f�P 0109`1 1 / lajouo.20
Ami.. / E,wranon oau
_�//,�E� ul3•�g6•o,23
Sibruiture —� Telephone
8.Registered Home Improvement Contractor: Not Applicable ❑
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Company Name - Registration Number
63L1 Mh114 Ro , W- IFr , , MR eml 2/S(-+ /wxo
AtltluFre'6 /)� F)pIratlon Date
Tel.pnppaNl3•e�9lb•o123
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 162,1126C(8))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial W the issuance of the building permit
Signed Affidavit Attached Yea....... K No...... 0
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City of Northampton
Maasachusatts S.
Drraavmrz or soraDm MSPECrroNS
212 Min etrwt • M,u,ici"l Buil6 nq �/ C
NortT ton, m. 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alienation, renovation, repair, moderwation, conversion,
impmvement removal, domolibon, orconstruchon of an additn to any pre-existing owneraccupied building containing
at least one but not mom than/our dwelling units....or to structures which are acyacent to such residence or building"be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC,that entity mast be registered
Type of Work: 1Z6NO'41XTl0f4 $ IAea > Cj"kc,E Est.Cost: 34°1 ,5to
Address of Work: 4I0 \J NEDY �D . I.EI S a MA.
Date of Permit Application: 6/A3 /)q
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
TINDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH,ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of thep>vner: ��
in I;LQ III Vrm-r
Date Contractor Name �— HIC Registration No.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
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j •'' Massachusetts
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D6R ..IrT OS BNIIDING INSPECTIONS (�
2122 Min 9Craat alLnidpal 9uildin1 Jr
HorNavQaWn, MA 01060 �O
Debris 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.
The debris from construction work being performed at:
1410 kCL-NNNEby 'aD
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onshe rented or leased from:
—DA*5'k tc.1t-l�5 , RNULrrl(�
(Company Name and Address)
2/yy / Al�
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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'\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02171-2017
www.matt goF/dia
Workers'Compensation insurance Affidavit:Builders/ContnMom/Eledricians/Plumbem.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoolic"I Information 11 Please Print Ltcibly
Name(Business/OrgMkA
MW,rMividual): j<I!PJT MWS CONST?-UiUrMW
Address: C�34 MAW 1Zb
City/State/Zip: WesT G4� xnAPhone#: q13• ;L01b •01;k3
Are.......term?Cheek th..ppropri to was; Type of project(required):
I.&amaan,I'm with anployms(call ud/m pm-hoc).• 7. ®New construction
2.❑Iamaxlepmmmrorpa.emhipar Nvenoemploymworking formic S. I,e�,�l Remodeling
my valued,[No wotkeri mop.mounted, required.]
❑1 am a hamawmr doing ell work myself IND wokas'cm^p.imurance requited.]t 9. El Demolition
4.❑1 a.a homeowner and will be hiring coMrmters.cmiduct all work an nor property. 1 will 10❑ Building addition
enure Chet all evenselm either have workers'compnaaion mounts:mare who 11.0 Electrical repairs m additions
prapdelon with no employees.
12.[]Plumbing repairs or additions
5❑land. mand naetrmtmand1havehim Nesubcooss,cnlisted mthe', sheet 13QRcufre airs
'Ione subcmtteaors have ernployees W have warkeri oomD.hssunim,t P
6W erearow t,.n"iu M.have m,.d theirfight ofe:remptim per MGL c. 14.❑Other
152.51(4).and we haven employees Mo workers'eamp_insurance requited]
'Any applicant thin,checks boa#I mus also 011 out the section below showing their wortmoseampeoation policy N ob om
I Homeowners who submit this eRetion indicating they are doing all wank and then hire outside exa muss mart submit a new amdava indicating such.
lCmtmctors and chock this box must attached an additional sheet showing the nme ofthesnb-contractors and state whether or not those emilies have
employ. If Ne sub conaactors lave employees,Ney must provide Ncir workerscompuh,numbe,.
I am an employer that is providing workers'compemadon insurance for my employees. Below is the policy andfob site
informottom
Inslaance Company Name:_ UNION (N S XV ANC6 CpMp"'i DF i?apa)1D6N CE
Policy#or SelSim.Lie.#:- 1000oR4tl2�0 r Expiration Date: 4/5/ii1Da't0
lob Site Address: 410 KENNEDY (ZD City/Staus ip: Ler-- 1 ')n 0I05-6
Attach a copy of the workers'compen latiou 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 fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cd, underthe ins and penalan gfperjury that the information provided above is true and correct
5igna �l _... Date 6/AO/i9
Phone# L113 •.1- 6.Oi^J3
Official use only. Do not write in this area,w be completed by city or town official
City or Town: PermiULiceose#
Issuing Authority(circle one):
1.Board of Haalth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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