24A-057 (2) I
110 JACKSON ST BP-2020-0647
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-057 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DON T HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2020-0647
Prosect# JS-2020-001104,
Est.Cost: $131.20.00
Fee: $91.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): 14853.96 Owner: VINSKEY GEOFFREY JAY&HEATHER D VINSKEY
Zoning: URB(100)/ Applicant. EDWARD RICKEY
AT. 110 JACKSON ST
Applicant Address: Phone: Insurance:
P O BOX 62 (413)695-7059
WILLIAMSBURGMA01096 I ISSUED ON:11/20/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING RAILING AND FRONT
DECK, RENO 1ST FLOOR BATH
I
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
i
Underground: Servicl:. Meter:
Footings:
Rough: Roug House# Foundation:
Driveway Final:
Final: Final: _
Rough Frame:
i
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
I
Final: SmokFinal:
I .
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy I Signature:
I
FeeType: Date Paid: Amount:
Building 1.1/2 0/2019 0:00:00 $91.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northa pto Status of Permit
r Building.Dep met ' Curb Cut/DrivewayPermit
fs
212 Main tre /SepticAvadability
�00 100 ol/ r "Availats lity
Map 060 T o Set of Structural Plaris
Northampt n
t, phone 413-587 1240 ��1 / -1272 9 ylot/si Plans
TyRtij�T/n/�/n r;
Othe Specify
lo
APPLICATION TO CONSTRUCT,ALTER,REPAIR,REM c 0�1 DEOLISH A ONE OR TWO FAMILY DWELLING
I '
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section 16,be completed by office
Map Lot ^� Unit
ry�� Zone:- y JOverla District: _•_
/�/i y
,EIm,St.Distract CB District
SECTION2-PROPERTY OWNERSHIP AUTHORIZED'AGENT
2.1 Owner of Record:
me R.�
' .. Current Maili Address:
Telephone
Signature
2.2 Authorized Aaent:
, G 2 C11016
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost Dollars to be Official Use.Only
completed by permit applicant
1. Building (a)(a)Building Permit Fee
5 /20.
2. Electrical (b)Estimated Total Cost of .
Construction from 6
3. Plumbing Building Permit Fee;
OCG • .
4. Mechanical(HVAC) ql�
5.Fire Protection
6. Total=(1 +.2+3+4+5) 3 /20. Check Number )
` This Section For Official Use Only
Building Permit.Number$Q-,:c7 U�1 4 7 IDssue 1
d:
Signature: kh
Building Commissioner/Inspector of Buildings { Date
I
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
l
SECTION 5 DESCRIPTION OP PROPOSED 11VORK lcheck all apallcablel`
1
New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [a2� Siding[❑] Other[❑]
Brief Descrip ion of Proposed ST
Work: -Ai neelk
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes _&Z No
Plans Attached Roll -Sheet
&a'}�1 N w,Fti i s "anc!'ar di di ionto xtsfi�a;' o>�atna,kct�maYet+ ;ttie foliauuin :
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unitf Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new col struction. 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 No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor b !low finished grade
k. Will building conform to the Buildin:and Zoning regulations? Yes No
I. Septic Tank City Sewer I Private well City water Supply
I
SECTION 7a OWNER AUTHORIZAfiION TO BE COMPUTED WHEN
OWNERS AGENT OR CONTRACTOILDINP
R APPLI77
ES FOR BUG ERMIT
I, J� 3M as Owner of the subject
property
hereby authorize
to act on my behalf,Wall matter lative toWork authorized by this building permit application.
mein
Signature of Owner Date
as Owner/Authorized
Agent hereby d re fhat the tatemerits 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.
L-,-A0WAk0 J l2JCIGJ'r
Print Name
Signature of OAndrIAgenv Date
SECTION 8 CONSTR.UGt10N$ERV.ICES
8.1 Licensed Construction Supervisor:I Not Applicable ❑
Name of License Holder:
License Number
A vX 62 1 plC%9` 7-13 - 262-0
Address Expiration Date
' 5.._
Signature Telephone
;9.`ilea`tstere - ome`Nlmprovemet:Gontracfor y ' F ,A rs kY° Not Applicable ❑
/50 r5go
Company Name Registration Number
avr -9-2 - 202P
Address Expiration Date
Telephone
_ f
ECTlEyN 10 WbRKER5'COMPENSATION INSURANCE AI=FtDAlllt(M G�. c 152,§2506))
Workers Compensation Insurance affida it must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil 'i g permit.
Signed Affidavit Attached Yes....... I No...... ❑
i
City of Northampton
Massachusetts
l:
`f DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building vb psi
Northampton, MA 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 home,a contractor must be registered as a Home Improvement Contractor("IM").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolitio,, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has c!retracted with a corporation or LLC, that entity must be registered.
Type of Work: / �uM, Est. Cost: 13.124 <A
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00 0
_Owner obtaining wn permit(explain):
Building not owner-occupied
_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
UNDER M.G.L.Chapter 142A.�SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
J/hil,i 15L
D e Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
A� DEPARTMENT OF BUILDING INSPECTIONS
3 -
' v. 212 Main Street •Municipal Building cad
Northampton, MA 01060
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 1111, S 150A.
The debris from construction work being performed at:
(Please printMouse number an' street name)
Is to be disposed of at:
(Pleasb print name and location 6f facil' )
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of P it ApplirAht or Owner Date
If, for an reason the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Y p pp fY
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
e m
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Auplicant Information Please Print Lesibly
Name (Business/Organization/Individual): ,
Address: J�o. 13a 6�
City/State/Zip: - �jf?�} 010 76 Phone#: 1-1/3 6 75- 70S7
Are you an employer?Check the appr pri a box:
Type of project(required):
1.E]I am a employer with employees(full and/or part-time).* 7. ❑New construction
2n I am a sole proprietor or partnership and have no employees working for me in 8. LZemodeling
any capacity.[No workers'comp.insurance required.]
9. ElDemolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must ago 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 atta+ed 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 req�iired 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 of a 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 certify under the pai s and penalties of perjury that the information provided above is true and correct.
r
Si ature: Date: ~
Phone#: 4//3- 6 705`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 on
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: