25C-052 (10) 55 LINCOLN AVE BP-2021-0989
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-052 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-2021-0989
Project# JS-2021-001692
Est.Cost: $23500.00
Fee: $153.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SCOTT NICKERSON 053156
Lot Size(sq. ft.): 10497.96 Owner: FERMIN-SCHON MARISELA
Zoning: URB(100)/ Applicant: SCOTT NICKERSON
AT: 55 LINCOLN AVE
Applicant Address: Phone: Insurance:
PO BOX M (413) 896-3347 () SOLE PROPRIETOR
LAKE PLEASANTMA01347 ISSUED ON:3/19/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERT GARAGE TO RECREATION ROOM
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 NORT AMPT N UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. I. I
Certificate of Occupancy signatt Ie:
FeeType: Date Paid: Amount:
Building 3/19/2021 0:00:00 $153.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2021-0989
7
APPLICANT/CONTACT PERSON SCOTT NICKERSON
ADDRESS/PHONE PO BOX M LAKE PLEASANT (413)896-3347() -L
PROPERTY LOCATION 55 LINCOLN AVE
MAP 25C PARCEL 052 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED DATE
ZONING FORM FILLED OUT
Fee Paid 4 `07
Building Permit Filled out
Fee Paid
Typeof Construction: CONVERT GARAGE TO RECREATION ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 053156
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
y 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
Aeft
kAttA,,.. 1 4 Ch 37 I 6 1/2 I
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.
l ,
/ p"-------0-- ---, rw
414R
The Commonwealth of Massachusetts / 6 202�
Board of Building Regulations and Standar FO
Massachusetts State Building Code,`780 C .°nukt./1; U E ITY
lAg7PI G lT c
Building Permit Application To Construct,Repair,Renovate Or is 4.Cr' ised Mar 2011
One-or Two-Family Dwelling Trio
i ction For Official Use Only
Building Permit Number: / g•, '' vi .f Date Applied:
,. . .10 I /iq
Building Official(Print Name) Signature I
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Number
SS Oyu.0(vi /ive- , N o✓Y►4 a WM Pttvi, Ml� 06a-
1.1 a Is this an accepted street?yes no Map umber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pp1y:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Di osal System:
Public Private❑ Zone: Outside Flood Zone? Municipal On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
IA ott,iSt(pi F[,vvV►i Pi-SeAne-v7 NOvI'Vl/114/ 1-4Y1, P'1 D I0 b O
Name(Print) City, State,ZIP
cS L '-i r e(vl ii-ve- al 13-- $-4I972 (^.kv✓viikteiv,44/1.(e),li/
No.and Street Telephone Email Address
l
SECTION 3:DESCRIPT OF PROPOSED RK2(check all that apply)�
New Construction 0 Existing Building fdWner-Occupied Repairs(s) 0 Alteration(s) Addition 0
Demolition ` 0 Accessory Bldg.B"/Number of Units I Other 0 Specify:
Brief Description of Proposed Work2:Co h vex exl/,/, 54.0 e) f 2'c e.44r.. /cowl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ a of e G 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 3 S O O 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ ,..49--- 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
�-
Suppression) Total All Fros..$
Check No.17-, Check Amount: " Cash Amount:
6.Total Project Cost: $ J3/Sd 0 0 Paid in Full 0 Outstanding Balance Due:
/c3 . L) O
City of Northampton
Massachusetts
ro DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 s•'s ��
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 &2 FAMILY DWELLING,ADDITIONS,POOLS,DECKS,ACCESSORY STRUCTURES,
FENCES,GROUND MOUNTED SOLAR, ETC.
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specification of proposed work(digital and hard copy).
3. Site Plan with location of proposed structure(s)and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/replacement windows).
S. Home Owner's License Exemption Form filled out and signed by homeowner(if applicable).
9. Note any Conservation and/or Special Permit requirements (if applicable).
10. Driveway Permit(if applicable).
11. Proof of Water and Sewer entry fees paid(if applicable).
12. Trench Permit-public land by DPW/Private land by Building Dept.
13. Stretch Energy Code—all new construction will require a HERS Rater Affidavit to be submitted with
permit application before issuance of permit.
•
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
ie/2.2—
--CC 'i11 'Ti) Nc r e►r j a tA License Number Ex iration Date
Name of CSL Holder U
PO 4° iv‘ List CSL Type(see below)
lion
No.and Street " Description
Unrestricted(Buildings up to 35,000 cu.ft.)
L I �Q Ash d �3 Y Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
8 p SF Solid Fuel Burning Appliances
l 6" 3 3 y ; .S�! It c% fd 7,7 I Insulation
Telephone Email address/t,(tD Demolition
5.2 Registered Home Improvement Contractor(HIC) in 3// ?if
1,/ x /
SA At c 4 s N 4•. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize co 1.1' V t Cad 6V)
to act on my behalf,in all matters relative to w• k authorized by this building permit application.
IA victlii Frrn�iii-3c�t9-14, I�I h/1" - 35/2-44,i
Print Owner's Name(Electronic Si Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains. ///enalties of perjury that all of the information
contained in this application is true and accurate to the :f my knowledge and understanding.
/ /
Print Owner's or Authorized Agent's Name(El- . lc Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
4
1
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
� 4 �i` SSE:.
�° �"�� Massachusetts "`;,,
w
DEPARTMENT OF BUILDING INSPECTIONS „
212 Main Street • Municipal Building "
"�-� Northampton, MA 01060 's'�, y "
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: V4 l/e 4c ,�/. 6471/u.�, 7:4,
JThe debris will be transported by:
Name of Hauler: _C.D & A.rclet 9 C .,
Signature of Applicant. Date: 3/0 /
The Commonwealth of Massachusetts
: Department of Industrial Accidents
I Congress Street,Suite 100
114 Boston,MA 02114-2017
www.mass.govidia
Workers'Compensation Insurance Affidavit:Buiklers/Contractors/Electririans/PIttinbers.
TO RE Fli_ED watt TUE PERMITTING AtiTtIORITY,
nolicant Information Plenfve Print Legibly
Name(flusincsmCVenizatroth 5"(..pttM „. he<if
Address: Pe) 141
City'State/Zip:1-414, ' .4-4 k "IY Phone#: t's S ?4 3 7'e 7--
Are you ail truployee Cbeck the appropriate boaii Type of project(required):
1.0 I amployer andarpattiorar' 7. 0 New construction
2 I ani a an proprietor or pannersha and hare no employees working fir ate in 8. 2erriodeling
any capacity [No workers'comp.inatiance required.]
9_ D Demolition
30 I am a homeowner doing all work myself.[No*ethers'coma.ionnator required
ao[7 Budding addition
4,0 I aril a huttutok/act and will be.hiring couraelors to conduct all work on ney porpeny, I will
ensure than all warn:ion either have workers'oampeneatioxi ittairunee are sale 110 Electrical repairs or additams
proprietor%with no employees_
12.0 Phimbirlij repairs or caltittintIS
SC1I am a general contractor and 1 bare hired die risibmiontractors binalcit3 the attached.sheet
31:1Roof repairs
These sub-eariaseiois asw assaloyets and hove workers*corn,.inarrance.:
1 4,,0Other
6.E3 We are a earporicton sal irs officers have exercised their rigid of sr
exemption e
152..ti 41.and webat no employees.[Sri WCIttnl comp.innorance required.1
'Any appheard that cheeks bin MOM also fill tat the action below showing their workers'corapensation poba extfornalitind,
linineownens who fiLithIttit this affishavit indicating they are thing all work and then hire outside contractors rtillut sonar a new affidavit narrating sink
:Contractors that chock this.bias lima attached an additional than abuw inn the name of the iaracontractoes and xsuss whether or nor those entities hare
spines If the antreolitractors hese employees.tIlL'!, 111.1,«id,-their workers'onnii.pulw?nurnker
I am an entphovr that is providing**writers'compensation insuranc e for my,employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy or Self-iris.Lie,#: Expiration Date:
Job Sue Addre : City/StatelZip:
Attach a copy of the workers'coitipensation policy declaration pali,c(showing the policy number and expiration date)
Failure to secure coverage as required under Mai e. 151. 25A is a criminal violation punishable by a fine up to$1300.00
motor orie-year imprisonment as 11 as civil penalties in the form of a STOP WORK.ORDER and a tine of up to$250..00 a
day al&inst die violator.A - Ithis statement rimy be&awarded to the Office of Ins estigations of the DLA for insurance
coverage verifitmtion.
l
do hereby certi e pains and penalties f[perjury that the information provided ohove i.%true and correct
Sianaturet pato 3/Phone -
rOffiehd use only. Do not write in this area to he completed fry city or town official
City or Town: Per mitLicenst
Issuing Authority(circle tine):
I. Board of Health 2. Building Deliartirimit 3.City/Town Clerk 4 Electrical Inspector 5. Plumbing Inspector
6,Other
Contact Person: Phone 4:
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