17C-254 (8) 21 NORTH MAIN ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1966
Map:Block:Lot: 17C-254-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1966 PERMISSION IS HEREBY GRANTED TO:
Project# PORCH REPAIR Contractor: License:
Est. Cost: 6700 EDWARD RICKEY&COMPANY 96159
Const.Class: Exp.Date:07/13/2022
Use Group: Owner: ALL NORTH LLC
Lot Size (sq.ft.)
Zoning: GB Applicant: EDWARD RICKEY&COMPANY
Applicant Address Phone: Insurance:
80 SOUTH ST (413)695-7059
CHESTERFIELD,MA 01012
ISSUED ON:09/28/2021
TO PERFORM THE FOLLOWING WORK:
REPAIR PORCH
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.
Signature: (640aL (NI
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
sep \�D�
The Commonwealth of Mass ie' ' •tts
Office of Public Safety and Inspec g� ��;�?T(-),w4r;
A��CpFn
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two- y )w • g
��f� (This Section For Official Use Only)
Building Permit Number.( ?''. /Ote Applied: Building Official:
SECTION 1:LOCATION
2/ Ze14. 2 .0 ifzaww. •ynA ava e 2-
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2 PROPOSED WORK
Edition of MA State Code used / If New Construction check here 0 or check all that apply in the two rows below
Existing Building 0 Repair SJ Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No IN
Is an Independent Structural Engineerin Peer Review required? p . Yes 0 No
Brief Description of Proposed Work: R�L.�et. Zoro 4/ a� PMc.L. T.��oo•Yv� k a
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft)
Total Area(sq.ft)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O IB O ILA O LIB O HIA ❑ BIB O IV O VA O VB D
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: /
Public Er Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Site E
Private 0 or indentify Zone: or on site system 0 required El or trench or specify
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No Cl Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
City of Northampton
opT H�Mv�o. S`S :... s,
✓ ^1 Massachusetts �2 "_ >
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I �l,F+ [ DEPARTMENT OF BUILDING INSPECTIONS i T
212 Main Street • Municipal Building Jti
Northampton, MA 01060 SSW T":'
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital & 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 CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11.Trench Permit(if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
13. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton
l SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
X 141-1-- NO(LTA- u.(. P..S.-V E. ,-f,li iv (Sr ?c.A( O F (e' Yt i4- 6 I07a
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information
X Fre s s d e.i-- 1/( -s V 00 4'7 Sa lcl yle- //4q V -P(areA ce ttardtaG m ocA sd'-.11,e.4
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
1791)-7j ke( iC2_ X 5-5 E, 'MA-&vJ S a -? INIFjE2-) /Li 4- d 10 7i)
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
edt - .l Cs-o94/S9
Name of Person Respoisible for Construction License No. and Type if Applicable
go .doh ,al!t Cd MA 0 oh-
Street Address City own State Zip
413-645- 7ot9 - - riGktghorne mpr'otit.hse,nt e.rya.Corn-
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the ' uance of the building permit.
Is a signed Affidavit submitted with this application? Yes 114 No 0
SECTION 1Z:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ C he." Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$ .
3.Plumbing $ //A�,, CD
4.Mechanical (HVAC) $ Note:Minimum fee=$IL" (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ ` 72Q.O° (contact municipality)and write check number here 39 Y S
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
& 4L 6,,,,,..a"o4. 9/3_d75- 7oS9 at
Please print and sign name Title Telephone No. yzi
te
$o )Josz`t 270 c/o/2- rich; hett,LAprs .. cAh @ 74%0 400
Street Address Ci /Town State Zip Email Address
� $ I dS
Municipal Inspector to fill out this section upon application approval: I a i r •'L., st NameTNT
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
t
The Commonwealth of Massachusetts
s 1 Department of Industrial Accidents
ell'_= r: 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govidia
)l ockers'Compensation Insurance Affidavit:BuildersI('ontractorsfE kctricians,'Plumbers.
10 lit.1:7111)!!ITH'fHE PERMI I I I G s1 l HORffl.
Applicant Information Please Print Leeilih
Name it antiatton lnetha1Jual):
Address: S-0 J 771,4 o/c IQ_
City/State/Zip: Phone : 9/3- c9S-7G 7
Arc yen as cam yte?Cheek the a prep'1.1e hen:
Type of project(required):
1.❑t am a employer rrik employees Ifill a.ddor part-[its l.' 7. 0 New construction
?, I am a mule peuprielotur i '&ipaidhoc no emphycYs nothing tar me m $. 0 Remodeling
any capacity.[Nu wwhers"ammp.iaatrtancw nwwastoli
I am a huninam lerdoingal wail[mtyxlf.(No wok0m'comp mummy rc uit d.l" 9. ❑Demolition
a.❑i am a hhmtutwrterand w ill be hiring wttarrciom to conduct all murk on my propcKy_ I will 10 CI Building addition
COMM:that all cudtacion either hate woiLe crttmpensatrwe insurance or are sole I I.O Electrical repairs or additions
pioorieims w oh no employees.
12.0 Plumbing repairs or additions
S�I am a general contractor and 1 hate hued the salb-ontracio s hood on the attached sheet.
I31:Roof repairs
These soh-contractors trate employees and hate notices'cum,.itsmitanccr
b_Q We arc a cwpuraucn and os otteeers hat c exercised then right of exemption pre MGl..c.
14.i2 Odle. Q" `'`^'
132,$it4t.and we harc no employees.[No worker?'tu.p.insurance required.)
'Any applicant that du:cas hen ail mist also fill out the anciion below shutting their rwmkcrs'oanperwtion policy i.fotenttiun_
Ilontnewima who stlkrtit din affidavit indicating they arc doily all work and then hire pen idt cw.ir.caus most aahatt a new atitaim a iralimling such.
leonttaeiuis that cht-ck this box[met ameba!an adihtianal%bun showing the name tithe subonarmarturs and?rate whalhet et not those argotic".hate
employees.. Nth,:sub-.en t adturs hart ern{rkry'cxs.they muss provide then worker`comp.policy aernbcr.
I am an employer that is providing worAers'compensation insurance for my employees_ Below it the policy and job site
information.
Insurance C'ornpans Name:
Policy#or Self its.Lie. :-: Expiration Date:
Job Site Address. C u% State.Zip:
Attach a rutty of the workers"compensation pudic" declaration page Ishoviing the policy number and expiration date►.
Failure to secuie coverage as required under\lt iL e. 152.*25A is a criminal violation punishable by a tine up to S1,500.00
and or ore-year imprisomuent,as well as cis it penalties in the form ofa STOP WORK ORDER and a tine of up to$250.00 a
das against the violator.A copy of this statement ma._ be forwarded to the Office of Investigations of the DiA for insurance
co.crage.cnticatitint.
I do hereby certify under the pains and penalties of perjury that the lafaraemlt)a provided above is true and correct
Signature: C I ' Date: 9/Z&f2oz/
Phone r. —7M.
Official use only. Do not write in this area.to be completed by city or town ofJtcial
City or-too+n: Permit/license!t
issuing authority (circle one):
1. Board of Health 2.Building Department 3.City Jimn('krk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#):
City of Northampton
Massachusetts
14 i
•. y DEPARTMENT OF BUILDING INSPECTIONS
* ti. 212 Main Street • Municipal Building y',.
s±F '' r Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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: Valk/ &IX, , Voatoiwpi, MI
The debris will be transported by:
Name of Hauler: Ati
Signature of Applicant: Ce: Date: 9/2g/2 24