25C-051 (11) BP-2022-0459
59 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-051-001 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-2022-0459 PERMISSIONISHEREBYGRANTED TO:
Project# KITCH/BATH RENO Contractor: License:
Est. Cost: 195000 SCOTT NICKERSON 053156
Const.Class: Exp.Date:01/10/2024
Use Group: Owner: SWEET GINTIS VALERIE &WILLIAM
Lot Size (sq.ft.)
Zoning: URB Applicant: SCOTT NICKERSON
Applicant Address Phone: Insurance:
PO BOX M (413)896-3347()
LAKE PLEASANT, MA 01347
ISSUED ON:04/29/2022
TO PERFORM THE FOLLOWING WORK:
KITCHEN/BATH RENO
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
•
It
Fees Paid: $1,268.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildine Commissioner
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i L APR 2 8 b The Commonwealth of Massachusetts
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c 2Q�2 /Board of Building Regulations and Standards FOR
h� MUNICIPALITY
j sz - ;Massachusetts State Building Code, 780 CMR
.� Fetncn, t USE
- `'T�.?'Bni c rvot Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
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One-or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number:AP".)? ySq Date Applied:
ems„�, ass ��� L1-29 ZoZZ
BuildingOfficial(Print Name) Fe Date
SECTION 1: SITE INFORMATION
1.1 Property Address: t/ 1.2 Assessors Map&Parcel Numbers
—inc.,c2.6r_.
1.1a Is this an accepted street?yes ✓ no Map Number ParceTNumber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) A/0 G 4 h N qr J
Front Yard � Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Waatter/Su�ply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D) osal System:
Public !� Private 0 Zone: Outside Flood Zone? Municipal On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,O ner'of R ord:
vo,v rte L.,t f\-tic N c ±1arAfri-On) nYR 046 D
Name(Print) City,State,ZIP
56k L I nco IN AU_ (-!/s Q In-8 BIOS Vale r tt. ►n-Jl1. a &nal 1.cmi
No. and Street Telephone Email dress
SECTION 3: DESCRIPTI N OF PROPOSED WORK2 (check all that apply)
VRepairs(s)Construction 0 Existing Building Owner-Occupied Cal Repairs(s) 0 Alteration(s) M Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units / Other 0 Specify:
Brief Description of Proposed Work2: JC.Ck,I tom.*il — Zn tL RQYtO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1. Building $ /.off pQ G 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ -- 0 Standard City/Town Application Fee
/5/ o D 0 0 Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 3 01 D co 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ b$
Check No. ‘'')A) Check Amourtii .la,,
6. Total Project Cost: $ f 9J� .00 0 0 Paid in Full CI Outstanding Balance Due:
City of Northampton
'��� � Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS,RENOVATIONS, ROOF 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 specifications of proposed work (Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new/replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code —all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Likens (CSL)
�Cd !/ /tCLto✓JG £ License Number E ira nDate
Name of CSL Holder
n O —Z o x List CSL Type(see below) V
No.and Strrjet Type Description
L A
e/3 U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town���SQQQtate,ZIP/ 414,4
R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
93_g'T b 3 �l �� ^ ^ SF Solid Fuel Burning Appliances
b f 7 p1► l 3 �j',tit I Insulation
Telephone Email address v D Demolition
5.2 Registered Home Improvemenontractor(HIC) 5.)- C 3 // c�
a .
_C4 si e /p t 4 4d v- HIC Registration Number xpir Lion Date
HIC Company Name or HIC Registrant Name
•fairlIcL(.1� e_ /44AI/• ("i
No.and Street Email addr s
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 mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu of the building permit.
Signed Affidavit Attached? Yes No . 0
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 SCo
to act on my behalf,in all matters relative to work authorized by this building permit application.
Valtr1Q C7e10:1•C `I, a ?• 2 Z_
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and p= . ties of perjury that all of the information
contained in this application is true and accurate to the best of' " knowledge and understanding.
f"Co751- Y7,0
Print Owner's or Authorized Agent's Name(Electronic S'_'= •i e 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"
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The Commonwealth of Massachusetts
Department of Industrial Accidents
) I Congress Street,Suite 100
146,;: ill
Boston,AilA 02114-2017
www.mass.gov/dia
Slorkers t:ompensation Insurance Affidavit:BuildersiContractors/ElectriciansfPlurnbers.
TO RE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeiblv
Name i BusiniessiOrgantzationi'Individustil:So /74- .-- X/(elee-Zel 41
Address: /6 --k)?‘ 114
City/Su eiZip: /A -, "YeA IA,/ Phone#: Yi 3 -V, ‘' 3(/
Are you n employer?Cheek thr appropriate box: Type of project(required):
1. XII a employer with ____,_ employees(fun:natio/puri-iinici.. 7_ 0 New construction
2 1 sea a iok proprietor or panne:stop and have no eneptoyora worlt:in# for tne in ' 8 0 Remodeling
any capacity.(No workers'comp.insurance required.]
9.3.0 lam a homeowner doing all work myself[No workers'corm.imuraince it-quire)]° 0 Demolition
ICI Ci Building addition
4.0 lam a hurneownier and will he hmes contractors'to oendllet In VVOrk on ray proyerty. I will
ensure that all Cilium:tors either have workers'compensation rnawun Ii)a Electrical repairs or additions
proprietors,with no employee'.
12.0 Plumbing repairs or;idiiitions
.5.C3 lam a general eontractor and I have hired the sub-cemtraciors listed on the attached sheet.
thta sub-contractors base employees and have workers'corim ursurance..; i.3,0 Roof repairs
14.0 Other
6.0 we gut a corporation and its offices have exercised their right of exemption per MGL c.
152,§114),and we haw no employees.(No workers'comp.insurance required.'
•Arf;applicant taut check,1,.-,.-'l mi..,-. ..1--., fill out the section below show Mg their workers'compensation policy information_
flomenumets who submit this.1111sia,,It Ind:waling they are doing all work and then hire outside coretracters emu.Silbnlit a new affidavit indi .."ting auch.
:Contractors that cbcci this hex must attached an additional them show ing the tialtle Of the i,n1-.0.itntrax.:tvfl and NtaT:e.w ficdicr or nut dup.!,linnea has
v.-Trip Ii.tyt-VS,. lithe sub-contractors Ease emplo.s t.-tm.they must provide Ili& workers'comp.Folic' nurithei
fall.an employer that is providing workers'compensation insurance for my employees. Below is the policy oar!fob site
information.
Insurance Company Nanie: —
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/StateZip:
.Attach a copy of the workers'compensation polic declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a LTiminal violation punishable by a tine 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 tine of up to S250.00 a
day against the violator. A copy 9stateimnt may be forwarded to the Office of Investigations of the DIA for insurance
co Verd ge yerification.
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I do hereby certify unikr , e pain ,-fittil the information provided 'hove is true and correct
Signature: Date. / V' ±
1 Phone#: V/ 3 - S f,4 - i 3
Official use only. Do not write in this area.to be compkted by city or town official
".-
1 City or Town: Permit/License#
Issuing Authority(circle one):
,., 1.Board of Health 2. Building Department 3.CIty/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
,-, 6.Other
Contact Person: Phone#:
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City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 sNxti , ^�
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:
4Location of Facility: Vile,/ ( � G �1,4u
The debris will be transported by:
Name of Hauler: �, // 1l c-Zer� c '^
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Signature of Applica . Date: ( /'� �'
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 3b.
Northampton, MA 01060yt ,.
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert fill legal name), born_ (insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land 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 person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of , 20_.
(Signature)