12C-085 (6) BP-2022-1293
12 RICK DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12C-085-001 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-2022-1293 PERMISSION IS HEREBY GRANTED TO:
Project# RENOVATION Contractor: License:
Est. Cost: 30000 WILLIAM SYMANSKI CSFA060290
Const.Class: Exp.Date: 04/16/2023
Use Group: Owner: THOMAS WICKLES
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant: WILLIAM SYMANSKI
Applicant Address Phone: Insurance:
233 STRAITS RD (413)247-9939 SOLE PROPRIETOR
WEST HATFIELD, MA 01066
ISSUED ON: 10/18/2022
TO PERFORM THE FOLLOWING WORK:
INTERIOR RENOVATION
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:
� PIT
Fees Paid: $195.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
rry
Board of Building Regulations and S ., da FOR
Massachusetts State Building Code, 7:O Cr 1 f C1PAL
USE
Building Permit Application To Construct,Repair, '_ f: .to Or Demolish a R ised Mar 2�011
One-or Two-Family Dwelling 4 If
This Section For Official Use OW 70,30
'r'bows
BuildingPermit Number: 614.?Z- /2 3 Date Applied:
1: • '#' ii ,. 2 7197, 10AV-da
Building Official(Print Name) Signature ii Dbtfe
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/4eldA,Z .'i'e. //orenze,Hio/Oba &0k02.268 ��e3y /ae-oas-ooI
1.la Is this an accepted street?yes V no Map Numbers y4e/40 Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
tI M /`e.4/[7IrnT/Ldi /07 00 S ./t /1. i11
Zoning District Proposed Use Lot Area(sq 4)) Frontage(Ii)
• 1.5 Building Setbacks(ft)•.,
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public l Private❑ Zone: _ Outside Flood Zone? Municipal Er On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Thomas r Brenda e%%s h'at/3i/d' Mg 0/633
Name(Print) City,State,ZIP
/o / kasan/ /ew jr/ve H43-J4/7.6"ii6• �a izil /es@comeBSA/lel
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg.0 Number of Units Other d Specify:recap ya.6n=
Brief Description of Proposed Work2: eertova.fian of the �io.we ;,/,,,or ,inn/vdi q 1 e hoi*
and ki�eh en. /Qep/set eniAs.de dee*. - .sa►a.4 •P Leo e• p(a el ✓ —
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ e24 aoo I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 3,o 0 0 0 Standard City/Town Application Fee
0 Total Project Cost (Item 6)x multiplier x
3.Plumbing $ a via 2. Other Fees: $
4.Mechanical (HVAC) $ a,O 0 o List:
5.Mechanical (Fire $
Suppression) Total All Fees ' \A
Check No ant Check Amount: 1, Cash Amount:
6.Total Project Cost: $ f0,DOD ❑Paid in null 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
� � _ (� GS %R oeoa-9a �- La�
j
,S T4 C u 1 `ok Q t Q&_ License Number Expiration Date
Name of6.SL Holder
3'3 1 /O t3 ! ' i, �, Q� List CSL Type(see below) Li
No.and Street Type Description
Sv u�h 4 -e i elok JYI o t 3 73 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 18E2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
I-I WS Window and Siding
SF
L. 3 CIa `mot;6� Solid Fuel Burning Appliances
v I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IC¢E-5 Z_ r
(-c..LC . a rw , 5qr'1.4 w 3 k I• HIC Registration Number xp. tion ate
HIC Company Name o4,WC Registrant Name
233 sit A t Ts e.D
No.and Street Email address
%P• N A7Ft*--Z-0 tit Q. S 16 ch 443 -217- 9137
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance 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 Akdm �fj,�) a n S`1'/
to act on my behalf,in all matters relative to work authorized by thi'"building permit application.
Tomas ' rew/a IlhA/es eakber 3,02002.
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 penalties of perjury that all of the information
contained in this application is true nd accurate to the best of my knowledge and understanding.
w � .(4/��.
Print Owner's or Auth Agent's ame(Electronic 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"
The Commonwealth of Massachusetts
=,-.4.u.• _,.:
lie portment of Industrial Accidents
1 Congress Street,Suite 100
---Iri:.:14_,---- ..:,• Boston.MA 02114-2017
... ...::-.
. .0 www.inam.govidin
'amov't
%ID:kers'Compensation leseramee Affidavit:BuildersiContiractorsiElectricians/Plumbers.
TO BE FILED WEI II I DE.PERMITTING Alrflitlittl 1.
Applicant Informnadoo Please Print Legibly
Name(BusinessoOrganinitionandividual): e/L im n ..D. S y/ii/9/1/5 el-1
Address: 33 sie.R/7.5- &2223,
CityState/Zip:A4r/Ldaae fr/)9Mf42 Phone#: •S ,.9--,2 /7-9959 le
_
Are you an employer?Cheek the appropriate hot: 1
'1),pr of project(required).
1.0 I am a employe/u oh employ Ce*pan asitui plianowl* 7. 3 New construction
2.[Fri am a scdc propoctoi on panneechip and have no mploy me ni II_ 21Cantiticling
am capacity.[No iscorkerc'comp.isoutance roptinedi
9. 71 1/einolitani
30 I am a 1110111111WViller dump all noel roycelif'No ovarkerc`comp.mouranee motored I'
Ill 3 Iluilding addition
4.0 I am a 114,111011441101 and will he hiring contractors to conduct nil Whoa.on no poverty I u ill
COMM:that all contractor/either have ovaileft*compeniabon Itle.Sit4nt,.:r14 one%.44: MC)Lieveltical invirs or additions
prnifirieuts with no employeec.
12.0 Plittlthiltg i t...Wit s of aviation',
5C3 I am a linmeral contra:tot and I have hoed the cob-contractotx kited on the attached sheet
I 3C:I Roof
a 0icpaers
Th.rne nistnn.ontian inn,have employees and hat e*other:comp.inatuance„'-
14.E3°the'
Ike ate a c...q....cainas and its ottlicen,have exerv:incal Theo tight of exemplum per Mitit.c
I IC_§ii4).and s...•base no amplopec.(No*oaken;comp anymarice orquaroil
`Ant applicant that cheeky.No it 1 MS alin fill out the wection beton,showing their%orlon's'easeplapatioa policy imfaisuoiaa.
f tiolik.smitets who minima thin affidavit indwating:iticy aged...lag all work and then hate mot&0010110d11111 MM.11116111111 a IBM offal"it ,.-- - mark
:coraradorn that check this box maw adiavheil an ahlatitioal shod showing the name of the NI1b-CtIldrietanialt0..444,1:tt htithil 4411 not!bow .•,-- WM
employee, If the,A11.4.AWIltlft.11011,kV,e employ 4.V.,,d1121'sivallrbilde alai Nkent.4.71%*Winp policy number.
; --lotoomminiamm.
I um an employer that is providing'workers'compensation insurance jar my emploms. Below is the policy and job site
information.
Instuancc t'ompany Name: —
Policy#or Self-ins.Etc.#: Expiration Date:
Job Site Address: CitvoState Zip:
Attach a copy of thr 1,1 kri s' t.tom pcitN.itIon polit lit Lir Afton page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152,.;25A in a nri'initial s'illation punishabk by a line up to S1.500.00
and,Or one-year imprisonment,as well as civil penalties in the final of a Sit)P WORK ORDER and a fine of up to$250.00 a
day against the s iulator.A copy of this statement may be fonvaided to the Otlice of Investigations of the DIA for insurance
co,cr.iga.-t LI tik atton.
44"
p
I do hereby certify ander the pains and a t llies of perjuly that the information provided above is true and correct
Signature. 61..)Ltito-:---- 1"""- . 1)ate, geTtidiig 3) oteg,942
Phone.P: 5//3-- 9,99
Official use only. Do not write in this area.to be completed by city or town official
I
A City or loan:__. Permitil.ieense*
---- -- - — - —
Issuing Authority(circle one):
' I.Board of Health 2.Building lIepartment 3.t'ay/Ionia Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
[
..i Contact Person: Phone#:
It. , ,, .• , , ,— „ , .. . ,.. _,
City of Northampton
Q,rHAM�`�, ,
o,� o s
Massachusetts �s m
4 DEPARTMENT OF BUILDING INSPECTIONS
•y
212 Main Street • Municipal Building Jti
Northampton, MA 01060 fty
HOME WNERS'EXEMPTION ELIGIBILITY AFFIDA
T ///ai//�3
1, Thomas Nose ► `j /S (insert full l•;al name), born (insert month,
day,year), hereby depose and state the .11owing:
1. I am seeking a building permit pursuant to the homeowners' • emption to the permit requi ements of the
Massachusetts State Building Co'', codified at 780 CMR 110. ' . .3.1, in connection with a proje t or work on a
parcel of land to which I hold legal 11e.
2. 1 am not engaged in, and the project r work for which I ' seeking the aforementioned homeown• s'exemption,
does not involve the field erection of m ufactured build' gs constructed in accordance with 780 C' ' 110.R3.
3. I qualify under the State Building Code's •finition ' "homeowner"as defined at 780 CMR 110. '..1.2:
Person(s)who owns a parcel of land o' whi ' he/she resides or intends to reside,on w ch there is,or
is intended to be, a one-or two-family 'we. g, attached or detached structures accesso i to such use
and/or farm structures.A person who c tructs more than one home in a two-year peri.d shall not be
considered a home owner.
4. I do not hold a valid Massachusetts c. .tructi. supervision license and, except to the extent t 't I qualify for
and will abide by the Massachusetts S 'to Buildin; Code's requirements for the supervision of the I/roject or work
on my parcel, I am not engaged in onstruction s ervision in connection with any project or ork involving
construction, reconstruction, alter,tion, repair, rem.,al or demolition involving any activity re: lated by any
provision of the Massachusetts S /to Building Code.
5. If I engage any other person .r persons for hire in corn' tion with the aforementioned project it work on my
parcel,I acknowledge that I ' required to and will act as t . supervisor for said project or work.
Signed under the pains and pena 'es of perjury on this day of 1 /caber ,202 -
/ . /•
(Signature) '
City of Northampton
,e714
•Y- Massachusetts ►. Nt
,,i DEPARTMENT OF BUILDING INSPECTIONS en
a c
454)
T 212 Main Street • Municipal Building p� d"*
�-:• Northampton, MA 01060 'ram' ,..iro�.e
317
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: jpriny. Pl4/yl9
The debris will be transported by:
Name of Hauler: Faye �7//CK<CS Ti'Pvck'i�
foe
Signature of Applicant.. j/ ��� -( A2e-mdrzA'e Date: io 3.a
e/e/ Or; 47- am )'1
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