23A-092 BP-2024-0127
16 FAIRFIELD AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-092-001 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-2024-0127 PERMISSION IS HEREBY GRANTED TO:
Project# KITCHEN RENO 2024 Contractor: License:
TUCKER JACOB TELEGA
Est. Cost: 5000 KENDRICK 117665
Const.Class: Exp.Date: 05/19/2026
Use Group: Owner: JASON KICZA
Lot Size (sq.ft.)
Zoning: URB Applicant: TUCKER JACOB TELEGA KENDRICK
Applicant Address Phone: Insurance:
367 RIVER DR (413)313-7101
HADLEY, MA 01035
ISSUED ON: 02/07/2024
TO PERFORM THE FOLLOWING WORK:
REPLACE KITCHEN CABINETS
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:
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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0 <20(9 Off/Ce of Public Safety and Inspections
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. �.,,Np-A-p Maiisachusetts State Building Code(780 CMR)
-,iiY it Ap ication for any Building other than a One-or Two-Family Dwelling
44i oFcTio (This Section For Official Use Only)
Building Permit Number:OW° D -,,Date Applied: Building Official:
SECTION 1:LOCATION
(L CA. f:G‘A moteow_ 0\06 `a—
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 0 Alteration`(1 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0
Is an Independent Structural Engineering eer eview required? \ Yes 0 No 0
Brief Description of Proposed Work: �e.,Q ,„,5 koa,. t2,, Q.4,1n4.
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) 0
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 0
I: Institutional I-1 0 1-2❑ I-3 0 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 ti
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 IIA 0 IIB 0 IIIA 0 IIIB 0 IV 0 VA 0 VB 0
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 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 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 0 Yes 0 or No 0 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 r''
cr?144. \ _ 3`j.-. Massachusetts �`
{
tr' DEPARTMENT OF BUILDING INSPECTIONS ,,'
rw
�. 212 Main Street • Municipal Building ,,.,, �,'+>,•
—"�K^," Northampton, MA 01060 '', \'
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
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
c 5oh —C ZC'‘ LDeeCE-i
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
- \13 -3W- cia(,e( I0"ylk)criPe is6)y0.,t.6o,,
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
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 D.
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
Q g '(ucb,eic i ei e(. t(--erZ(
Company Name
`-VGker Te.�eci 1 l�(7r,irvi 0 S [ \ 7b65
Name of Person Responsible or Construction License No. and Type if Applicable
`6-1 K cc {-i-,ALV C1035
Street Address City/Tow State Zip
U 13 -1g- 1[61 - - '(-u Y(K [ il e.1 wti:i.Cart
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No El
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Q O Cl Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ ;0 0 0 appropriate municipal f or)=$ .
3.Plumbing $ l DO 0 �'Vl
4.Mechanical (HVAC) $ Note:Minimum fee=$ t (contact municipality)
5.Mechanical (Other) $ Enclose check payable to /}�
6.Total Cost $ :�00 0 (contact municipality)and write check number here ` V l
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 nd understanding.
IlicKer -lei ey 1 Ke.t121[ `Clt ge) a9vvitdcr til3- 3() 7iU( d--=7 a-\
Please print and si name Title Telephone No Date
Street Address City/Tin State Zip Email Address
2 Municipal Inspector to fill out this section upon application approval: /i� 2'7.76Z41
Name Date
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
0,i rT t,,,r. S —t
/5' t Massachusetts }s` . see.,,
_, DEPARTMENT OF BUILDING INSPECTIONS '�k „g
- y 212 Main Street • Municipal Building + % ��
Northampton, MA 01060 °«. ,. `'0
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: UA 1` Cl�`�
�
The debris will be transported by:
Name of Hauler: AL( t,<_" `�
Signature of Applicant: 1� V 1 Date: ? — 1 1
The Commonwealth of Massachusetts
Department of industrial Accidents
— - I Congress Street,Suite 100
Boston, .3IA 02114-2017
wwigmass.gowdia
tIorkers Cnmpentation Insurance Affidavit:Builders/Contractors/Elect ricians/Plumbers.
lt)BE FILED Willi lifE PERAII ITING Ati'll011111'1.
.trinlicant Information Please Print I.egiblv
Name if3ustness-Urgantzahon Individual 1I C f_A yLer-ai
Address: —7--) b
City/State/Zip: \—\ i( \IV101 001S Phone#: -)2 3 — (
A re you an employ et?Check the appropriate boa: Ike of project(required):
LEI I am a employer with employees(full Itado(part-titnel.• 7 El New construction
IIM a prupnetur or partnership and has orkiam for me in 8. e4 Remodeling
LX% capacity.(Nu workers;comp.insurance requiroiti
9. El Demolition
3E3 I am a homeowner doing all work myself.INo workers'0:1011.1 insurance ro.portdj
OfJ Bantling addition
41:3 I ant a hocncownet and will be hiring exilic-Aetna to L'ondiret all work on my property.. I will
ensure that all acn ra1um other Iraie winters'001131KIVaatiLIII insuranee in ale sole I I.c3 Electrical repairs or additions
proprietors with nu employees.
12.0 Plumbing repairs or atkiit ions
I am a criminal coutratitur and I twit:hired torn sub-contractors listed un the allalCX1 alictt
.3.n Roof repairs
Thee sub-cutairAcrots have employees and have workers'comp.insurunee.
...p Other
6.0 W.:are a oorporatiem and its Ificen have caveised then right Oro:emotion per kiCiL c.
152..§1t4L and we!laic CIO 1.114,111:oVeri.[NO workeia'comp.mummer required.,
'Any applicant that cheeks 60a most also Fill out the notion below showing their workers'compensation pulley in tin-minim
bluinumis nem who submit this atlislawn indi,ating dicey are doing all work and then hue outside contractors mint submit a new aItiLait ualicataiir such,
It'untractorsi that cheek dia Lax must attached an addatinnal sheet show in the name of the sub-contracties and state whether or nut those imbues hate
croploy,ei . If the sub-contractors base CIT005.1.`CI.antra mmi provide their workers niatibet
lam an employer that is providitiv ovorAerN•compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Nam :
Policy#or Self-ins.Lie.0: rs,
4V1 0( (-4-09-Z Expiration Date:
Job Site Address: v City/StateiZip:
Attach$copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152.*25A is a criminal violation punishable by a tine up to S1,500.00
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line 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 un er the pains and penalties of perjury that the information provided above is true and correct.
Stenatitre: Date:
Phone 4:
Official use only. Do not write in this area.to he completed by city or town official
City or Town: PermiCLicense#
I s%uing Authority(circle one):
I.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical inspector 5.Plumhing Inspector
6.other
Contact Person: Phone#:
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the ninth edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Property Address:
Project: Check(x)one or both as applicable: New construction Existing Construction
Project description;
I MA Registration Number: Expiration date: ,am a registered design professional,and I have
prepared or directly supervised the preparation of all design plans.computations and specifications concerningl:
Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (760
CNIR), and accepted engineering practices for the proposed project I understand and agree that I (or my
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,.I shall submit field/progress reports(see item 3.)together with pertinent
comments„ in a form acceptable to the budding official.
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a"wet'' or
electronic signature and seal:
Phone number: Email:
Building Oida1 lIcg Only
Building Official Name: Permit No.: Date:
Note'1.Indicate with an project design plans,computations and specifications that you prepared or directly supervised..If'other'is
chosen,provide a description.
Version 01_01_2018
• Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x."where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 'Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.