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31B-118
oi -.)1. k r ) 7 r , l 7 / Q ) ....-,,,./../ ..... (0) 7t-4)r --, 1 11 "" 4111111111 i'° 1 1 ■ ( j_irffil_101111111011 1111/ ----- 1Y 1 ..... I ,r fje -1 ),L. ■ 11 ) \ i,c / 4 ...... 03 , 1----, b — t 1 ''.,_. ___ _ , -------_ i ) C., tiVil )15 79 0 f 1 / ° 1 \1PY .)'• , ■ * ' ", ..: 1,' , 1 > ; i t ', . 1 . : . h )',1' ,S , 't • — - ' s, L / 1 / r h i / A - , , y 1 1 ..., 0) _ r,/,,, ,.,,e c...2,- ,,./ • �S t'.Ahf p O; +e� ; � , \ 02 x* CI � : i1rp MT. ,��, V:- -� + �u a= saciTusc !e J . i '?Y ,. DEP? �TMr.N Or BUILDING INSPECTIONS a ,k c !z INSPECTOR 2 12 Math Street • Municipal Building Northampton, MA 01060 '� c� HOME OWNER EXEMPTION AC�'NGWIEDGEFFNT The State ofMassachusetts allows the homeowner the right under 780C MR 108.3.4 to act as his/her construction sups ,- . or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends 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." The building .department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footine,s (before bacIdiill). sonotube holes (before Dour). a rough building inspection (before work is _ cot cealeda. insulation inspection (if required and_ainal b_uildina The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until -the work can -1 e- .inspecte. d_ If the homeowner hires other trades to perform work (electrical, pbumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made • I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building. inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial accidents ,:,47,=_,—^m. ` Office of Investigations (F; ', , s 600 Washin Street ._ -. Boston, 14 02111 www.mass.gov /din Workers' Compensation Insurance ffidati Builders / Contractors /Electricians/PIumbers AD DIicant Information / - Please Print Lesibly Name ( Business /OrganizationAndividua1): Sep // ,< ty. C 41- l Address: Ill- a- AI_ L e e .� 1f /chi _ i-� ✓/� Cit /State /Zip: t.{ V t r,_ 7i Ai A G to s y Phone.,. Are you an employer? Check the appropriate box: Type of project (required): 1- Ell am a employer with 4. ❑ I am a General contractor and I have hired the sub- contractors 6 - ❑ New construction employees (full and/or part -time). 7 n Remodeling 2. ❑ 1 am a sole proprietor or partner- fisted on the attached sheet I I ship anti have no _e loyees These sub - contactors have g ❑ Demolition 1 working for me in any capacity. employees and have workers' � I Y p 9. Building. addition [No workers' cow_ Msurance corrm. insurance.: t required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions :. ❑ I am a homeowner doing all work ❑ myself. [No workers' comp. right of exemption 'per MGL 12. ❑Roof repairs inataance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance reged.) - - - 'Kny applicant oaat cnert3 oox F. angst aso Ills out the soon oetow snowma then workers' coropeasanoa.policy information. Homeowners who submit this affidavit indicating they are doing all work and the hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must.attached an additional sheet sbowine the name of the sub- contractors and stare whether ornot those entities have employees. If the sub- contractorshave empiovcs, they mist provide their workers' corm). policy numbs. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Con2pany Name: A '( 41--I Policy # or Self-ins. Lic. #: ‘ 1< 11 0 - ? L L - `i - 6 1 Expfration Date: /AV/ O Job Sire Address: City/ State /Zip: e. /Vvt,,�� •V-w� .,' C� /66 6 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1500.00 ant? /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of die DLA for -. ,azance cove2e verification. I do y hereb Gertz un' D airs and . • . -- - - • • that the information provided above is true and correct - fy . _ — �; _ - 4 7 — fSi�a�ir - �� /, � / �__ D ate: Phone #: y j7 — 'S5 6 -- 7 1V-3- O use only. Do not write tit Mts arerz, tb be completed by city or town officiaL - City or Town; — . -- _P- er-mit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone .. I SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I Not Applicable ❑ Name of License Holder : �v 7 /KCL K / f e( c ,�/ License Number / 9 !�• GcvC. �. /4/ p G E✓e,e �/ N17 076 f1 .J .3 / 4 Address ' Expiration Date ( - 6 - 33 Li 3 re Telephone / / 9. Registered Home Improvement Contractor Not Applicable ❑ Company Name / Registration Number S A ,,—a_ A t / 7 3 Address Expiration Date Telephone e7/ ej % — SECTION 10- 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 Cpl No ❑ 11. - Horne Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own 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 -vear period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official. that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [l Siding [D] Other [Er Brief Des iption of Proposed / / / . ¢ hip a -- . .(G c' 4. [n SW S , j Work: z „ 7! 4-4c--i" - i . ? �:- !__i , A L ! -�'.A' di _. 4. -". 0".‘ ' �.,- T Alteration of existing bedroom Yes ' Adding new bedroom Yes `� No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? 11 C. d. Proposed Square footage of new construction. / Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I (° I Se-Li F' Y\ V , as Owner of the subject property ,✓ hereby authorize co lt N) l cle, ft to act on behalf, in all ma relative to work authorized by this building permit appli ation. 1fr-✓ Signature of wner Date I, $cu 1 t Mc. C €, ,f c - c , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and ppenalt s of perjury. A/c c, C' 7 . . Print Name —_.._ q 7/( Signature er /Agent Date .a Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 5'000 ' � "T SdU`' Ff Frontage 5 Setbacks Front / 2, Side L. / . R : . .I L: .1d R: �. I 7'- Rear / 0 t iO Building Height D 3 0 ` 3 Bldg. Square Footage /s-,o 3 e % sfo 3 Fl Open Space Footage (Lot area minus bldg & paved 3 7 T 2 a :3 y.S b i / o 2 parking) # of Parking Spaces • a- - Fill: (volume & Location) A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was th ermit recorded at the Registry of Deeds? NO DONT KNOW Q YES 0 IF YES: enter Book Page and /or Document # . . B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (nlearing, grading, axon inn or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t 4. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /SepficAvailabil Room 100 Water/Well Availability . --•-„ . Northampton, MA 01060 Two Sets of S I a ' ° • Phone 413- 587 -1240 Fax 413 587 -1272 P .. • s� 1 ' . � `E APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DE�lG'OLISH A ONErOlI, T�CAMILY DWELLING SECTION 1 - SITE INFORMATION ' ,\I‘- `� r,� �, This ect�' _ n "Xq bepcbnapfet d - by office 1.1 Property Address: ;, /r Caw/ _' Map \ 1 Lot Unit l � Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: k /fC i�If f-TIN ni ( 2. Qr /14" -a ems. Nam- (P ..-----• - Mailing Address: r/ .�,� Telephone Signa re 2.2 Authorized Agent: Scott do it e e" y I .cl' 6 f/ie'./�Lc.,L Name (Print) Current Mailing Address: Q'i J `i 1 -1/3 8 6 -33 q3 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee /el 00© . 2. Electrical / (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) ,�/ 5 Fire Protection / + _ -_ -- ____ 6, Total = (1 + 2± 3 ± 4 ± 5)_ l j (1ff d Check Number 3 3 Li 2 6 o O This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector ofBUi1dings — Date 15 EDWARDS SQ f» BP- 2010 -0096 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 118 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0096 Project # JS- 2010- 000111 Est, Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT NICKERSON 053156 Lot Size(sq. ft.): 3049.20 Owner: OLANDER JAIME L & KELSEY A FLYNN Zoning: URC(100)i Applicant: SCOTT NICKERSON AY: 15 EDW RLJ SU Applicant Address: Phone: Insurance: 197 NORTH LEVERETT RD (413) 896 -3347 () Workers Compensation LEVERETTMA01054 ISSUED ON: 7/31/2009 0:00:00 TO PERFORM THE FOLLOWING WO ENLARGE EXISTING DECK, REPLACE DECKING & NEW STIARS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: jib' j /�,�; Footings: 6 ] l /r" 6 d;&(,/ L'v rt Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: O/ / — F - 0 q /,/tPil THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF AND REGULATIONS. /'' ANY OF ITS RULES A '/ :a....,.....t.teg Certificate of Occupancy r Si . nature: FeeType: Date Paid: Amount: Building 7/31/2009 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo