31B-035 (4) 4
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DEPARTMENT OF BUILDITIG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building 1
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as I-ds/her construction sups:•,, sor. T he state defines"Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two fami�_ '
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 buildin codes
and r'.egulations. The inspection process requires that the building departmenti be called
to inspect work at various stages, which include foundation/footings (before §ackfll),
sonotube holes (before pour), a rough building inspection (before work is
concealed) insulation inspection (if required) and a final building inspect on-The
building department requires these inspections before the work is concealed, f' ilure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& 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 ins ections are
made
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
i
Address of work
location
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A � E glts+arSlntrtte' _ —
a DEPAR72.sENT OP BUILDP\IG INSPPCTIOIdS -
212 Alain Strcct Nfunictpal DuddinG
j Northampton, Mass. OIOGO
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_ «'O RJ:QJ It'S CO,YII'ENS A'I'IO N LNS LrRAN CE A I'll A N'1T
S l`�
/All c k c-r.(
I c.,
%VI h a principal place of buslness/resIdence at: --- --
`fi c (phone:') � `�'e �
(SU=j/ci ty/s C12).P)
do hereby certify, under the.pi'ans and penalties of penury:, h:t
1 ( ) I am an employer providing the followine',Avorkcr'S COIDDCnSZzio, m
covese for Illy
emplovecs working on this job:
1 Onsu.rn=Comrzzy) (Polio. Nu--zb--r) Dzj--)
( ) I ail a sole proprietor, general contractor or homeowner (ci c:e of e) a0d hzve hired
the cona-adprs Estexdi below who have the folloI'vinQ workers co ?ensa�on pcEcies:
(i'amc ofCo_._...ccor) (Insumnc: CoInpaS1}rtout, ) )
i
- (Name of Cootnaor) (ISJSi17ZIIC Company/PoUcy Numc:r) (-E.-piradon Dare)
(Name of Couz-aclo.) (Insurance. CompanylPoUcy Nambj) (Exairuoa Date)
•
(Name of Coatzaetor) (Insurance Como
a>zy/Policy Number) (Expirttion Dais).
(+tuctt dti�ocal c�cct,f ceoaa_�to a�chsd '!nf«rJ+;oc pc�to J1 oo2r-moo a)
{ ) I am a sole_proprietor and have no one working for me.
} ( ) I am,a home oNvoer performing all the Nvork myself:
I
NOTE:pt=s be cvrim ttt:.j )c bco,=, cn v-bo employ pczooa to of
aot anct tl;e ' _=rx in u'seb the bomoo-^�rued=or oa t6e Rvur6 a,psrten ri tlreo L-c we C=.�-1y tee=d.-ed to to
eitploycs uoCc the•.ai rt r - -'cn Act(GLI152-=1(5)).s.ppIi=L600 b-y+bommava fee c lic=_or pcma n_y c-rdm LL`
Icgl n.a1=c of an cptoyw wader dl wo,S .Co�on of t
Aat_
- I uada-triad tit>oopy of tbi-mtrmmx o y t o fo� ded to tbo O
pcp�tmcvi of In�X+icl Accidaatr' fGioe 4a>n000 Cx h.
cova-xSe vaifjcatioo-d UUI L-iltac to Lc==`covan undo=cxioa 23A of MGL 152 m t,-d to the iyxxIIioa oCa imioll pecu -
coasLti%of a fiat of up to s I Soo.00+n&or of up to aoc yar end riNi)pcaatoo is tSc form of a stop Wort;Oric r nad+
fim 0(:S 100.00■d_y /t�
± ✓ r / Pcrtntt Nu abcl
/ !tom/'/` ✓ f �� J t��ip^-- Lot rt .
gn-a /^ ~ofLio=Lscc/Pcrrniucc e
SECTION.8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable '❑
Name of License Holder
License Number:
Address ,f,•>' , Expi ation Date
Sig a Telephone
§ aTseretor`irn"il# eme�n c o Not Applicable ❑
U `!
S--4!
Company Name 1 Registration um er
Address ' ' Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE`AFFIDAV IT'(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...... ❑
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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,grovIded 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 intendsto 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 coWdered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that be/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 glav be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"7andocal' and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Statq Zoning Laws and State of Massachusetts General Laws otated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF,PROPOSED WNORK(check all`applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding[❑] Other[❑]
Brief Desc�tption of Proposed � f
Work: C^c.4 S 1LCC Gc S
Alteration of existing bedroom Yes ✓Iqo Adding new bedroom Yes `'� No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6kl N41 WaNdUtd add' rnptd Nil:oFroWRE
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? n G
d. Proposed Square footage of new construction. y*- Dimensions x �'
e. Number of stories? �-
f. Method of heating? U A e,,4 e, Fireplaces or Woodstoves Number of each
g. Energy Conservation Com]pliance./ Masscheck Energy Compliance form attached?
h. Type of construction te-,"9 /
L 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-BUILD-I- PERMIT
1, y�` as Owner of the subject
Prop. y
hereby authorize
to act on bibhalf,in all a ers relativ irk authorized by this building permit application.
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Signature f wner Date
I, ..5e� 7` Ali i-k e,.r as Owner/ thorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my now edge
and belief.
Signed under the pains and penalties of perjury. '
Print Name ,,,'_ y j
Signat0 e D&
rX O C
Section 4. ZONING All Informatioh 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
Frontage i
Setbacks Front
Side L R L:' R:� _
Rear
eS
Building Height
Bldg. Square Footage E % --
Open Space Footage %
(Lot area minus bldg&paved
parking)
r--r
#of Parking Spaces
Fill:
(volume,&Location
A. Has a Speci ermit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page' and/or Doctjment#
B. Does the site contain a brook, body of water or wetlands? NO (3r"�DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 0 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
1
IF YES, describe size, type and location: i E
E. Will the construction activity disturb(clearing,grading,retion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Nortoampton
Building Department
2 12 Main Street
Room 100
Northampton; MA 01060 e
- shone 413-587A240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
a, This section tope completed by office
1.1 Property Address:
Zone � Overtay4Dtsnct,
t Cf3D�stnc�
SECTION 2-'PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
714 J �
Name(print) Current Mailing A dress:
516 S- -
Telephone
SignatLke
2.2 Authorized Agent:
Name(Print) i Current Mailing Address::
y t 1
Sig tur ;. Telephone
SECTION 3-ESTIMATED fCONSTRUCTION'COSTS'`-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical .(b)'Estimated-Total Cost of S
Construction from(6) 2�U'
3. Plumbing Building Permit.Fee C
4. Mechanical(HVAC) 50,
5.Fire Protection i
6. Total=(1 +2+3+4+5) T O Check Number
This'Sectio6 For Official Use.Onl
'`Date,.
Building Permit Number Issued:-
Signature: r
Building<Commissioner/inspector of Buildings Date
File#BP-2006-0581
APPLICANT/CONTACT PERSON Scott Nickerson
ADDRESS/PHONE 197 NORTH LEVERETT RD LEVERETT (413) 896-3347 Q
PROPERTY LOCATION 16 MYRTLE ST
MAP 31B PARCEL 035 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 76,t-'C7 s
Typeof Construction: enclose covered porch
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co n
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
16 MYRTLE ST BP-2006-0581
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 113-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
CatejZory: BUILDING PERMIT
Permit# BP-2006-0581
Project# JS-2006-0854
Est.Cost: $7250.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Scott Nickerson
Lot Size(sq.ft.): 4530.24 Owner: POWERS CHARLES B&AMY E MORAN
Zoning:URC Applicant: Scott Nickerson
AT. 16 MYRTLE ST
Applicant Address: Phone: Insurance:
197 NORTH LEVERETT RD (413) 896-3347 O
LEVERETTMA01054 ISSUED ON.121112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE COVERED 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.
Certificate of Occupancy Signature:
FeeType• Date Paid: Amount:
Building 12/1/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
16 MYRTLE ST BP-2006-0581
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:_ BUILDING PERMIT
Permit# BP-2006-0581
Project# JS-2006-0854
Est. Cost: $7250.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Scott Nickerson
Lot Size(sq. ft.): 4530.24 Owner: POWERS CHARLES B&AMY E MORAN
7nni,_p:UR-C Applicant: Scott Nickerson
AT. 16 MYRTLE S
Applicant Address: Phone: Insurance:
197 NORTH LEVERETT RD (413) 896-3347 O
LEVERETTMA01054 ISSUED ON:121112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE COVERED 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:
1144 Driveway Final:
Final: Final: /_ Rough Frame: ®�( '� I R Y1
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: q( 0'1/T6/orb L"'AiS -
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL TIONS
Certificate of Occupancy.. Signature: K-
FeeType• Date Paid: Amount:
Building 12/1/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo