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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 3 IL — 19� Additions
40 APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location '�� To f f7 Lot No.
2. Owner's name ` Address Tex�-\ h,'1k .
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration ly,,s 611(q t'.P1�tt%�['V✓�' 1..�i,edOuj5 I yJ1 [� ! T St t a
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost P o .O c
The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
ignature of responsible app icant
Remarks
• O�TtUMpTO
Y i 110 w
VI o b
109'DEPARTMENT OF BUILDING INSPECTIONS ;
INSPECTOR 212 Main Street ' Municipal Building '
Northampton, Mass. 01060
w
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE: �_� b '-�
JOB LOCATION: (Map) (P rcel) 4 ( Subdivision)
HOMEOWNER: 1 "' tN S kt
(Name & larev)& _� CJ1 X17 ��14 < \t c 7 l l
(Home Phone) (WaIrk Phone)
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. CMR780 Section 109. 1 . 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-year 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
BUILDING PERMIT #
0 4-�1tAMP�G
Of 'Nart4allrptoil
[
a � �blasaxrhnsctfa
DEPAR71MENT OF BurL)rw INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
� (liceusee/permittee)
with a principal place of business/residence at:
j � ��
C kAi li�'1"fthone#) '58'=��`
(streeUcity/stall/ap) —r
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following wok-kerJs compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (lnsurancz; Company/Policy Number) (Expiration Date)
(Name of Contractor) (1nnlranct- Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(auun additio(32i sled ifneccn ry to inchldc udbrmsiion perbL=ng to all ooctracf )
( ) I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please be aware that while homcowocrs who employ persons to do mAiajc+a+cr,caosnuctioa or rcpair work on a dwelling of
not m"o than throe units in winch the homeowner render of on tbo grvaads apNA&nanf therdo arc not gtoaally mandcred to be
employrra under the worker's compc=atioa Ad(GL152,ss 1(5)�application by a homeowner far a license cc permit may evidenm the
legal siatua of an employer under the Woriceda Compemaiion Ad
I understand that a oopy of thu statement may be forwardad to the De�of Industrial Acddca&Offioo of Insurance for the
coverage verification and that failure to sw=coverage wirier section 25A of MOL 152 can lead to tba imposition of criminal pon IW-
eomiSQng of a fine of up to S1,500.00 and/or imR isosmcnt of up to one ytar and civil pcmtties in the form of a Stop Work Order and a
find of 5100.00 a day against tom.
Fcc dq=tn=td use m1y
Permit Number
` Mao _Lot#
i of LiocnscxJPerri t tce
10. Do any signs exist on the property? YES NO
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES _ NO
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This —I—= to be filled in
by the Building Dcpar nt
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved parking;
# of -Parking Spaces
ht of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
W1111'DATE: �j°- � l APPLICANT'S SIGNATURE �
NOTE: Issuance of a zoning permit does not relieve an applioanYs WWden to comply Wltir_pll
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Publio Works and other applioable permit granting authorities.
FILE #
!i
R 2 719T. X6,3-3 y1
File No. �
..?ONING PERMIT APPLICATION (§10 . 2
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: M LV2VICC�1�)t�.�rl IS\I
Address: knit� Telephone:
r
2. Owner of Property: l (�K� l 1 �2✓1C�C��C`tAi� :
Address: Telephone: ,' � C
3. Status of Applicant: _Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map#�_ Parcel# District(s): ,
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property r c t(:)
6. Descri do of Proposed Use/Work/Project/Occ abon: (Use additional sheets if necessary):
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special PermiWadance/Finding ever been issued for/on the site?
NO DON'T KNOW YES IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document#
9. Does the site contain a brook, body of water or wetlands? NO—_)L DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,date issued:
(FORM CONTINUES ON OTHER SIDE)
FILE # J 6 , y 4 1 J� </
kV*CONTACT PERSON:� y;
ADDRESS/PHONE:
PROPERTY LOCATION:
MAP PARCEL: r% ZONE,
THIS SECTION FOR-OFFICIAL USE ONLY:
PERAHT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM ETTLED OITT 171-
IRni ding Permit Filled niit
NewCnmqtriirflnn
Addition to Existing
Accessory Structure
./
THE;PCLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedfbased on information presented
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received& Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
d'14Health Well Water Potability-Bd Health
.y—Permit from C'oynseervat' Comm' s'
Signature of Building Wector ate
NOTE:Issuenoe of es zoning permit does not relieve an applioant's burden to comply with gill
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Mepartment of Publio Works and other applicable permit granting authorities.
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