23A-016 (2) 1
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 5 `= f f ` c ,`aj S q5 `j
License Number
t ' t v.' , t 76 tvk Ctc' L 1 1112...S11 Dl
Address Expiration Date
52. -c
Signature Telephone
9s Routsteered Home fmrsovettn art ContractCh'. Not Applicable ❑
S �r'i r ! �c_r F z, rL -►ate :' �- / v if.: f � C r./ S i ��v 11 t r { / ,9- 7 9
Company Name Registration Number
t E e C = t i= T Yt'r' t ` l f \ 0 ( u 7 C 71 2.2 f'
Address Expiration Date
Telephone 5-Lci SL
C .
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (mat_ c. 152, § 25C(8))
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 lam' No ❑
11. - Home Owner E .f-E r e. t o
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-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)C
SECTION 8 - CONSTRUCTION SERVICES 1
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : St.f. f'` �� �=—�o S 1.45 7- > c i
License Number
/
' Z it�cL Y r . t 4 Fv.Aa p 7G lL'A 0tt -1..i / 1 V L S I Db -
Address Expiration Date
4 t 2 > 5 Z. °• - c t
Signature Telephone
9. Registered f lmerovetn Gentt eiV , ... 7 W . -- r Y _ ; = . Not Applicable ❑
/ 3 1 ,9- 7 `>
Company Name Registration Number
1.7 +� � ._ � \/ t , 7 O I u 2 7 W 1 Z- %J 2v f Y
Address Expiration Date
L
Telephone
1 �L cSa(
SECTION 10- WORKERS' COMPENSATION INSURANCE AFADAVIT:(M.G.L c. 152, § 2506))
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 EY' No ❑
11. Home 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-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(
Section 4. ZONING 1 AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete information
Existing Proposed Required by ning'
This column to fillef in by
Building Depart ent
Lot Size ._
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage �o
Open Space Footage c
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW : ' YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ) DON`T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or fitting) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
!F YES. then a Northampton Storm Water Management Permit from the DPW is required.
Section 4. ZONING A11 Information Must Be Completed. Permit Can Be Denied Due To Incomplete information
Existing Proposed Required by ning iii:‘
This column to fille0 in by
Building Depart ent —»- _
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage t"o
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 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 Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location:
E. WU the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 'J
IF YES. then a Northampton Storm Water Management Permit from the DPW is required.
t s