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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage 1l-�
1. Location i, i -c Lot No.
2. Owner's name Wo v7 - / �r� s ��, Address otts A Ci 2
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars 3 Size JS �X 30,
l�rm
10. Method of heating
11. Distance to lot lines 77 5( �- t/1 ' 26
12. Type of roof N4� U.'i/li rht�r^4Lw�s� �tir�s� �S Tyssc Room 2K r(, ilC c; c', I'ea.Zeers
13. Siding house y
14. Estimated cost: a o d
The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsible app icanl
Remarks
C�z# of Norf17,4»aPtall
9 0 , z
o P �R56ACI1118[Ild
DEPARTMENT OF BUILDIT'.G INSPECTIONS _
INSPECTO} 212 Main Street ' Municipal Building '
Northampton, Mass, 01060
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE:
JOB LOCATION: 117
, (Map) (Parcel ) ( Subdivision)
HOMEOWNER:
(Name & Tddress ) _
�(t? 22-S
( Horne Phone ) (Work Phone )
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one ( 1 )or two (2) fami 1 ies 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 #
7 �
0 ttM!PTO
M
�, � � {� �lasxcattsctla
m , 1 DEPARTMENT OF BUIL)WG INSPECTIONS
�,.• „212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
S�%
(licensee/permi tire}
with a principal place of business/residence at:
` r Cr AC (phone-4)
(stre✓t/city/sta 2r p)
do hereby certify, under the pats and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees wolfing 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) (Insurancc Company/PoLicy Number) (Expiration Date)
(Name of Counctor) (Insuranec Compauy/PoLicy Number) (Expiration Date)
(Name of Contractor) (InaLran(_— Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(andor additioml sheet ifnoccaary to inc}Udc infacmation pertaining to nit cow radon)
( ) 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 vehilo horncownm who employ pasom to do�immzn c o=str ioa or rcpairworic on a dwelling of
act moir a than tl>ree uaits in which the hoMoowncr r=dca or oa the voun appurtenant 1b=W am not gcrxraally oo=dcrcd to be
employes under tbo worka4 oompeasatica Act(GL152,ss 1(5)),application by a homeow=for a keener or pamd may evidence the
Iegil ctnhrs of an employer under the Workor's Compcmatioa,Act
I undauand that a copy of thin chtcmmt may be forwarded to tbo Dcpertax of I.&ustrial Asada&Offioo of Insurance for the
coverage wrificatioa and that failurt to secure oova-&V under section 25A of MGL 152 can lead to tbo imposition of Criminal penalti-
ooatiisting of a fine of up to$1,300.00 and/or of up to one year and civil pmaltia in the form of a Stop Work order and a
fine of 5100.00 a day agxinA tnc
For dcputmcntnl uao—Y
/} Permit Number
�"/�'�?yr G',L�G1/I✓1 2 "` '�t.� {s l� jy�3p�{ _Lot#
�, Si&ahire of Liocnsee/Pcrmittee '� {
f
n
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 cola= to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size o��� /`f � � /L 0, G
Frontage le C)
LL
Setbacks 6
- side L: R: L: R: 7 �J
- rear
�7
Building height !�3
Bldg Square footage
%Open Space:
(Lot area minus bldg FJ
&paved parki_ng)
# of Parking Spaces
# of Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
4 is true and accurate to the best of my knowledge.
7
DATE: - APPLICANT's SIGNATURE L`" C zj
NOTE: 1 uanoe of a zoning permit does not relieve an pplioant's burden to oomply with all
zoning requiraments and obtain all required permits from the Board of Health. Conservation
Commission, Department of Publio Works and other applloable permit granting authorities.
FILE #
y
r�
ft
IFp► Fi 1 e NO.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE O/R� PRINT ALL INFORMATION
1. Name of Applicant: �c> c{( C�rIs
Address: _Telephone:__
2. Owner of Property: �-
Address: Telephone:
3. Status of Applicant: fi�Owner Contract Purchaser Lessee
Other(explain): �7
4. Job Location: _50 -"e--
Parcel Id: Zoning Map# �--- Parcel# �. District(s):_,(? �C —�
R 0 E FILLE IN BY THE BUILDING DEPARTMENT)
5, Existing Use of Structure/Property
6. Description of Proposed Us/e/Work/Project/Occupation: (Use additional sheets if necessary): /
(-"t jz� S -x— x''( l^c
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 Permit/Variance/Finding ever been issued for/on the site?
NO. t,-' 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 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:
4u,kc{ (FORM CONTINUES ON OTHER SIDE)
vat[!-� CLO—ok-�_ �0 icCv'- , CkA
-ck�-E..1-?AAA WS)
�tiLt-E-
FILE # 0 c.. ,
L I AR 2 7 08
APPLICANT/CONTACT PERSON: L
OF" ADDRESS/PHONE:
PROPERTY LOCATION:
MAP PARCEL: 1/—s�,'' ZO.
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
70NING FORM M,Y,FD OUT
Fee Paid
lRu Iding Permit Filled wit
Type of Constructinw-
t~
z/
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION-
Approved as presented/based 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
Septic Approval-Bd of Health Well Water Potability-Bd Health
Permit from Conservation mmission
S�
Signature of Building or Date
NOTE:lasuanoe of a zoning permit does not relieve an applloant'a burden to comply with all
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commiasion, Department of Publio Works and other applicable permit granting authorities.
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