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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
aNORTHAMPTON, MASS. q Additions
-APPLICATION FOR PERMIT TO ALTER Repair
�- Garage
1. Location Lot No.
2`.'Owner's nam C'f`G Address 3. Builder's 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 Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
,- 4. Estimated cost:-
x-ae undersigned certifies that the above statements are true to the best of his, her
knowled and belief.
Signature of responsible app icanl
Remarks
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DEPT OF
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street Municipal Building '
Northampton, Mass. 01060
WORTCER'S COMPENSA'T'ION INSURANCE A11TIDAVIT
(li�nset/permitt�c)
with a principal place of business/residence at:
fik)�fAa 1//14 (phooef,to.s e
(str�Uri t}/statrJ�p)
do hereby certify, under the pains and penalties of perjury, thai:
O I cm an employer providing tfte following v"or'r er's compens3uoo cove age for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O 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) Qmsw-anc--- Cornpany/Policy Number) (F)cpimtion Date)
(Name of Contractor) (Insurance CompanyiPokcy Number) (Expiration Date)
(Name of Contractor) Qnsurance Compauy/PoUcy NnmN-r) (F—\-piraboo Dale)
(Name of Contractor) (Laa anct-Company/Policy Number) (Expiration Date)
(P fl—h additional cbeei ifnoom.rry to ioClvdc inforsnadoo pctaiaing to all mahac:on)
( I am a sole proprietor and have no one worldng for me.
I am a-home owner performing all the work myself.
NOTE:please be aw2r1c d=t whilo homcmwcn wbo cmplay pc Isom to do mniaknaoct ooasauctioa-or repair work on a dwt;niag of
aot more thsn thnoo units in wtrich the boazowncr rcideo oc oa the grounds xppurtcnwA tha,do arc oot gaocrally eoosidcred to be
emPloytxa under tho worker`s o=pamdim Act(G L152 ss 1(5)) appdcatioa by a homeowner for a Gecnx oe permit may evidence tha
legal statue of an employee uodeetbn Works t Compomaiim AeL
I un4=: d tbat a oc py of this mtcmaot may bo forwarded to tho Dopertinm2 of Accidcc Office of In=a=ne*for d-
oovcrxgc vaificstioo sad that&dwt to secure covcn go undo soctioa 25A of MOL 152 can tad to tbo impoa ion of aimiwl pcuartics
oocusting of a"fine ofup'to s1,5oo.00 and/or ofup to one year and cavil pcwitia in the form of a Stop WorkOrda and a
find of S 100.00 a shy&gaunt mc.
Signed this day o C 1997 For dcputmc>yslusoonly
? Permit Number
Map# Lot-9
i of Liccnscc/Pctmiti,cc
1 '
�(IiAM p�,
of 'Narfilaillp toil
i
" 6 $ RTMENT OF BUILDING INSPECTIONS
INSPECT R Main Street ' Municipal Building
N
DEPT Sh' ' f;Car �, • Northampton, Mass. 01060
NC^r .�
HOMEOWNER LICENSE EXEMPTION
( Please Print )
DATE: �}
JOB LOCATION: 7
(Map) ( Parcel ) � / ( S bdivision)
HOMEOWNER: 1_ �-P'(r� x l)�I P�I C l/V,2j- —
(Na & Address )
�r sfi rl C;,2 f110Kf n� � �9
( Home P Ph hone ) (Work Phone )
The current exemption for "homeowners" was extended to include
O4mer-occupied Dwellings of one ( I )or two (2) f irni 1 i es 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-A,, 0 y— 1/
BUILDING PERMIT #
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 column to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size 172 j(� goy e-t-C.,
Frontage
Setbacks -frnnt
- side L• R: L: R:
- rear
Building height
Bldg Square footage 020
%Open Space:
(Lot area minus bldg
' &paved parking) 1�
# ,of 4Parking Spaces
f of Loading Docks
Fill:
4 vol-ume-& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my
.1
l � know e.
DIIE: � APPLICANT s SIGNATURE
_. .
2" NOTE: Issuanoe of a zoning permit does not relieve an a lioant's burden to oom wit
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applionble permit granting authorities.
FILE #
�i wr
AL 6097 lei
DEPT Fi1e No.
ZONING PERMIT APPLICATION (§10 . 2
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address:_Ll/ Telephone: �U's 9
2. Owner of Property: J
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel# Q3�p District(s): —
(TO BE FILLED IN BY THE BUILDING DEPARTME T)
S. Existing Use of Structure/Property �
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
a, �� ,
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/Vadance/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 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)
�1-s--Lr' 0-=-• FILE # 969545
,I L 16 r
APPLICAN / ONTACT PERSON: /�
DEPT OF S!! _ ' ES9/P�ONE:
PROPERTY LOCATION:
MAP PARCEL: S. G2 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED 011T
Fee pnid
Rnilding Permit Filled Mit
Fee Pnid 6r -
-Rernndelin2 In
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
Approved as presented/based on information presented ?cr,I onlq , Duj j- ok— S Im +uh r i�
Denied as presented: cth'L' Fermi+ s to � �A� )V,*(� wl C+` J°S
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:
'ebrb Cut from DPW Water Availability Sewer Availability
Septic Approval-Bd of Heal Well Water Potability-Bd Health
i se -sion
Signature of Building Inspector Date
NOTE: Issuanae of a zoning permit does not relieve an applioant's burden to oompty with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applicable permit granting authorities.
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