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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
a NORTHAMPTON, MASS. 9 Additions
APPLICATION FOR PERMIT TO ALTER Repair
r
a Garage
1. Location 202 1c Lot No.
2. Owner's name �� Address �'�9
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition r�
5. Alteration_�K � ly�/�I /V / ( � Q wS
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 roofZ/
13. Siding house
14. Estimated cost-
ltt" �lOa The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signalure of responsible app,icant
Remarks Roge ��
` OQ'Ttl/�MPTO
$ � � �assxcltnsrtta
of
J ' 8 i9y I p;EPARTMENT OF BUILDING INSPECTIONS
ur`
INSPEC Oft"'}�¢ �.•x ,. , ;212 Main Street ' Municipal Building
s Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE• ( A ��e �� '"I
T '�
JOB LOCATION: b)
11 (M p) (Parcel) (Subdivision)
HOMEOWNER: n � �r T I CVl
(Name Address )
(Home Phone) (Work 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 persons) 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 # .,�
a4� T0
( 81997 Grit aaf nt r#nn
B �s�� + J�'a3Ert[ll tlEtttE
w m r DEP,�TMENT OF BUILDING INSPECTIONS
"_.. 212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFTDAVIT
b� F� e rib
(licensee/pelmittee)
with a principal place of busi-ness/residence at:
IL� V l Ne Y)a i y lQ V{ ( hone#)
(street city/statrJ�p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
(A I am a sole proprietor, general contractor o homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (In,�rrance Comnany/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(attach additioml shcct ifnoceary to include infvnnition patmining to all cootradon)
( ) I am a sole proprietor and have no one working for me.
( . I am a-home owner performing all the work myself.
NOTE:please bt awatc that whilo homeowners who employ pazoat to do mx*wa=tt coasuucUoo or repair work on a d -ding of
not mote than throe tails in which the bomeowner resides or on the grounds appurtenant thamw are not gene mlly ooandcred to be
employers under tbo worker's ooaVc=4cn Act(GL152-m 1(5)),application by a homeowar for a license a permit may evidence the
legal rtstus of an employer under tho Workeez Compmsatioa Act
I understand that a copy of this rEatemeni may be forwnrded to the Dtpartaraf of lei al Acadomh Of&oo of Insurm oo for rho
coverage verifieatioa and that failure to secure cover-mV under stctioa 25A of MGL 152 can Iced to tba imposition of criminal pcnal -
oomisting of a fine of up to S1,500.00 andlor ingni_ nmcat of up to one year and civil pcnattits in the form of a Stop Work Order and a
film of 5100.00 a day agninsi tn�
D
Sign this _day Of J0N)C? 1997 For caly
Permit Number
Map-4 Lot 4
Signature of Llcense&Permittce
10. Do any signs exist on the property? YES NO
1
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 colmm to be filled im
by the Building Department
Required
Existing Proposed By Zoning
Lot size 1Q
Frontage / O
Setbacks �O
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
' &paved parking;
of -Parking spaces
# of Loading Docks
Fill:
{vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my know e
.1
DATE: ( ''j 22 APPLICANT's SIGNATURE / 4j
?' NOTE: Issuance of a zoning permit does not relieve an applioanre bu en to oompty wlW_,pu
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applioable permit granting euthoritles.
FILE #
.r
X
L! 81997 s
� Fi 1 e No.
i 6 .. �
PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION t-1
1. Name of Applicant: 1 6e 'L •T -14 e V)
Address:9d) Q,WQ.fn PA 06fenN I I (!�, Telephone:
2. Owner of Property: P l by V-I Id ':':_ S I C'.VIQ
Address: q'fWQ_LA 6-0 Odjn(`enC_L Telephone: �S8D' t)CSq
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): n
4. Job Location: -'S6 rn� YtS b i/P
� � C
Parcel Id: Zoning Map#--k Parcel# District(s):
(TO BE FILLED IN BY THE 6UILDING DEPARTMENT)
5. Existing Use of Structure/Property �
6. Description of Proposed UseMork/Pro'ect/Occupation: (Use a itional sheets if necessa ): .
-jP e
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 Per ittVadance/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 ocument#
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)
FILE # x +
J
81997 +
1�
APPLICON ACT PERSON: �t ,?—All t�
PROPERTY LOCATION: 9� eeco
MAP Y- PARCEL: ::2a
THIS ZONE��' _
THIS SECTION FOR OFFICIAL USE ONLY:
PERK UT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM M.1.ED OUT 177
'Riffl ing Permit Filled 010
-Fee Pqifi
Type of Constnirtion-
Addition to Existing
Accessary Striirfiirp 7-
�S nf Plans /Plat Plan
✓�
THE OLLOWING 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/ZONIlVG 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
P ynti o t
Signature of Building hisKtor Date
NOTE: Issuanoa of a zoning permit does not relieve an applicant's burden to comply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
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