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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