29-553 (2) •
SECTION 8 - CONSTRUCTION SERVICES I ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : V /C 14,1 ' ( ` 2C27 /
License Number
I 4 r ( jvce et a= °, . (: f
Addres / Expiration Date
at, j . 8
Sign • ` Telephone
Not Applicable ❑
9 Re iered OVie rn roveme if Contt'aaiEiE' a , �"
c /C� i '�-r ' /6 BSI /
Comp y Name + Registration Number
Address Expiration Date
+f. i' C 4Iephone 0V1.
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L c .152, § 25C(6))
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 ❑ No ❑
It2;:4110M
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 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : V kA-4.... k/1 e V` ( / / /v bI o`er 'j
/
License Number
14 %ri raA Ai-e. f', 601 aatow 7/,3 0 , Lc c
Addres 07t.41/0198 Expiration Date
Sign Telephone
. ere.' , Co . m • rovemen: ; on ra or ' k` '-'', -.' - , s . -,* - Not Applicable ❑
>( T/ /coo , ' �z A. c /6 vim`` (
Com y Name /7 ► Registration Number
`t `r 1V l C ci —5,7 7 , S^ /-
Address Expiration Date
F . (_1',i, e q do (..,_/ M4elephone ` 4elephone I f 13 0 2 # 7 11/1 9
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
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 ❑ No ❑
1 L om • F ® I er onto: ..--,4:-,,,,;;;;;,: n
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 1083.5.1.
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 fans
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 All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b
Existing Proposed Required by'ioning
This column to be filled in by
Building De rtme.,
i ---
a,„ d
Lot Size
Frontage —' `
Setbacks Front i i
Side L: . R: L: R:
Rear ! I .
Building Height 3 i i
Bldg. Square Footage f 1 l i % r
t�'
Open Space Footage %
(Lot area minus bldg & paved l { I t 1 1
parking)
C
# of Parking Spaces
Fill: _ _.. _ _.._,__ ___ # , .. � __.._ .e_ , m . _.. _ __._. ___r __.. _ _.
(volume & Location) ` I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Page; I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES l0 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 filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning
This column ' be filled in by
Building D eet
Lot Size i ! 1 i (
Frontage
Setbacks Front 1 I 1 I
Side L:' 1 R: 1 L:L1 R:l 1 I J 1 1
Rear I f I
Building Height r I 1 1 ,
•
Bldg. Square Footage I I 1% I 1 ( ( L I
—_ Open Space Footage
(Lot area minus bldg & paved ' ' ( 7
parking) f
'
# of Parking Spaces '
Fill: i
i _ 1
(volume & Location) I 7
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Page; and /or Document # ( I
I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT 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 O , Date Issued: a
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: 9
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 filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
V •