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38B-083 8.1 Licensed Construction Supervisor. Not Applicabll ❑ ' ```� Name c,r Hot Cr 7 v I C f' A(4 Use Number Address V Expiration Date • l oe 1 3 -s o0 Signature Telephone • e . , . � _ 6 � w,m . - Not Appiicabl. n Compami Name _ Registration Number -T7L5K-1?, Address _ F�iration Date y- Telephone 1Norkers..Gompensatio i insurance affidavit must -be completed and= sabmtti3ed with this appGcation. Failure to provide this affidavit will result . lit the denial o f t h e the but _., _:... _ Signed Affidavit Attached Yes...... No ❑ The current exemption for `owners" was eXteadedto include Owner - occupied Dwelhnes of one (1) or two(2) families and to allow such homeowner to engage an tndrvidual for hire does not possess a license, provided that the owner acts as supervisor. C1VIIi; 780; Sixth Edition Section 10835.1. Definition of Homeowner. Person (s) who own a parcel of land o whicb-he/she: resides or intends to reside, on which there _ is, or is intended to be one or two family dwelling, attached o_ r• to such use and/ or farm structures. A person who constructs more than one bomo-in a two-year period shall not be considered a homeowner. Such_' shall submit to the Build Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work Performed tinder the biplane permit As acting Construction Supervisor your presence onthe job site will be required from time to time, during and upon completion of work for which this permit is issued. Also be advised that with reference do Cfiapterer t52'or�cers' won) 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 welt fin permit - .- : The undersigned "homeowner"certifies and awes re eponstbili .fce co phance with the- State Building Code, City of _ " Northampton Ordinances, State and Local Zoning Laws a>m Io f chiisettsGeneral Laws Annotated. Hoernirtare_ - • *tl -, 8.1 Licensed Construction Supervisor. Not Applicable ❑ / 0 l o rs i G 1� _ ]� _ Name vi �cense Hot�,.r: - � 6 � "`1 ) '� = -t •�-� `� � � License Number \ P <i"" yz,* - tik r- )0 --: - C>" a() a Addross' , Expiration Date C OlgefL IQ 6 41 / - •%73'66 00 a__ Signature Telephone ofiEtetor Not Applicable f [ i 1►t I / °;- Company a S1� l; k Registration lam. Address Expire ration Date W �.' . '``4✓`�i 1► Telephone - • __Workers Compensation Insurance affidavit must b6it.olajPietadiairtaiiriitted -with this application. Failure to provide this affidavit will result .in the denial of the issuanceof_the buiidn it. __ Signed Afildiert Afteched Yes.. No.. -_ • • The current exemption for "homeowners'' was ex ded to include Owner -off Dwellings of one (1) or two(2) families and to allow such homeowner to engage as m fin hire who does not possess a license, provided that the owner acts as supervisor. CMR 780; Sixth Edition'Sectfos= 10835.1 - Definition of Homeowner Person (s) who own it *recta land IM 1ndi- he/she resides or intends to reside, on which there is, or is intended to be,_a one or two family d ` to such use and! or farm structures. A person who constructs more th:n one home ti n two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form able to the Building Official, that he/she shall be responsible for all such work performed under the building 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 mtisstied ; Also be advised that with reference to Chapt! 5 Worker on) 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) youlnre to perform work for you under -Ms peanut Tie in dersigned "homeowner" c rtifiesand nsPonsnitl c ri Nance wjth- the ; Stme Bmg Code, City of Northampton Ordinances, Stale and Loeal-Z ng Laws ati of tsrtad'nisetts Gem a1 F.aws . • • ., .. Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zo ing This column to be lled ii, by Building Departm ?,,, Lot Size 1 I 1 4 i Frontage 1 Ii . 1 1 t I -- Setbacks Front I 1 = t I Side L:1 R:1 I L:1 1 R:1 I 1 I 1 1 Rear 1 1 1 1 F I Building Height 1 I 1 1 1 1 Bldg. Square Footage 1 1 1 1 % I 1 1 I Open_Space Footage _ __ -__°10- (Lot area minus bldg & paved I I I 1 1 1 1 1 = Parking) # of Parking Spaces 1 1 I I 11 Fill: 1 (volume & Location) 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 YE S 0 IF YES: enter Book 1 Page and/or Document # ; B. Does the site contain a brook, body of water or wetlands? NO 0 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 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: I 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 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 Zoning This column to be filled iu by Building Departmaht %. 1 i Lot Size ? , I C— ., _. Frontage I 1L__ , I $ Setbacks Front I I f1 I I Side L:I 1 R:= L:1 ! R:I I 1 Rear I ( ( I 1 Building Height I f Bldg. Square Footage I f % ( j open Space Footage 1 (Lot area minus bldg & paved i 1 I I I I I - I ping) # of Parking Spaces Fill: — .._."_ 1 (volume & Location) - u i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW Q YES . 0 IF YES, date issued:1 1 e IF YES: Was the permit recorded at the Registry of Deeds? . . NO 0 DONT KNOW Q YES "O . IF YES: enter Book 1 ! Page and /or Document #1 1 B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q ,Dat Issued ; �_ C. Do any signs exist on the property? YES © NO Q IF YES, describe size, type and location: I a D. any proposed changes to or..additions of signs intended for the property ? YES ® NO Q IF YES, describe size, type and location: I a 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required.