29-496 (4) PERMIT APPLICAT,IION CHECK LIST
PAGE ZONE C. -J" SCR r� YES NO DATE
1 . ZONING FORM APPLICATION -"
2 . PERMIT APPLICATION
3 . OWNER OCCUPANT STATE ENT LIC A IF NOT
4 . 3 SETS OF PLANS /PL CT PLAN
5 . NEW CONSTRUCTION
6 . CURB CUT
7 . WATER AVAILABILITY FORMS
8 . REMODELING INTERIOR
9 . ADDITIO
10 . ACCESSORY STRUCTURE
11 . SIG AWNING
2 PERMIT FEE - CHECK ONLY - MONEY ORDER � � '
13 . SPECIAL PERMIT RE UI ED WITH DEED IF APPLICABLE
14 . UNDER SECTION 127 - QMR 780
15 . FORM A
16 . FILL
COMMENTS:
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FAX N0. 518828 39 P. 01
1 92 1;IU 141,40 BA S LES r
CJ .�
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William F.Weld
Governor 2WWP&6 910s •.� !30!
Kentaro Tnutsuml
Chairmun nip.. s .i (617) 727•32W
Charles J. 1)lnezlo 3c� r '', 'p- /d g'
Administrator LID FUEL.BURNING FELLET STOVE AF"DAVIT �Q1Ae
TOJ�I
FOR F STOVES SATISFYING-NEGATfV1L PRnSURV TESTING
(FALL 1"WINTER 1"2 HEATING fL1.sON)
To the State Bard of Building Regula as and Standards, p.1e APri t ! Iq 92 j
'n
. ,
t, Janes R. Geramewsk as P1Peeident
on behalf of Austro 1cwn SA, Ina. ,
a manufacturer of lid fuel burnin it t ttoveatfieatenQire Inte
tacs r cIecIc appropriate products),
hereby certify that the following Pell' Ling appllanets,by eitplleu m+xlel Identification; ,
model(:): We a e Z LB t 8 t ve
Integra pettet stove
have been jsslglt,o ---.....�circle pprope{ate information)per the negative pressure tai requirements
of either ULC S627/CSA Standard 8366. or via rtethods/requlrements of similar nationally reoogrika atandarda,and found to
satisfy the applicable criteria of ULC S62 IA A Standard 8366.2 or,other nationally reeognind standards;additionally,burnback did not
occur either during normal or abnormal egative pressure"testing.
MANUFACrUnm Auet 6f t UV# Ine.
SIGNED:
TYPED OR FRINT N E ABOVE, J es R. C eBeweki '
TITLE: -
On this day of 1" ,l&then personally+pared before me,'tpd.;.,
above named lie ( ►i ,. .. i.;
:Iii`r'.'ll►1:.' Fa.l f
and made oath that the above statements by himfier,are true. t• - , i ,
BEFORE ME: `..�';.r
NOTARY PUBLIC
MY COMMISSION IRFSi `V 19
n•o...t ht Page 2 of 2 am
=o�-tttnaraTOy
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE- U
JOB LOCATION: 22 /
(Map) (parcel) (Subdivision)
HOMEOWNER: ILI ire L► /0, _ 7fC Sys/ ,C`� c !d�JL /�
(Name & Address)
(Home Phone) (Work Phone)
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one (1 )or two (2) fami 1 ies. and to allow such .
homeowner to engage an individual for hire who does not possess at
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 resided 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
BUILDING PERMIT #
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. S� -D/Sa Alterations
NORTHAMPTON, MASS. "r 19 `1� Additions
Repair
APPLICATION FOR PERMIT TO ALTER
a
nn ff Garage
1. Location �5 fir/ �LPY r� D, ,p Lot No.
2. Owner's name_ X4IL'iGr° / ' S�vS 7 � Address UfL/ �ULt r
3. Builder's name )4--1kesf-d - i64S Address -4-6 AIV ,,r/e 7y '5'enz'o e%f�
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration T-4ur&.114& of WOgel kejl * S Odt V eZ1,5btj4 Afe 1- 0 iel O&W T_
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
14. Estimated cost:-
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Sig to a of responsi-57e app,icanl
Remarks
002234
Date Filed /
File No.
ZONING PERMIT APPLICATION
1. Name of Applicant: SC
Address: Ste/ 6U-k: + f Telephone: , ' _ _ 01S-;.? .
2 . Owner of Property: 40-1141'1 �
Address :-/ r �►,� Telephone: ��,c-?.
3 . Status of Applicant: i,-6wner Contract Purchaser
Lessee Other (explain: )
4 . Parcel Identification: Zoning Map Sheet# ,q Parcel# //�6 ,
Zoning District(s) (include ove lays) u-eq'
Street Address
5. Required
Existing -- Proposed by Zoning
Use of Structure/Property
(if project is only interior work, skip to #6)
Building height
%B1dg.Coverage (Footprint)
Setbacks - front
- side L: R: L: R:
- rear
Lot size
Frontage
Floor Area Ratio
%Open Space (Lot area minus
building and parking)
Parking Spaces
Loading
Signs
Fill (volume & location)
6 . Narrative Description of Proposed Work/Pro 'ect: (Use additional sheets
if necessary) / �f W a� ell t
e;r�,sT7lhG =i-tb?a.107 eJ �Ylyr ,
7 . Attached Plans: Sketch Plan Site Plan
8 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
Date: 2,44, Applicant's Signature:
THIS SECTION FOR OFFICIAL USE ONLY:
J, PP roved as presented/based on information presented
Denied as presented--Reason:
Sp cial' Permit and/or Site Plan Required:
d 'ng eq i d: variance Required:
5 gnatu a Bui.ldin or ate
NOTE: Issuance 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 Public Works and other applicable permit granting authorities.
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