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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
O Additions
NORTHAMPTON, MASS. '� 191/—
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1.1. Location �� ���> . � `t,^ / R-dvewe Lot No.
2. Owner's name A/e'ye 2?n Y\/ w/C 1' Address /`�/�:r"
3. Builder's name ,/'off Address
Mass.Constr70. n Supervisor's License No. Expiration Date
4. Addition
5. Alteration 11
6. New Porch
7. Is existing building to be demolished? ��'
S. Repair after the fire �/0
9. Garage A/ �, No.of cars Size
10. Method of heating 6` )
11. Distance to lot lines
12. Type of roof � '� W
13. Siding house_
14. Estimated cost:-3nG
The unders' cents th he a temc ue to the best of his, her
knowle d-belief,
Signature aJ responsible appican!
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Remarks '� ;i
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3199
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m DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
DATE• 1� 1 3 (Please Print)
�f 7
JOB LOCATION: d9 — 3--), /
(Map arcel) ( Subdivision)
HOMEOWNER• ���2/v,,� q a,��
(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 person( s ) you hire to perform work for
you under this permit.
The undersigned "homeowne " certifies and assumes responsibility
for compliance with the S Building Code, City of Northampton
Ordinances, State and Loc -Zoning L State of Massachusetts
General Laws Annotated.
HOMEOWNER SIGNATUREi'
BUILDING PERMIT # ;. .
• Y
1vi 3 1997 ��: Crit� of Wart4amptan
$ � �1Tassarlittsetts
L?�PARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVTr
(licensee/permittee)
with a principal place of business/residence at:
1?l:�l (Phone#) may^ t/c� c�
(street/city/statelzip)
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 worldng on this job:
(Insurance Company) (Policy Number) (Expiration Date)
I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining to an ooawLatm)
( ) I am a sole proprietor and have no one worldng for me.
I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do maintman= coashvction or repair work on a dwelling of
not more than throe un*in which the homeowner resides or an the ground4 appurtenant thado are not generally considered to be
employers under the worker's oompeasation Ad(01,152,ss t(5)),application by a homeowner for a licenn or permit may m idcom the
legal stataa of an employer under the worker's compensation Ad.
I understand that a copy of this statement may be forwarded to the Deprutawol of Inckubiel Aecideat+'office of In uranoe for the
coverage verification and that failure to Secure coverage under section 25A of MGL 152 can lead to the imposdiat of criminal penalliea
oocnistiag of a fine of up to$1,500-00 and/or iagriso�of up to one year and civil penalties in the fans of a Stop Work Order and a
free of S10o.00 a day against tne.
culgIIed this For dgpatmental use only
Permit Number
Map# Lot#
Si of Licetme/Pe tree \ /
See reveme side fnr instmetions
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10. Do any signs exist on the property? YES NO �+
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 —.Lm= to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks 1:2 t�
- side L• R: L:1,5 'R: V
- rear 3� �� 3D
Building height '? -
Bldg Square footage 9� , � 7 � —i
J
%Open Space: I,5 S-P c
Lot area minus bldg q�l
&paved parking}
# :of Parking Spaces
f of Loading Docks
Fill:
(vol-ume--& location)
13 . Certification: I hereby certify that the info atio ont •ne erein
Gl is true and accurate to the best of my know ge.
DA E: 7 APPLICANT's SIGNATU I
NOTE: lasuanoe of a zonin `
g permit does not relieve a applioa burden to oompty witf�,.ell-
zoning requirements and obtain all required permits rom the Board of Health, Conservation
Commission, Department of Publio Works and other appliooble permit granting authorities.
FILE #
M ►"( � 3199
File No.
a �
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:_ �� h'1
Address:6507j 102O/ , TelephoneK
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): ,r
4. Job Location: ✓'P S ,��°�v1� c �c [ A '6
Parcel Id: Zoning Map#� Parcel# S� District(s):
(TO B D
IN BY THE.BUILDING DEPARTMENT)
5. Existing Use of Structure/Property , •-d' s QJ!
6. Description of Preposed Use/Work/Project/Occup 'on: ( se additio al sheets if nece v
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 Permit/Variance/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 Document#
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)
962236
FILE # _Jk A7
`„ MAY 1 31997
APRLICAN' i N 'ACT PERSON:
PROPERTY LOCATION:
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Pnid
IRnilding Permit Filled nVit
New Cnn,�triirtinn
ArressaryStriychire
73 'Sets nf Pin Inn
t/
THE,F,OnOWING 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/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
I/
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
!Permit from Conservation m ission
Signature of Building hs. ector Da e
NOTE:lssuanoe of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Pubiio Works and other applioabie permit granting authoritles.
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