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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. SS(0`�q7 � Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
i ' Q Garage
1. Location 129 W t l�1 CAY�1`� JT. Lot No.
2. Owner's name Brian t t 1tJ1ZI aYZ Address l o3tri 1J)\t it i r M S
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration
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
,/144. Estimated cost:-
, 3Qv�
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
All Jc)�� AAIIJA-,,
lSignatu4 of responsible app,icant
Remarks
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! 'fi`; r +gncj DEPARTMENT OF BUII.DrtjG INSPECTIONS
rr:
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
a (Please Print)
DATE: / C�r /
JOB LOCATION: C / / `7 L�__
(Map) (Parcel) ( Subdivision)
HOMEOWNER: By-%an . `(Y1A�I C�r2 1 ;)q i l l Aim
(Marne « Andress)
-
Nor a►Y,�. m� ,
(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: Persons) 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 persons ) 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 #
O¢(ttAMP�Q
of Wart4ampfor
ti
�asSaCl(nSCtlS -
,, t•
m r dEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licellseclpermittee}
with a principal place of business/residence av
►�
ilia c1 � ' �� one#}
(spa :t}i�-Lat' zi—,
do hereby certify, under the pains and p,�nalties of peguly, that..
( ) I am an employer providing the follo"Vving worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sale 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 CompanylPolicy Number) (Expimtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contactor) (Insurance Company/PaLcy*Nu.r� nber) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiornl sbcct ifnecxssuy to ibehrdc iafocnulion pertaining to all ooatrndors)
( I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please be aware that whilo homeowners who employ p==to do maiuimanct,ooastvdion or repair work on a dwelling of
not more than throe vads in which the homeowner resides or on the groun6 appurtenant thereto are not generally wondered to be
employers under the watkees oompcnsation Act(GLIS2,ss 1(5)),application by a homeownxr fora licanse or Permit tray evidcnoe the
legal stahra of an employer under the Workeez C.ompetnation Acl
I understrutd du l a copy of this stag maybe forwarded to the Departm of Tndu,b,ol Aodda&Off o0 of rrrnuar"for the
coverage verification and that failure to scare coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
oomisQng of a fine of up to S 1,500.00 andlor impzisoameut of up to one y=and civil penalties in the form of a Stop Work order and a
find of 5100.00 a day against me.
For deputntab1 use only
�La ' Permit Number
r $ Map*# Lot#
Signature of License&pe e
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 MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This column to be Pilled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size � � `f�a 0_
Frontage &01 _
Setbacks - frnnt
- side L: R: L:�R 0
- rear
Building height
Bldg Square footage �'/�� 4e)
%Open Space:
(Lot area minus bldg
&Paved parkingi
# of Parking Spaces
of Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
DATE: a APPLICANT's SIGNATURE
NOTE: Issuance of a zoning permit does not relieve an a plioant's burg' n to mply with 4111
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commissions Department of Publio Works and other applioeble permit granting authorities.
FILE #
I r� ys�
_..... ..._ : . File No. —
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: Ryl an
Address: I, �� i 1 i D 3 % _Telephone:
2. Owner of Property: I M(121 a+r z
Address: 1 all mq' S� Telephone:
3. Status of Applicant: ✓ Owner _Contract Purchaser Lessee
Other(explain):
4. Job Location: �� / �"JC�=C � ",A _
Parcel Id: Zoning Map#_ �2- Parcel# 1 �y District(s)�.��
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property < —
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
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 V 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)
FILE
APPLICANT/CONTACT PERSON: GCGJ(�''
p�pi,.ADRESS/PHONE:
PROPERTY LOCATION:
MAP ;� PARCEL: ZONE -Z,-2,0
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
Fee Pqid
Hiii1ding Permit Fffled ant
J
f j�
Rerandplin2 Tnterinr X3 11% 1
Additio
s�
TBI YOLLOWING 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
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
c-Appt6kal-lad of Health Well Water Potability-Bd Health
Permit from Conservatio ommission
Signature of Building for Date
NOTE:Issuance of to zoning permit does not relieve an applioant's burden to comply with all
zoning requirements and obtain all required permits from the Roard of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
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