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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. X°��l�� Alterations
a ri� :
NORTHAMPTON, MASS. DC 4(1 1 Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location ' '� C f = E4,0 F AA C Lot No.
2. Owner's name 0'1f t� 1-ff1j cx_ J Aa n ,/Y),; �,t. Address /0 4 4e f o C T �
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration S 7-Kl ' k'oof
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 s 10l1/9 L
13. Siding house
14. Estimated cost:-
/ The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
l'iU ._.
Signaturt of responsible app,icanl
Remarks
04(ttAMp�
OCT 71997 Cr f a #4ttntp urt
. k
OF BUILDrXG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Ii censee/permittee)
with a principal place of business/residence at:
/0 A lgrly G _F4v n1�A)C.s:t_/Y7,1� , 0/06 =t, (phone#)
(street/ci ty/sta try a p)
do hereby certify, under the pains and penalties of peglify, that:
( ) I am an employer providing the folloWmi g ,worker's compensation coverage for my
employees working on this job:
(II11=cc Coutpany) (Peiicy Number) (Expiration Date)
(,,,<I am a sole proprietor, general contractor o omeowner circle one) and have hired
the con-actors listed below who have th.e following worker's compensation policies:
iIl jr ,¢,) °vN ( �/ �,- �5'
. - , s .
(Name of Contractor) (Insurance Comparry/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompauyiPolicy Numlxr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additicenl shx Tnect-_m r to include mfoniutica pertaining to all coatrac on)
( ) 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 while homeowncn Nebo=play painns to do m.mt�mnstrl t oa or repair work on a dwelling of
not more than throe units is which the homeowner resides or oa the grounds appurtenant thereto are not gaxrally ooctiukrcd to be
employers under the worker's ocmpcas4oa Act(GL152,zs 1(5)),application try a homeowner for a license or panes may evidence the
legal ctatua of an employer under thn Worker&Compemation Act
I understand that a copy of thin etatcmeat auy be forwartW to tbo Dcpcutaxo2 of I.&L trial A zid—&Ofriw of Iz�for the
coverage verification and that failtn-e to secure covcraga udder secdoa 25A of MOL 152 can lead to the imposition of a musk penalties
comisti of a&ne of up to S1,500.00 snigger•imprisonment of up to one year and civil peaaltia in the form of a Stop Work order and a
fora of 5100.00 a day against=
Si ed this day of C 199jr For dcpQtar�ni use onty
( � Permit Number
Map# Lot#
Signature of itic=sS&ermittee
aril tt»i fait
OCT 7199-(
I .
yA38 ACI1IIII[IIII
DEPT Of 6 t
''i�7EPARTMENT OF BUILDITjG INSPECTIONS -
° """'"'°` 212 Main Street ' Municipal Building
'
INSPECTOR P g
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
(Please Print )
DATE: CC-taber �„y, J 5/�
JOB LOCATION: ,T
(Map) ( Parcel) ( Subdivision)
HOMEOWNER: fi%S I-')e/,' c/Z- _1' ,
(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 "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.
t
HOMEOWNER S I GNA ✓` �L___
BUILDING PERMIT #
10. Do any signs exist on the property? YES NO TW
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 cola= to be fi22,ed in
by the Building Department
Required I
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
' &paved parking)
# of Parking spaces
of Loading Docks
Fill:
4 vol-lime--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
_1
APPLICANT's SIGNATURE
NOTE-. Issuanoe air is zoning permit does not relieve an applioant- burden 16 oomply wlttl,. U
zoning requirements and obtain all required permits from the Board of HXalth, Conservtation
Commission, Department of Publio Works and other appliomble permit granting authorit;es.
FILE #
OCT 7 W7
File No 91 j t
ZONING PERMIT APPLICATION (§10 . 2)
�► PLEASE TYPE OR PRINT ALL INFORMATION
Name of Applicant: k L^
/Address: ��1 Telephone: = ��
2. Owner of Property: '5Am
Address: 5 ice/y1 r Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
--'4. Job Location:
Parcel ld: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. 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 '/ 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 it 2RTA
7 W
E APPLICANT/CON'Tr .CT PERSON:
DEPTOM p ,490
J as i
L
PROPERTY LO ATION:
N1�AP c2 Y PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM VU,T,FD OUT
Fee Paid
]Rnildin2 Permit Filled apt
,'— �...�
Addition to Rykfing
Tnrhyded-
(�-fq nt Plans /Plot Plan
THE LLOWING 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
Septic Approval-Bd of Health Well Water Potability-Bd Health
!Permit from Conservatio ommissiow
j xe 9
Signature of Building Ingoffor Date
NOTE:issuanoe 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
Commisslon, Department of Publio Works and other applioabie permit granting authorities.
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