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Miscellaneous Additions,Repairs,Alterations,etc. /' .No. Alterations
NORTHAMPTON, MASS. ' Additions
Repair
APPLICATION FOR PERMIT TO ALTER
Garage
1. Location L1� tIQ Lot No.
2. Owner's name �. h+� Address 0 t �'
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
14. Estimated cost- p
t 4D The undersigned certifies that the above statements are true to the best of his, her
k14 C-6 knowledge and belief.
CID - ul, �
Signature of responsible apps nt
Remarks ?' e 2 tv
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of 'NIZrtilailtptell
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cz✓ .., DEPARTMENT OF BUILDING INSPECTIONS -
INSPECTOR 212 Main Street ' Municipal Building '
Northampton, Mass. 01060
G� -7 HOMEOWNER LICENSE EXEMPTION
I ( Please Print )
DATE:
JOB LOCATION: l"x lyago ?G'i2a-( 3 2 C - Z
(nap) ( Parcel ) (Subdivision)
HOMEOWNER: L4 ti 1 leL010 3 d Vao
(Name & Addres )
5-7L - L2!�JN __ w • �1t3- 787- 7 f Z l
(Home Phone ) (ti ork Phone )
The current exemption for "hcmeo�;,ners" was extended to include
Owner-occupied Dwellings of one ( 1 )or (2) fami 1 ies and to allow such
homeowner to engage an individual for mire 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 tine , 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
1
BUILDING PERMIT #
O��t�pTO
� 6 `,J°C-fix � �lasaachasetfs
r •
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/pertnittee)
with a principal place of business/ widen at:
06�6o (phone#) y�3-�b'C-6z YY
� (streef/city/statelap)
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 working 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 Comparry/Policy Number) (Expiration Date)
(attach additional shed if neceaary to inc]ude information pertaining to all ooatrad=)
( ) I am a sole proprietor and have no one working for me.
(L-)'l am a home owner performing all the work myself.
NOTE:please be aware that wbilo homeowners who employ paw=to do construction or repair work on a dwelling of
not mole than thine units in which the homeowner resides or on the grounds appurtenant.thereto are not generally considered to be
employes under the vmrke's compenseim Art(GL152,ss 1(5))�application by a homeowner for a license or permit may evidence the
legal etatrrs of an employer under the Workees Compensation Ad.
I understand that a copy of thin ttatmxat may be forwarded to the Depwtmx of Ikunial Academes'Offloe of 1nsiva3ce for the
coverage verification and that failure to secure ooverago under section 25A of MGL 152 can lead to the imposition.of criminal Penalties
coasisting of a fine of up to$1,300.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 310000 a day agaiw a av-,
M
S' ed this J day of S a 1991 For depart="l tree only
Permit Number
Maps{ Lot#
Si of icenseelPermit#ee
147 , �.
lof
617 3
O
u
".. .,. ,.... .' 1°k'a ;: .',v r,.3d ,..��.�:,�•9i"'t. 3i'fi m'.'$ $Y:'„, j'&. + 2�. S a'f� ,.. ,';� .. - ..3 '° ...
► 9
File No.
ZONING PERMIT APPLICATION (§10 . 2
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: L1-1 kIn �[J 4hrJ'
Address: 10 VC' L, S4. Telephone: L((3 -S1 C - L Z 4(Y
2. Owner of Property: ( S40'7 t cchiJ
Address: '54D Val& Telephone:
3. Status of Applicant: ✓ Owner Contract Purchaser Lessee
Other(explain)r:
4. Job Location: d V
Parcel Id: Zoning Map# 'i C Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property --V
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 L-' 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)
4 e FILE it ..i e..
se P0
APP NT/CONTACT PERSON:
ADDRESS/PH04IE
PROPERTY LOCATION: 36)
MAP 3 C_- PARCEL: T y ZONE Gt!r c-,
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DA 1%
j ZZZ
Fee Pnid
lRytilding Permit Filled wit
ArressnryStruchire
I S�ts of Plans I Pint Plan
c�
U 6
.__
T OLLOWING 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
T�M
Septic Ap lal-Bd of Health Well Water Potability-Bd Health
Permit from Conserva ' C m on
9/
Signature o uil m g or a
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
Commission, Department of Publio Works and other applioable permit granting authorities.
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