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Q Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. ' u Alterations
NORTHAMPTON, MASS. I 194—le
Additions
• Repair
' APPLICATION FOR PERMIT TO ALTER
Garage
1. Location GY J-1r, Lot No.
2. Owner's name -Daw 1`-4-S 1Z. Address V .
3. Builder's name A:Q i:460CuZ- Address 24 Ll,)/T
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
5. Alteration
6. New Porch
7. Is existing building to be em lished9 ki h
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating'
1 l. Distance to lot lines
12. Type of roof 19Z-2DMiQ i d t,hKaLi 1 �
13. Siding house t � � r1r"�lr '
v
14. Estimated cost:-
The u d signed c if' s at the above statements are true to the best of his, her
kn w and be tef
Signature of responsible app,icant
Remarks
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOR-KER'S COMPENSATION INSURANCE A + , AVIT
A r 6611 -a
(1i crLSerlpernv ttcc)
with a principal place of business/residence at:
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following Nvor'r er's compensation cove:aoe for my
employees worlLing on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
( ) 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) Qmstuancz- Company/PoLicy Namba) (Expiration Date)
(Frame of Contractor) (Insurance CoupanyRoLicy Number) (Expiration Date)
(Name of Contractor) (Iruurancz- Compaay/poticy Num_bu) (Expiration Date)
(Name of Contractor) (Innlranc-- Company/Policy Number) (Expiration Date)
(mach additioozl rhoet ifnooeis,.ry to io'�intocmiao.pertaining to sll o0o ration)
( ) 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 th,t wtnlo bomcmw who emplay pazom to do cirri m,ace co¢xntcioo or rryair work on a dwelling of
not moce.then tbtoo units is which the baamwocr rc=dcn a on the goundr,ppurtewnt ther to arc not gax filly oowkkrcd to be
employaa under tbo wociva s.ocmpcasaticn Act(GLi52,s l(S)�appricaEon by a homcoavcr fcr a tin=e cc pain may widcaoe the
legal rtahra of an employer under tbo Worlcces CompooaLtion Aci
I understand th,t x ocpy of thi,rtlremeod may be forwarded to the Dgwtr c oflodiss:ri el Aocde a&Ofraoo of Imur,nae for tbo
ooverxge vaifitxtion wad that Endure to ta=rt coverago moiler soetioa 23A of MOL 152 can lead to tbo imposition of cxi-i pwaltiea
of a Eme of u�to 51,1 .00 aM/oc imprison of up to one year and civta pcmltia in the form of a Stop Work Order and a
(5100.00 a day
[ y of ,..,1(/t, 1997 For dcp=tm=3Wu, only J
Permit Number
Map{ Lot 4
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
DATE:
( Please Print)
JOB LOC T ON: t, 9�" ` L�✓C �,
(Map) Parcel ) Tbd
' vision)
HOMEOWNER: ' aA
ame & T d7 e s s )
Home hone ) (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" ,e rtifies and assumes responsibility
for compliance with e State B it ing Code, City of Northampton
Ordinances, State and;` oc 1 Zon laws, and State of Massachusetts
General Laws Annotated.
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HOMEOWNER SIGNATURE
BUILDING PERMIT
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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_X _
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This col==a to be fl-Iled in
by the Banding Department
Required
Existing Proposed By Zoning
Lot size 0 C_) tj-�
Frontage
Setbacks -frnnt
- side L: R: L R: T
- rear �-
Building height
Bldg Square footage l l of O
%Open Space: / 7
Lot area minus bldg
' &paved parking)
#. .Qf, "Parking Spaces J1
fof Loading Docks
Fill:
vol-time--& location)
13 . Certification: I hereby certify that the i f matt c tained herein
is t e and accurate to the best of my kno 1 ge.
DATE: APPLICANT's SIGNATURE
NOTE: 1 oa of a zoning permit does not relieve an a
pp b en to oompty wttl�l,pl1
zoning trsmants and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
FILE #
91991'
File No. k9a5-11
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: A�7"J
Address: _ L&4!5b�_,d�o rZ Telephone:__
2. Owner of Property,_
Address: 2 Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: CLz�
Parcel Id: Zoning Map# ;K-2KG Parcel# 192 District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property " 26- 1-4 a4u-j'(1,
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
J:lke-A.-
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 PermitA/adance/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 # %J h go i
APPLI'�ANVCONTACT PERSON:
ADDRESS/PHQNE:
PROPERTY LOCATION: _
MAP PARCEL: ZONES
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOS D REQUIRED DATE
ZONING FORM OUT "ef 169
Fee Paid 136;��7
Rprnndelin2 Interior
Additinn to Existing
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TH�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
Septic Approval-Bd of Health Well Water Potability-Bd Health
Per it from Conservation ' Sion
07//49 1,9
Signature of Building Insp r Date
NOTE:Issuance 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 Public Works and other applicable permit granting authoritles.
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