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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. / 19LL Additions
a APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location t� Lot No.
✓�
Owner's name Address 1a�7 if ��6�+�S
3. Builder's name Address
Mass.Conswction upervisor'sLLLicense 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
L,4-4-Estimated cost- 5-016
The undersigned certifies that the above statements are true to the best of his, her
knowled a and belief.
Signature ojrespo sib a appicanr
Remarks
w
4�ttAM p�,
�o oy
a e Grxt� of Nart4a ptou
$ 9 �xaaxchnartta
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 e�ti
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
permitter)
with a principal place of business/residence at:
!,)__(phone#)
(stref_-U6 tyh=ehi p)
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 worming on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance CompanyiPo6cy Number) ()rxpira6on Date)
(Name of Contractor) (Insurance Comparn•iPolicy Number) (Expiration Date)
(Name of Contractor) (Insurance Comp:ulyiPolicy Numher) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addit;onal sbce if necessary to include information pertaining to all occttracwm)
( ) 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 persom to do makdem cc coastr"oa or rtpair work on a dwelling of
mot micro than tbroo units in which the lwtnoowncr resides of on the grottn6 appurtennrrt therdc arc not grncally ooaridered to be
employers under the worlccts compc matica Art(GL152�s 1(5)�application by a homeowner for a license or permit may evidence tho
legal status of an employes under thn Wockera Compensation psi
I understand that a copy of thin s2atcmcut ntay be fowurded to tho 134xutumt of tndusnid Acct Offioe of Inwrance for the
eovemgc vaificatioa sad that failure to sea=covcrngo urxicr section 25A of MOL 152 can lead to the imposifioa of criminal penalties
oomtstmg of a fmc of up to S 1,300.00 and/or imprisonments yf up to one y car and civil panitia in the form of a Stop Work Order and a
find of 5100.00 a day mG
Sign this __day of (� 1997 For dgmtncL" eonly
Permit Number
Lot#
9=lttrre of Licensee/Pcrmi ee
0�(11/Uy pT0
a Grzf� of wart!T&nt}Ifon
� B'-' f,Uasexchuertla _
NOV DEPARTMENT OF BUILDING INSPECTIONS =
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
( Please Print )
DATE; /�//c�/ 7
JOB LOCATION:-
Map) ( Parcel ) ( Sub ivision)
HOMEOWNER
(Na e & d ress }
s 1
( Home Phone) (Work Phone )
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one ( 1 )or t�.m (2) fami 1 ieS 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 rest)onsible for all such work 2erformed under the buildinq
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 Annotate
HOMEOWNER SIGNATURE
BUILDING PERMIT #
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 columa to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- 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:
�(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my kn"edge.DATE: / APPLICANT's SIGNATURE NOTE: Issuance of a zonin ermit does not relieve a 9 P rden wltla,,all-
zoning requirements and obtain all required permits from the Board of Health, Cdhservtstion
Commission, Department of Publio Works and other applicable permit granting authorities.
FILE #
NOV 1 3199( File No. 9 �C
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
l--,F�t1. .
1. Name of Applicant: � Ir c_c �` I'•
Address: !J Z 9L2t°ie p
L� Tele hone:
2. Owner of Property: )/ /L4 y
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): �� I
4. Job Location:
n
Parcel Id: Zoning Map# Parcel# District(s):
(TO E LLED 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 PermitNadance/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 # 24
1 31991 /
Nov �)
APPLICANT/CONTACT PERSON: ,!� 4 �251
ADDRESS/PHONE
PROPERTY LOCATION: � i
MAP PARCEL: ZONE /?
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZOMNG FORM FH,T,FT) OUT
Fee plid
IRnilffing Permit Filled nut
Fee pniri
Type f Construction-
New Cnnstriirtin
Arcessary Structure
.�
lam_,
THEE LLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
Approved as presentedfbased 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/ZONIING 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 Server Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
Permit from Conserva ' n mmission
Signature of Building Inspector Date
NOTE:Issuanoe of a zoning permit does not relieve an applicant'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 authorttles.
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