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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
1 NORTHAMPTON, MASS. 19 Additions
• ' APPLa ICATION FOR PERMIT TO ALTER Repair
Garage
1. Location d 7� it i7 �'/L"t ��` f�/ L Lot No.
2. Owner's name OL t`-`r /J&L• r4,e-vj Address VG�- /t cl
3. Builder's name 75 Q-by? E G r i'%e r 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
L.)Type of roof S�e/)G 7lU iY
13. Siding house
14. Estimated cost:
The undersigned certifies that the above statements are true to the best of his, her
kn I dge and belief.
Signature o ponsible app icon!
Remarks -
- '2
�'CttAMP�.
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$ d �lassrtchnsctts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
censee/permlttee}
with a principal place of business/r sidence at:
761
(Street/ci /stat&2i
n' 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 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 workers 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 Company/Policy Number) (Expiration Date)
(attach additional sheet ifnecessary to include information pertaining to all 000bradora)
( ) 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 homeownera who employ persons to do m intcaaace,coastiuction or repair work on a dwelling of
not more thaw three units in which the homeowner resides or on the grouudr appurtenant thereto are not gears ty oo=dercd to be
employraa under the wor=e=compensation Act(GL152,a 1(5)),application by a homeowner for a licerrn or permit may evideace the
legal status of an employer under the Worlcoea Compensation Act
I understand that a copy of this ttatemem may be forwarded to the Deputmcet of Li u.4rial Aocident+Offioe of lasuranc a for the
oovav4p verification and that failure to axon coverage undo section 25A of MGL 152 can lead to the imposition of arimmal penalties
consis of a fine of up to$1,500.00 and/or impr 6owncrri of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against tne.
Signed this _day of 1997 For dep taoeatbl use only
�) Permit Number
/ Map# Lot#
Signahue of i 'tt,ee
® w F (riff of 'Nort4antptan z ,
lAssn dlusetts
' DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ' Municipal Building
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE: — !� � _
JOB LOCATION: ? �!
(Ma ) Parc 1) (Subdivision)
HOMEOWNER: .✓ / D ' Le
(Zame 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.-
HOMEOWNER SIGNATURE
BUILDING PERMIT #
10. Do an signs exist on the roe YES NO
Y 9 property?�
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 cols to be filled in
by the Building Department
Required
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)
.�f -Parking Spaces
f of Loading Docks
Fill:
Avol-time--& location)
13 . Certification: I hereby certify that the information contained herein
G y is true and accurate to the best of my kno ledge.
DXTE: APPLICANT's SIGNATURE 1
NOTE: 1 u no® of a zoning permit does not relieve an applioant' ' burd #t th,oomply w Ip,, ll-
zoning requiremants and obtain all required permits from the Board of Conservation
Commission, Department of Publio Works and other applioabla permit granting authorities.
FILE #
MAY 80
,f
<' File No.� �J�
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: Telephone: —S_
2. Owner of Property: - ��
Address: & Telephone: _ W—J-16 C
3. Status of Applicant: ___Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: ��` �Li✓� /j G� ;.�Q� _/� �, ���
Parcel Id: Zoning Map# � � Parcel# 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):
r
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 # 96 ?215
: i
f
U �19A7 PL ANT/CONTACT PERSON: ' � '�" /ir 9
ADDRESS/P116NE:
PROPERTY LOCATION: �L
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZQNTNC�FORM Ell LED OUT
Fep Paid
Rnilding Permit Filled
Fee Paid t 0--- c-, _ .....
l
of Plnnq /Plot Plan
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
I
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 Conservation Commission
Signature of Building Insp6lior Date
NOTE:Issuance of to zoning permit does not relieve an applicant's burden to comply with all
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission, Department of Pubiio Works and other applicable permit granting authorities.
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