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/. Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. f Te' ' Alterations
a rNORTHAMPTON, MASS. ^��''�'`= V, 197 Additions
APPLICATION FOR PERMIT TO ALTER Repair
_ I Garage
1. Location �rC�L Lot No.
2. Owner's name /f;l d3 e/1 p Address 3 lG iiF 1A) �� i�- X"•e1,f--1,,5-X 4.t--,Y4, e,/e'A,7-
3. Builder's name �1 e—V, Address J r /f-
Mass.Construction Supervisor's License No. O' y Expiration Date ql
4. Addition
5. Alteration w ,IGCr-Wt
6. New Porch
7. Is existing building to be demolished? ��1�
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-
/ — The undersigned certifies that the above statements are true to the best of his, her
L L.1 knowledge and belief.
vp S, 7 e of responsible app icant
Remarks
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YbEgARTMENT OF BUILDING INSPECTIONS
a%212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE rl t AVIT
(li pemutice,)
with a principal place of business residence at:
(str�i/ci tp/sta.ici�p)
do hereby certi` , under tale pains and penalties of perjury, t lzua
( ) Tam an employer providing the followin,;v,1orr'er's compensation cove age for my
employees wor�-ing on this job:
( nasu=c� arapmy) (Polio Number) (Expiration D=)
( ) 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 Cornpany/PoUcy Number) (LapimEon Date)
(Name of Contractor) (Insuianc-- CompanyiPoLiq Number) (H-xp am ion Date)
(Name of Contractor) (Instrancz Company/Poky Number) (Expiration Dale)
(Name of Contractor) (Las-u c-- Company/Policy Numb(-,r) (E)piration Date)
(attach a6di600a1 sboct ifnoccuiry to include inform ioa pertaining w all ocaaacion)
( ) I am a sole proprietor and have no one work�ng for me.
am a home owner performing all the work myself.
NOTE:please be aerate that whilo homcrnvacra wbo cmpfoy pczoat to do mamlcaancS co¢rsuction or tcpur work on E dwcllin.g o£
not mote than throa tails in which the bomoow midcs or oa the goandr appttrknant tS=w arc not gcoavlly co=do c to be
employers under tbo wockcr`s o=pcm lion Act(GL152,s 1(5)�application by a homeowar for a liaax oe Permit may evidence tho
`+ le�tl ctznra ofaa omployx unde,rthe Worlccle Compomatioa Act
1 un&rxtaad tbst a copy of this rtztcmc[d may bo focwcrtw to tbo Dtpnrtm�of In banal Arxi&m Ofboo of las xua for thn
covaxge vaificafioo and that failure to scatre covcrago uodcr s0c21oa 25A of MoL 152 can I=d to tho imposition of aimin Pcn cs
000sistiag of a fine of UP to S1,500-00 and/or m>Pr Sot�of uP to ow yctr and civil p=Lltics in the focm of a Stop Wort;Order and a
fins of 5100.00 a day aggain�s-t mC.
Signed this -�� day of 1997 For oaly
a Permit Number
i aP_4 Lot�r}
Signature of i crtni'
y�0�Ct1NMP7O e q
I ,af 'Nar#lIalliptall
r � f '' �ASaac(tuaetla
2 5 W DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ' Municipal Building '
Northampton, Mass. 01060 "
F
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE:
JOB LOCATION:— �C C✓✓r �L�
(Map) aarr ) ---' ( Subdivision)
HOMEOWNER• 6 lam' rC
ame & Addre-s
�5- - u�
( Home Phone) (Work Phone )
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one (1 )or two (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 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 Zojning Laws, and State of Massachusetts
General Laws Annotated.
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 DDE TO
LACK OF INFORMATION.
This colt to be Pilled 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:
(Lotarea minus bldg
&paved parking)
_pf -Parking Spaces
# of Loading Docks
Fill:
4Vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge
i
ATE: /Z A'PPLICANT's SIGNATURE
?' NOTE: Issuanoo of'a zoning permit does not relieve an applW#nra burden to oom wltt�,ill
zoning requirements and obtain all required permits from th Board of Health. naervtstion
Commission, Department of Publio Works and other applioable permit granting authorities.
FILE #
' JW 2 51997
File No
8C
S
--- - � ° = ZiQN 'NG PERMIT APPLICATION ( 10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: ,_,,t
Address: jLh.A21A Z� � Telephone: " _1,7d X5-
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map#__i2?_V Parcel#_ District(s): 1
(TO BE FILLED IN BY THE BUILDING DEPARTME
r �
5. Existing Use of Structure/Property ,y
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 #
APPLICANT/CONTACT PERSON:
ADDRESS/PHONE:
PROPERTY LOCATION: r°
MAP_ ' _ PARCEL: / ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PER UT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM Eff LED OUT
Fee PAid
IRvii ding Permit HIM mit
d20
New Cnmqtrnrfinn -A
Tnrhided-
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TEE
LLOWIING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
t 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/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 ' from oat' Co n
Signature of Building for ate
NOTE:issuanoa of es zoning permit does not relieve an appiloant's burden to oomply with all
zoning requirements and obtain call required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other npplioable permit granting authorities.
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