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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
�. Location ✓/�.✓ LA.�.e / o" ll%1/h�io� /1q/t �/ `�
Lot No.
Owners name Address
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
4. Addition
J5. 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
,J4. Estimated cost: Po
The undersigned certifi that e a ve statements are we to the best of his, her
knowledge and beli
Signature of responsible app.icant
Remarks
I� r,
DFC 1 21997
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DEC 1 21991
3 6 �YSaxrElasctta
w DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building ' o
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(hcenserJpermlttee)
with a principal place of bt.lsiness/residence at:
D/0 L70
2 `� � ,//SAN Ln/ /�/ol�il r►'�J�. �/ 131A (phoned) gVS/9
(St me-Uci ty/5a tchip)
do hereby certify, under talc pains and penalties of perjury, that:
O I am an employer providing the following workers compensation coverage for my
employees working on this job.
(Lasumuce 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) (Ins=cc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compmy/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insuranc: Company/Pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atlarh additiooad tltcct if nocczs to inchrdc information pertnimng to ell coatradon)
( ) 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 wbh lc homcotiwen wvo employ pa-row to do rt ;,,+ nn 0=sbudioa er repair work on a dwelling of
not morn than thtroo unit,in which the bomnowncr r cidcs or oa the Vouads appurtenant ha do uc not&cncratty ooawknd to be
employers under the worker's pompcas4oa Act(GL152,"1(5)�apptication by a homoowncr for a licca-a Permit may cvi6mcc tho
legal dshta of an omployoc under the WorkoeL Compcozation Ad
I undcnt.and th:t a oopy of thu rtatcmcnt may bo forwnmdod to the DcS�of Indttstri d Ao641�&Otfioo of LaRu noo for tho
oova-&c vaifiiadioa and that failure to=oovcrago under socUon 25A of MGL 152 can toad to d,1 imposition of mmi W pcanitics
oocnisZing of n rma of to S1,500.00 andtoc i-prisotmxat of tip to one year and civil Peaattics in the focm of a stop Work older and a
find of S 100.00 a ttx
Signed _day of.Dr 199 gFCr&Pntn=L&1 U-bo only
Number
Lot
Si of Li /Permittcc
of Yost alnvtoit
r =
$ fflsss MCI)list till
DEPARTMENT OF BUILDIXG INSPECTIONS
INSPECTOR kt" 212 Main Street ' Municipal Building '
41M '``�•
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
DATE:
Z - 11 - 97 (Please Print)
JOB LOCATION-
(Map) (Parcel) (Subdivision)
A/_Al-HOM EOWNER: 4 ,v✓e?-J"r,-,
2 e �(1�mN & st re s s)
"Ovo l
(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 i Laws , and State of Massachusetts
General Laws Annotated.
HOMEOWNER SIGNATURE
BUILDING PERMIT # .. :
an signs exist on the roe YES NO
10 Do y g 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 cola= to be filled in
by the Building Dtpnrtment
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:
-(volume -& location)
13 . Certification: I hereby certify that the info a n Lontained herein
G is true and accurate to the best of my knowl d
.1
DATE: 2-- f2 _�� APPLICANT's SIGNATURE ,
NOTE: Issuance of a zoning permit does not relieve an pplicant's burden to comply wit" oil
zoning requirements and obtain all required permits from the Board of Health. Conservation
iCommission. Department of Public Works and other applicable permit granting authorities.
FILE #
DEG I I9
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 41151-
Address: j�/�i�" � ''J Telephone: d�� y `�
2. Owner of Property: Z./7)Ly ' -
Address:—, Telephone: _
3. Status of Applicant: �� Owner Contract Purchaser Lessee
Other(explain):
4. Jab Location: �.
� C
Parcel Id: Zoning Map# Parcel# `District(s):
(f0 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):
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.
S. Has a Special Permit/Vadance/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
C a
APPLICANT/CONTACT PERSON:
ADDRESS/PHONE:
PROPERTY LOCATION:
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZQNTNC�FORM M.T.FM OUT
Fee Pnid
TVI)p of Crinstriir inn-
New Cnn.,qtriTrtinn
Remndplin2 Interior
Addition t�Fxisflng
ArcessnryStriirtnre
THE LLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
d 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
Permit from Conservat' Commission
Signature of Buildin ector 15 ate .
NOTE:lasuanoa of a zoning permit does not relieve an applioant's burden to oompty with all
_ zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applionble permit granting authorities.
tom.,
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