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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
�. Location 1 ��' Lq�r e � j rW°�.r� h Lot No. Xf5l
V2. Owners name -4^;L A e'L-'---/c2 Address
3. Builder's name Address
Mass.Construction Supervisor's License No. Expiration Date
i
4. Addition v2� q .4G� o0
5. Alteration il—
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
14. Estimated cost- S 0
The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsible app,icant
Remarks
�� +$ Gllif r of Yorthamptall
77 r
t �] nsasch its tits
' DEPARTMENT OF BUILDITNG INSPECTIONS -
INSPECTOR 212 Main Street Municipal Building '
Northampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
/Z/��7_ (Please Print)
DATE:
JOB LOCATION: �; ' C/
(Map) (Parcel) ( Subdivision)
HOMEOWNER- /1/{,_t_ "
(Name & Address ) )/�y/
y �y/VG "1 L si tw �i/A/ �-/YL•si f./1 c;c� �'./ VG�J
(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 e----
HOMEOWNER SIGNATURES-�
BUILDING PERMIT # ':,.:
�O O�
• ,gg� (rz� �� �>�z�f�ttnt���n
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°DEPARTMENT OF BUIL)r NG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMTENSATION INSURANCE A)FMAVIT
(licenser/permittee)
with a principal place of business/residence at:
')p fY1vp,, �� /(��a� J`�G..,�' ��; U 115�,)_(phone#) f-
(st reet/ci ty/stab/a 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 homeowner ( cle one) and have hired
the contractors listed below who have the following wor e s 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 Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed ifnxeauy to inehide infoemifioa pextaining to all coatrad )
( ) I am a sole proprietor and have no one woAing for me.
( ) I am a home owner performing alt the work myself.
NOTE:please be aware that while homcownem who employ person:to do maintenance,coast uctioa or repair work on a dwelling of
not awe than three units is which the homeowner resides or on the grounds appurtenant thereto are not g«xralty ooaridercd to be
employers under the worker's oration Ad(GL 152,ss 1(5)),application by a homeowner for a license a permit may evidence the
legal ctabua of an employer under tbo Workeet Compemation Act
I underuaad that a copy of this&Wcrneat may be forwarded to the Departmca2 of Lulu ri al A.Oddm&Off oo of Insurance for the
coverage verification and that failure to secure covecago under seetiort 25A of MOL 152 can lead to the imposition of criminal pemahiea
ooesisting of a fine of up to S1,500.00 and/or of up to one year and civil penalties is the f—of a Stag Work Ordtr and a
find of 5100.00 a day against me
Foe deprutm--OW use only
��t Number
Lot#
t
Signature of Lioansee/Permittee
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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 N04
IF YES,describe size,type and location:
11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DOE TO
LACK OF INFORMATION.
This cclumm to be filled in
i"1-"` by the Building Department
Required
Existing Proposed By Zoning
I Lot size
Frontage /"cT
Setbacks `%' w " �
L
- side R: ! L: � R:
- rear
Building height
F
Bldg Square footage oc
%Open Space:
(Lot area minus bldg
&paced parking)
# pf -Parking Spaces
# 'of Loading Docks __.....:. _.
Fill:
-(volume location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: �j ! �c APPLICANT's Sl-GNATURE�;�_ y���
NOTE: Issuanoa of a zoning permit does not relieve an mpplioant's burden to oom 4
zoning requirements and obtain all required PIY with all
q permits from the Board of Health. Conservation
Commission. Department of Publio Works and other applicable permit granting authorities.
FILE #
File No.- 33L ) 1
BONING PERMIT APPLICATION (§10 . 2
)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: L11 /27'/i ele/phone:
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# V Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING "
DEPARTMENT)
5. Existing Use of Structure/Prope Ce�vt,�c. �
6. Des ription of Proposed Use ork/Project/Occupatib: Use additional s ets if necessary)
Ao :oErn� �w,�, ;�s� ooy
Y-/' L-2, %c-1-e zhxr
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 KNOIA 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_2-< 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 I 9 F d 1
BAR 3 I 8
APPLICANT/CO TACT PERSON:
ADDRESS/P$6NJ: 2eir
PROPERTY LOCATION: �'C_
MAP PARCEL: ZONE ,J
THIS SECTION FOR-OFFICIAL USE ONLY:
PERNIIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OUT
Fin- Paid
Fp�; Paid
✓"
G ✓
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Renindeling Interior /,)J"x/d
sA
ATHE OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
pproved 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
�it from Conservatio mmission
Signature of Building Wector ate
NOTE:issuanoa of a zoning permit does not relieve an applioant'a burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commisalon, (Department of Publio Works and other applicable permit granting authorities.
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