36-003 (4) a
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. _ Q1 Alterations
NORTHAMPTON, MASS. 4�_ f] 19 Additions
. Repair
APPLICATION FOR PERMIT TO ALTER
Garage
1. Location 10 Fa ✓�e 5't /r r, r--/ -P VA L -k" Lot No.
2. Owner's name J >�L 2 Address 10 r�.��s >L Lee' ✓
3. Builder's name J - e Address 10 -e S1 ✓
5 ( Expiration =} p7
Mass.Construction Supervisor's License No. Date Ld �
4. Addition
S. 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
14. Estimated cost:- . jam
/ The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsi appicant
Remarks
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DI PARTMENT OF BUILDING INSPECTIONS
DEPT OF SUILDN(e W " �;
NORTt _ v L 2 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
- (li permittee}
with a principal place of business/residence at:
10 A (phoneg) ; q I
(strecVcity/state/zip) 0 i 0(/e') —
do hereby certify, under the pains and penalties of perjury, that:
O 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 art a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
` (blame of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insuran(-- Comprry/Pokcy Number) (Expiration Dale)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(attach additionl shed if n6o nary to inchrck infncw m pcztaining to all omu=ton)
( ) I am a sole proprietor and have no one working for me.
4�_ am a home owner performing all the work myself.
NOTE:please be aware that whilo homeowners who employ pc==to do mainicn +ce�comuvdion or repair work on a dwelling of
not Moto than thrno units in which the homoowncr r=da or on the®rounds appurtenant tbwcto arc not Sto=ny considered to be
employes under the worker's ccmpcosaiioa Act(GL152,s 1(5)�application by a homeowner for a license or permit May evidcaoe tho
legal datua of an employer under the Workor'a Compensation AcL
I undersiaad that a oopy of this rw cmcnt may be forwarded to tho Depertmcoe of Industrial Ao6&-&Office of Iaau*nce for tho
coverage verification and that allure to sea=coverago tinder sceiion 25A of MOL 152 caa lead to tha imposition Of criminal penalties
consisting of a fine of up to S1,500.00 an&ot imprtso®cut of up to one year and civil pcmlt cs in the form of a Stop Work order and a
fine 0(5100.00 a day against me.
Signed this `�_day of '&' , `0•'x'1991 Ford anlusooaly
Permit Number
r a"l Map# Lot#
SiVmtme icensec/Permit'1
i
+�oac tivur pTOL
of Narf(fttillpfall
B =291W99JE4MENT OF BUILDING INSPECTIONS
INSPECTOR ' Main Street ' Municipal Building DEPTOf SUILDIt�OIIh "'Northam ton, Mass. 01060
PIORTiiAPfrt N 4,, ,iii t, m.m P
HOMEOWNER LICENSE EXEMPTION
( Please Print )
DATE:
JOB LOCATION:
_ (Map) ( Parcel ) ( Subdivision)
HOMEOWNER: )
(Name & A dress )
( Home Phone ) Nork Phone )
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one ( 1 )or bum (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. �l
HOMEOWNER SIGNATURE / -,E!✓�
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 colmaa to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage 1
Setbacks
- side U06 R: 1,6J r L: R:
- rear
Building height i
Bldg Square footage (
%Open Space:
(Lot area minus bldg
&paired parking)
# of -Parking spaces
#
of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
G 1 is true and accurate to the best of my knowled e.
_
DATE: APPLICANT's SIGNATURE
f'G
NOTE: lesua 00 of a zoning permit does not relieve an ap' lloant's burden t mply "i"''Apll
zoning requirements and obtain all required permits from the Board of Hea h. Conservation
Commission. Department of Publio Works and other applicable permit granting authorities.
FILE #
. `
`
v }
SEP 2 9 1;;7
� File No'
�
. �� ���� �� �� �
�u�����"� ������ ��� �������� « �r�� ~ ��
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant-
-
Add
_ ----' -' Property-
Address:— Telephone:
3. Status mfApplicant: ^^ er Contraot Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
6. Existing Use ofStructure/Property
G. Description fProposed Use/Work/Project/Occupation: (Use additional sheets if nec,amory):
7. Attached Plans: Sketch Plan -Site Plan nQineonsd/SunxsyedP|one
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
O. Has o Special Permit/Vohunoe/Finding ever been issued for/on the site?
NO DON'T KNOW YES |F YES,date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO DON'T KNOW YE
IF YES: enter Book Paga and/or Document
—~�
Q. Does the site contain a brook, body of water orwetlands? NO DON'T KNOW `/E
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobe obtained Obtaineddate issued:
'
(FORM CONTINUES ON OTHER 8|OB
.
-
L, ,f' FILE # 962342 4A�5 �
2 9Ir i
APPLICANT/ ACT PERSON: dna) ,:o C y„ 2c,
DEPT 0
PROPERTY LOCATION: Q 7
MAPS PARCEL: ZONE
THIS SECTION FOR.OFFICIAL USE ONLY:
PERAUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONINC-FORM 171I.I.E.11 OUT
Fee Pnid
'Building Permit Filled ntit
Fee Pnid q �
Type of Constniction- A
�-hf Plans. I Pint Plan
THE�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
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
CurY ,t from DPW Water Availability Sewer Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
_P it fro Cons
n ' sion
Signature of Building 1poFector Date
NOTE:Issuance of a zoning permit does not relieve an applicant's burden to oomply with all
zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Public Works and other appiioabie permit granting authoritles.
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