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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
'
APPLICATION FOR PERMIT TO ALTER Repair
Garage
'ite9tion=1-7:�z r�i" ✓ �sZ_ Lot No.
w
0 ner's name `tin)�P , Pa / C v_, s ? 7—�r,y�.tio�
-
3. Builder's name Address
Mass.Construction Supervisor's License No. _/ Expiration Date
4. Addition � %l 1. d n o V( Pell-el-
5. S f%f
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
timated cost:- {4`
The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
e of responsible app,icanr
Remarks
43
O O
i (rzt� af 'Wart anyton
� d �asaszchasctta
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
l WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenswJpermittee)
with a principal place of business/residence at:
(phone#) 5
(street city/state/ap)
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 worker's compensation policies:
(Name of Contractor) (Insurance Comparry/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 shed ifnecenary to include informaIIon pertaining to all ooarad )
( ) I am a sole proprietor and have no one working for me.
'Ki am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do maintenance,constructioa or repair work on a dwelling of
not mote than three units is which the homeowner resides or on the gcouads appurtenant thereto are not saxrally ooasidered to be
employers under the tvorlcees oanpe nation Ad(GL152,ss 1(5)).application by a homeowner for a license or permit may evidence the
legal ctatua of an employer under the Wor�a Compensation Ad.
I understand that a copy of this ctatcmcnt may be forwarded to the Deputasmt of ufu t. el Accida ats'Otl;oe of Instuaom for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of a=kd penalties
oomistmg of a.fine of up to S1,500.00 and/or of up to one year and civil penalties in the form of a Stop Work Order and a
fimo 0f3100.00 a day against ma
Signed this_-Lday of &er, 199-7 For dcpa tmestal—only
Permit Number
. Iviap#
Lot#
of L kenseeJ Permittee
i
oa�1wipp _-\
$ e OCT 2 71997 ,��seRCa,1Qt<<s
d DEPARTMENT OF BUILDING INSPECTIONS -
INSPECTOR 212 Main Strect ' Municipal Building �
Worthampton, Mass. 01060
HOMEOWNER LICENSE EXEMPTION
( Please Print)
NO 'WTE
JOB LOCATION:
(May) ( Parcel ) ( Subdivision)
OWNER: -� G �L, i
(N me & Address )
r� U�;E
( Home Phone ) (Work Phone )
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings. of one ( I )or t�-.o (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 Zoning Laws , and State of Massachusetts
General Laws Annotated.
AMItEOWNER SIGNATURE
LDING 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.
/ Thi= C01=a to be filled in
/ by the Building Department
Required
f. Existing Proposed By Zoning
L t si,e
6ront e
Setbacks
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved Farkingi
# of -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.
41', KICANT's Sl'GNATURE
`kOTE: laauano of a zoning permit does not relieve an7i4ppli-anthi burden to oomply witty oll
zoning requirements and obtain all required permits from the Board of Health, Conaervtation
Commission, Department of Publio Works and other applloable permit granting authorities.
FILE #
OCT 271997 _
File No.
96NING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
Name of Applicant: K1�
Telephone: 7I .
`.- Owner of Property: ..
"Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: 7-7 3
Parcel Id: Zoning Map# Parcel# District(s): :SAC
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property 10-24m4
6. Description of Proposed UseANork/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/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 # 96 ?35
NOT 2 7 1997 ,�✓
APPLICANT/CONTACT PERSON: �, /I C 62
ADDRESS/PHONE:
PROPERTY.LOCATION: ""w
MAP ` (Q PARCEL: ZONE
THIS SECTION FORAFFICIAL USE ONLY:
PERNIIT APPLICATION CHECKLIST
.ENCI,OSED REQUIRED DATE
ZONING FORM EH IND OITT
1Riii1fjin2 Permit Filled nvit
Fee Paid 2C2
Additinn to Existing
of'Pinns /Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION'
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 Conservation C mmission
/D Z
Signature o f ' Date
NOTE: Issuanoa o a zoning permit does not relieve an applioant's burden to oompty with all
zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioabie permit granting authorities.
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