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23A-120 (3) City of Northampton � r „ Massachusetts A. * ' { c c t ; ' DEPARTMENT OF BUILDING INSPECTIONS �', 1 °._ 212 Main Street • Municipal Building �bjS ,�q �% « N.. -' -1 Northampton, MA 01060 N JY .∎1% Property Address: (/ 3 Pit "OT9 Sf / " L't" i 44A ti (4'' 6 2 Contractor Name: ?Art i (ZI rbe'1 ... Address: � 2- Ull k t1 i C ' City, State: l yt,r 1 a ' , AA ,A 0 / l Phone: (t1 / ) 3 - t Property Owner Name: //k l//'? r fi 4 Address: 0 A' '' fit' City, State: 64 /9-rAf it-c /1 / 4 P/ i` 6 I, i . r 7( (contractor) attest and affirm that the building I intend to insuliate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature ! % — ,- Date Y / c / C1r2 CO-OP L , . `∎ POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal I Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co- op Power will remove all waste from the job site located at: Owner Name Street Address Town /State/Zip Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our removal service is Waste Management. .t Q 3 rL Paul Schmidt Date • Co -op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop W1111 =_ ------- ; Office of Consumer Affairs and Business Regulation _z= 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165217 Type: Corporation Expiration: 1/21/2014 Tr# 220702 CO -OP POWER, INC. PAUL SCHMIDT 324 WELLS ST GREENFIELD, MA 01301 Update Address and return card. Mark reason for change. Address El Renewal El Employment Lost Card DPS-CA1 it 6CM- 04104- G101216 Zoarri�ncl ure�Ll�z o License or registration valid for individul use only Office of Consumer Affairs & Business Regulation g y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 165217 Type: Office of Consumer Affairs and Business Regulation r Mist= e 9 Expiration: 1/21/2014 Corporation 10 Park Plaza - Suite 5170 p Boston, MA 02116 CO-1P POWER, INS PAUL SCHMIDT 324 WELLS ST \ - GREENFIELD, MA 01301 Undersecretary Not v without signature • tiiassachusetts - Department of Public Safety Yi Board of Building Regulations and Standards Construction Supervisor License License: CS 103635 - Restricted to: 00 PAUL SCHMIDT 24 CHESTNUT ST HATFIELD, MA 01038 Expiration: 5/20/2013 ormu isrivner • Tr#: 103635 S The Commonwealth of Massachusetts -- - - Department of Industrial Accidents. . „ `° Office of Investigations 4`°- z 600 Washington Street t 7:11 Boston, MA 02111 $ 4 =gar www. mass.gov /din Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Lettibly Name ( Business /Organintion/Individaal): C F614, ^ iA C Address: 3 6 ( el (S < City /State /Zip: Cr - & - h_ (--(d.. . ' Phone #: ( 1 l 8 Are ou an employer? Check the appr i +rime box: Type of project (required): 1. I am a employer with I t 4. 0 I am a general contractor and I employees (full and/or partinie). have hired the sub- contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub- contractors have g. 0 Demolition working for me in capacity. employees and have workers' g any tY tom insurance .T 9. ❑ Building addition [No workers' comp. insurance p' 10.0 Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs _ insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0, Other VAG, fit, i oLflUY■, camp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. . �, Insurance Company Name: t W i C i / F ` C6-- -1-1\S tA'r Gvv'� Cam— c, n Policy # or Self -ins. Lie. #: 5 ` i/1.i e t; _ I_ C (Q 8' CP G Expiration Date: R -- t 6- 1 2-- Job Site Address: City /State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby car , , under the , : ' , nd p' ' 'es of petjury that the information provided ab, e ' true and correct. S'_ a Date Phone #: C g — `" g 8 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License ## Issuing Authority (circle one): I. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A D CERTIFICATE OF LIABILITY INSURANCE 11/29/2011 D) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy {ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Joseph Judd Blackmer Insurance Agency Inc . ( H Fitt: (413) 625 -6527 FAX No }: (413) £25-1321 1147 Mohawk Trail : joe @blackmers.com INSURER(S) AFFORDING COVERAGE NAIC Shelburne MA 01370 - 9707 INSURERA:Twin City Fire Insurance Co 29459 INSURED INSURER B : CO -OP POWER, INC, INSURER C : PO BOX 688 INSURER D PC Box 688 INSURER E : GREENFIELD MA 01302 INSURER F: COVERAGES CERTIFICATE NUMBERM'taster 11 -12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 'OR MAY - THE INSURANCE' AFFORDED EY THE POLICIES DESCRIBED HEREIN -IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP UMITS INSR WVD POLICY NUMBER (MMIDDPYYYY) (MWDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY Pe) $ CLAIMS -MADE Ti OCCUR MED EXP (My one person) $ PERSONAL & ADV INJURY S _ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG S 7 POLICY Ti IF a Ti LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY (Per person) S ALL OWNED _ SCHEDULED BODILY INJURY (Per accident) $ AVMS _ HIRED AUTOS ^, AUTOS /Per /Peter PROPERTY accident) _ $ $ UMBRELLA LAB OCCUR EACH OCCURRENCE _ $ — EXCESS LLAB CLAIMS -MADE AGGREGATE $ DED I RETENTIONS S A WORKERS COMPENSATION 1 TARS 1 BAITS R AND EMPLOYERS' LIABILITY ANY PROPRIETOR,PARTNERIEXECUTIVE N (A (Ma ndatory in NH} EL. EACH ACCIDENT S 1,000,000 OFFICER/MEMBER In NH } F�CCLUPED9 ' I 06STECLC 6B66 11/1/2011 11/1/2012 EL DISEASE - EA EMPLOYEE S 1,000,000 (Ma U describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (Attach ACORD 101,AddlUonal Remarks Schedule, If more space Is required) Operations usual to energy efficiency services - energy audits, air sealing, insulation and solar hot water system installation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Rd, Ste 4, 2nd Fir Canton, MA 02021 -1461 AUTHORIZED REPRESENTATIVE S Deneault, CISR /BLAJ L ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD Ac D CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDD/YYYY) 11/22/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Shannon Pala,7o James J. Dowd & Sons Ins iNCNo.Extl :4 13 -538 -7444 OW,No1:413- 536 -6020 14 Bobala Road Holyoke MA 01040 ADDRESSq)alazzO@dowd.com INSURER(S) AFFORDING COVERAGE NAIC A INSURER s Safety Indemnity Company INSURED COOP INSURER E Great American Insurance Companies Co Op Power, Inc. INSURER C :U, S. Liability Insurance Company 324 Wells Street Greenfield MA 01302 INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1050225280 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECUIREMENT, TERM OR CONDITION CF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF PO WV POLICY EXP LIMITS LTR INSR D POLICY NUMBER (MM/DD/YYYYI (MM/DD/YYYY) C GENERAL LIABILITY CL1566148 11/8/2011 11/8/2012 EACH OCCURRENCE $1,000,000 AMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREM PREMISES (Ea occurrence) $100,000 CLAIMS -MADE OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE _ $ 2,000,000 GEM_ AGGREGATE LIMIT APPUES PER: PRODUCTS - COMP/OP AGG r 2 000,000 7 POLICY PRO- X $ LOC — A AUTOMOBILE LIABI I LITY COM6212701 3/23/2011 3/23/2012 (Ea ac COMBINED S1N1LE LIMI i (E ac $1,000,000 ANY AUTO BODILY INJURY (Per person) $ AL OS OVVNED X SCHEDULED BODILY INJURY (Per accident) $ NON -O ED PROPERTY DAMAGE $1,000,000 X HIRED AUTOS X AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE . $ EXCESS UAB CLAIMS -MADE AGGREGATE $ _ DED RETENTION $ $ WORKERS COMPENSATION 1 I WC STATU- I OTH- AND EMPLOYERS UABIL.fTY Y N TORY I IMITS ! FR ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCWDED? N I A (Mandatary In NH) E.L. DISEASE - EA EMPLOYEE S If yes dal ibe under DESCRIPTION OF OPERATIONS bslnw E.L. DISEASE - POLICY LIMIT $ B Directors & Officers Liability EPP1117563 5 /2/2011 5/22012 1,000,000 5.000 Deductible DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 181, Additional Remarks Schedule, if more space Is required) Waiver of Subrogation Applies. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Honeywell Utility Solutions ACCORDANCE WITH THE POLICY PROVISIONS. 65 Shawmut Road Suite 4, 2nd Floor AUTHORIZED REPRESENTATIVE Canton MA 02021 -1461 /7: © 19BB -201 0 ACORD CORPORATION. All rights reserved. • ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD • SECTION 8 - CONSTRUCTION SERVICES , icensed Construction Supervisor: 8.1 Licensed Construction Supervisor: 'aul Schmidt Name of License Holder : !4 Chestnut St. -Tatfield, MA 01038 :S # 103635 U Address ?xp. 5/20/2013 43-772-8898 t . Signat, Telephone -Tome Improvement Contractor: 7,o-op Power Inc. / Paul Schmidt 9. Registered Home Improvement Contractor: ;24 Wells St. lreenfield, MA 01301 Company Name # 165217 /' Exp. 1 /21 /' Address 113- 772 -8898 i i ,. )aul @cooppower.coop SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption 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. CMR 780, Sixth Edition Section 108.3.5.1. 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. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) F r- Roofing ` Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[ ] Siding [O] Other [El] Brief Description of Proposed Work: t t" : i i ' h t l rw^ 3 . / 1 1 N u 1 V: t L- St et fd 6- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS A GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 4 _ V `1 \(l , as Owner of the subject property hereby authorize rinv l S1�1'f" "` ! (D e �� A � �l`� to act on behalf, ters 've to work au orized by this b ilding permit application. 4-I I2 Signature of Owner Date I, i L ��iG . , as Owner /Authorized Agen hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Pin e Signature irwn- gent Dat- - s Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department ' 4 Lot Size I I I I I I Frontage I I I I I I Setbacks Front I I I I I Side LA I R:I I Li I RA I I I I Rear I I 1 1 I I Building Height I I I I I Bldg. Square Footage I I I I % I I I Open Space Footage % (Lot area minus bldg & paved I 1 I I I I I I I parking) # of Parking Spaces I I I I I Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ev r been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO ©----- IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 0'°— IF YES, then a Northampton Storm Water Management Permit from the DPW is required. _ Department use only Fi ELT,' �a ,• City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability 2012 Room 100 Water /Well Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT. OF sur go ne= 413 -1240 Fax 413- 587 -1272 PIot/Site Plans NORTHAM A 3' � _ Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 14P17t S1—. Map Lot Unit J 104) 7 - 1.14 �' Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: kinWi tA t L N A I t, C(0,te . f l.t ce-- Uk- c t L. Name ( int) Current railing As i l ' Teleppho e Signature 2.2 Authorized Agent: Name (Printy, 1 Current Maling Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (), ,L & I (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 1 2.7-- C - Check Number jaO (?j3 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0905 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS /PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 8 MIDDLE ST MAP 23A PARCEL 120 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid �,/ Building Permit Filled out Fee Paid -(3016 30 �6 S1C6 l Typeof Construction: WALL INSULATION & VINYL SIDING UNIT B New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 103635 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION PRESENTED: V Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date g g Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information.