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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. -/ Tel.No. Alterations
NORTHAMPTON, MASS.T/ ,-(#C 192�-- Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location f S Cr- I VI r--LA / f Lot No.
2. Owner's name c,r4 Ce A-AV Address /.S�-G`�g ��G A
3. Builder's name �1:ilJ 4:�Z V-1 er-tr- Address f—& -S'/ / rr�S
Mass.Construction Supervisor's License No. ,/� �Oa O Expiration Date
4. Addition
5. 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 cosL- �.
The undersigned certifies that the above statements are true to the best of his, her
knowledge an belief.
Signature of responsible app,icant
Remarks
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060 'v•y
WORFCER'S COMPENSATION INSURANCE AFF'IDA.VTT
with a principal place of business/residence at:
"5—(p J141(PGK S� s .�} G4/O J (phone#)
(strr~.t/ci tylstaie/zi P)
do hereby certify, under the pains and penalties of pcgury, that:
( ) I am an employer providing the following wor'ker's compensation coverage for my
employees worming on this job:
(Insurance Couspany) (Policy Numbcr) (Expiation Days)
( ) 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compa-ayiPolicy Number) (Expiration Date)
(Name of Contractor) (Ln--L raP.Cv Co=pazay/Poucy 11,r e) (E ^Yi2tien Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additioai!sfxct ifnccexzary to include infocrosrioa pertaining to all ooatracion)
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 whilo homeowncn wbo cmplay pc ma=to do m intraa= amstuaioa or repair work on a dwelling of
not mo e than throe units in which the homoowncr r=&=or oa the ground,appurtenant tb=o arc Dot gcncsv cowidcrcd to be
employers under the s compensation Act(GL152,=1(5)),appiica6on by a homoowrdr fora Gemsc or permit may wid—the
legal etatua of an employer under the Workce%Compemation Act
I undcrstwd thst a copy of this eratcmcat may be forwarded to tho Departnxni of Indux a!Acadmij 01500 of 1a=r*1)oe for the
coverage wnficaiioa aad that failure to secure covcrago under socUoa 25A of MGL 152 can lead to the impos Oa of ttimi W penalties
oomisting of a fine of up to S1,500.00 muVor imprisonment of up to oac year and civil pcaaitics in the form of a Stop Work Order and a
firm o(5100.00 a day against toe—
Signed this day Of / � 199 Fordeputnt-W trio0Q1y
Permit Number
Map; Lot;
tgnahrre of crmittce
10. Do any signs exist on the property? YES NO
IF YES,describe size,type and location:
Ax
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 cols to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paired paz*ing)
# pf _Parking Spaces
# rof Loading Docks
Fill:
(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
G' is true and accurate to the best of my knowl dge.
DATE: APPLICANT's SIGNATURE
NOTE: issuaino4S of a zoning permit does not relieve can s burden to comply wltl7,.atl-
zoning requirements and obtain all required perm rom the Board of Health. Conservation
Commission. Department of Publio Works and other applicable permit granting authorities:;.
=:' , FILE #
*MAy 61998
AL
J„ Fi 1 e No. 9 —3 �� 1
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: S-(o U ) MO C-1 c Telephone: -
2. Owner of Property: &ZVA2 AC4 Q46A-"
Address: ,L C r- �'i Jr +��-(/ Telephone: Is
3. Status of Applicant: Owner _Contract Purchaser' Lessee
Other(explain):
4. Job Location: I° / f
Parcel Id: Zoning Map# � Parcel# a District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTVIEN
5. Existing Use of Structure/Property j L r--. y MI L�f
6. Description of Proposed Use/Work/Project/Occupabon: (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 KNO"At 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 # .j
1 * f
„APPLICANT/CONTACT PERSON: . 4n O
`0XDDRESS%PHONE:
PROPERTY LOCATION: -
pp PARCEL: a ONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERNUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM VU.YFD OUT
Fee Pa*d
Rnilffing Permit Filled mit
o J
lRerrindelin2 Interior
Addition t�Ryiqfln2
Accessary Structure
THE OWING 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:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval $d'of Health Well Water Potability-Bd Health
_
it froty Conyry C 's ' n p�
Signature of Building ector AD ate
NOTE:lasuanoe of a zoning permit does not relieve an applicant's burden to comply with ail
_ zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioable- permit granting authoritles.
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