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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. � �� Alterations
NORTHAMPTON, MASS.
�9 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location l DOC Cru S&-�j Dll FLa2..5,C--- Lot No.
2. Owner's name NA- 4.44-r ��� Address
3. Builder's name AddressPj 302, Z*T1
Mass.Construction Supervisor's License No. d/-)6 ci `3 Expiration Date / / _zk
4. Addition 37� 3 f
5. Alteration (jg-40,o %i A-,e 711 ,A A c ,e- 8r � .� U�c FI)
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire JG s
9. Garage r1-Jb No.of cars Size
10. Method of heating C,,4 C l-�ts �C �-- la+�et .t c'r1
11. Distance to lot lines ,,....lA
12. Type of roof T'i
13. Siding house 01 nJrO �-
14. Estimated cost-
e and rsigned certifies that the above statements are true to the best of his, her
nowl ge and belief.
Signature of responsible app scant
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVrr
(licenseeJPermittee)
with a principal place of business/residence at:
o (3,3,>- -N-L L1AS: Lz roc a AAA (phone#)4t3-,5-ZS-3 t�
(st=Ucity/sta&2jp)
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:
MI. -L S,� n-urn -S'0z x-41 k-n c� 3 A/
(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 Company/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 additiomi shed Tnecenary to iaohtde information pertaining to all coatractom)
( ) 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 homeowners who employ pc==to do maim�0=wuctioa or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto am not gen rally eo=dered to be
employa3 under the worker's oompens4on Act(GL15Z=1(5))�,application by a homeowner for a license or permit may evideaoe the
legal slats of an employer under the Worker's Compemation Ace.
I understand that a oopy of thin siatemmi may be forwarded to the Departaxot of Industrial Accidm2>Otlioe of Insurance for the
coverage vmficatiou and that failure to secure coverage tinder section 25A of MGL 152 can lead to the imposition of criminal penalties
ofat�'me of up to$1,St�.QO atxlfor imprisonmeaL of up to one year and civil pennitia in the font of a Stop Work Order and a
firm 5100. a day against me.
geed;this 2-/ day of M,&.Y , 1997 Far del use only
Permit Number
Map# Lot#
Signature of Licensee/Permittee
10. Do any signs exist on the property? YES NO All
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES-111)43- NO
IF YES,describe size,type and location:
11. ALL INFORMATION MOST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This cc?== to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size /4 'v
Frontage
Setbacks
- side L:2--� R: 23 L: R:
- rear
Building height 14-
1�
Bldg Square footage �-Z T90
%Open Space:
(Lot area minus bldg , t
&paved parking) 'v�A
.Qf Parking spaces
f of Loading Docks
Fill:
4 vol-ume--& location) �,►��
13 . Certification: I hereby certify that the nfor ation contained herein
a
is true and accurate to the best of my k owle ge.
DATE: 2 4'7 _ APPLICANT's SIGNATURE `-V-4 fY-
NOTE: lss anoe of a zoning permit does not relieve an applicant's burden to com wit ,all
P�7/ h-.
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applicable permit granting authorities.-
`.` `t FILE #
File No.
1
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: lephone:
2. Owner of Property:
Address: &'3 -aL,-71'j Telephone: .>`— � —
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property -'�'/A3Gc�" f'7o M-+L-y
6. Descriptio of Prop o se/V1lork/Pro' t/Occupatio, : (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/Variance/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 L'z 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)
i
FILE # n
j J
APPLICANT/CONTAC PERSON: J�/ ����� l A/
ADDRESS/PHONE: Cr
PROPERTY LOCATION:
MAP -3 5'" PARCEL: % ZONE
THIS SECTION FOR�OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM E11,121) OUT
Building Permit Filled wit
Type of Constniction-
-Remndelin2 Inter'
Stritchirt
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T i-FOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATIOM
ll// 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 Conservati ommissi
Z
Signature of Building r Date
NOTE:Issuanoe of a zoning permit does not relieve an applicant's burden to comply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applicable permit granting authorities.
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