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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 4 19— Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location �� GG< �y i-' Lot No.
2. Owner's name i Address
3. Builder's name Address
Mass.Construction Supervisor's p License No. T d� Expiration Date_
/� "
4. Addition C
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 ✓� G
13. Siding house
14. Estimated cost-
The undersigned certifies that the above statements are true to the best of his, her
knowled,ge and belief.
Signature of responsible app icant
Remarks ''Z
=o� Crif� of 'Nazt4aiitptoll
6199 1 j :saachnsctta
`d G
u. m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y '
WORKER'S COMPENSATION INS'UTZANCE A iDAV r
(licenserJpeTmi tt tie}
with a p cipal place of busmess/residence at:
j.
(phone#) tl
(StI'C�l/Cl ty�St�1.1.f�Zl p}
do hereby certify, under the pains and penalties of penury, 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 am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Expiration Date)
(Name of Contractor) (Inntrauce Coniparry/Policy Ntlmbcr) (��
(Name of Connctor) G surancc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insu=4 Company/Policy Naulber) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(attach additioa2l short if ncc:sciry to mc} infon nxtioo pertaining to all=atmcton)
(�am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:p(eaac be aware that vrizilo homeowners woo employ pcxzons to do r„ atc xncc coint,=on or icpair work on•dwelling of
aot more than tbroo units is which the bomoowncr raiidcs oc oa the vouad5 appurtenant hx�n arc oot generally masidacd w be
cagloyc s under the vmo kt oocnpc=atica Act(GLl52,ss 1(5)),application by a homoow nir for a license cc perm"may evidence the
legal dstuia of an omployoc under the Workees Compematioo A-
I undmz i_And thst a copy of this cratcmmt mAy bo fom vdod to tha Dcpartmcnt of Ic aL,,,i $Acad,�& of La 1° for tba
oova-x c vaificeioa and that failure to scaixt coverage under soction 25A of MOL 152 can lrsd to the"imposdioa of mmmal Penalties
consisting of a 1me of up to S 1,500.00 armor imiirno�t of up to o x yiar end civil pcxn2tit�in the form of a Stop Work t?cdcr and a
fine oCS100.00&.&Y•g�inA mc. d,
Signed this /� �- day of , 1997 For dcgartnrxdnl use only
Permit Number
map# Lot#
Si of Li crmit tcc
P
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 cols to be filled in
by the Btal.,amg Department
(Required I
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&Paved Parking)
# of Parking Spaces
# '6f 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.
DATE:�� ? APPLI CANT's SIGNATURE ` : !"
NOTE: lasunnoe of a zoning permit does not relieve an a licant's burden to comply Witl -oll
zoning requirements and obtain all required permits fro the Board of Health, Conservation
Commission, Department of Publio Works and other app cable permit granting authorities.
FILE #
l 6 199 1 �-
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: ,Laz
Address: ' �'�—� Telephone:
2. Owner of Property:
Address: 4�.�u � 'th-L Y Telephone:_
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): c
1
4. Job Location: ?l�z✓ , 4�`i ��`°�
Parcel Id: Zoning Map#_ -;r( Parcel# J District(s): lt'77t �2
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Use/WorkJProject/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/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 �� 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 L` J
DEC I '
APPLICANT/CONTACT PERSON:
ADDRESS/PHONE: Q
PROPERTY LOCATION:
MAP PARCE : ZONES t
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM MLE-D OITT
Fee Paid
BuilfjinZ Permit Filled nut
V'p ��� ` ✓
ownerjorrupantStaternent
�.
THM LOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION.
Approved as presentedfbased 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 Conservat. Commission
Signature o uil ector Date
NOTE:Issuance of a zoning permit does not relieve an applioanYs burden to comply with all
_ zoning requiremants and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public works and other applioable permit granting authoritles.
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