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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. S Alterations
NORTHAMPTON, MASS. h!QV . 10 192Y Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location r' eke ec)ow ;�:>R. "tee M MA, Lot No.
2. Owner's name i 1'l�I'e J CS�'�el (T Address / Q ewe-beaw, ',1�f2} ',2Cr7Ct� Y�R
3. Builder's name �cdl.A Li- ,,,��T"t S Address d �Cf ST,
Mass.Construction Supervisor's License No. 06C,K 6 Z Expiration Date
4. Addition 9
5. Alteration f1lJ�TNL1 �7'� ) X1372 Il �o��2y�o21/ 6/� C�tl 7 voe Cst� 6"AeIN
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 cost:- C(ap
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of responsible appicant
Remarks
0 0 R�
NOV 2 !99_, Crz�r of
��z#l�ttni�tutt L
1 i �bTassachnsrtta
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
MB I I n b 7;e711 afrs7 ST, 601e5bE, f4A C r0?6
511-8 q EST C o�b A C/e-z (phone#� ��� W8--IMS"
' (street/city/stale/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 Comrparry/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)
(quad,additioml sheet ifnecenary to include information pertaining to all coah=tors)
NA 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 homeownera who employ pasoar to do maintc u construction or repair work on a dwelling of
not more than three units in which the bomeowner resides or on the grounds appurtenant thacdo an not generally co=dcred to be
employem under the worker`s compensation Ad(GL 152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workers C.ompamation Ad.
I understand that a copy of this statement may be forwarded to the Dcpartmcaa of I.&atrial Aoodasef Oflioo of hnseusnce for the
coverage verification and that failure to secure coverage under se cUoa 25A of MOL 152 can lead to the imposition of criminal penalties
000sisting of a fine of up to$1,500.00 and/or of up to one year and civil penalties in the form of a stop work Order and a
fine Of 5100.00 a day against the
Signed this day of 1997 gPennit dal—only
�. � Ntunber Lot#
Sim of LicenseelPermittee
NOV
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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.
Thin cols to be filled in
by the Vulldiag Department
Required
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)
#. :pf Parking Spaces
# f 6 Loading Docks
Fill:
-4vol-time--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowle e.
D71TE: ,
/)V,- J D j�Q APPLICANT's SIGNATURE
NOTE: Issuano® of a zoning permit does not relieve an applioant'a burden to oomply wit4,,att
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Publio Works and other appltoabla permit granting authorities.
FILE #
Nov i � a
{
File No. 6360P
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: z' L-TIS
Address: S8}{ FRST S--', fii jf&b 6, MA OLL6 nTelephone(�%3�
T-
2. Owner of Property: efenP U SSepU 1-r
Address:_oil A g&eA,2 oa is"i�>t;?r 7lo gen e c M P Telephoner//±
3. Status of Applicant: Owner — Contract Purchaser Lessee
Other(explain):
4. Job Location: -/ x epebe�X) \Vc �6dlcnC e, d 1k.
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property 6A 0µ6e
6. Description of Proposed UseM/ork/Project/Occupation: (Use additional sheets if necessary):
IN5 raa li_ a .S d/.Y S S"N�( , 7�y CY)2 I N O 1c, 6000(7-t-
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 7 z 6 l r U
NOV 1 / kq
APPLICANT/CONTACT PERSON: �;
ADDRESS/PHONE: �/
PROPERTY LOCATION: 46'
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM Eft.I.FT) OITT
Fee pAid
Building Permit Filled opt L/
Fee Pgid
Type nf Construction-
New Cnnstriirfin
Accessary Striirfiirf,
Building Plano, Included-
a5
'A Set� of PtM_1bL12ln&fin )
T OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
0 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 mission
Signature of Building Ins Date
NOTE: Issuanoa of a zoning permit does not relieve an applioant's burden to oompty with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commlealon, Department of Public), Works and other applioabie permit granting authorltles.
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