35-167 (2) r - > o
v -o o• �
a
3 0 Z
.. ., z m
Z
O
Z .+
1 r
Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.N4,l&2-5"2 2L77Z, Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location 1,331 6 a rL 6±L T��- �/4"�/4��l—J �l r��' Lot No.
2. Owner's name s"Ix K MCe.f�YJ�t f�1Sl�:`-) Address ?3/ 1,LEL. ,7 i��l fL.frL. rL—tc_l
" tiJ /_i_s Address 1/ AA,�y 1C1A) /� n�. 1
3. -Btt�i�eFS name ��c t>c-� N'1� �
Mass.E License No._ 2 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 �l✓ ' F. c: � �. rA <. r4 S
13. Siding house
14. Estimated cost-`B'/p y Q'Q
The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsible app icant
Remarks
MW
y >
+0 4`� TQ -...
-
f.
a B �'` �tasaxcllnsctfa
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 �~
WORItER'S COMPENSATION INSURANCE AFFIDAVIT
1
1, S 1 e�l�� 1�,1`��.��z� tt�►
with a principal place of business/residence at:
/ �( hoe ) Z G A57 Lld) �—� 77,
tY 1 p)
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) (Lasurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Irinu-ancc Company/Poticy Number) (Expiration Date)
(Name of Contractor) Gaa rangy Compmy/Pobcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml xboa if nocc=x y to include im%mati a pataiaing to au 000tr.c )
} I am a sole proprietor and have no one working for me.
( ) Y am a home owner performing all the work myself.
NOTE;please be aware that whim homeowners who employ p xions to do maiatcsanc,,C=anxtioa or repair work on a dwelling of
not molt'*than throo units in which the ho=ownw ridca or on the grounds appurtenant lb=w am not gaoaally ooandcred to be
empiayCM under tbo workcc`z oomprns4oa Act(GL 152,ss 1(5)),application by a homeowner for a licc=or permit may evidence tho
legal ctshsa of an employer under the Woriceet Compomalioa Act
I understand dul a copy of this tfaremcnt may be forwarded to tbo Dcpa�of In&=trinl Aocidmb'Office of InvAranee for the
-v-age vaificatioa and that fader a to soatre eovecago uod< section 23 of MOL 152 can lead to tba imposition of criminal penalties
eoaustmg of a fine of up to 51,500.00 and/or kambomac nt of up to one year and civil pcuzWi in the form of a Stop Work Order and a
fim 0(5100.00**y against ma
Permit Number
_Lot#
Slgdlab=of LiomsedPermiuce
'r ILe
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 MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This columm to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height r/'a�(�
lr c on f Z-'
Bldg Square footage
SCI 0
%Open Space:
(Lot area minus bldg
&paved parking)
# of -Parking spaces
# of Loading Docks
Fill:
Avolume--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowled e.
DATE: �� APPLICANT'S SIGNATURES
NOTE: lasuan a of a zoning permit does not relieve an applicant's burden to oomply with gall
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
FILE #
a. F
Fi i e No. 7&1
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: J`�F V fU r0r7 /Z
Address: /J�ft Wl ) lPi4C Telephone: CC113/_ SZ ! k
�s !'fli4 rYl{mil '/J,. rvt 1�l 0 i d Z
2. Owner of Property: J yl, n k-`/ )
Address:_1 3 3 1 6q eT--.s _Telephone: SLy""SOq r7
�L6 JeFc✓C,F,� Iv!�.
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): -�y-
4. Job Location: .13.�L 1i 12T-s P E t 't Tt L� r P,,cze l !C7
Parcel Id: Zoning Map# Parcel# District(s): b�
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Usex9p roject/Occupabon: (Use additional sheets if necessary):
�PtD o„G,e, Lcl. jQjjj_t e—c i G r1 Q-� LQQ
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 KNO:^:__2� 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__k- 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 I J 3 8 /
OT
/
1' Eg
2 6 T
APPLICANT/CONTACT PERSON-
ADDRESS/PHONE: L ,
PROPERTY LOCATION: / ;�Z � ,�- ��t �I%�
MAP 133 PARCEL: ZONE �5 e___
THIS SECTION FOR..OFFICLAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM MIED 0111
Fee pnid
,./
a —
e �j
'3 'Sek Plany /Pint Plan
nf
THEE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION'
A'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
pproval-Bd of Health Well Water Potability-Bd Health
_Permit from Conservat' ommissi
Signature of Building ector 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 Publio Works and other applicable permit granting authorities.
` • b Z
o
CD �, �• � o ° � ° � 77 �
� � ° ~ a w
cr
CD CD C N
CD
"d'b r+ ° c A cn a
cn cD O R
CD f�Db ' r
CS n
rt
Or4 Ob O (D
11J G O
U� Cn rh M�•
V1 �_ cra C (D
c (o N "r
' n O 3 H ~
Ln
Cl
d z c�
Q. S ° ° (D
o (D
c tit
CD W b7 'Z7 4 V) C7
Gr. c• CD a
Cl LI)
C)
tz co
a `o
7 ao o CD
O cn O OG cn UG O v QG O G. cn CD O �vy�
tz
n R" O O =r v y D
L, cl- o
�C1i7j c.
o
(IQ
Cad
b �
c�