35-180 (2) ' >v
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. — '3 S Alterations
NORTHAMPTON, MASS. 7-- 7P f 9 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location Lot No.
2. Owner's name �' r t 0-11 A.CAivyrte Address -3n:5, R41
3. Builder's name Address 4411- /a
Mass.Construction Supervisor's License No. / 0 O - C. '2 Y Expiration Date G - g
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 cost:-
F
The undersigned certifies that the above statements are true to the best of his, her
_I a knowledge and belief.
US
gnature ojresponsible app,icant
i
Remarks
s JUL 1 I (rx� of II� lj&11t 7 II7I ..
A13aschnsctta
OF RI INS PE,, 0NS EPARTMENT OF BUILDWG INSPECTIONS
'212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WOM CER'S COMPENSA710N INSURANCE AXITIDAVIT
(li�nscc/permitirc)
with a principal place of bumness/residence at:
(stzm;c-t/cih'/ -daP)
do hereby certify, under the pains and penalties of perjury, thai.
I am an employer providing the following v.,or'i er's compensation coverage for trey
employees working on this job.
ce npany) (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) (Lnsvranc-z Cornppauy/Pohcy Numhcr) (Expiration Date)
(Name of Contractor) (Insurance CompanyrPoticy Number) (Expiration Date)
(Name of Contractor) (Lnsztran(-- Company/Policy Nunnbu) (Fxpumdoo Date)
(Name of Contractor) (Iasu=c_- Compauy/Policy Number) (Expiration Date)
(coach a'3&6omt sbcct iFnoanuy to ia'}— infocnuaoa pctaiaing to all o�ahvcfon)
( ) I am a sole proprietor and have no one working for me.
( ) I am a-home owner performing all the work myself. "
NOTE:plcasc be aware thlt vAiilo bomcowrxra wbo¢ap!oy pawn,to do,,,•:..I-3�masruciioa or rcPair work on 1 dwelling of
not moor than thtroo unit,in wtrich the bomoowocr rc idc3 or on the gvun&1pp�tbacto arc not geoavlly co=i6aod to tic
cmployen under tho vvorkr_r`s ccmpc="iim Act(GLI52,ss I(5)�applicaSon by a homooW=for 1 ticmx or perm may cvidcncx the
legal status of an mployx undertho Wockoda ComponuAka AeL
I undcrrixad thli a copy of this catcmcra may bo focwwxW to tbo Dcpnrtmc.3,t of Indus d AocdmLf Of54'o of for dw
covaa ge vcx%cztioa atzd that failure to secure coverago unda soctioa 23A of MOL 132 can lead to tba impoi On of-imi W pcaaltics
comist wz of a fine bf up to S1,500.00 mdloc 63pr6oamxmi of up to one year and civil pcaLltia in the form of a Stop W ork Orda sad a
sac of s 100.00><day agniw%mc-
Sigqo this // _day gf 1997 For dial use oats
Permit Number
Q
te �— Map4 Lot#
Signature of Li fermi
10e 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 cola= to be filled in
by the Banding 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)
of -Parking Spaces
f of 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.
DAZE: APPLICANT's SIGNATURE
NOTE: Issuance of a zoning permit does not relieve an a ioants urden to oom
p Ply wit4,.$tl
zoning requirements and obtain all required permits from the Boa of Health. Conservation
Commission. Department of Publio Works and other appliomble permit granting authorities.
FILE #
•m
juL I 1 1997
tiEP10F R!.' y Irdcs: . �, Fi1e No.
O
�t Fib.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: v-
Address: Telephone: PS — Z 3 I5
2. Owner of Property: a�t�t
Address: 3 �vu�2 V Telephone:
3. Status of Applicant: Owner Contract Purchaser i/ Lessee
Other(explain): I
4. Job Location: \V/� R�
Parcel Id: Zoning Map#- -�" Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property �� ,
6. Description of Proposed Use/Work/Project/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)
9 6 ti 5 z 9 t,►�"�'�
D FILE
t
ALAPPLIICANtCONTACT PE ON: a44,t _ &V-z 963 75
DEPT OF 13t! SS SUgNE:
PROPERTY LOCATION:
MAP ��� PARCEL:
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OUT
Bnilrfing Permit Filled nlit
Fee pnid
Addition to Existing
THE LOWING 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-Bd of Health Well Water Potability-Bd Health
Permit from Con�se/r'vatio ommission
/7'
Signature of Building Ins r Date
NOTE:lasuanoa of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other appiioable permit granting authoritles.
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