44-104 File#MP-2016-0091
APPLICANT/CONTACT PERSON ZAJAC NATHAN
ADDRESS/PHONE 137 PARSONS ST (413)214-2607()
PROPERTY LOCATION ROCKY HILL RD
MAP 44 PARCEL 104 001 ZONE
THIS SECTION FOR OFFI�IAL USE ONLY:
PERMIT APPLICATIOIJ CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA- SINGLE FAMILY HOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE,FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
7IN RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND/OR Special Permit with Site Plan
Major Project: Site Plan AND/OR Special Permit with Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: § I
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Z'-- �'/ S 2
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning&Development for more information.
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Please type or print all informatio and return this form, to the Building
InspectGr's Office with the $30 fllingfel e (check or money order)payable to the
City ofATorthamptort
1, Name of
Address:
2' Owner of
Address: Telephone:
]' Status of Applicant: Owner _ Contract Purchaser Lessee Other (explain)
� —
4. Job ^/ �
Parcel Id: Zoning Map#_4,7" Parcel# District(s):
In Elm Street District In Central Business District
(TO BE FILLED IN BY TH� BUILDING DEPARTMENT)
5. Existing Use of Structure/Property:
6' Description of Proposed Use/Work/P roj : (Use additional sheets if necessary):
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
D. Has aSpecial site?
moDONT KNOW YES (FYES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON*T KNOW YES
IF .E"' enter ovu^ Page and/or Document#
9.Does the site contain abrook, body ofwater orwetlands? No DONT KNOW _______ Y[S ______
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs Uobeobtained Obtained ` date issued:
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(Form Continues OnOther Side)
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10. Do any signs exist on the property? YES NO 1X',
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. Will the construction activity disturb (clearing, gradinga excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO 4
IF YES, then a Northampton Storm !Mater Managlement Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERI-41T CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
,dor use by the Building
Department
EXISTING PROPOSED REQUIRED BY
ZONING
Lot Size
VZ
Frontage
Setbacks Front
Side L: d. f R: ' L: R: 3 L: R:
Rear
Building Height
Building Square Footage
%Open Space: (lot area /
minus building Et paved t
parkingL�
#of Parking Spaces
v/ Z-
#of Loading Docks
VIV
Fill:
(volume Et location) -T
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: S Applicant's Signature
NOTE:Issuance 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,
Historic and Architectural Boards,Department of'',Public Works and other applicable permit granting
authorities.
WA\DocumentsTORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doe 8/4/2004
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