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05-001 (3) File # MP- 2011 -0028 APPLICANT /CONTACT PERSON MASONIC HEALTH SYSTEM OF MASS ADDRESS/PHONE 88 MASONIC HOME RD (508) 434 -2262 PROPERTY LOCATION 222 RIVER RD 0"T5'PARML 00 f 001 Zd1NE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ING FORM ILLED OUT e Building Permit Filled out Fee Paid Typeof Construction: ZPA - DEMO NURSE'S RESIDENCE & WATER TOWER New Construction Non Structural interior renovations Addition to Existin 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 INFORMATION 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: § 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 Signature of Building O facial 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. pUG 3 1 2010 -' File No. 9,, Please type or print all information and return this form to the Building Inspector's Office with the $15filingfee (check or money order) payable to the City ofNo o ' 1. Name of Applicant: V v A(° '_ `�" e it et Address: 2, � 2 1 J �� t� . © J 1 7eIep onnn `� [ 3 O ` �� �� pp k T ( Z 1 2. Owner of Property: Address: �O MO's Vr J G �Q9MC �410 Telephone' 5 4 SbT *3q . "Z4 0 4 3. Status of Applicant: Own_ er Contract Purchaser Lessee Other (explain) 6uAkr t `� 4. Job Location: V-2 S Q `o 5" - 5. Existing Use of Structure /Property: , V U►�S C 14 0 Mp 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): (' d [Nq deWd = 'W J Nje-t�(�4 +o - +ter CIO tL) uN OS"1 VOW � �a�►� S-1� I ��� +[)a -+ (has c, N cars F de- 4ce-- . Ue, Q.ISo w 'L C +0- 1� t otJ +h r - w a4i!�- r f q© C-4 7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans 8. Has a Special Permit ever been issued for /on the site? NO DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # 9.Does the site contain a brook, body of water or wetlands? NO DONT 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) W:\Documents\ FORMSb rigina l\Building- Inspector\Zoning- Permit - Application- passive.doc 814(2004 10, Do any signs exist on the property? YES — _ _ NO IF YES, describe size, type and location: Are then: an proposed ch ges to or additions of signs intended for the property? YES NO IF YES; describe size, type an cation: 11. Will the construction activity disturb (clearing, excavation, or filling) over 1 acre or is it part of a common plan of development that will disturb over 1 acre? Y NO IP\ES, then a Northampton Storm Water Management Permi m the DPW is required. 12. ALL INFORMATIONNIUST j* COMI�LE ED,_or PEIBVII f CAN BE DENIED DUE TO K OF INFORMATION This column reserved for use by t. fib Building EJ�IST111T.G PROPOSED 1 ■ 4. »en14 w " 7 ILot Size 7Y BEM . Y Frontage Setbacks Front - Side L: R: L: R: IZ Rear Building Height Building Square Footage ' 76 Open Space: (lot area �.5 Y minus building & paved``° pa rkin g # of Parking Spaces ' # of Loading Doc Fill: (volume & locatio 13. Certification: I hereby c ify that the information contained herein is true and accurate to the best of my knowledge. Date: 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. 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