10B-031 Pile # MP- 2010 -0041
APPLICANT /CONTACT PERSON GUNDERSEN SHAWN E & ANANDA M LENNOX
ADDRESS /PHONE I EVERGREEN RD (413) 585 -5745 Q
PROP TY LOCATION 1 EVERGREEN.RA t
MAP 1013 PARCEL 031
.
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FO FILLED OUT
- F ee Pai
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA - ACCESSORY APT IN DET GARAGE
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 ACTI N HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRE TED:
Approved V 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: § 34yo " alo *
Variance* 1� ��7�
Finding Special Permit ,d
— f�— s?29Jc-7&Je11?:-
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 Co ssion Permit DPW Storm Water Management
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.
J APa 2 7 2014
s File No. 9 �
F�
Please type or print all information and return this form to the Building
Inspector's Office with the $15 filing fee (check or money order) payable to the
City ofNorthamp ton
1. Name of Applicant: S l l CM&I)C'es
Address: ' �V'�E,12L�- 221�.f./U /�� s Telephone: /���� S —5
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee Other (explain)
4. Jobl.ocatiora_
5. Existing Use of Structure /Property: I«S o r'VGF / oN b 1V1I LY) 6 e �r-w O)'lll'
6. Description of Proposed Use /Work/Project/Occupation: (Use additional sheets if necessary):
LIVT lly
%a C�Ny�T S��iy� h�a� /�rTie �a•a -vim) �F E�es�ri ✓6- �.�2AG - ��r�e���
7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special Permit/Variance /Finding 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\ FORMS\ original \Building- Inspector\Zoning- Permit - Application- passive.doc 8142004
10. Do any signs exist on the property? YES NO t/
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO 1/
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
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EXISTING PROPOSED F
Lot Size
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Frontage
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Setbacks Front r,
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SideSZ' L: 53 R: ,.:.
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Rearl /0 No
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Building Height i
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Building Square Footage
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1 110 pen Space: pot area ti
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13. Certification:] hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: AN 2- 70/19 Applicant's Signatur
__
NOTE.: Issuance of a zoning pern'.it Foes not r elleve an pp>rca*±t.'s burden to comply with all: zc►nirig . .
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.
W.\Do=ents\ FORMS\ original\ Building- Inspector\Zoning- Perrmit- Application- passive.doc 8/4/2004
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