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11C-006 (4) a ,9 < n. r v -4 o� c v H a 1,--- 3 c oc.,, o• t:: C 1 -1 Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel:/No. Alterations %r NORTHAMPTON, MASS. //77 Gl 19 Additions %41 APPLICATION FOR PERMIT O ALTER Repair Garage 1. Location C /7 r' (E e �-(" Lot No. 2. Owner's name ''''77-2,7 % / //c r-Ci Address '1' F/ r'r4 te/-7 7-1, ,-.7� 3. Builder's name Li) 5 7`4?"--P1 P72- s5 5i'cfr2c 'z "f Address C 3 �n 4 7 S7 i c 7ir4 �7trh Mass.Construction Supervisor's License No. C 3 y�� f/ Expiration Date /1/91/ -8--- 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 S', 01/,.7 /1C 7 Re73/.c c ,-)7-- zU I,plc'd w5 14. Estimated cost- C7 s, 0 d The undersigned certifies that the above statements are true to the best of his, her know led lief. ' > -i,--x--"7---,(7. ,,,,44- Slgna,ure of responsLble applcanl Remarks oQ- TOy vI-_ 'of.Nett B AIo. f asasJnsctta _gai'.. �� ME BUILDING INSPECTIONS -cn 212 Main Street • Municipal Building Northampton, Mass. 01060 ' to' WORKER'S COMPENSATION INSURANCE AFFIDAVIT I F'/2.4 I5- 4 � T`0 (li censerlpermi ttee) with a principal place of business/residence at: 3 E4 5-7" 57- cc:s ,r,-/rote / (phoney#) s ' C 5'7- Z (strati I/city/statelzip) 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) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necessary to include informahoa pertaining to all cease on) I am a sole proprietor and have no one workin for me. ( 13 ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a dwelling of not mote than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally oomidered to be employers under the worker's compensation Act(GL.152,s1 1(5)),application by a homeowner for a license cc permit may evidence the legal status of an employer under the Wodcela Compensation Act. I understand that a copy of this atatcmaat may be forwarded to the Department of Industrial Accidmb'Office of Inswanoo for the coverage verification and that failure to secure coveeago under section 25A of MOL 152 can lead to the imposition of criminal penalties oocauting of a rme of up to S1,500.00 andfor imprisonment of up to one year and civil penalties in the form of a.Stop Worts Order and a fine of S100.00 a day against me. Signed day of /` 1997 For departmental use only 72 - L/� - Permit Number Lot I Signature of Li IPcrthitt ` 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 MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled in by the Building Department Required Existing Proposed By Zoning Lot size Frontage Setbacks - front - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg bpeved parking) # of Parking Spaces # of Loading Docks Fill: _(volume -& location) 13 . Certification: I hereby certify that the information contained herein G is true and accurate to the best of my know 7". /17 DATE: f/ 7 7 APPLICANT's SIGNATURE r�,'/ 41111111;41111111;NOTE: Issues e' 7 a zoning permit does not relieve an cap oant'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 applicable permit granting authorities. FILE FILE I 9� , , U 7 /0if ?.; 1 7199 I APPLICANT/CONTACT PERSON: d, I ADDRESS/PHONE: Lem ;7,7 7 PROPERTY LOCATION: i , , Z40•12.d o4=c- 1?.,,.e; MAP //G PARCEL' • ZONE THIS SECTION FOR-OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZfNTN.G FORM 'FIT,TET) OTTT Fee Pairi Building Permit Filled out ✓ Fee Paid /9oz2 Type of C nctruction• New Construction iC dE1vX,ei _ Remodeling Tnteri.nr Artiu -0 Addition to Existing Accessory Structure Building Plans Tnrliided• Owner/Occupant Statement o use # C),3 y(p� T c� 3 Sets of Plans /Plot Plan THELLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: ��$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 Conservation ommissiou Signature of Bui ding?. .r M Date NOTE: Issuanoe of a zoning permit does not relieve an applioant's burden to oompty with all _ zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works and other applioable permit granting authorities. n a a. - o ?; * o, O MO, > '�b C . .y.. ."T P] H p H P A 5 - P v)4 n �" ,„,g � „ c. 0cocr o y •..m' .. w o 5. g. x� 0 w ".°' o n W C � � y y rob go aw � 1_, tgli, 'il fD L/1 c r � n C-'<� c, � r� 0r, g rt r el til � P , , a° o g g• I a Cl) ao o–o E. tea. ° c.' 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