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L5 j u; L� t \J �'I', FILE I 9 6 2 8 3 7
9/3Y 1 ,i
. . , 9
••• C'L •. /Ck3I4 ACT PERSON: (j! t58�-4 51 C
H
DEPT OF SUILD!t4 ; 1f47
N PROP rA ti 4 r;; •
by °t � _
—P ERTYALOCATION: - ___ dk !
MAP di PARCEL: C � ZONE i 40
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FIT.T,F,11 OTTT
Fee Paid
Building Permit Filled nut r.....-''.."'
Fee Paid a Pr &OC ✓
Tyre of C'nnctrurtinn•
New C'nnctrurtinn (/ ,7,/�� ,,
Remndeling Tnterinr � ids t -rnt_IG-'Y�
Additinn to Fxicting it 3
Arreccnry Structure
Building Planc Tnrluded•
Owner/Orrurant Statement nr ence (jlo 775 Q `'
3 Setc of Plans /Pint Plan
TIM/FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
IZ 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 A‘Val-Bd of Health Well Water Potability-Bd Health
_!Permit from Conservatio, 'ommiss�ion
mi
Signa s e o ":ri", . r -
- r, Date
NOTE: Issuanoe of a zoning permit does not relieve an appiloant's burden to comply with all
_ zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioabie permit granting authorities.
a • 0
1, i II
2 L'
File No.go p727, / 1
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON MA 0106 ING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: Fe/ reiCSe i-r c)rt.
Address: It ee4?d S.7- Telephoner/-(p-5-7/
2. Owner of Property: R!C K P-e-4,4--
Address: y� 6j/,/4J9•b'tv RC/ Telephone: 'C -S y 66 y7
3. Status of Applicant: Owner ✓Contract Purchaser Lessee
Other(explain):
4. Job Location: 511'x...
Parcel Id: Zoning Map# 22 Parcel# S District(s):
(TO BE FILLED IN BY TI BUILDING DEPARTMENT
5. Existing Use of Structure/Property .
,..74,
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 Ir� 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)
•
10. Do any signs exist on the property? YES NO
Rae
IF YES,describe size,type and location: S
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
&paved parking)
# of -Parking Spaces
it of Loading Docks
Fill:
(vol-izme--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
DATE: 9'21 9 7 APPLICANT's SIGNATURE a
t"• NOTE: Issuance of a zoning permit does not relieve an 9 P applicant's burden to comply With,.&l
zoning requirements end obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applloable permit granting authorities.
FILE #
v • u u
4TttAMPT 9
o oy III
4•- X of Narf ntp nt ■ '-
L if�i+� I ,N. AMPTNN M PECT40NS JlaasAclinsctte � �^I 60
4 DEPARTMENT OP BUILDrKG INSPECTIONS 4 ^ �i_ _
212 Main Street • Municipal Building ' o,�—1V.�,
Northampton, Mass. 01060 us
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, T 1d9 ,_77--;./0
(licenste/permittee)
with a principal place of business/residence at:
f'e/ Si- lU /t1"/ • 1,14 O/,I,9e (phone/0 :gy 657/
(street/city/state/zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers 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 additim7t sheet if necessary to include information pertaining to all contactors)
(XI am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while hotncowncra who employ persons to do rr ,air//sae's construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not generally ooasidcrrd to be
employers under the worker's ceanpezzatien Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workee'a Compem.arion Ace.
I understand that a copy of this r""`"*"."`"may be forwarded to the Department of Industrial Amidmie Offioo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fax of up to S 1,500.00 and/or imprisoamcai of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against tnc.
Signed this ' day of Se f , 1997 For departmental use only
Permit Number
Map# Lot#
Signature of Licensee./Permitice __
Nag
a
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C �o C -0 '�: .a
CTI m
3 a
oy
C7 � .4% Z m Z r i
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Zi z ,_ o
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I '9
Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
=r NORTHAMPTON, MASS. 19 Additions
" `'A'
' APPLICATION FOR PERMIT TO ALTER Repair
i
' f Garage
I. Location %2 Pi/hark/ i?C/ Lot No.
2. Owner's name RI C K Pe i)4- Address 4'1 41/i v°.4.✓ Rd
�'cl �a� y
3. Builder's name �:"t'T �1k Address L/ J�:�-�/ -ST
Mass.Construction Supervisor's License No.6 7y_SC) Expiration Date 9-3o—D..41.;
s
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.$3/L,O -
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
it'
Signature of responsible applicant
Remarks 2ws,4// c
•