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29-462 (5) a ,> o T a r � Z > n 0 o c Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations a rNORTHAMPTON, MASS. /24V 1922 Additions APPLICATION FOR PERMIT TO ALTER Repair 1 Garage 1. Location �7 7 �,/ ���Ul f?.G./ � Lot No. 2. Owner's name A)6 Address - — 3. Builder's name p n l C nrz op?T .)-(Z Address C/ J2�i-L-j S Mass.Construction Supervisor's License No. fa 7 gS"Z) Expiration Date 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 YZAI&Z 14. Estimated cost:- The undersigned certifies that the above statements are true to the best of his, her knowledge and belie Signature of responsible app,icant Remarks ¢�t�MpT 0 0 1W Crio Of Nort4a tpton a + �tassachnsctts m DEPARTMENT OF BUILDING INSPECTIONS ��TTWain Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT with a principal place of business/residence at: ll Wee-e (phone#) (street/city stntrJ2ip) 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 shoes ifnoasssry to include information pertaining to all 000tmod ) I 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 homeowners who employ persons to do muidmancq o=mxtion or repair work on a dwelling of not more than throe vans in Wfuch the homeowner resides or on the groun6 appurtenants thereto are not generally considered to be employto under the worker's oompcnsatim Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Wodcees Compensation Act, I understand tint a copy of this statement may be forwarded to the Departarsa of Industrial A=dm2s OfSoe of law anoe for the coverage verification and that failure to sea=coverage under sectioa 23A of MGL 152 can Lead to the imposition of criminal penalties oomisting of a fine of up to$1,500.00 andlar iatprisonment of up to one year and civil penalties in the form of a stop W ak Order and a fine of 5100.00 a day aping me Signed this �7 day Of� 19V For depwtmratal use only Permit Number Mao Lot# Signa4tre Wrlpermit#ee two 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. Thin cols to be filled in by the Building Department Required Existing Proposed By Zoning Lot size Frontage Setbacks -frnnt - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg ' &paired parking) of Parking Spaces of Loading Docks Fill: Avol-ume--& location) 13 . Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DA'L'E: Al 6' Al,5�,7 APPLICANT's SIGNATURE Iy NOTE: Iss anoe of a zoning permit does not relieve an applioanYs burden to oomply wlttl,,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. FILE # 14 i9J File No. ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant:_ ' ', Address:_ Lf Telephoner 2. Owner of Property: Address: i/7 Cf Sf�zezj Q 42 Telephone:_ 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): 4. Job Location: Parcel Id: Zoning Map# Parcel# District(s): (TO BE FILLED IN BY THE BUILDING DEPARTMENT) ' 5. Existing Use of Structure/Property �L°s/Clp�?fj 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 KN0l1' 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) FILE # 969- 2_ 4 J APPLi ICANT/CONTACT PERSON: � � � � �pf, �'J'� &W-65-21 ADDRESS/PHONE: - PROPERTY LOCATION: �Q MAP PARCEL: ZO Lt THIS SECTION FOR-OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM MLED OUT Fee Pnid Feepnid ✓,. ai?sr Sao — THF,.FOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ftlICATION: 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 from Conservat' Co Signature of Building irjo&tor D to NOTE:issuanoa 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, Department of Publio Works and other applioabie permit granting authorities. 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