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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. (-a`°k 19� Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location ReVncatiSc: Dck"k Lot No.
2. Owner's name I i r� Address ^t&A 6
3. Builder's name YNAv421L Address t
�1 �-
Mass.Construction Supervisor's License No. CS'SLI Expiration Date_ 'r 9-C ICA
4. Addition
5. Alteration
6. eX�S� �� e°1
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 :,-t-e -k u�
A t -,c
12. Type of roof
13. Siding house
14. Estimated cost:- L/� C)
The undersigned cenifie that e abov 'state nts are true to the best of his, her
knowledge an tef. -'
G`
Signature of respo Bible app icant
Remarks __�)ecL�_ a U, cs,c
t rr ( of A(id' s`
r
D LT J -61, �
JUN 1 01997 C�izf�r z#I�ttnt art
OF 90
$ d � �asaacElasetta
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
O1 RI lV•y�
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L KA Arc\L �►a�2w F��
(Iicense&permittee)
with a principal place of business/residence at:
�CQ (phone#) X31--7 V I -J
(street/city/staWzip)
do hereby certify, under the pains and penalties of per3ury, that:
01 1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
ausurahce Company) (Policy Number) (Expire on 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 ifneoessary to include infwmation pataiaing to all oontrnsdosa)
( ) 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 avrare that while homeowners who employ persons to do maintenance,construction or repair work on a dwelling of
not more than ihtft units m winch the homeowner resides or an the grounds apoutanaud.thereto are not genially co=dercd to be
employers under the workers ownpeasation Act(GL152,ss 1(5)),application by a homeowner for a liocim or permit may evidence the,
legal statuua of as amployer under the Workor's Compemation Ad.
I understand that a copy of this statement may be forwarded to the Depatarna of Industrial A=dm&Ol$oe of tasuranm for the
covaxge,verification and that failure to swim coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
oomb ing of a fine of up to$1,500.00 and/or imptisoames of up to one year and civil penalties in the form of a Stop Work order and a
fuse of 5100.00 a day against mo.
Signed this Of V� 199 Foe dep twe use only
Permit Number
Map# Lot#
Signature of LicenseeJPermittee
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JUN 1 01997
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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 COMPLE'T'ED, 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 --5,1
Frontage ► �w�^�' J
Setbacks
4!
- side L: R: L: 3 V R:�
- rear
Building height
Bldg Square footage 0 2,Cy3,-j h,0-4- COV
,
%Open Space:
(Lot area minus bldg
&paced Harking) I u
f Parking spaces
# of Loading Docks
Fill: -
4 vol-ume--& location)
13 . Certification: I hereby certify that the informat ` n cont in d herein
G is true and accurate to the best of my knowled
_1
D71TE: APPLICANT's SIGNATURE
NOTE: lssuanoo of a zoning permit does not relieve an appiioanro burden to oomply witty,,all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission. Department of Publio Works and other appiloable permit granting authorities.
FILE #
a t�
Jl>�t
t 1 01997
DEPT OF,Kll 7 IPlfi�ECT���`? File No.
e
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 1`M\A21L �Vz'<7 rr V\1
Address: ��54F1' �;:1�.r� f7cQ I)-ovi Telephone:_ ,SD-1 -Tl J
2. Owner of Proper.-Z:Q-t A ���A-c
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: L
Parcel Id: Zoning Map#--C;2 q Parcel# 9 District(s): -�
(TO BE 9LLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Descri lion of Proposed Use/Work/Pro" upation: (Use additional sheets if necessary): Q
�otin� izec t� I X� - y '7 3"
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_ YES IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW__Y 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
PROPERTY LOCATION: �'"
MAP PARCEL: Q�=3 ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERNUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
7,ONIFNC-FORM M,1 ED OUT
Fee Paid
Fee Pnid 19219 y ,�
New Cnnqtrnrtinn
s
Of Plnn^� 16
_
T LLOWII�tG ACTION HAS BEEN TAKEN ON THIS AP ICATION:
Approved as presentedfbased 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 Conservat' Commiss' n
Signature of Building ector ate
NOTE:lssuanoe of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, De"rtme_nt of Publio Works and other applicable permit granting authorlties.
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