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32C-165 (28) I 2 7C `v 0)� D m { vDi Z ni or co G S z i7 a=-. ' (A Z Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations NORTHAMPTON, MASS. 19 Additions APPLICATION FOR PERMIT TO ALTER Repair Garage 1. Location ``� Lot No. 2. Owners name LYA21 D rJ <—g'a i— ° Address 3. Builder's name wt k,) Address 75_ Mass.Construction Supervisor's License No. Expiration Date 4 � / 4. Addition S. 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 t�C 11. Distance to lot lines 12. Type of roof 13. Siding house 14. Estimated cost:-f , The undersigned certifies that the above statements are we to the best of his, her knowled and belief. Signature of responsible app icant Remarks 4-�ttAMpT �o oy Of 'Nart4a11tptan $ 6 �asxcbtractta m DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT 1, �© d with a principal place of business/residence at: �� r4 • (phone#) � ( city/statrJap) do hereby certify, under the pains and penalties of perjury, that: Iaam an employer providing the following workers compensation coverage for my employees working on this job. 5-// .14ki ek'Ls -40 (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 Comparry/Policy Number) (Expiration Date; (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sboet ifzoornuy to inchsde infamaiion patdning to all ooatrad ) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:pleaAC be aware that wbira homeowocra who employ persom to do mair�comtrvetioa.or repair work on a dwelling of not more than throe units is wttich the homoowncr raids cc oa the grounds appurtenant tbercto are not gc orally 00¢ride-d to be anploYcra under tbo worker's omTcns4cn Act(GL152,m 1(5)),application by a homeowner for a license or permit may evidcom tho regal atntua of an employee under the Workeet Compeoaatioa Act. I understand that a copy of this rnicmc any be forw.vdod to the Dopwtmca2 of Ioduitrid Aoc iJm Offloo of Inver anoo for the coverage verification and that fa um to sauro covaago under sx iou 25A of MOL 152 can lmd to tin imposition of criminal penalties oomistmS of a•tine of up to 11,500.00 0 and/or impaisomnciat of up to one yzar and civil penalties in the form of a Stop Work Order and a fim of 5100.00 a day against ma For dcgutmwW use oaly Permit Number Map# Lot# ti Sigt shire aLi crmit3cc Wte- 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 Colin 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 &paged parkingN # of -Parking spaces f 'of Loading Docks Fill: -(volume--& location) 13 . Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: :3-//a APPLICANT's SIGNATURE NOTE: luau noe of a zoning permit does not relieve an a t pplicans burden to comply witty alt 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 # MAR 1 3 ,998 . I l I File No. C,' 3 � t ZONING PERMIT APPLICATION (§10 . 2 PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: AO'O( -4.v'-'s G" Address: :25- l ( J tlt�4,Telephone: 2. Owner of Property: jL,) (9 ' 5 Address: �Z-� ,5?�v� __. Telephone: S5- 3. Status of Applicant: Ll-(5w-ner Contract Purchaser Lessee Other(explain): 4. Job Location: Parcel Id: Zoning Map# �01�' Parcel# &�J' District(s): 03 (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5, Existing Use of Structure/Property /t? ,7Qid� �-d 6. DeE tion of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): IQ &`t�j 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 1� DON'T KNOW \---' 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) i FILE # 963 J no OR ►998 J _ APPLICANT/ ON ACT PERSON: +.ADDRESS/PH.. 7 J 6ya4S,,,_ 2C PROPERTY LOCATION: MA.P PARCEL: > e-' ZONE THIS SECTION FOR-OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM VH,T,FT) 01TT Fop pflid 0,�mprlOcrnvnnt Statement t/ r THE F LOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION: 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 `Se i@► ;.4tpprp.v-Bd of Health Well Water Potability-Bd Health !Permit from Conservation mmiss'ion Signature of Bui g or Date NOTE:Issuanoa of a zoning permit does not relieve an appiioant's burden to oomply with all _ zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Public), Works and other applioable permit granting authorltles. +: , ` ,��' 7, , � . 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