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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS.— M��n4 L Additions
APPLICATION FOR PERMIT TO ALTER Repair
a Garage
1. Location Lot No.
2. Owner's name Address
3. Builder's name Address S-e-ro" Civ,wjrj� k-)A&.,P
Mass.Construction Supervisor's License No. C23 76 3 Expiration Date__l 0 1 CO-
4. Addition
P. V-4- t��
5. Alteration
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage N 0 No.of cars Size
10. Method of heating A—TI Q IL
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost:- SO- Ar-
to The undersigned certifies that the above statements are we to the best of his, her
knowled7d belhef* .,�4 q�
Signature of responsible app,icant
U v�
Remarks
Crif� of Wart4amptan
W ,
$ � �1Tasaacllnsetls
� W
APARTMENT OF BUILDING INSPECTIONS c
j 212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVTr
cilttee)
with a principal place of business/residence at: 4
V-9A tLv- �F-N`+ �L l � a (phone#) 44 3 - —(Z.24
(street/city/state/2ip)
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)
C") 1 am a sole proprietor, neral contract or homeowner(circle one) and have hired
the contractors listed below,w o ve a following worker's compensation policies:
n wc. �$3 �-�l
�, ( a�CleX R7l�i�r'l'7
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy umber) (Expiration D-late)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed if neeenary to include information paRaiaing to an ooaftcWra)
( } 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 vrhilc homeowners who employ pawns to do maintenance,con&uction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the groins appurtenant thereto are not generally considered to be
employers under the worker's compensation Ad(GL152,ss l(5)�application by a homeowner for a Gewme or permit may evidaroe the
legal status of an employer under the Worfreeis C.ompenseboa Act
I undetstaad that a copy ofthis statement may be forvvardod to the Depwu=os of Industrial Amidan&Offroo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal pemhies
confisting of a fie of up to$1,500.00 andlor imprisownent of up to one year and civil penalties in the fans of a Stop Work Order and a
fine of 5100.00 a day against eta.
t d�'1�
Signed this { day of Y` 1997 For depamixotal use only
Permit Number
Map# Lot#
Signabm of Licansee/Pem4itee /
See reverse side fnr instntetinnv
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 colt to be filled in
by the Bnildiny Departs nt
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
- rear
,Building height `
Bldg Square footage �r „
%Open Space:
(Lotarea minus bldg
' &paved parking)
# Pf Parking Spaces
ht of Loading Docks
Fill:
-(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my know dge.
DATE: VI � APPLICANT's SIGNATURE
NOTE: lasuanoa of a zoning
g permit does not relieve an applioanYs burden to comply wit4,,.4pi1
zoning requirements and obtain all required permits from the Board of Health..Conservation
tCommisaion. Department of Publio Works and other applicable permit granting authorities.
FILE #
l
MAY 1 91997
t Fi 1 e No.
T CF
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: e; �2yV Telephone: 2 �1
2. Owner of Property: J X1/1 4-w-2c "o
Address: S 'i� S'�. Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): 2
4. Job Location: k 5 A- Og-1- Ste.
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property VVk o U SIrz-
6. Descripti of Proposed UseMlork/Project/Occupation: (Use ad itional sh ets if necessary):
p CL` c.�
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 Pe it/Vadance/Finding ever been issued for/on the site?
NO DON'T KNOW YES IF YES,date issued:
IF YES: Was t permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or DD ument#
9. Does the site contain a brook, body of water or wetlands? NO V 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)
9� �
€ FILE # 6
to q1
MAY
qq ��qq77
APPLICA7V`T'/CONTACT PERSON:
r T , ARESS/PHONE: J� C'
PROPERTY LOCATION:
MAP c C PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OITT
Rnilding Permit Filled piit
Fee Paid ° R7 —
THE LLOWING 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
Septic Approval-Bd of Health Well Water Potability-Bd Health
!Permit from Conservatio ommissio
Signature of Building or 11ate.
NOTE:Issuanoa of a zoning permit does not relieve an applioant's burden to oomply with ail
zoning requirements And obtain all required permits from the Board of Health, Conservation
Commission, Department of Pubilo Works and other applicable permit granting authoritles.
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