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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location i yT l r Lot No.
2. Owner's name�`'r� nAL*' u�/ S Address c.5- -'R)CN AIF /G�c=,C)111 141rl P /27
3. Builder's name I,C�r ��r`�1ri1 (T'N�t�k Address �fC` JAq oe, 3s -
Mass.Construction Supervisor's License No. G`/ Z J W) Expiration Date !7/- /- fF
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 /)/A� � LIS'. ���r r,C-A irD S Sr�r. 'Ira i> r��KID
13. Siding house
14. Estimated cost-
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of rLponsible appicant
Remarks
04�tiAM PLO
°� Crzt of 'Xrrztl ampt.an
e SEA- 2 5 �liaairEtasctla
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
,,WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenseeJpermittee)
with a principal place of business/residence at:
�d &2/s s e,C� 4 Fy 191d d ejs-(phone#) 113)
(SU=t/Clty�)
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) (Insumcc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addr6oail sheet ifnec�to inchLde informs oa pertsiuing to all c«rtradon)
O 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 persom to do�%utmxn„c construction or repair worts on a dwelling of
not mote than throe units is which the homoowncr resides or on the grounds appurtenant thereto are not gcucally considered to be
employers under the worlux's oompc=saricn Act(GL152,ss 1(5)),application by a homeowner for a liccax or permit may cvidcme the
legs)status of an employer under the Worlcees Compensation Art
I understand that a copy of this sratcmcat may be forww ded to tha Dtpn. a fl-h> al Accidmrl Of oc of Isxaanco for the
coverage verification and that failure to secure coverage under secuoa 25A of MOIL 152 can lead to the impos ioa of aiminsl penalties
coosistiug of a fine of up to S1,300.00 an&or imprisonment of up to one year and civil pcnaltics in the form of a Stop Work order and a
f=of 5100.00 a day agpiast tea.
Signed this a _day of 1997 For depatmtrztal tree only
Z L� ' Permit Number
„� Map# Lot#
sigmture of Licemee/Permittee
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 —.Iu= to be filled in
by the Bailding Deparemene
Required
I Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved parking)
., f -Parking Spaces
# fof Loading Docks
Fill:
_(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: 7 S�� y� APPLICANT's SIGNATURE ��
NOTE: Issuanoe of a zoning permit does not relieve an applioanYs burden to comply m0tkokll-
z9ning requirements and obtain all required permits from the Board of Health, Conservation
Commisalon, Department of Publio Works and other appiioable permit granting authoritles.
FILE #
SEP 2 5 h
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 1iil�i�l CrT�/ f
Address: �tJ Telephoner��3� �3P1Ty-s�ll
2. Owner of Property:
Address:_ / N CV i/ lLc '��,gmjP1,+, Telephone:� ��) J
Y?)w
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): //
4. Job Location: /212V pX//
Parcel Id: Zoning Map# c Parcel# District(s): ,GLA✓�
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property _ 1-'Y7 �/Irrl) �� ' �S",'
6. Description of Proposed Use/Work/Project/Occupation: (Use addition I sheets if necessary):
Y)c" �O 'r 17 /1) J S 1.�?
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/Vadance/Finding ever been issued for/on the site?
NO DON'T KNOW jl-� 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 # !96.229-1 WAX SEP 2 5 !9N
APPLICANT/CQNTACT PERSON: X, .4 ,
ADDRESS/PflOt4E'• lei
r
PROPERTY LOCATION: —
MAP e PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM EMILED OITT
Fet- Paid
]Epp Pnif]
Addition to Fxkfin2
-3 Sek of PlAns /Pint Plan
✓.
�.
THE ALLOWING 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 C,4t from DPW Water Availability Sewer Availability
A 4
Septic Approval-Bd of Health Well Water Potability-Bd Health
Pert ' from Conservat, o
Signature of Building for Date
NOTE:issuanoe of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioabie permit granting authorities.
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