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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 7 1 c n Lot No.
2. Owners name r1ov-i0 v\ Rva(2 IS*/ Address fkzwf--Pd+ .sL
3. Builder's name 1) Avl � �lAOSon Address yy Aria✓ fall �. G(lifllamsbuva
Mass.Construction Supervisor's License No. 0,5-1-26-3 Expiration Date
4. Addition
5. Alteration Q da, �x �� �+.`e+ �s'f'�o nef' Slaor oo✓c��
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 If
14. Estimated cost:- ?SS0
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
IL _j a ".A�l
Signatu of responsible app icani
Remarks
2 6 1199
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
O1ti Sv,y'
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AiE'F'IDAVIT
(liceusee/permittee}
with a principal place of business/residence at:
(phone#) 02(og 73 gq
(Stne city/ gip)
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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insuuance Company/Policy Number) (Expiration Date)
(attach additional shoot if necesuary to include mfocrosuon pertaining to au coat and m)
Q9 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 Arlo homeowners who employ pasom to do makden .,e construction or repair work on a dwelling of
not atom than throe units in which the homeowner reside or on the grouads appurteau t thereto are not gaxrally oo=dcrrd to be
employers under the worker's compensation Act(GL152,ss l(5))�,application by a homeowner for a license or permit nary evidw oe the
legal crabs of as employer under the Wor c g compec at Act.
I understand that a copy of this etatcaxa may be forwarded to the Dgwftnms of Indush ial A=dco&Office of Insurwoe for the
covmge verification and that failure to secure covemp tmxkr section 25A of MGL 152 can lead to the impositioa of criminal penalties
oomisting of a fine of up to 51,500.00 andtor imprison of up to one year and civil pmal6cs in the form of a Stop Work order and a
firm of S 100.00 a day against me.
For departmental taro oaly
Permit Number
�s2 -I&—q? Map# Lot#
Sign fi=of LicensuoPPermittee Late
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 cclumm to be filled in
by the Building Aepartment
(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
&pac•ed parking)
# of -Parking spaces
#
of Loading Docks
Fill:
Avolume -& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
DATE: 9 APPLICANT's SIGNATURE d
NOTE: Issuanoe of a zoning permit does not relieve an applioants bur en to oomply with 4xil
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 #
L6 2 6 098 / ,
File No.96 39.-5 3
c
PEP-MIT APPLICATION (§10 . 2
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: '0 14 V'� 60 ,
Address: 44( 4,Y( Aj• l!af r, b Telephone: a 6 ' 73T9
2. Owner of Property: lFlov-;an Rog a
Address: 77 a—u Ve4 St Telephone: �S�h'� lt� 93
3. Status of Applicant: Owner _Contract Purchaser Lessee
Other(explain):://
4. Job Location: 7 1/04,L' S L
t
Parcel Id: Zoning Map# � Parcel# ��� District(s): 2�_
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
T1 reLudd ✓n-gr- O-era G X ? ' 6 " V%,-*
N SQ yA-q Fctyf A r .-{- QS d Id 'j ery-r.
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 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)
l FILE # 963253
,3P
F B 2 6 19983
APPLICANT/CQNT LCTPEIRSON:-�Dai�4 ��yL C26'? j
ADDRESS/PHONE:
Al 41 T IM
PROPERTY LOCATION:
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULET) 011T
Fee Plid
Fee Pqif]
Tyne of Cnnstnictinn-
A(Mition to Existing
.qt-tq n Pint P1
d- ✓
s
T OLLOWING 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
Per it from Conservatio ommiss'ion
GL /C� f
Signature of Building iagj3ector Date
NOTE:Issuanoe of a zoning permit does not relieve an applicant's burden to oompty with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Public Works and other, applicable permit granting authorities.
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