32C-232 (2) >
tv
70 a
Z M
C67 ft
5* Z
C12) >
Z A turf
>
Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19— Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location -,t Lot No.
2. Owner's name Z Address
�T
3. Builder's name- A 1-4 Address
Mass.Construction Supervisor's License No. Expiration Date
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 roof -tti,v 4) Laa
13. Siding house ✓
14. Estimated cost:-
The undersigned certifies that the above statements are we to the best of his, her
knowl dge and belief.
I- a-,
Signature ofresponsible appicani
Remarks
0�HA1 fp,
i O
u
! Alass ach use Us
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSA'ZTON INSURANCE AFFIDAVIT
(11Cen- Perlinttce)
with a principal place of business/residence at:
( city/sZatf/ap)
do hereby certify, under the pains and penaities of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
l�LG �Zc?cl7C<�> Cl/ `f !f'/
(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 Company/Policy Number) (Expirabon Dale)
(Name of Contractor) (InsZiraace Company/Policy Number) (Expiration Date)
(attach additional sheet ifne, s to include informaIIoa pertaining to all ooatradorz)
( ) I am a sole proprietor and have no one working for me.
( ) X am a home owner performing all the work myself.
NOTE-plcasc be avrare that whilo homcowncra who employ per;.=to do m.inicaa ncr,aousuuctioe or repair work on a dwelling of
cot morn than Lbr» units is which the homeowner raid=or on the grounds appurtenant thacto ace not gsmrally coasidacd to be
employm under the vmd tez eampensation Act(GL152,ss 1(5)�applicaboa by a homeowner for a liaise cc pennU may evidence the
legal stanca of an employer undertho Workees Compe sdion Act
I undec:tand that a copy of thin ctat—may bo forwarded to tho DVutr :can of Ia&LxU ial Accidca&of -of Imsucanoa for the
coverage veificauoa and that failure to s==coverage under seetioa 25A of MOL 152 can lead to the imposition of criminal penalties
comistiug of a fine of up to 51,500.00 and/or imprison of up to one year and civil penzWcs is the f—of a Stop Work Order and a
firm 01S100.00 a day against me.
'Signed this ,Xd'_day of C�C-1 1997 For icpatm v l uic ocay
Permit Number
c. Map# Lot#I
Stgnatttre of LianserJPetmitfee
-
___ i
10. Do any signs ebst 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:
I1. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This colt 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
' &paved parking)
# Pf Parking Spaces
f 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.
.1
DATE: S- -g APPLICANT s SIGNATURE )
( c � � .
NOTE: Issuanoe of in zoning permit does not relieve an applioanYs burden to oomply W!W,.oll
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 #
`
��r � � 0U7
~=' � v =u'
�l \
File No. Lv--
�� ��� �� � �
=���°== � ====~� °'� � ====��== « ���� . ��
PLEASE TYPE OR IRZYT ALL INFORMATION
1. Name eKApplicant:
Addve '
2. Owner of Pmwpmrty '
Address: iephona
3. Status of Applicant: Ovvner �Contract Purchaser Lessee
Other(explain):
4. Job Location: k5_ 114il-111
Parcel Id: Zoning K0ap Parcel District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use ofStructure/P rope rty -/
8.
T. Attached Plans: Sketch Plan Site Plan ngineared/Guna*vedP|ana
Answers on the following c questions may ueobtained uy checking with the Building Dept o,Planning Department Files.
8. Has e Special Pennh//ahunoa/Finding ever been issued for/on the site?
NO DON'T KNOW =~ YES IF YES,date issued:
lFYES: Was the permit recorded nt the Registry ofDeeds?
NO DON'T KNOW YE
IF YES: enter Book Paga and/or Document
8. Does the site contain o brook, body of water orwetlands? N DON'T KNOW YE
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs tobo obtained Obtained— date issued:
(FORM CONTINUES ONOTHER SIDE)
FILE #_ "
RR7F/CONTACT PERSON:
P�I 40
ADDRESS/PHONE: lU 'j, L�
PROPERTY LOCATION:
- � .
MAP 301 PARCEL: - ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERNIIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZQNTNC�FORM VU,T,FD OUT
Fee Pnid
Rernnrlelin2 Interior
J '
f of
7� u
THE �;6LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICAT1W
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 Conservation Commission
Signa o ..Q Date
NOTE:lssuanoe of zoning permit does not relieve an applicant's burden to comply 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 authorities.
n
r � �
o '�
ky CD U-1
LO
n
cDO W " n N
ir CL
CD-0 n
� W g t g n
°o F n
m o o m cn
p' � C.,, c� cv p I--
r o . S amxrt
GCS Qq IS N O
° n O
g a
CA 0-9
rt D
IZ
C)
tz
r g cy tz r d
°a
�. E3
_
a Ff, o ] o• �: cT w N
qq ao
v , O
.� (D C'GD,, �• QO. QG Q cn- UG O. � Ut7 G G C M. O CD O O C O a
� C7
4t C�
try . , z
0 v