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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
a
1. Location L' 1JL�YI2(� S l Lot No.
2. Owner's name 9, Address
3. Builder's name �1� �� u:t e Address
Mass.Construction Supervisor's License No. Q 4/O yy3 Expiration Date ���U—99
4. Addition Q /�/�
5. Alteration /) C� CA:2 yNdc OuC� �c X �- d �c /sue V
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
14. Estimated cost:-
�U 7` `� The undersigned certifies that the above statements are true to the best of his, her
°7 tv knowledge and ief.
Signature of responsible appucane
Remarks
�O
' lyW Crz �# flax# ttnt}�tnn L
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0 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building 'a
Northampton, Mass. 01060
WORI ER'S COMPENSATION INSURANCE AFFIDAVIT
(licensetipermittee)
with a principal place of business/residence at:
17Y,7 -/'7;a (phone#)
(street/city/stairhip)
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) (Insui-ance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attadl additioml shed ifneccasry to io$ information pertaining to all 000sractors)
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 persons to do maintenance,omstruction'or repair work on a dwelling of
not mode than throe units in which the homeowner re=des or on the grounds appurtenant thWeto arc oot generally ooasidered to be
employer;under the workces compensation Act(GL152,Ts l(5)�application by a homeowner fora license or permR may evidence the
legal status of an employer under the Worlcces Compemation Ad
-
I understand that a oopy of this ctatemew may be forwarded to the Depwmxot of Iodusixial Aceiddn&Office of lnsu lmm for the
coverage verification and that fail=to secure coverage under section.25A of MOIL 152 can Iced to the imposition of criminal penalties
oomisting of a fine of up to S1,500.00 and/or finprisonnxnt of up to one year and civil penalties in the form of a Stop Work Order and a
fins of S100.00 a day against mc.
Signed this _day of 1997 For d use only
Permit Number
Map# --Lot#
Signature of Licensee/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.
This column to be Pilled in
by the Building Department
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)
.of -Parking Spaces
f 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 knowledge.
DATE: APPLICANT's SIGNATURE J64
NOTE: foe
zoning permit does not relieve an pplioant's burden to comply witip,4111
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Publio Works and other appiloable permit granting authorities.
FILE #
. 31991
Fi l e No. ,03
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: /7�/ Telephone:
2. Owner of Property: ��n ,
01 A
Address: ,�!7 �Le�i»'t2 Q Y Telephone:
3. Status of Applicant: Owner /� Contract Purchaser Lessee
L.,11 Other(explain): C ,eQ
4. Job Location: 1-3 8
Parcel Id: Zoning Map# c Parcel#_ (z District(s): O t-c-
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/PropertyP�l
6. Descri ti n of Proposed Use/Work/Project/Occupation: (Us Oditionql sheets if necessary):
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 PermitA/adance/Finding ever been issued for/on the site?
NO y er 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 G/' 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 I J V
g 3
ti
JUN 31991
APPLICANT/CONTACT PERSON:
,A–DDR,,E, flN�:
o� ;
PROPERTY LOCATION: ;� �� ,O
MAP PARCEL: �?G �ZONEZJ-_
THIS SECTION FOR-:OFFICIAL USE ONLY:
PER 11T APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM EITLED MIT
Fee Pnid
�Y
t
T OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
jV 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 Conserva ' C i n
Signature of Building W115ector ate
NOTE:Issuanoa of a zoning permit does not relieve en applicant's burden to oomply with ail
zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Public Works and other applicable permit granting authorlties.
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