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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
a RepaNORTHAMPTON, MASS. 19 Additions
APPLICATION FOR PERMIT TO ALTER
ir
Garage
1. Location � ���� /�.�irtl&1AJ Z1-r/o4 L Lo o.
2. Owner's name ? �L-Address ��L� ,`�C!/1S i
3. Builder's name l P—� Address Z3 XVL �/�4r�'�Si.ti S �G`�.U/✓�,41�
Mass.Construction Supervisor's License No. CSC°S��o��2 Expiration Date /.S= 9
4. Addition
5. Alteration )4 1 -W 7' l7C �l✓ ' a
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- LIZ
undersi d certif•'!:�e above statements are true to the best of his, her
knowle
Signature of responsible app,icant
Remarks
�11tAMP�
3 � .�, �, �iasaxcElnsrtis
lu r
St
rte. m �t DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORT,C—ER'S ENSATION INSURANCE All AVIT
(li censer/permi tree}
with a principal place of busimss/residence at:
(phone!#)
(stsret/ci ty/statrJzi p)
do hereby certify, under the pains and penalties of perjury, that:
V/I am an employer providing the following wor-ker s compensation coverage for my
employees worinng 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurancti Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnxc=ary to iachidc iaformalioa perhtiaing to all coat! 13)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plc=bo aware that Altilo homcow=3 wuo ernplay person to do rr xh t,�0=st too Cr repair work on a dwelling of
not morn than throe traits in which the homeowucr rezidcs or oa the g mnd3 appurtenant J=cto arc Dot gcnrrnlly oomBcrcd to be
employers under the%vvdvA's compcns4oa Act(GL152,n1(5)),application by a homeowner for a liecwe oc Permit Dzay evidence the
legal rut a of an employer under the workcea Compwa&tion Act_
I understand that a copy of thu statcmcat may bo fo ywurded to tho Dcpwtncot of Indushial Accidw&Office of taztiuw aoo for the
coverage verification and that failure to acatre covcr under soction 25A of MGL 152 can lead to tha imposifion of criminal Pmaiva
oomisting of n fine of up to 51,500.00-&-imprison,of tip to one year and civil pcmltia in the form of a Stop Work Order and a
find oC5100.00 a day agniwl me.
Si ed Of ��l!', 199-7 For acp=tr ic"use colY
Permit Number
Map# Lot#
grlahtre of Licansed- Per"ait tee
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 column 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 park.inq)
# of -Parking Spaces
0 of Loading Docks
Fill:
Avolume -& location)
13 . Certification: I hereby certify that the ratio co ained herein
.a
is true and accurate to the best of my nowle ge. >
DATE: „(�-- —�� ApPLICANT's SIGNATURE
NOTE: lusuanoe of a zoning permit does not relieve an pplioant's burden to oomply w!ih-4.11
zoning requirements and obtain all required permits IF'fom the Board of Health. Conservation
Commission. Department of Publio Works and other appiioabie permit granting authorities.
FILE #
s
Fi 1 e No.
j
ZONING PERMIT APPLICATION (§I0 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: t� T
Address: l�1, �. 'C� >S �o� ijl, ;� Telephone: c �—cbi3�
2. Owner of Property:_( Q /— //�s�/�I�S�
Address: D_�%l�.s% U�. Ai91V/�1elephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: _
Parcel Id: Zoning Map# Parcel# District(s):
(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):
_I'�J��G'I��TE �/�S'i/✓c�� L..liiE'��/ �.oE' � t/`/�/cS/� „ Z.S , ' j,�/�
---7 .�,t�TO
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)
FILE # :7 1� 2 f yy��
� .. �.. J � V
1997 '
A2PLICAN7�/CONTACT PERSON:
t3F tADD3 SIPIIO;E:
PROPERTY LOCATION:
m-AP PARCEL: tONE.
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM MLED MIT
Fee PAid
lffiiilding Permit Filled.niq
Fee PAid
New Cnngtriirtinn a14 -1/y
Addition to Exi&ti-ng 4'IL71-3 s
�1--
e
a
THE FOLLOWING 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 Conservation Co Sion
Signature of Building Insp Date
NOTE:issuanoe of a zoning permit does not relieve an appiloant's burden to oompty with ail
zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commisalon, Departmental! Pubiio Works and other applioable permit granting muthorttles.
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