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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
a GaraNORTHAMPTON, MASS.— J u h e— 7 19 Additions
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APPLICATION FOR PERMIT TO ALTER Repair
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1. Location _&nCjL U\Y - Lot No.
2. Owner's name— t+ilrt c c �►rnCn/JD AfX2( 1 Address n
3. Builder's name LY-}r rN—jj K6 Address T X gag l r
Mass.Construction Supervisor's License No. 0 557 3 33 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
13. Siding house _ ' Q
14. Estimated cost- '\
v The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of re ibfe app, a
Remarks
.�0 QSttAMp2oy €
.A111 i 71997 Cry Jaf
9 d l; y �asaachnsetta
g ' r"7OFRV y •-1
PAR�MENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
LG UJ f -e n(C_ �. ��/e .
with a principal place of business/residence at:
0
no. l'-44 1C phone ) LEY .
(str eet/ci ty/stairlb p)
do hereby certify, under the pains and penalties of perjury, that:
V l 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 Compauy/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addition2l sleet ifnoocnury to bwJ%ido information pertaining to all 000trncton)
( ) 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 wWlo homeowners who employ pa-s-o=to do maia�coaviuc too or repair work on a dwelling of
not more than tbree units in which the hormowocr rt=dcc or on the V*unde zppurtamtd thacw aro not Ernaally oomuicred to be
employers under the worka's o=PcosAtion Act(GL152-m t(5)�application try a homeowner for a licrase or permit may evidmoc the
legil etntua of an employee under the Wor$ees Compe.&6on Act
I unda:hnd that a copy of this rhtemen t may be forwnrdad to tbo D"rtmcat of Industrial Acddm&Offioo of Imuranco for the
oovez a verification and that failure to wane covccngo uuda 3-don 23A of MOL 152 can lead to tbo imposition of criminal patatties
oomisting of a fine'of uQ to S1,300.00 and/or imprison of up to one ysar and civil penaities in the form of a Stop Work Order and a
firm of 5100.00 a day agnitnt me-
Signed this tiay Of---
1997 For dgmtnc"ua000ly
Permit Number
4t, Map# Lot#
re of Li cant L
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
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
Thia 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)
of -Parking Spaces
f Hof Loading Docks
Fill:
(volume--& location)
13 . Certification: I hereby certify that the information contained herei
is true and accurate to the best of my knowledge.
DATE: 1-7—q7 APPLICANT's SIGNATU
NOTE: IssuanOe of a zoning permit does not relieve a p ioant` "oaly t
zoning requirements and obtain all required permits from the I n
Commission, Department of Publio Works and other appiiomble permit granting authorities.
FILE #
File No. �J i
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PR-7T ALL INFORMATION
1. Name of Applicant:
Address. KL Telephone:_ 441.3- 5 s y 3-
01
Lor
2. Owner of Prope 4r W ? !r
Address: n Telephone:
C 'r7F'S�p 7`�
�lo(en(e 0�-t� to(-00
3. Status of Applicant: owner Contract Purchaser Lessee
Other Q(`explain
4. Job Location: / �o
Parcel Id: Zoning Map#_.. Parcel#1-,�d 6fl' District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMEN
5. Existing Use of Structure/Property P'e-5; den-'�
6. Description f Proposed Use/Wor roject/Occ ation: (Use additional sheets if necessary):
Vim— y
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 t/' 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 #
71997 _
APPLICANT/CONTACT PERSON:
PROPERTY LOCATION:
MAP PARCEL: ZONE r
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOS D REQUIRED DATE
ZONING FORM VFT,T,FD ()TTT
RiiiMing Permit Filled nilt
Fee Paid
d
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 mission
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Signature of Building In Date
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NOTE:Issuanoe of a 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 Publio Works and other appiioabie permit granting muthoritles.
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