24D-203 (5) ,.
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS.
eJ /5;1 19 �,� Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location r �� //��� l Al Lot No.
2. Owner's name P, i + l4'1 e-L C" Address `��g � dif 4r— % Q/�0j
3. Builder's name 7 h AJ 4�v-,S�t Address .s�G oi/rnGc-lc -sZ
Mass.Construction Supervisor's License No.. /`f 1 /vO4 Q Expiration Date -7 ��`
4. Addition _
5. Alteration s//;� lal� y!'
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:- CFO
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of responsible app icani
Remarks
04�ttpTC
AUG 2 1 199 i` Crzmr#f�ttntnn
a .- aSIIBCIInII[11II
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE AFFIDAVIT
ry C10 r S Ott
(li censee/permi tt ec}
with a principal place of business/residence at:
(street/ci ty/stalrla p)
do hereby certify, under the pains and penalties of pegury, d t:
O I am an employer providing the following wor'ker's compensation coverage for my
employees working on this job:
(Lass cc 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) (Insurancc Company/Policy Number) (E)piration Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (E)cpiration Date)
(?Name of Contractor) (r_n uraric-c Co=Paz--rPoiicy ivum,`,er) (E piradoa Dale)
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
(attach ad&6oaal sboct ifnaxaary to include infoemation pertaining w nil oo@radors)
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 whUo homcownaa who c ploy pasons w do m irrfmsncc om5tnr oa or repair work on a dwelling of
not morn than three units in which the homoowuw resides or oa the grounds appurtcnwA thereto are not generally coasidcred to be
employers under the wm+cz'a c=pcnsition Act(GL152,=1(5)�application by a homeowner far a liecwt cc permit may evidcnec tlrc
legs.(rt—, of an employer under the Workeez Compca&&ion Act
I undastand drat a copy of thu rtLt�may be forwnnied to the Dope tram of 1n&L to d Aca&a&Office of Iasaranoe for tbo
coverage Wnficatioa and that fadUrc to sazrre coverngo under section 25A of MOL 152 can lead to tba impasifioa of aimiaA peaalrics
oomi.sting of a fine of up to S1,500.00 andlor imprison of up to ooc year and civil pcnaltia in the form of a Stop Work Order and a
find of S 100.00 a day against me.
Signed this day of 199 7 For dcp�use only
permit Number
Nfap Lot#
gnaturc of - crmitt=
v
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 MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This colt to be filled is
by the Building Department
Required
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:
4vo1-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
1
DAVE: 7 APPLICANT's SIGNATURE -
1' NOTE: ineuisnoos of a zoning permit does not relieve applioan s burden to comply wit4,.ptl
Czoning requirements and obtain all required Pe-rmfrs from the Board of Health, Conservation
ommission, Department of Pubno Works and other appiioable permit granting authorities:-.
:'.`, FILE 7C,
A 2 1 ick
File No
-ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: S� Anl d C.jC SI _Telephone:
2. Owner of Property: /�&P—) Cl u c m e-1/ 1
Address: ��� ✓�/-ICS iC_ S 7 Telephone: ,SXY-
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s):--Z4/?-
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property— n—r / ei e ,5 4
6. Description of Proposed Use/Work/Project/Occupation: (Use additional 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 Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNO"Al 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 A-_ 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 if 9c, ) , 8 9
AUG 2
APPLICANT/CONTACT PERSON: '
ADDRESS/PHONE:
PROPERTY OCATION: �(�
MAP PARCEL:
THIS SECTION FOR.OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OITT
Fee PAid
Buildin2 Permit Filled mit
C)c
gernndelin2 Interior
Additinn to Existing
�-"
T OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
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
Pe�r/�' from Con�at' o n
Signature of Building hLwgtor Date
NOTE:issuanoa of_a zoning permit does not relieve an applioant's burden to oomply 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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