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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No.::J K e s 7 Alterations
NORTHAMPTON, MASS. ' /J 2� ig 9f Additions
APPLICATION FOR PERMIT TO ALTER Repair
a
Garage
1. Location ,2/,a kya zC , fX';P,/ Lot No.
2. Owner's name S yc'- j<UAJC-1.a Address S.AOIv e-
3. Builder's name 6W CGaaet,-y-- (- Address 9 rQ o� � ST iL t✓,
Mass.Construction Supervisor's License No. Co 7 /V S-D 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 t�e�"/y ri��f✓
14. Estimated co t:-
R2*- 2�a
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of responsible app icant
Remarks
�ttA>yP f t
a z .>� �lasaackasctts
�&BRARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060
WOR EWS COMPENSATION INSURANCE AFPTDAVIT
(lio msee/permittee)
with a principal place of business/residence at:
s ✓ ,� (phone#) 5:!r'/-S7/
(street/city(statehip)
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) (Insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnec nary to include kdbrmalion pertaining to nil ooatradors)
(lam a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE-pleax be aware that while homeowners who employ pasoac to do maiate awev conch lion or repair Mork on a dwelling of
not mote then throe units is which the homeowner resides a on the grounris appurtenant thereto an not generally=sWcrcd to be
employers under the vmd e's compmsatim Act(GL152 m 1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compemation AcL
I underslaad that a copy of this statement may be forwarded to the Depnrtmen2 of Industrial Aocideatd Office of 1nvx anm for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
oonsbdng of a line of up to 51,300.00 and/or imgxisorm> of up to one year and civil penalties in the form of a Stop W ode Order and a
limo of S100.00 a day against tnc
For departmenta use Only
Permit Number
M 2 Lot#
Sim of Li ermittee �
A
1& 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 ccl== to be filled in
by the Building Department
t Required I
Existing Proposed By Zoning
I Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&p?coed parking)
# of Parking spaces
# (of Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
DATE: /—Z APPLICANT's SIGNATURE Z
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply wit4-ali
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Public Works and other applicable permit granting authorities.
FILE #
1
f
JAN 2 9 199
rlFp° 'IF pf ,9 File No.
g
��.. .�. ......._0._
ZONING PERMIT APPLICATION (§I0 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 'C'?/ t��i�i7~✓.G'l
Address: L �C�� Y S% ` Telephone:
1 Owner of Property: S L il'n<d
Address: T/�'�-r Telephone: 3
3. Status of Applicant: Owner --16ntract41QZI er--- Lessee
other(explain)/:
4. Job Location: L-(, -5-,keVA
Parcel Id: Zoning Map# Parcel#_ 3'j�2 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):
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 11� 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 r.'' 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
l�
AWM"g a
C A FACT PERSON:
ADDRESS$YHO E:1
3
_PR-OTE'I TY LOCATION:
MAP ) PARCEL: , r; ZONE
THIS SECTION FOR.OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM ITHLED 0111
Fee Paid
Rnildin2 Permit Filled nut
Fee Pnifi
Type of Constnirtion-
-Rernodelin2 Interior
Arreqsnry Structure
`f 0
3 ,qpts of PlAny /Plat Plan
c
THEEOLLOWING 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
Permit from Conservation Commission
a-a'q
Signature of Building ector Date
NOTE:Issuanoe of a zoning permit does not relieve an applloant'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 applioable permit granting authorltles.
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