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Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. �' /� L''/'S� Alterations
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NORTHAMPTON, MASS. l / : l 22 Iq Additions
f
' APPLICATION FOR PERMIT TO ALTER Repair
--—1� Garage
1. Location _ - � Lot No.
t.
2. Owner's name Address
3. Builder's name Address
Mass.Conswctio Supervisor's License No. y f o7 �/ 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
14. Estimated cost-
The undersigned certifies that the above statements are true to the best of his, her
knowledg d belief.
Signature of responsible app,tcant
Remarks
4TttAMPT
0 of 'Nart4aiitpfan
DEC g 199f
ass aril usats
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMAVIT
of l��)
with a p cipal place of business/residence at:
(phone#)
(stre�tici ty/statriz�p)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employ working on this job:
I nsuran Company) (Poli umber) (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 additioml shod ifnoccssary to iochsdc infocm,rioa pertaining to till a fs)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcaae be aware that wbilo homcownm wno aaploy persons to do mxje,, =cc,omsuN oa or repair work on a dwelling of
not nioca than throe units is which the homeowner resider oc on the grounds appurtenant tba+cto arc not Coxcilly oo-Wered to be
employ=under tba worker's ooapcnsatioa Act(GLI52 M 1(5)),application by a homeowner for a license or permit may cvid the
Iegd datisa of an employer undertbn Workeet compomation ALL
I undavAnd that a copy of this rw mneat may be foewefded to tbo I)Vutmcoa of Indan d A,d&r; 'MOO of Iaauanoe for the
coverage vexifiesuoa and that failure to accrue coverage trader section 25A of MOL 152 an iced to the imposition of crimiDA penalties
oowb ing of a Em of up to S1,500.00 anNOc imprisomxut of up to one year and civil praatties in the form of a Stop Work.Order and a
tiro of S1oo.00 a day against mC.
Signed this _day of 1997 For dgaatmeatal use only
Permit Number
Map# .Lot#
Si of Liccnsee/Perihiittcc
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 COlLu= to be filled in
by the Building Llrpnrtment
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
#
of Loading Docks
Fill:
(volume -& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: `— ` C c APPLICANT's SIGNATURE �2
NOTE: tssuanoe of a zo ping permit does not relieve an a plioanVs burden to oompty Wide all
zoning requirements and obtain all required permits iro the Board of Health. Conservation
Commisslon. Department of Publio Works and other app oable permit granting authoritjas.
FILE #
D r,,
Fi 1 e No
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: d Telephone:
2. Owner of Property: L
Address: Telephone:
3. Status of Appiica Owner t> Contract Purchaser Lessee
Other(explain):
7
4. Job Location:
� r
Parcel Id: Zoning Map# Parcel# �( ; District(s):
(TO BE FILLED I Y THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property
i!C ("o
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/Vadance/Finding ever been issued for/on the site?
NO DON'T KNOW L. 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 #
�%42t.NT/CONTACT PERSON:
ADDRESS/PHONE: c '
•
PROPERTY LOCATION:
MAP 7 PARCEL: t ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERAM APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING E0'RM M.T.ED OUT
Fee pnid
Remodeling Tnterinr
Addition to Existing
'7
THrOLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
K 0 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
I
Si .cZ Date
NOTE:issuanoe 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 Public Works and other npplioable permit granting authorities.
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