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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. ZiC�r, 3C, 19 Additions
APPLICATION FOR PERMIT TO ALTER Repair
a
Garage
1. Location ` ) Lot No.
2. Owner's name 1, r Address ` L
3. Builder's name ` Address
Mass.Construction Supervisor's License No._ L� �y y Expiration Date 'j"-Lc, 3 . /%J
4. Addition
S. 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 '�CCl CDc j-� 9- (`t 1Q10 el.i�
13. Siding house
14. Estimated cost- � _ _ _� / .
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of responsible app,icant
V
Remarks
��ttA)I p�,
9�oD4� _
GrZt� of &Nart4aiilpfail
a e OCT 3 0 /997 tasaacEinsctta
m DEPARTMENT OF .BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVU
1i aipermittee)
With a principal place of business/residence at:
l A/ e_ :��' (Phone#)
(street/city/st a1P/zip)
do hereby certify, under the pains and penalties of pequry, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiation 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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sled if nacenuy to irwl information pertaining to all ocafrndors)
( ) 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 wbilo homcow=3 wvo employ pawns to do mai.,r__r�a,,*^M wastrvctioe cr repair work on a dwelling of
not more than throe units is which the homeowner residca or on the grounds app xteaaat thereto are not gawilly co—dend to be
employers under the worketa compensation Act(GL I52,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal darns of an employer under the Workeez Companation Act
I understand that a copy of this statement may be forwarded to the Dq,,w c,,d of lndzufri d Aecid=&Omen of lasruanoo for the
coverage vaification and that failure to secure oovamgo under scctaon 25A of MGL 152 can lead to the imposition of criminal penalties
O0 of a fine of up to$1,300.00-df-itmpa at of up to one year and civil penalties in the form of a S top Work order and a
fine of S 100.00 a day against ttx.
Sign this day of 199 F�dgrut nl,rae only
Permit Number
j Map#_ Lot#
S of LicenseelPermittee
10. Do any signs exist on the property? YES NO 1�
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 column to be filled in
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 fof Loading Docks
Fill:
-(vol-lime--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
_1
DATE: APPLICANT's SIGNATURE �
NOTE: Issuanoe 46t a onin `
g permit does not relieve an IioanYs burden to comply witfx,,ali
zoning requiramante and obtain all required permits f the Board of Health, Conservation
Commission. Department of Publio Worka and other ap lionble permit granting authorit;es.
FILE #
OCT 3 01997
File No._ �/
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: f, .r � r ° 2 e /
Address: Telephone:
S it P Telephone:
2. Owner of Property
Address: v Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: c of
Parcel Id: Zoning Map#-- Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT) -
5. Existing Use of Structure/Property
6. Description of Propo ed Use/Work/Project/Occupa'on: (Usq additional eets 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 V 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 ( 3
OCT 301997 , -
APPLICANT/CONTACT PERSO u-
ADDRESS/PHONE: '
PROPERTY LOCATION: z 1
mAp �j'L�_ PARCEL: / ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM Eff LET) MIT
'Byfflding Permit Filled Out
Fee pnid
New Construction
THE FF�OWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
!/Approved as presentedibased 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
9
Signature of Building Insp Date
NOTE: Issuanoa of a zoning permit does not relieve an npplioant's burden to oomply with all
_ zoning requirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Public), Works and other applioable permit granting authorttles.
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