32A-152 (21) 'v
"7' JUN 3 0 IV
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
APPLICQk ATION FOR PERMIT TO ALTER Repair
Garage
1.1. Location z, Lot No.
2. Owner's name l� =� Address
3. Builder's name S Address 01 t Imo- �r
Mass.Construction Supery is License No. 0 ' 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:-
r/S�'O �3
The undersigned certifies that the above statements are true to the best of his, her
knowledge lief.
L Signature of responsible app,icant
Remarks_
o��ttnJfP�O
a� `a (biz of 'Nartlla»tp toil JUN 3
`� 6 Rtasaxchnsrtta
DEPARTMENT OF BUILDDIG INSPECTIONS'
212 Main Street ' Municipal Building
Northampton, Mass. 01060
RICER'S COMPENSATION INSURANCE < ' A.VIT
(li c:Ynse;ypermi t1�)
NVIth a principal place of business/residence at:
(phone;0 L ��
(strr.°I/cit}' statrJ�p)
do hereby certify, under the pains and penalties of perjury, Thal:
( 1 am an employer providing the following v.,o -er s compensation coverage for my
emplo ees working on this job:
(Las, Ilce Company) (PoLicy Number) (Expiration D )
( ) 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) (Lasuranct- Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (I.n_nlran�Companyi?oUcy Number) (Expiration Date)
(Name of Contractor) (In_surancz- Compauy/Pobcy Numbe-r) (Expiradon Date)
(Name of Contractor) (Lnsurance Company/Policy Number) (Expiration Date)
(attach additional sboct ifnoocazry to inclisdc infuinati oa pertzining w all 000irncion)
( ) I am a sole proprietor and have no one working for me.
( ) I am a-home owner performing all the work myself.
NOTE:plea sc be aware that whilo homcowncra who c=p!oy perroat to do r in m,ncc coastiiaioo or repair work on a dwelling of
aot more th=tbrt tmitt in which the boaioov n asides or oa the gvuDd3 zppurtenaM lhercto arc not ga3a-24 ooandcrcd to be
employ=under tho woritrr's.C=Va rim Ad(GL152,ss t(5)�application by a homeow=for a!iccux oc pczmh may evidcaoe the
legal statLu of an employoc under the Workces Compoosation Ad
I understand dul a copy of thin rw—cat may bo fcrwardod to tbo Dcpertmmt of Iod+rS d Aoadm&Ot50o of Ia;+uanoo for tbc
coverage vc6fieation and that failure to acatrc covcmV under scdioa 2 5 A of MGL 152 can lead to tba impositi on of a-iminal pcaal6cs
ooasisting of a Em of up to S1,300.00=&oc iu nisoamcnt of up to ooc year and civil p=06cs in the form of it Stop Wort Ord=and a
fum of S 100.00 1 day against ar-
Signed this �day of-3t1,4 1997 F«dc,masal rt,o only 1
Pcrmit Number
1/Z Map4 Lot#
S, LiocnscelPcrmiticc
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 V
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This —.Iu= to be filled in
by the Building Department
Required
A-///,/ C�
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - front
- 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:
4 vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
y is true and accurate to the best of my knowle .
DATE: APPLICANT's SIGNATURE
NOTE: Fasualfiae Of a zonin
g permit does not relieve an pplio s burden to comply with,,+pll
zoning requirements and obtain all required permits from th oard of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities,
FILE #
JUN 30199-(
Fi 1 e No.
ZONING PERMIT APPLICATION (§10 . 2
P TYPE OR PRINT ALL INFORMATION 17
1. Name of Applicant: �''zT°'1
Address: R Telephone: <//3.s
2. Owner of Property: /lfr r�/7n Ate .._
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): �y `[ f<�.c XV,vt—_
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s): C
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
/'1 9 c.
5. Existing Use of Structure/Property � �E z lGr� G�
�iy�y��e-z 14 < S�(,P���j�
6. Description f 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 bee 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/oent#
9. Does the site contain a brook, body of water or wetlands? NO 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)
I �
FILE #
U l► UL�'
JUN
" APPLICANT/CONTACT PERSON: CGI,ti -' �� 7' � -
�. ADDRESS/PHONE O o
PROPERTY LOC TION:
MAP PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OITT
Fee Pnid
Rivildin2 Permit MUM nitt
nor
Addition to Existing
THE OLLOWING 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:
r
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
!Pe it from CConsseervat' ommission
Signature of Building 1015ector at
NOTE:Issuances of a zoning permit does not relieve an applioant's burden to comply with all
zoning requirements and obtain ail required permits from the Board of Health. Conservation
Commissions Department of Publio Works and other applicable permit granting authorltles.
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