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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.Tel.No. {/ Alterations
a NORTHAMPTON, MASS. � at 19 0 Additions
APPLICATION FOR PERMIT TO ALTER Repair
r
Garage
1. Location L17 /���N�[ b,i2 Lot No.
2. Owner's name/`ldr✓tf L�iU�3 w lc--A�/ Address /�_ �,t i✓�/ Z
3. Builder's name r— CC1s'� ?7--C.1 Address L( /��Cl 57— /y
Mass.Construction Supervisor's License No. G 11k06 2 Expiration Date -5'-- /S - i F,
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
knowledge and belief.
Signature of responsible app,icant
Remarks r✓
r 4�ttAMpT
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
�l : /104414,,f' ✓ XW ofaGo' (phone#)
- � . ( city/state/zip)
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)
(atIaeh additional shoo ifnoarsuy to include infvrmafion pmtaining to all cootracton)
(/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 while homcowneta who employ pasaas to do maiatcuanc q oonsnuction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not genemlly c oosidaed to be
employers under the workers oompeasation Act(GL152,-s 1(5)),application by a homeowner for a license or permit may evidence tho
legal staters of an employer under the Workee,compeoution Act.
I uudesstaad that a copy of this rbi=xnt may be forwarded to the Deputmm[of Inrbutrial AodderH>'Offioo of Inwrsnce for the
coverage verification and that failure to&==coverage uasda scdion 25A cf MGL 152 can lead to the impos ioa of criminal peaal -
oomisting of a fine of up to 11,5oo.00 and/or imprison of tip to one year and civil penalties in the form of a Stop Work Order and a
fma of 5100.00 a day against mc.
For dqmtnwb use only
Permit Number
Z 1'l; 5- ivlap# Lot#
Signature of Li ermittee Date
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 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
&p_aved parkingi
# of -Parking Spaces
# (6f Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
�r is true and accurate to the best of my knowledge.
DATE: � �/--�/` d" APPLICANT'S SIGNATURE����j�
NOTE: Issuance of as zoning permit does not relieve an applioant's burden to oomply with 4all
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission, Department of Publio works and other applicable permit granting authorities.
FILE #
File
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:LD G0f,6_--_T _,l
Address: q Aiec S - /"/ ;�i✓ Telephone:
2. Owner of Property: AA121 /JD'�� 4� C 1 A-A'I
Address: ���� ya�,� z /�/Z Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s):_ S �
(TO BE FILLED IN BY THE 8UILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
N/rV��w
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/Vahance/Finding ever been issued for/on the site?
NO DON'T KNOI:f 4--i 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)
_ 33 i
N FILE # Jvrk
J0
�A,.� L' ,&NT/CONTACT PERSON:
ADDRESS/PHONE:
PROPERTY,LOCATION:
MAP PARCEL: ZONE r
THIS SECTION FOR-OFFICIAL USE ONLY:
PERK HT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
Fee Pnid .
lRijilding Permit Filled mit
Fee Pnid .,2G-,7 0
Addition tn Existing ,7
/bra
T � LLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION' <
Approved as presentedfbased 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:
b Cut from DPW Water Availability Sewer Availability
` of Health Well Water Potability-Bd Health
Permit from Conservation mmission
Signature of Building or IYate
NOTE:Issuance of a zoning permit does not relieve an applioant'a burden to oomply with all
_ zoning r@quirements and obtain all required permits from the Board of Health. Conservation
Commisalon, Departmant of Public Works and other applicable permit granting authoritles.
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