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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. // Tel.No. 4 V 11-2 Alterations
NORTHAMPTON, MASS. 19 Additions
�
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location v��-m ��r. of'041 Z/�T--e 4_ F � 4 - /- Lot No.
2. Owner's name e diMl d; i I Address �Y r;A
im a
3. Builder's name l 11�/')d �� Address
Mass.Construction Supervisor's License No. ,%n�yl �� 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 ( r "
14. Estimated cost-
The undersigned certifies that the above statements are we to the best of his, her
knowledge and bAlef.
Signature of responsible app icant
Remarks
�gttAMp�
ego `e Gf its of 'Wart4a pion
�aSfRCllnStttf
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(lipermittee)
with a principal place of business/residence at:
(phone#)_ !
(streeucity/stawzip)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
NOu 106L
(Insurance Company) (Policy Number) (Expiration Date)
( -am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) Gli u ranter;Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to inch►de information pertaining to all coatraaors)
( ) I am a sole proprietor and have: no one working for me.
( ) I am a home owner performing, all the work myself.
NOTE-plea be aware that while homeowners who employ pc=m to do maintenance,mastnution or repair wont on s.dwelling of
not more than throe units is which the homeowner rides or on the grounds apputteawA thereto errs not generally wandered to be
exnployen under the vmrlcees compensation Act(GLI 52,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal ctatrra of en employer under the Wor r z compensation Act.
I understand that a copy of this siatcmcnt may be forwarded to tbo Depwtmend of Indiutrial Aecidea&Of$oo of In-wnnoe for the
coverage verification and that More to seatre coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to$1,500.00 andlot imptis xt of up to one year and civil p cn wes in the form of a Stop Work Order and a
find of 5100.00 a day against the
Signed this _day of 1997 For departmental►►ere Only
Permit Number
p�{ Lot#
Signwam of Li ernn
try
z'
4 w_
10e Do any signs exist on the property? YES NO
:a
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 colu= to be filled in LL?
by the Building Departmeaffi
Required
Existing Proposed By Zoning
Lot size
3
E t
h
Frontage "
Setbacks frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
a �
%Open Space:
(Lot area minus bldg
&paved parking;
of 'Parking spaces
f (of Loading Docks
Fill:
=(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my know ledg .
DATE: �
�' APPLICANT'S SIGNATURE �t
NOTE: Is ua a of a zoning permit does not relieve an a lloa is Phi
urden to oom wit
zoning requirements and obtain all required permits from the rd of Health, Conaerv�rt{
Commission, Department of Publio Works and other applioabla permit granting author '
itllw . �,;-
FILE #
r
- .�
Pile No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: 71 � -
Address: / f ��fl _ // ,e; / f 11 Telephone:
2. Owner of Property: o Z.
Address: 6f � � Telephone: c4 01/10,
3. Status of Applicant: Owner Contract Purchaser v� Lessee
Other(explain): �r�_�;_�¢(y�{{-[�_-
4. Job Location: - --- C •�r��< C �.��z
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE ILDING DEPARTMENT)
5. Existing Use of Structure/Property �� z.��1�2' C"E
6. Description of Proposed UseNVork/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_ 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 #_ vac CJ
a ��I
7
AFFI, /COiVT CT PERSON:_;s �i� �tr.t
ADDRES /PHQX /7'7 d f - - c ,{ �� �• yLl
PROPERTY WCATION:
�_Lc
MAP �13 j PARCEL: % ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
7,ONTNG E0RM FTT,T.F.D OUT 7
Fee Pnid
Rnil_dina Permit Filled not
Fee Paid ' �� s-�
Type of C"nnstnirtinn-
New C'nnstrnrtinn
Addition to Fxistinu L f` jtt ,�L`
a�-
Arressnry Str»ehire 0
$nilrli Plans Tnrlilderl-
Owner/Orrnvnnt 4tntement nr TJ3 6 a
3 Sets of Plnns /Pint Plan _
THE�rOLLOWING 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:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
!it fro one C on
Signature of Building lrx6Fector Date
NOTE:Issuanoe of a zoning permit does not relieve an appiloant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioabie permit granting authorities.
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