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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel No. J� �/ ~-� Alterations
NORTHAMPTON, MASS. ! 2 19 Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location a �if't ,�0 - A,6� t-- Lot No.
r1 �l
2. Owner's name Address
3. Builder's name ^ e^ .F Address / �,Z 2 k
Mass.Construction Supervisor's License No. t7`7(c` ? 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
knowledge and belief.
/ Sign re of responsible app icon!
Remarks �' �(Z I^
I C�riAM P
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$ e JUN 1 31997 fasaarflnsrtla
m {�� i2 &TMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFMAVIT
(licenseeJpermittee}
with a principal place of business/residence at:
��40 (Phone#)
(strt~t/city/statrJa p)
do hereby certify, under the pains and penalties of pequiy, 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)
(l� I am a sale 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 CompanyNhcy Number) (Expi 'on Date)
(Name of Contractor) (insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoLicy Numb--I) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additi«ssl rhoct ifnoocssary to iaclUdc informaaoa pert u to all oo.tra rs)
('-�/l 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 homeowners who crnplay per;=to do mxiafl,,.,,�oms ucuon or repair work on 1 dwelling of
not mac than tbrue units in winch the bomeowocr rides or on th.e grounds appurtenant thxcto arc Dot gcacrnlly oo=dcrcd to be
cmployrrs under tbo workees ampcnsatim Act(GL152,s 1(5))�application by a homcowDa for a Gccase or permit may evidcnoc the
legal statue of an employor under the Workees Companmika Act
I understand thlt a copy of this mrcmcsrr may bo forwarded to tho Departmcat of Industri al Acadcnh'Offioo of l=mu anco for tho
coverav-vaificstioa and that failure to realm covcrago tmdcr scuica 25A of MOL 152 can lead to tbd ikon of aiminal penalties
oomistatg of a fine'of up to 51,500.00 and/or impri3,c m of up to ont year amd civil pcaaltia in the focm of a Stop Work Order and a
fine o[5100.00 1 day against me-
Signed this `✓> day of , r " 1997 For dcpxrt n-'tzl—only J
p �1 Pcrmit Number
Map;t Lot#
Signature of Li rmittee
`4
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?Ved parking)
# of Parking Spaces
#K of Loading Docks
Fill:
vol-time--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledg .
D�II"E: �' 1
t.. �' APPLICANT'S SIGNATURE
NOTE: lasCualloa of a zoning permit does not relieve an app ioant',,4 bu den-fa oomply wit4,Y$ll
zoning requirements and obtain all required permits from the B a of Health. Conservution
Commission. Department of Publio Works and other appiioabte permit granting authorities.
FILE #
or m " '
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n, C File No. G 1
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:_ _G
Address: /%� { /�7 Z A;z Telephone: J�;�
2. Owner of Property P12
Address: x g� O � - ( Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: ���� ��rs E/>y ��^�� /N
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Propertyv
6. Description of Proposed UseAAlork/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 PermiWariance/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)
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FILE
a
.U1 1 31997
APPLICANT/C915TACT PERSON:
E4
PROPERTY PROPERTY LOCATION:
MAP < j PARCEL: ZONE _5�e,
THIS SECTION FOR-0FFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OUT
Fee pnifi
/G' �--
Addition to Vyktin2
U 4LP
3 Sete, of Plan-, I Pint Plan
THE
OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION-
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 Conservati ommissi
Signature of Building hyowor Date
NOTE:Issuance of a zoning permit does not relieve an applicant's burden to oompty with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commisalon, Department of Public Works and other applicable permit granting authorttles.
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