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" Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.Not 2�d Y S'hrz/ Alterations
NORTHAMPTON, MASS. S~ _ / 19ev Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
,o Garage
1. Location z Lot No.
2. Owner's name Address
3. Builder's name la Address 1
Mass.Construction Supervisor's License No.f �' �� 7 9 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
knowle and belief,
nature of responsible app icani
Remarks
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z SAY 1 1998
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° >...' MAY 11998 ;Gri4 Xfif Nart4a17Y:7t0jj y
ae 1EPT nF lasrxchnsrltr
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE t TI AVIT
(licensee/permitter)
with a principal place of businessJresidence at:
r9A L?J �' %� %� ��Elr
(stTz City/stat-ehip)
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 Con(ractor) (Lasuranc: Company/Pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Podcy Number) (Expiraaion Date)
(Name of Contractor) (Lnsurancz Compaay/Pokcy Number) (E(piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(aaach a6di6oml zl t fD sry to rn.u nform3ii oo permitting to ell m radon)
( 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 awun that whila homcownaa who employ pusom to do ;.,r -cnus:n Won or n-paif work on i dwelling of
not Mora than tluoo units m which the homoowncr r=dcs or eo the gnwndb appurtcnurt lh rdo arc Dot gcmally oomidcr cd to bo
avployaa under the wmkces o safica Act(GL152,"1(5)),appdca6oD by a homcovma for a Eo=c a P=ul=Y oN� tb�c
legal ciat"of an employer under the Wock Ves compecw ti Ad-
I undcru*=d that a copy of tbu mtcmcai miy bo forwnrdod to the Dcpnrtmcat of Indztdrial Accid11&Offs o of Inver■race for the
oovaxge vcri cation and that failures to sown oovango under soetioa 25A of MGL 152 can lead to tbd impos�oa of crirninal peaalties
co-Ung of a f nc of up to 51,500.00 arsNcc impri3onuscat of up to o�year and asnl penaltia in the form of a Stop Work Otdcr and a
firm of 5100-00 a day against ttY--
For dep�uw eoly
Pcrmit Number
--1 Mao— _Lot#
>gnaiure Unte _
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.
Thin C-1-M to be filled in
by the Building Departmeent
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks frnnt
- side L: R: L: R:
- rear ---
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&Pa.ved Par ljnr i
# of -Parking spaces
htrof Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: 1'5 j -- / APPLICANT's SIGNATU
NOTE: Issunnoa of at zoning permit does not relieve applio s b to oom
zoning requlremants and obtain all required IPiY witty all
q permits from the Board ealth. Conservtation
Commission. Department of Publio Works and other applicable permit granting authorities.
FILE #
pq
1998
_. File No. t
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: U YZ
Address: '� OeD ( p hone: y/
2. Owner of Property: ArA Lyl"�IA
Address:/off ^,��, / (V���,`���,,,r p— Telephone: �'/ ir�4�
3. Status of Applicant: Owner Contract Purchaser Lessee
_Other(explain): '
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s):5felec1 P
(TO BE FILLED IN BY THE BUILDING EPARTMENT)
5 Existing Use of Structure/Property _
6. Des ription of P UseNV k/P ject/Occupation: (Use a I sheets if nece ary):
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 I
SLJ{ � 3
P��'y 1 11998 °` _. �
L-APPLICANT/CONTACT PERSON: °`Tip
TPT"ADDRESS/PHONE: d
PROPERTY LOCATION:
MAP s.. PARCEL: !1 3 ZO Ste?
THIS SECTION FOR.OFFICIAL USE ONLY:
PERNUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
Fi-p R9 id
'Riiildin2 Permit MUM nnt
4pe of Construction-
New Cnnqtrnrtinn
Addition to Existing
THE LOWING ACTION HAS BEEN TAKEN ON THIS AP ICATIOM
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:
fb Cut from DPW ..Water Availability Sewer Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
it f oyspty C n
S_Alx5
Signature of Building tor Date
NOTE:lssuanoe of a zoning permit does not relieve an applicant's burden to comply with all
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission. Department of Public Works and other applicable permit granting authorities.
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