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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No,=.29� Alterations
NORTHAMPTON, MASS.0' 19 Additions, __
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1.
a Lot o.
2. Owner's name Address r-
3. Builder's name Address °
Mass.Construction Supervisor's [tense o. 6 d o2c? Expiration qWe
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 we to the best of his. her
knowledg and belief.
,Z CA
LX
Signat oJre onsiblt appicon!
"�
Remarks
04,��,f pTO
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$ MAR 2 ice$ lasaar[luartta
DIfARTMENT OF BUILDWG INSPECTIONS
12 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CO ENSATTON INSURANCE AFFIDAVTT
n �
(licensee ttee)
with a principal place of busine residence at:
�j bone#) �' lYS ^47`�
(street/city/ zip)
do hereby certify, under the pains and penaltie 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 work&s compensation policies:
(Name of Contractor) (Insurance Cornpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
Ottadr additiomt then ifnoocnuy to include infncmiaoa pertaining to all nod maots)
(Xl 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 homeowocra who employ pa-;o=to do,,aiatc�consfrvction or repair work on a dwelling of
not more than tbroe units in which the hogrownct resides cc on the grounds appurtenantilhmdo arc not generally 000sidazd to be
employers under the worker's compcasatica Act(GL152,ss 1(5)�application by a homeowner for a license or Pcmit naY evidence the
legal status of an employer under the Workee,compoosaiion Act
I understsad that a copy of this rut--t may be forwwded to tho Departmm2 of Indzutrial Acadco&Offioo of Iasruwoe for the
covuxge verification nod that failure to secure coverage under section 25A of MOL 152 an lead to the in>position of criminal penalties
co=stmS of a-&ne of up to S1,500.00 and/or imlttiso�of up to one year and civil penattia in the form of a Stop Wodc Order and a
flee of 5100.00 a day against tree.
For dgmtw a tun only
Permit Number
Mao _Lot#
gri�ture of Li e
I
kW
J`
i
1
a f
f �„
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 MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
Thin column to be filled in
by the Building Dep,,t_,,t
(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
&paved parking)
# of -Parking Spaces
# of Loading Docks
Fill:
4 volume-& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowl ge.
1
DATE:�--.3 2K APPLICANT's SIGNATU
NOTE: Issuance o a`t�zoning permit does not relieve ppiioan s pty with 4111
zoning requirements and obtain all required permits from the 13 and o alth. Conservation
Commission. Department of Publio Works and other applioable permit granting authorities.
FILE #
MAR 2 '1998 y� '
File No.
r..M - 4ING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: elephone:'-� .Pl
2. Owner of Property:
Address! Telephone: 2
3. Status of Applicant: Owner Contract Purchaser Lessee
_Other(explain):
4. Job Location: 4.4-c-tk 1z'
Parcel Id: Zoning Map# �,46-_ Parcel# o2b3 District(s):
(TO BE FILLED IN BY THE BUILDING PARTMENT)
5. Existing Use of Structure/Property -0 E /
6. Dption of Propose se/Work/Project/Oc ti ( s itional s is if n c `
I An
f r
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)
96325
FILE # '7 �
k ,t f
MR
APPLICANT/CQN ACT PERSON:
ADDRE`SSf Hf iE: p
PROPERTY LOCATION:
MAP�; `} PARCEL: C ZONE ''lie)
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORMEff LF11) 011T
Fee Plid
Fee Pnid 30�2 109,
Remndeling Interior ./
,14 G - �C6'e0,---
t h
Arce-.r,nrV Structure
.�-
THE^LOWING 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
Permit from Conservation Commission
=,�zgr,.!� e��14:z ?Iel�;_
Signature of Bui ding or 6ate
NOTE:lasuanoe of a zoning permit does not relieve an applioant's burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conaervation
Commlasion, Department of Public Works and other, applicable permit granting authorltles.
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