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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. q Additions
APPLICa ATION FOR PERMIT TO ALTER Repair
} Garage
1. Location l l Q �" d� G _��r� Lot No.
2. Owner's name - � Address ` w
3. Builder's name C a Address ! �� "'
Mass.Construction Supervisor's License No. E �'y Expiration Date '3 71 c e
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:-
i The undersigned cert ifies t e ve sta tsar true to the best of his, her
knowledge and belief. Ci
C
Signature of responsible app,icant
JV� J1 �ft�to 1(3 VC-Z4,t,-
Remarks
Q-�1tAMP�.
Boo Fe 2 `� 199 Crit� of 'Nart4allipton z
$ d �assarhnsrtts
c� DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WO R'S COMPENSATION INSURANCE AFFIDAVIT
(licenseeJpermittee}
with a principal place of business/res'dence at:
(phone#)
33�c
(street/city/state zip)
do hereby certify, under the pains and penalties of pegury, 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) (lasurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet if n6cenazy to inclade information pertaining to fill ooatsadora)
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 homeowners wbo employ persons to do mami�construction or rtpoir work on a dwelling of
not more than three units in Wnch the hotneow=r=dea or oa the grounds appurtenaut thereto are not generally 000side ed to be
employers undet the%writer's compensgdion Act(GL I52,ss 1(5))�application by a homeowner for a license or permit may evidcaoe the
legal status of an employer under the Worker's Compamation Act.
I understand that a copy of this statement may be forwarded to the Dcparwwad of Dial Amdm&Office of rn%wwx`e for the
coverage verification and that failure to seam cowmv under section 25A of MGL 152 can lead to the imposition of criminal penalties
ooasisting of a fine of up to S1,500.00 and/or imptisoim=it of up to one year and civil penalties in the form of a Stop Work Order and a
firm of 5100.00 a day against ma
SII16d tblS y C4-i� 1997 For dgrataoe�sl uao only
— Permit Number
gyp# Lot#
Sim of Licensee/Permit tee
T
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.
This cold 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
&paged parkingi
# of -Parking spaces
ht of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledg .
, 0.
DATE: APPLICANT'S SIGNATURE C
NOTE: lasuanoe of a zoning permit does not relieve an applicant's burden to oomply With oil
zoning requirements and obtain all required permits from the Board of Health. Conservtation
Commisslon. Department of Publlo Works and other applloable permit granting authorities.
FILE #
7 2 j99 i
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: QV I lam, M 6Cj4C9(*-1
Address: C(QSjVt
2. Owner of Property: -Ti3ar
Address: �i I a)A Telephoner -�
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: iLa� >��S �,"r
Parcel Id: Zoning Map#S,_<! Parcel# c::2� District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property la ctr�
6. Description of Proposed Use/Work/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 # 962959
]
ACT 2 7199 i
APPLICANT/CONTACT PERSON:
ADDRESS/PHONE:
977 &Aedtl-
PROPERTY LOCATION:
MAP PARCEL: ZONE
THIS SECTION FORAFFICIAL USE ONLY:
PERNUT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED MIT
2d
THE LLOWING 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 Conservation Commission
Q
Signature of=af 'zaning Date
NOTE:Issu permit does not relieve nn applioant's burden to oomply with alt
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Pubiio Works and other applioabla permit granting authorities.
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