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36-163 (2) > ? a VI T 7l7 o "1 Z > p r JJI n Zoning U1 P Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. 3(:7" 91S- 7 Alterations NORTHAMPTON, MASS. 19 Additions APPLICATION FOR PERMIT TO ALTER Repair a Garage 1. Location i 07 S �U 1yS P tT R D N 0 tk b Lot No. 2. Owner's name E Lk-ts C t—OU(J`N Address_ O U ff S PIT" Ro, N a A D 3. Builder's name U-1\L A(AM 6-k 13 Sotj Address N f(L 0 J MoNTA-(X L i�A� Mass. Construction Supervisor's License No. n `1 S—`1 g Expiration Date 6Z 7 4. Addition D( co U Z ZCK w k-M W t Z z L L)FT- 5. Alteration 6. New Porch 7. Is existing building to be demolished? o 8. Repair after the fire 9. Garage No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof A�Pt\14tT sl�l�Gt�s 13. Siding house 14. Estimated cost:- soy The undersigned certifies that the above statements are true to the best of his, her knowledge an belief. lam' Signature of responsible app icant Remarks 10. Do any signs exist on the property? YES NO R 1F 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 I Required Existing Proposed By Zoning - 11' 55 a Lot size 11 MaJ � Frontage Snc� Setbacks - -946 50 - side L: �R: L:34 R: ri - rear Building height ( � 1'� Bldg Square footage 1 C7 0 %Open Space: (Lot area minus bldg &payed parking) 1 # of Parking Spaces e fof Loading Docks Fill: Avol"ume--& location) 13 . Certification: I hereby certify that the information contained herein (, is true and accurate to the best of my knowledge. J DATE: APPLICANT's SIGNATURE NOTE: Issuanoe of a zoning permit does not relieve an applioant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Publio Works and other applionble permit granting authorities. FILE # t f� r .� MAY 4W 1 File No. ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: �) 1<_L f�M C'- S3 SO rj Address: 1.9 ()1`V 144"- Telephone: 2. Owner of Property: 2--L-UA. C L 0 G'A Address: (O� % Q U'(CIS PtT rw Telephone: 3. Status of Applicant: Owner _Contract Purchaser Lessee Other(explain): 2 4, Job Location: �0 YZ (309TH (DI -" 6 .0 Parcel Id: Zoning Map# 3 Parcel# (�3 District(s): S Y (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5, Existing Use of Structure/Property 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): 7. Attached Plans: 'V\—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. S. Has a Special Permit/Vadance/Finding ever been issued for/on the site? NO ,X 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_j� _ 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) a d i♦{�� l� bbl:saxcansctta � Pt m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WOREER'S COMTENSA'ITION INSURANCE AFFIDAVIT �1t—ytNM �(3Sdv\J (licenserJpermittee} with a principal place of business/residence at: (ZO y\/tb+`-'xW&-uT 1-")13171 (phontli) -S67-115J (strevt/ci ty/sta2rJzi p) 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 on(,) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (lnsuranc-c Company/Policy Number) (gyp rmtioa Date) (Name of Contractor) (Insuring Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance ComGranylPolicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (anach add?dccal sheet f nocc� to indudc wf«mi m pertnia ng to a ootrac n) ( I ant a sole proprietor and have no one working for me. ( ) I auk a home owner performing all the work myself. NOTE:please be aware that whila bo,�who employ pc"=w do cn�oxntnuzioaor repair work on a dwelling of not moire than throo units in which the homoowna resides or oo tbo grounds appttttenant th=W arc not gcncrally ooasidcrcd to be employrra andcr tbo wm+.cr'a compc 54ca Act(GL152,n 1(5))�application by a houtoowncr for a licco3c cc permil may evidence the legal ctxlno of an employer under tho Workces Compcn al Act I understand that a copy of thu zw cmcnt may ba forwnrded to tha DcQart mco2 of Inds ,j Ac6dms5'OfSoe of Insur,<noe for the co—ge verification and that Yailum to aoc—coverage undar section.25A of MOL 152 can lead to tbo'imposition of criminal penalties ` oom fisting of a fine of up to S 1,5oo.00 and/or imluisonmcat of up to one year and civil pcn Wcs in the form of a Stop Work Otdcr and a fino of 5100.00 i day against me— For dgmtmr use oily /ZJ/"z Pe rmit Number " 1� L , _IAt# - Signati=of Uccnsec/Pcr itlCe — Lbte 61996 MAY EpTOF O s � W ; 4N, O " � A k j i s G 1©5' .n. W V W ` s FILE # l x U 4 MAY 4 ,19% APPLICANT/Cf NTACT PERSON: _ DEPT UDRESStI'HONE: �.:.. PROPERTY LOCATION: D pe MAP 36 PARCEL: /0 j ZONE THIS SECTION FOR-OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE F,-0 Paid 'Building Permit Filled nut Type of C-onstniction- X. New C_nn.,qfriirtinn !2 Addifin Arregsn v� �-.. THE LLOWING 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 ofenl ell Water Potability-Bd Health Permit from Conservatio mmission g Signature of Building for Prate NOTE:lssuanoe 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 Commiss e Commission. Department of Publio Works and other applicable permit granting authorities. 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