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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
'
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location Js— A Lot No.
2. Owner's name Address
3. Builder's name Z Address %
Mass.Construction Supery isor's License No. �3 Expiration Date
4. Addition
5. Alteration
6. New Porch
7. Is existing building to be de li ed?
8. Repair after the fire
9. Garage /77 No.of cars Size
10. Method of heating t1n
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cosL-
dd` The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsible app icani
Remarks
O4�1tAM 01
iii °e CC1 of �QZ�j��11C�7�Dtt
ae �asaxrhasrtts
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CONUENSAII-ON INSURANCE AFFIDAVIT
(licenseeJpermittec)
with a principal place of busi-ness/residence at:
� '��� (phone#) 9 /a
(stmW6 ty/statrhi p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workerjs compensation coverage for my
employees worming 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:
(Nome of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompalryiPoLcy Number) (Expiration Date)
(Name of Contractor) (Insur lac CorDpan /Policy Number) (Expiration Date)
i
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additions!d3cci if ntcca to inclu<,b inforrnsrioo Pertaining to all ccutraeton)
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 v&Uo hoo"cowners who cmPlay p-low to do ma iri*m•nce cotBUuc6on or repair work on a dwelling of
not mote thin throe unite in which the hwmeozvncr rc=dci a on the grounds appurtenant thereto arc not generally oocndard to be
employers under the` ork&'oocrrP�on Act(GL152 ss 1(5))�aWlication by a homeowner for a liaax or permit may evidence the
legal gratis of as employer under the WO&mJ'L Compemation AcL
I understand that a copy of this ctatcmcnt may bo forwarded to tbo Department of 1-6, ial Accid=&Cffioc of ltnuranco for tba
covaxga vcnficatioo and that failure to&taut covcntgo mxkr section 25A of MOL 152 caa lead to tho impositioa of crimi W penalties
co¢sisting of a fine of UP to S 1,300.00 ar-Nor irnprisonmcat of up to one year and avi pmnttics in the form of a Stop Work Order and a
fins 0(5 1 DO.00 a day rgainA Inc.
Signed 's I day of rpe--� 1997 Fordcp=twjw use ooly
Permit Number
Map# Lot#
St tore of Li caJUttee
i
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 colnam to be filled in
by the Building 1),.P,tmen t
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
&paved parkingi
# of -Parking Spaces
ht of Loading Docks
Fill:
-(volume--& location)
13 . Certification: I hereby certify that the information contained herein
_a
is true and accurate to the best of my knowledge.
DATE: F 7 APPLICANT's SIGNATURE
NOTE: Issuance of a zoning permit does not relieve an applioanYs burden to comply with all
zoning requirements and obtain all required permits from the Board of Health. Conservtation
Commission, Department of Publio Works and other applioable permit granting authorities.
FILE #
,
UU OCT 81997
File No.
DEPT OF BUILD"tdG IPdSs ECT13tt5
rloRjHAVI E N'A 0 1 NING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:/}?
Address: / -7 S&v L-f'l Telephone:
2. Owner of Property: wL ze4
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): � q ,
4. Job Location: 7,S-- D CL4lu� q (��u-
Parcel Id: Zoning Map# 2�' Parcel# l 7 District(s): S if
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5, Existing Use of Structure/Property
6. Description of Proposed Use/Work/Project/Occupabon: (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-V1�— 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)
962976
FILE�..-. FILE #
0a 8 X97
APPLICANT/ a'ON ACT PERSON: dZU46k
7
DE�ORTHA,01,04 MA 01c:I
PROPERTY LOCATION:
MAP (, PARCEL: -7 ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM EITLED OUT L17
Fee Pnid
f1iii1din2 Permit Filled nnt
Fee Paid f/7
AcressnryStriichire
�-
T OLLOWING 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 Conservatio ommissio
6 0 9
Signature of Buillaq Date
NOTE:Issuance of a.zaning 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 applicable permit granting authorities.
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