36-272 (8) r �
FT. Deep
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M 0
> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C --�
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00
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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NOTE:IN ORDER THAT THIS APPLICATION MAY BE ACCEPTED,THE DATA CALLED FOR BELOW MUST BE SO SET FORTH
THAT WE CAN DETERMINE FROM THE APPLICATION AND THE ACCOMPANYING PLANS WHAT THE EXISTING CONDI-
TIONS ARE AND WHAT THE FUTURE CONDITIONS WILL BE.
Plot Plans and Plans,must be filed with this application before a permit be granted.
MAR 310
Zone
APPLICANT NOT TO FILL IN SPACES ABOVE THIS LINE
Application for a Dwelling Permit
a Northampton,Mass. . . . . . . . . . . . . . . . . . . . . . . . 19 . . . . .
Telephone No. `��, .` $�.-`l� . . . . . . . . . . . . .
7b the Supt.of Buildings:
Application for a permit to build is hereby made according to the following:-
1. Location,Street and No. . . f. .�. .mR. P.G.E. . .r'C 1.D& • • AD• • • • • C} Lot No. . . -2- . . .
2. Nearest cross street �of t:k�!G�. . �:.. . . . . . . . . . . . . . . . . . . . Size of lot . . . . . . .
3. Owner's name (Y1 4. 6v6.1.M. LAGA. . . . . . . Address .31 .(�W. ?,!. .o.C':. . .rr�t Ltlwtr . . rn P
4. Architect's name C).&,31(,.N• •6A.S1G,f. rt�L. . . . .. . . . . . . . . Address`f.v .�. . .B'1(w1.N. .aT. . . .Ot,.p.1AA. . .N.E,
5. Builder's name d C.�.OYI . .s g .�
Address . ITT. . ouJ7. .{��.. .W .i. .Ei.�. .mA'
Mass.Construction Supervisor's License No. .� .
l g cl
. . . . . . . . . . .. Expiration Date . . . . . . . . . .. . . . . .. . . .. . .
6. Use of Building:One-family .X. . . . . . . . . . . . . . . . . Two-family . . . . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . .
7. Number of rooms in each family unit: . . . . . . . . . . Number of Bathrooms . .3. . .L. . . . . . . . . . . . . .
8. Is there a garage attached? . .` L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
-9. Size of building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Square footage . 1-::W0.. . . . . . . . . . . . . . . . . . . . . . . . . .
10. Number of stories .21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
11. Distance from finished grade to high point of roof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
-12. Type of construction �1�� Q��h�mi~..� .J "r` S� ��:L. . .r��;N. .j. . �.w. �.�1, c�. . . . . . . . . . .. . . . . . . . . . . . . . . .
13. Distance from building to street line in feet . . . . .t Q. re�eT. . . . . . . . . . . . . . . .
14. Distance from building to side lot lines in feet:Left . . . ./.�f&4-i. . . . . . . . . . • • . flight . ...°1. .
15. Distance from building to rear lot line in feet . . 60P.7�A-�6�T. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . • • • . . • • • . . • • • .
16. Is a plot plan being filed with this application? . . . d.tEs . . . .. . . . . . . • • • . • • . . •
17. Species of framing lumber:DF . . . . . . . . . . . . . . . . . . . . Spruces. . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . .
-18. Are all structural conditions noted on drawings? . . . . . . . .`�"� .. . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . .
19. Nature of land upon which the structure will be erected:Natural .NA7-.V eq L. . . . . . . Filled . . . . . . . . . . . . . . . . . . .
r
20. Depth of basement or cellar floor below finished grade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . ./ . . . . .
21. Material of foundation walls . .Pv.�t?t_fl. , �,trC.(?t`j�. . . . . . . . . . . . . . . . . Thickness in inches . . .`. . .ilr 0. . . . . . . .
22. Type of roof:Flat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pitched . .PtTt.H to . .. . . . . . . . . . . . . . . . . . . . . . . . . . .
23. Material or roof covering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24. Method of heating ���' C
.(aOr.rc. . .K.t.taln•. . . .. .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .
25. Will the building conform to the Building and Zoning Ordinances? . Yt . . . . . . . . . . • • • . • • • . . • . . . . . • . . . • . . .
26. Septic'Dank? . . .y es. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City Sewer? .M.o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27. Construction within 100 ft.of wetlands? .NO . . . . . . . . . . . . . . . . . . . . . . • • . . . . •
28. Construction within 100 year flood plain? ./VP. . . . . . . . . . . . . . . . . . . . . . . • . • • . .
29. Estimated cost:Total $ . . .c��SD. . . . . . . . . . . . . . . . . . • . . . . . .
No building or structure which is erected or altered,shall be used,in whole or in part,for any purpose until a certificate
of occupancy is issued by the Building Inspector.
The undersigned certifies that the above statements are true to the best of his knowledge and belief.
,t-. . . . . . . . . . . . . F
Signature of Contractor g Si nature si h applicant
WRITTEN DESCRIPTION OFWORK TOBE (}
ll r
E-. ('FG . .1 .�Jo? . . ' �3r � r' t.-,. .
j 0. . '� . . .�I:�
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CITY OF NORTHAMPTON
BUILDING PERMIT CHECKLIST
All 1&2 Family Proj ectS The following items are to be
considered MINIMUM
information to be submitted with ALL permit applications
A Scaled drawings & details shall be submitted with each application proposing
construction, reconstruction,addition, alteration, or repair. The building o cial
may waive the requirements for filing plans when work is of a minor nature.
B. Scaled drawings & details shall indicate&describe all proposed work, including location,
size,grade of materials &equipment to be used.'
C. PLOT PLAN, property address;map &lot number, zoning district&overlays (such as
wetlands) [ ]
Show well septic locations (if applicable) [
Location of lot s, dimensions of lot, frontage
Location&dimensions of public easements,public utility easements, railroad right of ways
and establish zonin etback requirements. [ ]
Locations &dimensions of primary and accessory buildings &structures.
D. FLOOR PLANS,floor plan of each floor and intermediate levels including basements,
crawlspaces,terraces, porches garages, carports, and decks, showing existing condition and
proposed construction
Dimensions, locations &materials of foundations, footings, columns &piers {including
reinforcing when required}u
Direction, dimensions, spacing &grade of all framing {floors, roofs, walls, partitions)A
Location of all walls,partitions,windows, stairs &doors jl , __.� �
Location&description of all electrical equipment and alarm dues [ ] SM c r C _ �; Q S
Location&type of all heating and air conditioning(HVAC) equipment. I .sue j"A r
HVAC schematics (where required check with building inspector) [ ] , %�: to
-EXTERIOR ELEVATIONS Front, rear&side elevations including foundation and finish
grades.b
Location&dimensions of windows &doors.
Description of exterior cladding or siding material. [�
Show exterior stair locations &dimensions:-[-
Show chimney and vent locations hY
.DETAILS &SECTIONS, Sections through exterior walls showing details of construction
from footing to the highest point of the building. ki
�Sections through fireplaces&chimneys (show clearances)1
tion&details of any roof trusses,glue-lam,or engineered lumber {include connection
deta ls-wd,Massachusetts professionals stamp on specification sheet} [ ]
Exterior envelope energy requirements:Uo-of walls,roof-ceiling&floors..OR.R value of
t walls/roof/floor,also percent of window area to wall area.
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24-98
k.
Conditions: Driveway Permit
In lieu of plan approved by City Engineer
I agree to the following added conditions:
1) I will contact the Department of Public Works and have
an inspector check and approve the graded gravel base
prior to paving to insure compliance with slope and
location;
2) I further agree that if in the inspections any of the
permit conditions are not met that I will at no expense
to the City remove and replace the driveway as directed j
by the City Engineer.
By: ✓/ ✓.
Petitioner
NOTE: The Public Works Department recommends that you provide a
plan showing the proposed driveway with grades and location
in the future to avoid possible expense which you will incur
by not getting approval of actual plans in advance.
}
24-98
C I TY OF NORTHAMPTON, MASS.
February 11 19 98
THE BOARD OF PUBLIC WORKS
The undersigned respectfully petiition your honorable body for
Permission to install driveway at 148 Maple Ridge Road (Lot 27)
Fifteen (15) foot maximum width at the street line. Gutter drainage not to be
disturbed. All drainage shall be directed off the driveway surface to
adjacent land and not on the existing roadway. Driveway surface to be
paved if the grade of the proposed driveway exceeds 37 or more.
By:
Mike Laga 586-4326
31 Golden rive Florence, MA 01062
Proposed Location
Inspected by:
Gravel Base Grade
Inspected by:
Final Approval:
THE BOARD OF PUBLIC WORKS
Voted that petition be granted.
$25.00 Fee Paid Ck. No. 2847
Samuel B. Brindis, P.E. , Director of Public Works
(SUBJECT TO ATTACHED CONDITION I & 2)
s� Crib of 'Hart sin fon
e tass Rchnsetta MAR 4 i
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Buildirfg '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
tAL — C6 L�C-A
(Iicenseelpermi flee}
with a principal place of business/residence at: 7
(phone#) LD v 0
(streei/ci ty/stalr/a 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 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 Contracior) (Insurance Company/Poky Number) (Expiration Daft)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shed ifneo=u y to include infwmadon pertaining to all 000tn d )
1 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 who employ pasom to do main�conshuctioa or repair work on a dwelling of
not mote than throe umtt is which the howoowncr resides or on tbo grounds apprrtmm ihercto an not&comity oonudercd to be
—ploy'-und4t the ms's O=Pcaulica Act(GL152,m 1(5)),application by a homeowner for a license or permit tnay evidcnx the
legal duttu of an employer under the Workees Compenseioa Act
I understand that a copy of this rfat—rd may be forwarded to tbo Depwftacnt of Iahitrial Aecidea&Ofoo of InAuanoo for the
coverage vaiftcatioa and that failure to warn covaago under section 25A of MOL 152 can lead to the impos—of criminal penalties
comisting of a fine of up to S1,500.00 and/or imp itomm of up to one year and civil penalties in the form of a Stop Work order and a
find of 5100.00 a day against mc.
For dcpattzr� u-only
Permit Number
Maps _Lot#
Sipahare i 'rice
�O�K1V�Af p�O'`
g Cr ifs of Norf 1 amp tau z
'm xsescituaetill
' DEPARTMENT OF BUILDING INSPECTIONS
rz €, 212 Main Street ' Municipal Building
INSPECTOR j�'li'iZ Northampton, Mass. 01060 j
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE: � J�7
JOB LOCATION:
(Map) (Parcel) (Subdivision)
HOMEOWNER: rY 1 C VVf\1.=.._ L A LSA
(Name & Address ) 3 3L(_
CTo L�0 Z.i f,�c lJ�t�c 5 In—� Z
(Home Phone) (Work Phone)
The current exemption for "homeowners" was extended to include
Owner-occupied Dwellings of one ( 1 )or two (2) families. and to allow such
homeowner to engage an individual for hire who does not possess a '
license, provided that the owner acts as supervisor. CMR780 Section 109. 1 . 1
DEFINITION OF HOMEOWNER: Person( s ) who own a parcel of land on
which he/she resides or intends to reside, on which there is, or is
intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures . A person who
constructs more than one home in a two-year period shall not be
considered a homeowner . such "homeowner" shall submit to the Building
Official, on a form acceptable to the Building Official, that he/she
shall be responsible for all such work performed under the building
permit.
As acting Construction Supervisor your presence on the job site
will be required from time to time, during and upon completion of the
work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers '
Compensation) and Chapter 153 (Liability of Employers to Employees for
injuries not resulting in Death) of the Massachusetts General Laws
Annotated, you may be liable for person( s ) you hire to perform work for
you under this permit.
1
The undersigned "homeowner" certifies and assumes responsibility
for compliance with the State Building Code, City of Northampton
Ordinances, State and Local Zoning Laws , and State of Massachusetts
General Laws Annotated.
HOMEOWNER SIGNATURE
BUILDING PERMIT #
OAT PTp
Qu a �ttI of Nartflailiptall
Y
O5T <s DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, Mass. 01060
Square Footage Amount
Basement @ .10 j L
lst Floor @ .40
2nd Floor @ .20
1/2 Floors, Attic, Garage .10 -� Y
Deck, Porches .10 ( � j
TOTAL
5£'£ oL -o
021YA341 S N � �-N I W T4
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,> 780 CMR Appendix J
Manual Trade-Off Worksheet
Per mit
Builder Name Date
Builder Address
Checked E
Site Address Zone❑12 X13 X14
Submitted By Phone Date
PROPOSED e
Ceilings, Skylights, and Floors Over Outside Air
Requited
Insulation x Net U-Value
Description R-Value U-Value Area =UA
(table J6.2.21% x Area = U
Ceiling ft2
(Table J6.2.2a) —�
Floor Over Outside Air ft2
(Table J6.2.2a) —i
ft2
ft2
Total Area ft2
Walls, Windows, and Doors
Insulation x Net Required
Description R-Value U-Value Area = UA U-Value x Area = U:
Walls ft2
(Table J6.2.2b,c,d) --'
Windows — ft2
(NFRC or Table J1.5.3a) —�
Doors — ft2
(NFRC or Table J1.5.3b) —'
Sliding Glass Doors — ft2
(NFRC or Table J1.5.3a) —�
ft2
ft2
Total Area ft2
Floors and Foundations
Insulation Insulation x Area or Required
Description Depth R-Value U-Value Perimeter =UA U-Value x Area =UA
Floor Over Unconditioned (Table ft2
Space J6.2.2e)
Basement Wall (Table ft2
J6.2.2f)
Unheated Slab ft
(Table J6.2.2g) in.
Heated Slab ft
(Table J6.2.2g) in.
ft2
ft2
Total Proposed UA must be less Total Total
than or equal to Total Required UA Proposed UA Required UA C
Statement of Compliance:The proposed building design represented in these documents is consistent with the building plans,
specifications,and other calculations submitted with the permit application.
Builder/Designer Company Name Date
DRAFT (for training purposes) 53
Door panels
m.Iinte n>t(e) a fh!I,,-look ul
o( D,,:q c, 11 r I IIIII, Ieadt I..*
11t or Stain
nrlil'ned Ix�yu c�h,�i -f, ur ed eerre
n�uiin re�ni5ulrn,�n Yalu � .cl�ik j'
'i �U e I �Infur,id ixe,piur ixAt,nn /
rrp iii " It I r,�trIpl III ke,i
n �tt5 and vmlel oui
te,I II h"I»in ."101 V I Iem-
ed in,II tteci ,4355 tors ifetp an<I J �,
n uca�e f ne rF,> cfh.iene
f X44.
• tk°eor,111,1,slays is inserted bwt n
re
t'C' p lllr",�rf.;l —to pr,tc t it�r"m
china e anti ak,r allrnv for c°asr�
e;rnin�t Standard prep i5 mgle
bore or 2-b,rre with 2l%;, cro—hb re
• Rrass c.3�ie is n ailable t�,,rdd'i I) -s'or 2 1 b,icksetl I I centers,
tcuich rJ e t, ,cur entrance 7's<Iurrre corner f xeplatc. I
• ')andnrd U;ine Size I, x 'LI cd.,'holc
ass chanted 1 0 '111d 18 w dths ,ur Lc^r,bate of k hl,ck reaiiable
bad,r��urd mdi .,t,<„ �assde5ign� certain incxiels a butt tt1 pt, I 1/ palrl
pure blas
I
�s 1
N.R- I N+Il';' N:ll:' "J iIU' njillJ' `"tIXX*
N84KK' NReKK N8�1R' N8(,R' N8,10 NF;60 N81 N85 N8-3T
has
r
NrY) NI I Nh>R' V15R' Mot' NI,N NI`),I' Nl,u' NIVXX' NI AX'
,r - Head
Glass Gas U- R- Air _
Sidelites. Unit Type Fill Value Value Infiltration
A sidelitc size is 12"x 68" Newport N300
Entry Door NIA NIA 017 5.88 0.13
14 widths also available Newport N31
gain Composite or Entry Door Std Air 0.30 3.33 0-13
ne Is ready to stain or paint 1"CJ�A.o71 RCC NewportN19
Ch your trim- Entry Door Std I Air 1 0.39 1 2.56 0.13
Thermal values indicated have been obtained from physical testing to NFRC
Ipered Insulated glass for DO-91.Specifications by a Certified Independent Laboratory.
ind Increased energy Air Infiltration values indicated have been obtained from physical testing to
icy. ASTM E 281 Specifications by a Certified Independent Laboratory,
itive glass is inserted
n two panes of glass to
it from damage and
�x easy cleaning
�— -- T)
ame also mailable
Frames.
variety of frame and
in optlom is featured on T, ) _ Sill
)'s-25
Hinge Iamb Strike Iamb
f
N31YY* N34YY' N300 N331 N331B N800 N900
ff
i
Y � ..
ry
v�
N85V N83V N93A N94A N95A N92WG N92RG*
n i i
AMC.
N15YY' N9,'C N94 N95E N95S N15S' N97S* N34S' N96S*
17
.� �._, U
ENERGY CONSERVATION APPLICATION MkM 12
FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION
AS
Applicant Name: rl I t Gy l r � �G �� Site Address: 1 y i�/g���� f t�,G�G e
Applicant Address: ,3 7 l) r City/Town: y✓ �!�?w�u�'1
D Use Group:
Date of Application: Z z
Applicant Phone: y/ 3 -_9' 3 _ ` Applicant Signature: j
Compliance Path (check one):
( Prescriptive Package(for 1-or 2-family residential buildings not heated by electric resistance)
Fill in all values that apply from Table J5.2.1b: Package Number(A through KK):
a. Gross Wall Area 3 0 sq.ft f. Wall R-value R 1 3
b. Glazing R.O. Area L/0 b sq.ft. g. Floor R-value R-
c. Glazing%(b_a) l y y % h. Basement wall R- 1 3
d. Glazing U-value U- i. Slab Perimeter R-
e. Ceiling R-value R- j. Heating AFUE
/
Component Performance(Manual Trade-Off)
Climate Zone(from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 (Zone 14
Attach Trade-Off Worksheet from Appendix J, [and I VAC Trade-Off Worksheet, if applicable]
MAScheck Software
Attach Compliance Report and Inspection Checklist printouts.
Systems Analysis F1 Renewable Energy Sources
Attach approved Analysis
Official's Name: Official's Signature:
Application Approved Date of Approval: 8
Application Denied Date of Denial:
Reason(s) for Denial:
(over for more) BBRS 12/0s197
NORTHAMPTON WATER DEPARTMENT
237 PROSPECT STREET
NORTHAMPTON, MA 01060 61
587-1098
Subject : Municipal Water Availability
Location: LOT 27, 148 Maple Ridge Road
Inquiry Made By: Michael Laga
Date of Inquiry: March 3, 1998
Municipal Water Main in Front of Location: YES X NO
Size/Material/Age of Water Main: 8" DI Pipe 1989
Approximate Street Pressure : 45 PSI
Size of Service Connection: 1" Copper
Comments :
A corresponding "water entrance iee" shall be paid prior to making any connection to the municipal
water system. Arrangements of' such installation shall be made with the Northampton Water
Department with a minimum of 5 working days notification. All work shall conform to
Northampton Water Department specifications.
Charles Borowski
Superintendent of Water
Enclosure: Letter to Frank Sienkiewicz from Sam Brindis, dated June 14, 1991.
cc: Samuel B. Brindis, Director, DPW
Guilford Mooring, Assistant Director, DPW
George Andrikidis, Assistant City Engineer
Anthony Patillo, Building Inspector
A:\WATER\Availabl.50S
� r
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 cola= to be filled in
by the Building Dapnrtm nt
Required l
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - — n G
side L: R: L:�R:
- rear + 600 ' /N
Building height r 7
Z
Bldg Square footageS{
%Open Space:
(Lot area minus bldg
&paved parking!
# of -Parking Spaces O
ht of Loading Docks
O
Fill:
{volume -& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
1 l_
DATE: /3/J APPLICANT's SIGNATURE
NOTE: Issuance of a zoning permit does not relieve mn applioan n to comply witt7'ali
zoning requirements and obtain ail required permits from the a of Health, Conservtation
Commission, Department of Publio Works and other applionble permit granting authorities.
FILE #
MAR 3 ,,998 Fi 1 e No..
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: �A c- t=L m. 7
Address: 31 Lro (OL hJ nr, " Telephone:
2. Owner of Property: 1 r\k OAR Lam, R L� G R
Address: I i(n 406-- OL, Telephone: S b —q 3cc -�
3. Status of Applicant: _Owner Contract Purchaser Lessee
Other(explain):_
4. Job Location:
Parcel Id: Zoning Map# ` Parcel# V7 District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property L)N E�
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
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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 KNC!A: 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 # 963267
MAR 3 ►993
APPLICANT/CONVICT PERSON:
ADD ,Ej$XHONE:,
PROPERTY LOCATION:
MAP (o PARCEL: c;Z 7oZ ZONE 59
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZQNTNCI FORM FH,T,FT) OUT
Fee Pnid
lRiii1ding Permit Filled nyt
)/
Additinn to Existing
G /
THE FOLLOWING 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 mission
Signature of uilding Inspector Date
NOTE:Issuanoo of a zoning permit does not relieve an applloanYs burden to oompty 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 authorttles.
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