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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS.
t'-2— L 5 19 Additions
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APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location Lot No.
2. Owner's name AlAWLCi l f l Address n Qe-nc (11 r
Mae
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3. Builder's name P40- � � ( .IJ �N?Ce Address fci
Mass.Construction Supervisor's License No. 0(r)0 1:1112 n Expiration Date --1
4. Addition#}(�� � C,2=_ t_SQCX ' C-1 CI An�cae� t-1Cy ml, 0c
5. Alteration
6. New Porch
7. Is existing building to be demolished? N 0
8. Repair after the fire PAC)
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
knowledge and belief.
f`
Signature of responsible appd icani
Remarks
�ly"t MPS
�O
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bApAkTMENT OF BumDrNG INSPECTIONS
�° dF 212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
\, n ZnC .
(li censerJpermi ttr=e}
with a principal place of bugmess/residence at-.
(phone!,) �
(street city/stair/zi ) C)i0a;74"
do hereby certify, under the pains and penalties of perjury, that:
O 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 contract or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
f �e Q1� �i �1 1 12-��t� 4-
uation Date)
(Name of Contractni. tx Company/Policy Number) (Exp�
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
6� CCZLC. 1�� l�a, c >;�, r ►aorta b 2-- 9$
(Name of Contractor) (1nSU=Ct Compwy/Policy Ntunber) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(attach additioml zlxct ifnec="xy to include inforuvtion pert"=g w all c�n)
( ) 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 wlino homcowncn who employ persons to do mamicn3mcr,coastru co or repair work on a dwelling of
not morn than thruo units in which the homoowocr rcidcs or oa the grounds appurtenant.haetn ,not grncralry comakmd to be
employers under tho wor kcr`a pompcns4cxx Act(GLt52,=1(5))�application by a homeowner for a GecWc cc Pamd maY cvidcmc the
Icgd ctniim of an employot undertbo Workers compcmatioa Act
I undcrsisad dDd a copy of thu cr=am(may bo forwnrdad to tho Dcpar�of Indsiitri al poodmb'Offs"of tosxw-forth'
coverage vrrifieatioo and that all=to$own coverago under suction 25A of MOL 151 can Icad to tbl inTPos¢'—Of mmin penalties
ooaststiag of a-rme of up to 11,300.00-r N-bmprisoamcIIi of tip to one year and civil pcml6c,in the form of a Stop Work Ordcr and a
find of 5100.00 a day agaitut m-
Signed this _day o 199-7 Foc dcputns zeal tun oatY
- Pcrmit Number
MaP4 Lot# —_—=
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10 Do any signs exist on the property? YES NO n
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.
Thin column to be filled in
by the Building Department
Required
Existing Proposed By Zoning
I Lot size
Frontage 1
Setbacks - frnnt
- side L: l R: L: R:
- rear
Building height ,
Bldg Square footage
%Open Space:
(Lot area minus ,bldg
&paved pa.-king)
# of Parking Spaces
# fof 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 knowledge. '
DATE: ��-l`rj ��- APPLICANT's SIGNATURE
NOTE: Issuanoe of a zoning permit does not relieve an applioanvs burden to 0o Witt7-4.11
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
FILE #
~~- File NO. Wk3M
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:
Address: -\Ll— elephone:_J[�'� 1
2. Owner of Property:
Address:-FZZ ��`liLLYYI,fnU telephoner
3. Status of Applicant: Owner Contract Purchaser Lessee
_Other(explain): Csj mC-I °r
4. Job Location: 5b '-'-0def'eAQn t 1 �
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Parcel Id: Zoning Map# �. Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property t( i U-
6. Descri lion of Proposed UseNVorkJProject/Occupabon: (Use additional sheets if necessary):
`TD n�51-, +�n� x r > rFt� _C �An1 �c�, a- luu-,,
C1w 0.(l Jzr4rl�:����A c li r CI>C.X v�
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.
6. 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_X _ 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 # 4
PLICANT/ O TACT PERSON: ) ��
- a
PROPERTY LOCATION: ' %n-
MAP � C.o PARCEL: ZONE
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM Fn,T,FD OUT
Fee PAid
.'RPmncjPlin2 Interior
Addition t�Vyiqfing
--
THE F OWING 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 Con ervation Co ion
Signature of Building Inspector Date
NOTE:Issuance of a zoning permit does not relieve an applioanYs burden to oomply 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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