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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. f 19th Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location 1 Lot No.
2. Owner's name Q n A, K J2� Address --
3. Builder's name l' ,,[-�` c, -nom Address
Mass.Construction Supervisor's License No. /1�7/6 /k Expiration Date /G a2 r''5;,
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 cosL-
:� --
The undersigned certifies that the above statements are true to the best of his, her
knowledge and belief.
Signature of responsible app icon!
f� ��14 Remarks �" /
IV
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m DEPARTMENT OF BUILDrNG INSPECTIONS
,
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORICEIR'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence�at-.
(phone#)
(Sumf-/city/sta trla p)
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:
(Durance 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) Onsurancc Company/Policy Number) (Expiration Date)
(Name of Conncior) (lnsulance Company/Policy Number) (Expiration Date)
(Name of Contractor) (lnsurancti Compauy/Poticy Number) (Expiration Dale)
(Name of Contractor) (Insurance Compmy/Policy Number) (Expiration Date)
(attach additional shtct if ntcc=z ry to inchrdc inftxm,6 pct�riaing to all o ration)
(., 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 awirc that whilo homeowDers wino ernplay pcz;ons w do row��eoastruetioa cr repair work on s dwelling of
not morn than tluco uruU is wftich the twn»owncr resides or no tho uvj ds appurtenant th, cr o arc Dot gcocr+ ooatidacd w be
anploye s undo'tho vvocica`s oompcasaticn Act(GL152,ss I(5)�application by a homcowmr for a License or pamd may evidence the
Iegil rtschir of an omployec under tbo Workor's Compensation AoL
I undcrsi=d thzt a oc py of thu Omt.cmcsu my bo forwarded to the Dt V tmcnt of Indr>_dri al Amd�&Off Oe of Inau+nce for tlm
oova4ge va-ificeioo=d that failure to secure coverago under sceiioa 25A of MGL 152 can lead to tbs inmposition of criminal penalties
oomisting of&fnc of up to S 1,500.00 WnNOC impiisonmcrl of up to one year end civil pcniltia in tfie form of a Stop Work order and a
find of 5100.00 a day agsiast me
Signed this --day of_, Sr 199$ FCC dcpxrtxnCCaluJ-0 oaly
Permit Number
Ma p4_ Lot# -----
Siplab re of LiecusceRcrmittce
w
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 col— to be filled in
by the Building Department
I 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 parking)
# of Parking Spaces
ht of Loading Docks
Fill:
volume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
_1
DATE: 9T APPLICANT's SIGNATURE Z
NOTE: Issuanoe of a zoning permit does not relieve an applioant's burden to oompty wit y
1� ,a11
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 #
e' C
FEB 2 61988
t File No. 3- / I
€ �,s .
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: .0 (�° �
Address: �! / �/ Ott^- o Telephone: �> '' �-�9
2. Owner of Property:
Address: Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain): r!Dv��Jie�
4. Job Location:
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property za--OU'61-
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 �'-X 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)
z ,
96324
FILE #
FEB 2 61,998
APPLICANT/CO& ACT PERSON: Z&A y ,
C ADDRESSfPHQItE~
PROPERTY LOCATION:
MAP o? PARCEL: tl ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED 011T
Fee PAid
Iffiii1ding Permit Filled nnt
Fee Pnid
Arresynry Structure
v-
a �� A
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THEVCSLLOWING 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 Conservation ommission
,3 L
Signature of Building or Date
NOTE:l"uanoo of a zoning permit does not relieve an applioant'a burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commlealon, Department of Publio Works and other applioable permit granting authorities.
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