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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. 19 Additions
% �
APPLICa ATION FOR PERMIT TO ALTER Repair
Garage
1. Location r-0 a A u - -7-O )11-4- Lot No.
2. Owner's name Pr � , /�'/- J-%��f; Address Co 1 �� ,�u% A AT1,,4 70n� �1'-
3. Builder's name'R`*,e `'�,0%,0 e O —"I've- Address *7i 1' 6)G i !6-JW. A16,'071-X Aj
Mass.Construction Supervisor's License No. 021,19 915 Expiration Date t�a-�?'- aoo 4
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 N y Si/l K
14. Estimated cost:- )o t, The undersigned certifies that the above statemcnts are we to the best of his, her
knowledge and belief.
S vonsible app,icanl
Remarks
LX
04TNAMp�O
O
aB i ` �blasaxcanactta
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION lNS`(JZANCE AFFIDAVIT
/�G L/
(licensct•Jpermitzee)
with a principal place of bufsinesss/residence ax:
7V- 1 AF- sz A/cS�Tlfr4r,� 76�� y (phone#)
city/sta1dzip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following Nvorker's compensation coverage for my
employees working on this job:
(Insurance Cc(mparry) (Policy Number) (E_xpim on Daze)
( ) 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) (lnsurancc Company/Policy Nu.mba) (Expiration Date)
(Name of Contractor) (Laurance Company/Poky Number) (Expiration Date)
A 4
(Name of Contractor) (Insurance Compauy/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additional shod ifooccssary to inchsdc information pettaiaiag to all ooa rxLe n)
( ) I am a sole proprietor and have no one wodang for me.
( ) X am a home owner performing all the work myself.
NOTE:pltaae be aware tb i Ammo homcownas who employ parom to do makd uan or,mostivction:or rcgaa work on a dvxUiag of
not more than throe units is which the booloowacr r=dw err on rho grounds appttr W xd tb=w ace not gc=idly c oosidcred to be
employv-under tbo Wxka`s oompeus4oa Ad(GL152,a 1(5)1 application by a homeowner for a liecnso oc pclmd may evidcnoe the
legal dahca of as employer under&*WoclC x Co cap cadioa Act
I undersUnd that a copy of truer cwcmcat may be forwarded to tale Dopact.s of Todushial Aeddeats'Oboe of 1-mrsum foe the
coverlge verification and that failure to coatre oovaago under socbm 25A of MOL 152 cari lead to tbd ikon of ai wd peaalb-
oomitting cf&-E=of up to S1,500.00 an&or imptisom= of tip to one year and civl pcmttia in the form of a Stop Wodc Order and It
fine of 5104.00 a dry against mf--
Foe depcata+ata—coly
kPCimitt Ni]IIll)CS Lot#1
Sigz=tiire.taf Liomseepermi _
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 co.1— to be Pilled in
by the Building Department
I Required I
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&Paved parking)
# of -.Parking Spaces
# "of 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: ; APPLICANT'S SIGNATURE''14— �
NOTE: lu anon of a zoning permit does not relieve an applioant's burden oomply with Jail
zoning requirements and obtain all required permits from the Board of alth. Conservation
Commission, Department of Publio Works and other applioable permit granting authoritiou.
FILE if
APR 3 11999 i'.
File No.
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: R R s/ 'i'u 6 S��c °') '4 igir"M
Address: ! /��r X�-/ /1 '•deV76� W,'/'- Telephone:
2. Owner of Property:
Address: +�� �Owner"/ 1 81,1 �3'0-jelephone:3. Status of Applicant: Contract Purchaser Lessee
Other(explain):
4. Job Location:
Parcel Id: Zoning Map#_'-:a' ' Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5, Existing Use of Structure/Property —
F. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
—1// di`l .51,C7;o&
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 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 #
10
RJR 3 M
APPLICANT/CONTACT PERSON:
ADDRESP$QNE:
PROPERTY LOCATION:
PARCEL: ZONE ,��
THIS SECTION FOR-OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
lRivildin2 Permit Filled ont
'?V/
New Cnnstriirfinn
Remndeling Interior
AdditinnAn Existing
��..
T OLLOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION:
Approved as presentedfbased 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 Commission
0!�,e 17//?'
8
Date
NOTE:Issuanoe a zoning permit does not relieve an applioant's burden to oomply with all
_ zoning raquirements and obtain ail required permits from the Board of Health, Conservation
Commission, Department of Public), Works and other applioabla permit granting authorities.
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