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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No.s y ��`'`� Alterations
NORTHAMPTON, MASS. �` ��� 1S►� 7 Additions
APPLICATION FOR PERMIT TO ALTER. Repair
Garage
1. Location I's C41 o 11 Lot No.
2. Owners name a�-/�"e S/y+'K e L w +C`z Address
3. Builder'sname J �'� ��, rte`' SI l Address P 0 ate F-U,4 /L3fo
Mass.Construction Supervisor's License No. Cl 1"2,Tf% Expiration Date
4. Addition
5. Alteration CE),wc D E2.l Pt 6 6 ATo- A-;,jD j),sS( 'VLc, -bW t 14 rc_i'{'z-)o > N�-A /i=r�z y c- L 1�•�+c7u�.
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-
coo The undersigned certifies that the above statements are true to the best of his, her
/ knowledge and belief.
tore of responsible app,icant
Remarks
•�oQ� T�y 15 ��J Lti U i5
SEP 2 9 097
� Aa34 itch n4rt14
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�'T OF 13OILOI';C;777, P TMENT OF BUILDrNG INSPECTIONS
Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
2- pn l —s 5lC /
(iicensee/permittee)
with a principal place of business/residence at:
_(phone#) Y13 - S-�'> 5f'u az.
(strcf/city/sta teha p)
do hereby certify, under the pains and penalties of pef ury, that:
(� I am an employer providing the following workerjs compensation coverage for my
employees working on this job-.
A27_�i`s At • I
(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 Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shit ifnxessary to inchxfe information pertaining to all ooatrn r3)
( ) I am a sole proprietor and have no one working for me.
( ) X am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ person:to do m, i•,•_ a, c cos anxtion or repair work on►dwelling of
not More than throe units is which the homeowner sides or on the groun6 appurtenant thereto arr not ga xratly oomidercd to be
employers under the work=-'%oompens4oa Act(GL152,ss 1(5)),application by a homeowner far a t eerie or permit may n idcnoe the
]cgsl slahta of an employer under the Workeet C.omp�at Act
I understand that a ODpY of thu stag may be forwarded to tbo Dcpartmcad of Industrial Aocid=&Of$oo of Iazucaaoa for the
covmga verification sad that failttte to&cure coverage under sectioa 25A of MGL 152 can lmd to the imposkioa of criminal penalties
. ooasisting of a fine of up to S1,500.00 and/or imptisonmrni of up to one year and civil pcnx hies in the form of a Stop Work Order and a
firm of 5100.00 a day against me
Signed this _day of f 1997 For dcputmtaW use only
Permit Number
�L--- Map#_ Lot#
Si of Li e ttee
J J P 2 91997
UILDING INSPECTIONS!I?TON,MA 01060
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10. Do any signs exist on the property? YES NO pm
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 columm to be filled in
by the Building Department
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
# pf Parking Spaces
1.f of Loading Docks
Fill:
_(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my k owledge.
,y c7>
DATE: L 17 APPLICANT's SIGNATURE �-
NOTE: Issuanoe of a zonin `
g permit does not relieve an p lioant's b en to comply with all
zoning requirements and obtain all required permits fro he Board of Health. Conservation
Commission. Department of Publio Works and other apps cable permit granting authorities.
FILE #
e 9� �H MRP01060NS Fi 1 e NO. 9t1'1'77
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: �C, °7 7 ED—/ S7c
Address: v rJ£� �L� `I� 4 n€ r Telephone: Y Y C, ° �--
2. Owner of Property:
Address: t8 6,9-11 x Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
X Other(explain): CZ �_`';_r."4
4. Job Location:
Parcel Id: Zoning Map# O''� Parcel# District(s):�� /--
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property l Dr"C"
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
�x-1�i�E2 e i3� °TIf
DI S( ca rtE�a i I�r =[fib
7. Attached Plans: Sketch Plan X 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 K 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 k'' 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)
9 15, U U 15 FILE
t
5EP 9199�T
APP CANT/C ACT ERSON: �!
DEPT :> HC1NE c� �
NORTNA °?T 0fq,a:.
PROPERTY LOCATION: — �s�✓LC>: Z
MAP cJ 1} PARCEL: ZONE
THIS SECTION FOR..OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FULED OITT
Fee Paid
113iiiiffing Permit Filled mit
L.�
L
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-f
THE�OLLOWING ACTION HAS BEEN TAKEN ON TS APPLICATION'
tt// App HI
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 `ut from DPW Water Availability Sewer Availability
Septic Approval-Bd of Health Well Water Potability-Bd Health
,)Per 't from onseyva . C on /
Signature of Building hi,,OKctor Date
NOTE:Issuance of a zoning 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
Commisalon, Department of Public Works and other appliaeble permit granting authorities.
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