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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. � / Alterations
NORTHAMPTON, MASS. 1 q Additions
a APPLICATION FOR PERMIT TO ALTER Repair
) �,2 Garage
1. Location ,//���!✓r�Cc � � 'rte- Lot No.
2. Owner's name Ah. Address
3. Builder's name Address _j
Mass.Construction Supervisor's License No. D / / Expiration Date
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 cost-
p The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Signature of responsible app icant
Remarks —`°
s Grit of 'Nart4ttntpfon
� + pF BUILDING INS�06 lay.,,� �lassacF{nsctts y
-
-m DEPARTMENT OF BUILDITjG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(IlcenserJpeTmlttee}
with a principal place of business/residence at:
(phoney#)
(st=UCity/stalrfzjP)
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) (Polio 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 Cornpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Pokcy Number) (Expiration Daze)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiomi shoot ifnccus:ry to includo informarioo pertaining to an ocdradm)
(-/ I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pl ease be aware that whilo homeowners who employ persom to do mamtcnan coastrudion or rtpeir work on a dvmllmg of
not Moro than three cads in which the homoowner raider a oa the grounds appurtenad tb ertto art not generally coonder ed to be
employers under the worker's compauation Act(GL 152--s 1(5)),application by a homeowner for a li cwc cc permit may evidence the
ltgal status of an emPloyec under the Worker's Compemation ALL
I undentaad that a copy of this siaremcat may be fmwwded to the Dgmrtn a of Industrial A=dam''Offioo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of Criminal penalties
oomisting of a foe of up to$1,500.00 and/or irapriso=crd of up to one year and civil penalties in the form of a Stop Work Order and a
fins of 5100.00 a day against me
For dgnat=;W use ody
Permit Number
Ma�{ Lot#
<: Signabm of Licrosee/Permittee e
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 cols to be filled in
by the Building Department
Required
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:
4vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
1
DATE: 47_' APPLICANT's SIGNATURE ��
NOTE: Issuanoe of at zoning permit does not relieve an applioant's burden to oomply wlt
1r,a11.
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applioabla permit granting authorities.:-.
?'', FILE #
SP 2 4110
File No. t
DEPT OF BUILNG DI t4SPECTIONS
VJ
NORTHAMPtbtl MA 01660 ING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: �&- d' —t��'yrT.ly
Address: q f ;mss' CL>& _Telephone:
`��a'"��
2. Owner of Property: /� P 9�h
Address: ° 'Cif 1h, � Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: 2„3-el
Parcel Id: Zoning Map#�?J� Parcel# YT2 District(s):�L
(TO BE FILLED IN BY THE BUIL ING DEPARTMENT)
5. Existing Use of Structure/Property &4
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 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)
Department: Reference No: BP-1999-0326
...................................
Building, Electrical & Mechanical Permits
Fee Type: Receipt No:
Roofing REC-1999-000831
...... ................................................................................ ••.•.. ..••.•••.•••....•.••.........•.
Paid By: Paid in Full On:
DA Williams Thu Sep 24 1998
......................................................................................... .................••........•..........
Received By: Check No:
Linda Lapointe 4174
......................................................................................... ......................................
DEPARTMENT'S COPY Amount: $20.00
..............•............
D[,"PART ?1T FILE COPY 234 NORTH ST
CITY OF NORTHAMPTON
BUILDING PERMIT
Owner's pulling their own permits or dealing with unregistered contractors for applicable work do
not have access to Guaranty Fund(MGL 142A)
Issued: Permit No: Inspector: Tracking No.: Fee:
24 Sep, 1998 BP-1999-0326 $20.00
GIS Map Block: Lot: Address: Zonin2: Use Group: Lot Size:
4371 25A 157 001 234 NORTH ST URB 55756.8
Contractor: License Type: Insurance:
DA Williams CSL
Address: License No.: Insurance No.:
81 Water St. 014612
City: State: Zip Code: Phone:
NORTHAMPTON MA 01062 (413) 586-3139
Project No: Category of Work: Const. Class: Cost Estimate:
JS-1999-0671 roofing $800.00
Description of Work:
STRIP & SHINGLE PORCH ROOF
GeoTIVIS(ff)1997 Des Lauriers&Associates,Inc. Signature: